Legionellosis

– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Patient’s Name: Phone No.: (
)
(Last, First, MI.)
Patient
Address: Chart No.:
(Number, Street, Apt. No.)

Hospital:

(City, State)

(Zip Code)

– Patient identifier information is not transmitted to CDC –

2013 Legionellosis 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
– SHADED AREAS FOR OFFICE USE ONLY –

1. STATE:
(Residence of Patient)

5.STATE HEALTH DEPT. CASE NO.
(From CDC Legionellosis
case report form for passive
surveillance):

6.DATE OF SYMPTOM ONSET
OF LEGIONELLOSIS: (note this is
NOT date of admission)
Mo.

Day

Yes
No
Unknown

1
2
9

7a. WAS PATIENT
HOSPITALIZED?

Year

7b. If patient was hospitalized,
7c. Did the patient require
was this patient admitted to
mechanical ventilation?
the ICU during hospitalization?
1
2
9

4a. HOSPITAL/LAB I.D. WHERE FIRST
CULTURE IDENTIFIED OR FIRST
POSITIVE TEST:

3. STATE I.D.:

2. COUNTY:
(Residence of Patient)

1

Yes

Mo.

If yes,
Date of
admission:

Day

Private residence

1

Homeless

1

Acute care hospital

Long term care facility

1

Incarcerated

1

Other (specify) _________________

1

Long term acute care facility 1

Assisted Living

1

Unknown

12a. AGE:
( at time
of onset)

Year

13. SEX:

12b. Is age in day/mo/yr?
1

Days 2

Mos. 3

15a. WEIGHT:
______lbs______ oz OR ______ kg OR

Unknown

15b. HEIGHT:
______ft   ______ in OR ______ cm OR

Unknown

15c. BMI:

___ ___.___ OR

17. OUTCOME:

1

Died 9

Unknown

1

CT 2

X-ray 3

Both 4

Neither 9

1

Male

1

Hispanic or Latino

2

Female

2

Not Hispanic or Latino

9

Unknown

Yrs.

1

Yes 2

No

9

Unknown

1

White

1

Black

1

1

Asian

1

American Indian
or Alaska Native 1

Military

Indian Health Service (IHS) 1

Uninsured

1

Medicaid/state assistance program 1

Incarcerated

Unknown

1

Native Hawaiian
or Other Pacific Islander
Unknown

Other (specify) __________________

1

18. If patient died, was the initial culture or first positive test obtained from autopsy? 1

Unknown

Atelectasis

1

Empyema
ARDS (acute respiratory distress syndrome)

1

Lobar (NOT interstitial) infiltrate

1

Cavitation

1

Cannot rule out pneumonia

For pneumonia/consolidation/infiltrate

1

Pleural effusion

1

No evidence of pneumonia

1

Single lobar

1

Pneumonitis

1

Report not available

1

Multiple lobar infiltrate (unilateral)

1

Pulmonary edema

1

1

Multiple lobar infiltrate (bilateral)

1

Interstitial infiltrate

Other (specify)
_____________________________________

22. Discharge diagnosis (check all that apply):
482.84 (Legionnaires’ disease)
482 (other bacterial pneumonia)
482.8 (pneumonia due to other specified bacteria)
482.83 (other gram-negative bacteria)
482.89 (pneumonia due to other specified bacteria)

1
1
1
1
1

Yes

2

No

9

Unknown

20. WAS THE PATIENT DIAGNOSED WITH PNEUMONIA?:
1

Air space/alveolar density/opacity/disease 1

CDC 52.15C REV. 01-2013

8b. If YES,
hospital I.D.:

10a. Was patient transferred 10b. If YES, hospital I.D.:
from another hospital?

1

1

No

Year

Year

1

1

Yes 2

Day

Unknown

Medicare

Consolidation

Unknown

9

Private

Pneumonia/bronchopneumonia

1

No

1

1

9

2

1

1

1
1
1
1
1

Day

14b. RACE: (Check all that apply)

14a. ETHNIC ORIGIN:

If yes, check all that apply from the radiology report:

21. D
 id this patient have
a positive flu test
10 days prior to or
following a positive
Legionella test or
positive Legionella
culture?

Yes
Mo.

Year

19. DID THE PATIENT HAVE A CHEST CT OR CHEST X-RAY WITHIN 72 HOURS OF ADMISSION?:
1

Mo.

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

Unknown

Survived 2

Date of discharge:

Year

No

9b. If resident of a facility,
what was the name of
the facility?

1

Day

Day

Date
of discharge:

1

Mo.

Mo.

8a. Excluding the current hospitalization, was the
patient hospitalized at any time in the 10 days
prior to illness onset?

