Invasive Methicillin - Resistant - Staphylococcus aureus ABCs Case Report Form

20

16. UNDERLYING CONDITIONS: (Check all that apply) (if none or no chart available, check appropriate box)

1

None

1

Unknown

1

Abscess/Boil

1

Current Smoker

1

HIV

1

Peptic Ulcer Disease

1

AIDS or CD4 count<200

1

CVA/Stroke

1

1

Peripheral Vascular Disease (PVD)

1

Chronic Liver Disease

1

Cystic Fibrosis

Influenza
(within 10 days of initial culture)

1

Decubitus/Pressure Ulcer

IVDU

Premature Birth

Chronic Pulmonary Disease

1

1

1

Chronic Renal Insufficiency

1

Dementia

Metastatic Solid Tumor

Solid Tumor (non metastatic)

1

1

1

1

Chronic Skin Breakdown

1

Diabetes

1

Myocardial Infarct

1

Other: (specify only for cases ≤ 12 months
of age) _____________________________

1

Congestive Heart Failure

1

Hematologic Malignancy

1

Obesity

1

Connective Tissue Disease

1

Hemiplegia/Paraplegia

1

Other Drug Use

17. CLASSIFICATION – Healthcare-associated and Community-associated: (Check all that apply)
1

1

Previous documented MRSA infection or colonization
Month
Year
OR previous STATE I.D.:

Culture collected >3 calendar days after hospital admission.

1

Hospitalized within year before initial culture date.
Mo.

Day

Year

1

1

Unknown

Date
Surgery
1. __________________________________________ _____ /_____ / _____
2. __________________________________________ _____ /_____ / _____
3. __________________________________________ _____ /_____ / _____

Date of discharge
If YES:

None

If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:

If YES:
1

1

Surgery within year before initial culture date.

4. __________________________________________ _____ /_____ / _____

Unknown
1

Dialysis within year before initial culture date.
(Hemodialysis or Peritoneal dialysis)

1

Current chronic dialysis
Peritoneal
Type
Unknown
Hemodialysis
Type of vascular access
AV fistula / graft
Hemodialysis CVC
Unknown

1

Residence in a long-term care facility
within year before initial culture date.

1

Admitted to a LTACH within year
before initial culture date.

1

Central vascular catheter in place at
any time in the 2 calendar days prior
to initial culture.

18. SUPPLEMENTAL PNEUMONIA QUESTIONS. Please complete if the patient was determined to have pneumonia per question 15a (Timeframe of interest: within +/- 3 calendar
days of initial culture).
Not done
a. Chest Radiology Results (Check all that apply) 1
b. 1
MRSA positive non-sterile respiratory specimens
Type

CT

X-Ray

1

Bronchopneumonia/pneumonia

1

Consolidation

1

Air space density/opacity

1

No evidence of pneumonia

1

Cavitation

1

None listed

1

Cannot rule out pneumonia

1

Not available

1

New or changed infiltrates

1

1

Pleural effusion

Other: (specify)
______________________

– SURVEILLANCE OFFICE USE ONLY –
19. Was case first
identified through
audit?
1

Yes

2

9

Unknown

No

20. CRF status:
1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

21. Does this case have
recurrent MRSA
disease?
1

Yes

2

9

Unknown

No

If YES, previous
(1st) STATE I.D.:

22. Date reported to EIP site:
Mo.

Day

23. Initials of
S.O:

Year

24 COMMENTS:_____________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 1-2012

Page 2 of 2

CS228427