Invasive MRSA

Patient ID: _____ _____ _____ _____ _____ _____ _____ _____
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Phone No.: (

Patient's Name:

(Last, First, M.I.)

Address:

(Number, Street, Apt. No.)

Hospital:

(Zip Code)

(City, State)

–

–

INVASIVE METHICILLIN-RESISTANT • STAPHYLOCOCCUS AUREUS
ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) CASE REPORT – 2013

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

– SHADED AREAS FOR OFFICE USE ONLY –

1. STATE:
2. COUNTY:
(Residence of patient)
(Residence of Patient)

3. STATE I.D.:

5. Where was the patient located on the 4th calendar day prior to the date of initial culture?
1

Incarcerated

1

Long Term Care Facility

1

Hospital Inpatient

1

Long Term Acute Care Hospital

1

Other __________________________

1

Homeless

1

Unknown

8a. SEX:

8b. ETHNIC ORIGIN:
1

1

Male

2

Female

2
9

Yes

2

No

9

Not Hispanic or Latino

1

Native Hawaiian

Unknown

1

Black or
African American
American Indian
or Alaska Native

1

Unknown

1
6

ICU
Surgery/OR

7

Radiology

2

Other Unit

1

Survived

2

Mo.

Day

5
13
14

Surgery
Dialysis/Renal Clinic
Other
Outpatient

9
10

No 9

Died

9

Unknown
1

Yes 2

No

Yes

2

No

9

1

Yes 2

No

Unknown

1

Blood, Date:________

1

Muscle, Date:______

1

CSF, Date:________

1

Internal body site
Date:________

1

Other sterile site
(specify)____________
Date:________

1

, Date:________
Date:________

, Date:________
1
1

Autopsy

Unknown

Unknown

10b. DATE OF INITIAL CULTURE:

Unknown

Mo.

Other

Day

Year

1

Blood

1

1

CSF

1

1

Pregnant

1

2

Post-partum

1

3

Neither

9

Unknown

Bone

1

Muscle

1

Internal body site (specify)
_____________________

1

Other sterile site (specify)
______________________

15. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)

1

None

1

Unknown

Unknown

If yes, indicate site and date of last positive culture:

1

8f. BMI:
_______

LTCF
LTACH

culture, patient was:

Year

14. Were cultures of the SAME or OTHER sterile site(s) positive
within 30 days after initial culture date?
1

_______ ft _______ in OR _______ cm

13. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY
ISOLATED: (Check all that apply)

Was MRSA cultured from a normally sterile site, < calender day 7 before death?
Yes 2

Unknown

8e. HEIGHT:

Observational Unit/Clinical Decision Unit

16

Year

4

Yrs.

Emergency Room

3

Day

Outpatient
8
Clinic/
11
15

Mos. 3

_______ lbs _______ oz OR _______ kg

10a. LOCATION OF CULTURE COLLECTION: (Check one)

Hospital Inpatient

Days 2

Year

8d. WEIGHT:

1

Year

7b. Is age in day/mo/yr?

7c. If case is ≤12 months of age, type of
birth hospitalization:
9
NICU/SCN
1
Unknown
Well Baby Nursery
2
Asian

If survived, was the patient transferred to a LTCF?
If survived, was the patient transferred to a LTACH?

1

Day

1

Unknown

If Died,
Date of Death:

Mo.

White

Day

11. PATIENT OUTCOME:

7a. AGE:

1

Date of discharge
Mo.

6. DATE OF BIRTH:

8c. RACE: (Check all that apply)

If YES: Date of admission
Mo.

4b. HOSPITAL I.D. WHERE PATIENT TREATED:

Hispanic or Latino

9. WAS THE PATIENT HOSPITALIZED, AT THE
TIME OF, OR IN THE 30 CALENDAR DAYS
AFTER, INITIAL CULTURE?
1

Form Approved OMB No. 0920-0978

4a. HOSPITAL/ LAB I.D. WHERE
CULTURE IDENTIFIED:

1

Private Residence

1

)

Patient
Chart No.:

Date:________

1

Abscess (not skin)

1

Empyema

1

1

AV Fistula/Graft Infection

1

Endocarditis

1

Skin Abscess

1

Bacteremia

1

Meninigitis

1

Surgical Incision

1

Bursitis

1

Peritonitis

1

Surgical Site (Internal)

Septic Shock

1

Catheter Site Infection

1

Pneumonia

1

Traumatic Wound

1

Cellulitis

1

Osteomyelitis

1

Urinary Tract

1

Chronic Ulcer/Wound (non-decubitus)

1

Septic Arthritis

1

Other: (specify)

1

Decubitus/Pressure Ulcer

1

Septic Emboli

Bone, Date:________

_______________________

_______________________

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 OMBcontrol number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0978)

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

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

1

None

1

Unknown

1

Abscess/Boil (Recurrent)

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

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

Decubitus/Pressure Ulcer

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

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

1

Culture collected >3 calendar days after hospital admission.

1

Hospitalized within year before initial culture date.
Date of discharge
Mo.

If YES:

Day

Year

1

None

1

Unknown

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.

Unknown

Surgery
1. __________________________________________

Date
/
/
_____ _____
_____

2. __________________________________________

/
/
_____ _____
_____

3. __________________________________________

/
/
_____ _____
_____

4. __________________________________________

/
/
_____ _____
_____

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).
1
Not done
(Check all that apply)
a. Chest Radiology Results
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)
______________________

– SU R VEILLANCE OFFICE USE ON
20. CRF status:
audit?
1

Yes 2

No

9

Unknown

1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

21. Does this case have
recurrent MRSA
disease?
1

Y es 2

9

Unknown

LY –

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

No

22. Date reported to EIP site:
Mo.

Day

23. Initials of
S.O:

Year

24 COMMENTS:_______________________________________________________________________________________________________________________________

________

_______________________________________________________________________________________________________________________________

____________________

_______________________________________________________________________________________________________________________________

____________________

CDC 52.15B Rev. 9-2013

CS235703

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