CDC 52.15A REV. 10 2016 Active Bacterial Core Surveillance (ABCs) CASE REPO

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

2016 Active Bacterial Core
Surveillance (ABCs) CASE REPORT

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

Year

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:
5

1

Neisseria meningitidis

3

Group B Streptococcus

2

Haemophilus influenzae

4

Listeria monocytogenes 6

1

Bone

1

Peritoneal fluid

1

CSF

1

Pericardial fluid 1

1

Other normally sterile site (specify)______________________________________ 1

Muscle/Fascia/Tendon 1

Pleural fluid
Internal body site (specify) _____________

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

1

Yes

2

Mo.

Day

Date of discharge:

Year

Mo.

Day

1

18a. Where was the patient a resident at time of initial culture?
1

Private residence

4

Homeless

7

Non-medical ward

2

Long term care facility

5

Incarcerated

8

Other(specify) ____________

3

Long term acute care facility 6

College dormitory 9

______lbs______ oz OR ______ kg

OR

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

Survived 2

Died 9

Unknown

Unknown

Asian

1

1

American Indian
or Alaska Native 1

Native Hawaiian
or Other Pacific Islander
Unknown

Yes 2

1

Placenta

1

Wound

1

Amniotic fluid

1

Middle ear

No 9

Unknown

Yes

2

No

9

1

1

Yes 2

9

Unknown

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

No

1

Private

1

Military

1

Other(specify) _________________

1

Medicare

1

Indian Health Service (IHS)

1

Uninsured

1

Medicaid/state assistance program

1

Incarcerated

1

Unknown

22a. If survived, patient discharged to: 1

Home 2

LTC/SNF 3

LTACH 4

Other

9

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

1

Bacteremia
without Focus

1

Peritonitis

1

Endometritis

1

Pericarditis

1

STSS

1

Meningitis

1

Otitis media

1

Septic abortion

1

Necrotizing fasciitis

1

Pneumonia

1

Chorioamnionitis

1

Puerperal sepsis

Mark if this is a HiNSES fetal death with placenta and/or amniotic fluid isolate,
a stillbirth, or neonate <22 wks gestation.

1

Cellulitis

1

Septic arthritis

1

Septic shock

1

Epiglottitis

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

1

Osteomyelitis

1

Other (specify)

1

Hemolytic uremic
syndrome (HUS)

1

Empyema

1

Abscess (not skin)

1

Endocarditis

1

Unknown

Gestational age:
CDC 52.15A REV. 10-2015

(wks) Birth weight:

Unknown

If discharged to LTC/SNF or LTACH, what is the Facility ID

24b. If pregnant or postpartum, what was the outcome of fetus:
Abortion/stillbirth 9
Unknown
1
Survived, no apparent illness 4
Induced abortion
5
Survived, clinical infection
2
6
Still pregnant
3
Live birth/neonatal death
24c.

Sinus

Unknown

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

23. If patient died, was the culture obtained on autopsy?
1
Yes 2
No
9
Unknown
24a. At time of first positive culture, patient was:
Postpartum 3
1
Pregnant 2
Neither 9

1

Black

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

Unknown

Unknown

OR

1

Facility ID:

Unknown

20b. HEIGHT:
______ft ______ in OR ______ cm OR

White

1

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

Year

No

20a. WEIGHT:

1

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

Joint

Blood

If YES, date of admission:

Chart unavailable
after 3 requests

Streptococcus pneumoniae

1

16. WAS PATIENT
HOSPITALIZED?

Incomplete 4

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

Group A Streptococcus

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

(gms)

– 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
1
Alcohol Abuse, Current
1
Alcohol Abuse, Past
1
Asthma
1
Atherosclerotic Cardiovascular Disease
1
(ASCVD)/CAD
1
Bone Marrow Transplant (BMT)
1
Cerebral Vascular Accident (CVA)/Stroke/TIA
1
Chronic Kidney Disease
1
Chronic Liver Disease/cirrhosis
1
Current Chronic Dialysis
1
Chronic Skin Breakdown
1
Cochlear Implant

