Legionellosis Case Report

– 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 –

2014 Legionellosis Active Bacterial Core
Surveillance (ABCs) Case Report Form

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/A48.1 (Legionnaires’ disease)
482 (Other bacterial pneumonia)
482.3 (Pneumonia due to other specified bacteria)
482.83/J15.6 (Other gram-negative bacteria)
482.89/J15.8 (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. 01-2014

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/J15.9 (Bacterial pneumonia unspecified)
483 (Pneumonia due to other specified organism)
1
483.8/J16.8 (Pneumonia due to other specified organism)
484 (Pneumonia in infectious diseases classified elsewhere) 1
484.8/J17 (Pneumonia in infectious diseases classified elsewhere) 1

4 85/J18.0 (Bronchopneumonia
organism unspecified)
486/J18.9 (Pneumonia, organism
unspecified)
None of these listed
No ICD codes in chart

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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
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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

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 Kidney Disease
Current Chronic Dialysis
Cirrhosis/Liver Failure
Complement Deficiency
Dementia

1
1
1
1
1
1
1
1

Legionella Test

Date Collected

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

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

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

/

/

/

Unknown
1

Premature Birth (specify gestational
age at birth)
(wks)
Seizure/Seizure Disorder
Sickle Cell Anemia
Smoker, Current
Smoker, Former
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)
Other (specify) __________________

1
1
1
1
1
1
1
1
1

Result

/

/

1

Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity
Other Drug Use, Current
Other Drug Use, Past
Parkinson’s Disease
Peripheral Neuropathy
Plegias/Paralysis

/

Acute
1 Yes
2 No
9 Unknown

1
2
9

29. IHC
(immunohistochemistry)

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

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. 01-2014

36. Date reported to EIP site:

– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Date:

/

/

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