Yes
No
Unknown

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

If YES, date of admission:

2

9a. Where was the patient a resident in the 10 days prior to illness onset?
(Check all that apply)

11. DATE OF BIRTH:

OMB No. 0920-0978

Yes

2

No*

9

Unknown*

*If no or unknown, choose syndrome or infection type:
1

Pontiac fever (fever and myalgia without pneumonia)

8

Extrapulmonary infection (specify):
__________________________________________

9

Unknown

1
482.9 (bacterial pneumonia unspecified)
483 (pneumonia due to other specified organism)
1
483.8 (pneumonia due to other specified organism)
484 (pneumonia in infectious diseases classified elsewhere) 1
484.8 (pneumonia in infectious diseases classified elsewhere) 1

4 85 (bronchopneumonia organism
unspecified)
486 (pneumonia, organism
unspecified)
None of these listed
No ICD-9 codes in chart

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 of
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.
– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

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

1
1
1
1
1
1
1

AIDS or CD4 count <200
Alcohol Abuse, Current
Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease (ASCVD)/CAD
Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Renal Insufficiency
Cirrhosis/Liver Failure
Complement Deficiency
Dementia
Diabetes Mellitus
Legionella Test

Was this test ordered?
1
2
9

24. Urine Antigen, EIA

1
2
9

25. Culture

26. Paired Serology, IFA
or ELISA

27. PCR
(direct specimen only)

28. DFA
(direct fluorescence
assay, direct
specimen only)

1
1
1
1

Date Collected

Yes
No
Unknown

/

Yes
No
Unknown

/

/

Acute

Convalescent
1 Yes
2 No
9 Unknown

Convalescent

1
2
9

1
2
9

/

/

Yes
No
Unknown

/

Yes
No
Unknown

/

Yes
No
Unknown

/

1
1
1
1
1
1
1
1
1
1

1
2
9
1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

/

/

/

Unknown
1
1
1
1
1
1
1
1
1
1

Renal Failure/Dialysis
Seizure/Seizure Disorder
Sickle Cell Anemia
Smoker, Current
Smoker, Former
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)
Other (specify) __________________

Result

/

/

1

Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity
Other Drug Use, Current
Other Drug Use, Past
Parkinson’s Disease
Peripheral Neuropathy
Plegias/Paralysis
Premature Birth (specify gestational
age at birth)
(wks)

Site

/

Acute
1 Yes
2 No
9 Unknown

1
2
9

29. IHC
(immunohistochemistry)

Dysphagia
Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation)
IVDU, Current
IVDU, Past
Leukemia
Multiple Myeloma

None

1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________
1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

Species

Positive
Negative
Unknown or Indeterminate
1

1
2
9

Positive
Negative
Unknown or Indeterminate

2
8
9

L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
9 Unknown
L. species (non-pneumophila)
L. species, other
(specify)____________________
L. species, unknown or not specified

Acute
1 Positive
If yes, titer: ____________
2 Negative
9 Unknown or Indeterminate

Acute
Species: _____________________________

Convalescent
1 Positive
If yes, titer: ____________
2 Negative
9 Unknown or Indeterminate

Convalescent
Species: _____________________________

1
2
9

Positive
Negative
Unknown or Indeterminate

Serogroup(s): ________________________

Serogroup(s): ________________________

1
2
8
9
1

1
2
9

Positive
Negative
Unknown or Indeterminate

2
8
9
1

1
2
9

Positive
Negative
Unknown or Indeterminate

2
8
9

L. pneumophila
L. species (non-pneumophila)
L. species, other
(specify)____________________
L. species, unknown or not specified
L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
9 Unknown
L. species (non-pneumophila)
L. species, other
(specify)____________________
L. species, unknown or not specified
L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
9 Unknown
L. species (non-pneumophila)
L. species, other
(specify)____________________
L. species, unknown or not specified

30. COMMENTS:

– SURVEILLANCE OFFICE USE ONLY –
32. Was this case also identified
31. Was case first
through routine passive notifiable
identified through
disease surveillance?
audit?
1

Yes 2

9

Unknown

No

1

Yes 2

No 9

Unknown

33. CRF Status:
1
2
3
4

34. Does this case have
recurrent disease?
Complete
Incomplete
1 Yes 2
No 9
Unknown
Edited & Correct
If yes, previous (1st) state ID:
Chart unavailable
after 3 requests

35. Case status:
1 Confirmed
2

Mo.

Day

37. Initials of
S.O.:

Suspect
Year

Submitted By:

Phone No. : (

)

Physician’s Name:

Phone No. : (

)

CDC 52.15C REV. 01-2013

36. Date reported to EIP site:

– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Date:

/

/

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