1
1
1
1
1
1
1
1
1
1

None 1

Unknown

Complement Deficiency
Connective Tissue Disease (Lupus, etc)

1

Immunosuppressive Therapy (Steroids,
Chemotherapy, Radiation)

1
1

CSF Leak
Current Smoker
Deaf/Profound Hearing Loss
Dementia
Diabetes Mellitus
Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency

1
1
1
1
1
1

1
1
1
1

1
1

IVDU, Current
IVDU, Past
Leukemia
Multiple Myeloma
Multiple Sclerosis
Myocardial Infarction
Nephrotic Syndrome
Neuromuscular Disorder

1

Obesity

1
1

Other Drug Use, Current
Other Drug Use, Past

Parkinson’s Disease
Peptic Ulcer Disease
Peripheral Neuropathy
Peripheral Vascular Disease
Plegias/Paralysis
Premature Birth (specify gestational
age at birth )
(wks)
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Other prior illness (specify):

1
1
1
1
1
1

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

1

b

2

Not Typeable

3

a

4

c

5

d

6

e

7

f

8

Other (specify)

1
Yes 2 No 9
Unknown
28b. If <15 years of age and serotype ‘b’ or ‘unknown’ did
patient receive Haemophilus influenzae b vaccine?
If YES, please complete the list below.
DOSE
DATE GIVEN
VACCINE NAME
MANUFACTURER
Mo.

Day

9

LOT NUMBER

Year

1

1

Yes

2

No

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

2
3
4
NEISSERIA MENINGITIDIS
29. What was the 1
A
serogroup?

2

B

3

C

4

31.Did patient receive meningococcal vaccine?
DOSE

Not Tested or Unknown

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

TYPE

Y

1

Yes 2

DATE GIVEN
Mo.

Day

5

W135
No 9
NAME

Year

6

Not Groupable 8

9

Other

Unknown If YES, complete the table
MANUFACTURER

LOT NUMBER

Vaccine Registry

1
1

Healthcare Provider
Other(specify)
30. Is patient currently attending college?

Unknown

1

Yes 2

No 9

Unknown

STREPTOCOCCUS PNEUMONIAE
32. Did patient receive pneumococcal vaccine?
1

1

1

Yes

2

No 9

Unknown

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

2
3
4
5

®

1

Prevnar , 7-valent Pneumococcal Conjugate Vaccine (PCV7)

1

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

1

Pneumovax , 23-valent Pneumococcal Polysaccharide Vaccine (PPV23)

1

Vaccine type not specified

®
®

If between ≥2 months and<5 years of age and an isolate is available for
serotyping, please complete the Invasive Pneumococcal Disease in
Children expanded form.

6
Type Codes: 1= ACWY conjugate (Menactra, Menveo, MenHibrix) 2= ACWY polysaccharide (Menomune)
3= B (Bexsero, Trumenba) 9= Unknown
31b. If survived, did patient have any of the following sequelae evident upon discharge? (check all that apply) 1
Paralysis or spasticity 1
1 Hearing deficits 1 Amputation (digit) 1
Amputation (limb) 1
Seizures 1

None 1 Unknown
Skin Scarring/necrosis

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

No 9
Day

Unknown

34.Did the patient deliver a baby (vaginal or C-section) ?
Yes 2

No 9

Year

Mo.

If YES,
date of delivery:

If YES, date of surgery or skin incision:

Other (specify)

35. Did patient have:

1
Mo.

1

Unknown
Day

Year

1
1
1

Varicella
Penetrating trauma
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:
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,

Do not send the completed form to this address.

37. Was case first
1
identified through
9
audit?

Submitted By:
Physician’s Name:
CDC 52.15A REV. 10-2015

Yes 2
Unknown

No

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

Yes 2
Unknown

No

39. S.O. Initials

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

Phone No. : (

)

Phone No. : (

)

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Date:

/

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