Case Report

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Patient’s Name:

Phone No.: (
Patient
Chart No.:

(Last, First, MI.)

Address:

(Number, Street, Apt. No.)
(City, State)

)

Hospital:

(Zip Code)

er information is not transmitted to CDC –

2013 Active Bacterial Core
Surveillance (ABCs) CASE REPORT

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
A CORE

COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
OMB No. 0920-0978

– SHADED AREAS FOR OFFICE USE ONLY –
1. STATE:
(Residence of Patient)

2. STATE I.D.:

3. DATE FIRST POSITIVE CULTURE COLLECTED
(Date Specimen Collected)
Mo.

Day

Mo.

Day

Year

9a. AGE:

8. DATE OF BIRTH:
Day

10. SEX:

Year

9b. Is age in day/mo/yr?
1

Days 2

Mos. 3

1

Male

1

Hispanic or Latino

2

Female

2

Not Hispanic or Latino

9

Unknown

12a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:

Neisseria meningitidis

3

Group B Streptococcus

2

Haemophilus influenzae

4

Listeria monocytogenes 6

1

Bone

Blood

1

Peritoneal fluid

1

CSF

1

Pericardial fluid 1

1

Other normally sterile site (specify)______________________________________ 1

Muscle/Fascia/Tendon 1

1

Yes

2

If YES, date of admission:
Day

White

1

Asian

1

Black

1

1

American Indian
or Alaska Native 1

Native Hawaiian
or Other Pacific Islander

Date of discharge:

Year

Mo.

Placenta

1

Wound

1

Amniotic fluid

1

Middle ear

No 9

Unknown

Internal body site (specify) _____________

Day

1

Yes 2

1

No

Yes

2

No

9

18b. If resident of a facility, what 19a.Was patient transferred
from another hospital?
was the name of the facility?

Private residence

4

Homeless

7

Non-medical ward

2

Long term care facility

5

Incarcerated

8

Other(specify) ____________

1

Yes 2

Unknown

9

Unknown

College dormitory 9

20a. WEIGHT:

19b. If YES, hospital I.D.:

No

21. TYPE OF INSURANCE: (Check all that apply)

______lbs______ oz OR ______ kg

OR

Unknown

______ft ______ in OR ______ cm OR

Unknown

20b. HEIGHT:
20c. BMI:
___ ___ . ___
22. OUTCOME: 1

Sinus

Unknown

1

Long term acute care facility 6

1

17. If patient was hospitalized, was this patient admitted to the
ICU during hospitalization?

Year

18a. Where was the patient a resident at time of initial culture?

3

Unknown

1

Pleural fluid

INFLUENZA 15. Did this patient have a positive flu test 10 days prior to or following any
_____________ ABCs positive culture?

Mo.

1

14. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)

Joint

1

16. WAS PATIENT
HOSPITALIZED?

Chart unavailable
after 3 requests

Streptococcus pneumoniae

13. STERILE SITES FROM WHICH ORGANISM ISOLATED: (Check all that apply)
1

Incomplete 4

12b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
(specify)

Group A Streptococcus

5

1

Complete

2

11b. RACE: (Check all that apply)

11a. ETHNIC ORIGIN:

Yrs.

Edited & Correct

3

1

7b. HOSPITAL I.D. WHERE
PATIENT TREATED:

7a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:

6. COUNTY:
(Residence of Patient)

Mo.

5. CRF Status:

4. Date reported to EIP site:

Year

OR

Died 9

24a. At time of first positive culture,
patient was:

2

Postpartum 9

1

Military

1

Other(specify) _________________

1

Medicare

1

Indian Health Service (IHS)

1

Uninsured

1

Medicaid/state assistance program

1

Incarcerated

1

Unknown

23. If patient died, was the culture obtained on autopsy?

Unknown

24b. If pregnant or postpartum, what was the outcome of fetus:

Neither

3

Pregnant

Private

Unknown

Survived 2

1

1

Unknown

1

Survived, no apparent illness 4

Abortion/stillbirth 9

2

Survived, clinical infection

5

Induced abortion

3

Live birth/neonatal death

6

Still pregnant

Unknown

1

Yes 2

No 9

Unknown

25. If patient <1 month of age, indicate gestational age
and birth weight. If pregnant, indicate gestational
age of fetus, only.
Birth weight:
Gestational age:

(wks)

(gms)

26. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
1
1
1

Bacteremia
1
without Focus
1
Meningitis
Otitis media

1

Pneumonia 1
Cellulitis
Epiglottitis

1
1

Hemolytic uremic 1
syndrome (HUS)
1
Abscess (not skin)
1
Peritonitis

Pericarditis

1

Septic arthritis

1

Endocarditis

1

Necrotizing fasciitis 1

Septic abortion

1

Osteomyelitis

1

Endometritis

1

Puerperal sepsis

Empyema

1

STSS

1

Septic shock

Chorioamnionitis 1

1

Other(specify)

