Pseudomonas NICU_CA

A ppendix 1: Chart Abstraction Form

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Patient Name: ________________________________________________________

CDC ID#:____________________________________________________________

Chart Abstraction Form

Name of Person Completing Form _____________________________ Date: ____/_____/____

Case Control: Matched to case (CDC ID): _______

Date of onset/positive culture (for case or matched control): _______________

30day window period: ________ to _________ 7day window period: _________ to _________

1. Demographic Information

Sex: Male Female Age (specify years or months if <2 years):________________

Race: White Black Asian American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander Other____________

Ethnicity: Hispanic/Latino Non-Hispanic/Latino

2. Birth History

Gestational age: ____ wks ____ days Birth weight: ______ grams or _____lbs.____oz.

Birth: C-section Vaginal delivery Multiple birth APGAR: 1min____ 5 min____

3. Maternal/ Obstetric History: G____P____

Chorioamnionitis

Cigarette smoking

Drug use:_____________

Fetal distress

Gestational diabetes

IUGR

Maternal infection

Preeclampsia

Premature delivery

PROM

Unknown

Other______________

4. Medical History

1. Comorbidities: Unknown

Aspiration

Gastric residual >30%

Intracran. hemorrhage

Patent ductus arteriosis

Perinatal asphyxia

Reflux/ Regurgitation

Sepsis

Cardiac abnormalities (e.g., congenital heart disease): _________________________________

Pulmonary disease (e.g., BPD, HMD/RDS, meconium aspiration): ______________________

Gastointestinal disease (e.g., NEC, gastroschisis, omphalocele): _______________________

Other: _________________________________________________________________________

2. Did infant have any of the following 7 days prior to positive culture? Unknown

GI surgery Non GI surgery Retinopathy of prematurity (ROP) treatment

Mechanical ventilation Umbilical catheter Other central venous catheter

Oro/nasogastric tube G-tube Jejunal tube

RBC transf: (Date: ________, # units:____) Supplemental O2

Other devices (describe): ___________________________________________________________

5. Medication History

1. Was infant treated with antimicrobial 30 days before onset/positive culture?

Yes No Unk.

Antimicrobial	Route	Start Date	Stop Date

2. Other medications received 7 days prior to onset or positive culture?

Medication	Route	Start Date(s)	Stop Date(s)

3. Other injectables received in the 7 days before onset or positive culture?

Product	Start Date(s)	Stop Date(s)
TPN Yes No Unk

6. Illness History: Please fill out for case-patients only

1. Date of onset/positive culture: ____/___ /____

2. Outcome (include date):

Ongoing illness Symptoms resolved__________ Colonization only ____________ Death____________ Unknown

If death, attributed to Pseudomonas? Yes No Autopsy performed? Yes No

3. Pathology results from surgery or autopsy: ____________________________________________

___________________________________________________________________________

4. Pathology samples from surgery or autopsy available? Yes No

H. Clinical Information: Please fill out for case-patients only

1. Signs and Symptoms within 48 hours of onset or positive culture (check all that apply):

Unk.

Fever

Sepsis

Tachycardia/ Rapid heart rate

Tachypnea/Rapid breathing

Other________________

________________________________________________________________________

2. Abnormal laboratory findings within 48 hours of onset or positive culture (check all that apply):

Unk.

Anemia: Hb______, Hct______

Coagulopathy: INR_______, PTT_____

Leukocytosis: WBC______

Metabolic acidosis: pH_____, HCO3___

Neutropenia: WBC______, ANC______

Thrombocytopenia: Plt ______

3. Microbiology findings: List all positive cultures from sterile sites (blood, urine, etc.) and surveillance culture sites

(Date range: 1 week prior to illness onset until resolution of illness)

No cultures drawn All cultures negative Unknown

Date	Source	Organism	# Positive Bottles (x/y)	Surveillance culture?(Y/N)

9. Bathing/skin care history

Skin care products used	Brand/Manufacturer	Dates

9. Oral care products

Oral care products used	Brand/Manufacturer	Dates

9. Staff exposures

Staff	Role	Dates

L. Notes/Remarks (Anything unusual about hospital course not included above, including patterns of medication/thickener use, patient course at home, etc.)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

K. Medical Chart Abstraction Form Complete?

Yes---- date of completion _____/_____/_____

No

Public reporting burden of this collection of information is estimated to average 30 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)