Unknown

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to CDC,
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0978). Do not send the completed form to this address.
CDC 52.15A REV. 9-2013

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

Page 1 of 2

27. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE,check appropriate box) 1
1
1

AIDS or CD4 count <200
Alcohol Abuse, Current

1

CSF Leak

1

IVDU, Current

1

Current Smoker

1

IVDU, Past

1
1
1

Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease
(ASCVD)/CAD

1

Deaf/Profound Hearing Loss

1

Dementia

1

Diabetes Mellitus

1
1
1
1
1
1

Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Renal Insufficiency
Chronic Skin Breakdown
Cirrhosis/Liver Failure
Cochlear Implant

1
1
1
1
1
1

Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy (Steroids,
Chemotherapy, Radiation)

1
1
1
1
1
1

Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity

1
1

Parkinson’s Disease
Other Drug Use, Current

1

Complement Deficiency

1

Other Drug Use, Past

1

Peripheral Neuropathy

None 1

Unknown

1
1

Plegias/Paralysis
Premature Birth (specify gestational
age at birth )
(wks)

1
1
1
1
1
1
1

Renal Failure/Dialysis
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)

1

Other prior illness (specify)

– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISM –
28a. What was the serotype?

HAEMOPHILUS
INFLUENZAE

1

b

2

Not Typeable

3

a

DOSE

DATE GIVEN
Mo.

Day

4
1

28b. If <15 years of age and serotype ‘b’ or ‘unknown’ did
patient receive Haemophilus influenzae b vaccine?

Yes

c

5
2

d
9

e

7

f

Other (specify)

8

9

Unknown
LOT NUMBER

MANUFACTURER

Not Tested or Unknown

28c. Were records obtained to verify
vaccination history? (<5 years of age
with Hib/unknown serotype, only)

If YES, please complete the list below.

VACCINE NAME

Year

6

No

1

1

Yes

2

No

2

If YES, what was the source of the
information? (Check all that apply)

3

1

Vaccine Registry

1

Healthcare Provider

1

Other(specify)

4
NEISSERIA MENINGITIDIS
29. What was the serogroup?

1

A

3

C

5

W135

2

B

4

Y

6

Not groupable 8

31. Did patient receive meningococcal vaccine?

1

Yes 2

No 9

9

30. Is patient currently attending college?
(15 – 24 years only)

Unknown

1

Other (specify)

1
DATE GIVEN
Mo.

Day

VACCINE NAME

MANUFACTURER

No 9

Unknown

STREPTOCOCCUS PNEUMONIAE
32. Did patient receive pneumococcal vaccine?

Unknown

If YES, please complete the following information:

DOSE

Yes 2

LOT NUMBER

Yes

2

No 9

Unknown

If YES, please note which pneumococcal vaccine was received:
(Check all that apply)

Year

1
2

®

1

Prevnar , 7-valent Pneumococcal Conjugate Vaccine (PCV7)

1

Prevnar-13 , 13-valent Pneumococcal Conjugate Vaccine (PCV13)

1

Pneumovax , 23-valent Pneumococcal PolysaccharideVaccine (PPV23)

1

Vaccine type not specified

®
®

If between ≥3 months and<18 years of age and an isolate is available for
serotyping, please complete the Invasive Pneumococcal Disease in
Children expanded form.

3

GROUP A STREPTOCOCCUS

(#33–35 refer to the 14 days
prior to first positive culture)

33. Did the patient have surgery
or any skin incision?

1

Yes 2

Mo.

No 9

Day

34. Did the patient deliver a baby (vaginal or C-section) ? 35. Did patient have:
1

Yes 2

No 9

Year

Mo.

If YES,
date of delivery:

If YES, date of surgery or skin incision:

Unknown

Unknown

Day

Year

1

Varicella

1

Penetrating trauma

1

Blunt trauma

1

Surgical wound
(post operative)

1

Burns

If YES to any of the above, record the number of

(if > 1, use the most recent skin injury)
1

0-7 days

2

8-14 days

36. COMMENTS:

– SURVEILLANCE OFFICE USE ON LY –
37. Was case first
1
identified through
audit?
9

Yes 2
Unknown

No

38. Does this case have 1
recurrent disease with
the same pathogen? 9

Yes 2
Unknown

No

39. Initials of
S.O.:

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

Submitted By:

Phone No. : (

)

Physician’s Name:

Phone No. : (

)

CDC 52.15A REV. 9-2013

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Date:

/

/

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