VERSION:01-2016 2016 Multi-site Gram Negative Surveillance Initiative (M

Form Approved OMB No. 0920-0978
Expires xx/xx/xxxx

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

2016 Multi-site Gram-Negative Surveillance Initiative (MuGSI)
Healthcare Associated Infection Community Interface (HAIC) Case Report

Patient’s Name___________________________________________________________________________ Phone no. (________)___________________________________

(Last, First, MI)

Address________________________________________________________________________________________ MRN_________________________________________
City___________________________________________________ State___________ Zip__________________ Hospital__________________________________________

­— Patient identifier information is NOT transmitted to CDC —
1. STATE:

2. COUNTY:

3. STATE ID:

4a. LABORATORY ID WHERE
CULTURE IDENTIFIED:

4b. FACILITY ID WHERE PATIENT
TREATED:

5. Where was the patient located on the 4th calendar day prior to the date of initial culture?
Private residence
Hospital Inpatient
LTCF
Facility ID: _____________________
Was the patient transferred from this
LTACH Facility ID: _____________________
hospital? Yes
No
Unknown
Homeless
Facility ID: ___________________
Incarcerated
Other (specify):_______________

Unknown

6. DATE OF BIRTH:

7a. AGE:

8a. SEX:
Male
Female

8d. WEIGHT:

8c. RACE (Check all that apply):
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Unknown

8b. ETHNIC ORIGIN:
Hispanic or Latino
Not Hispanic or Latino
Unknown

7b. Is age in day/mo/yr?
Days
Mos
Yrs

______lbs ______oz OR ______kg

Unknown

8e. HEIGHT:
______ft ______in OR ______cm

Unknown

8f. BMI (Record only if ht and/or wt is not available):
___________________________

Unknown

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

No

Unknown

If yes: Date of admission

Date of discharge

10a. DATE OF INITIAL CULTURE

11a. Was the patient in the ICU in the 7 days prior to their
initial culture?
Yes

10b. LOCATION OF CULTURE COLLECTION:
Hospital Inpatient
Outpatient
ICU
Clinic/Doctors Office
Surgery/OR
Surgery
Radiology
Other Outpatient
Other Unit
Dialysis Center
Emergency Room
12. PATIENT OUTCOME:

LTCF Facility ID: _______________
LTACH Facility ID: _______________
Autopsy
Unknown

No

Unknown

11b. Was the patient in the ICU on the date of or in the 7
days after the initial culture?
Yes

No

Unknown

Observational Unit/Clinical Decision Unit
Survived

If survived, transferred to:
Private residence
LTCF Facility ID: ______________
LTACH Facility ID: ______________
Unknown
Other (specify): ________________

Died

Unknown
If died, date of death:

Was the organism cultured from a normally sterile site or urine, < calendar day 7
before death?
Yes
No
Unknown

Public reporting burden of this collection of information is estimated to average 20 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 Information Collection Review Office, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).
VERSION:01/2016

IMPORTANT­— PLEASE COMPLETE THE BACK OF THIS FORM

PAGE 1 OF 4

13a. ORGANISM ISOLATED FROM INITIAL NORMALLY STERILE SITE
OR URINE:
Carbapenem-resistant:
Enterobacteriaceae (CRE):
E. coli
Enterobacter cloacae
Enterobacter aerogenes
Klebsiella pneumoniae
Klebsiella oxytoca
A. baumannii (CRAB)

14. INITIAL CULTURE SITE:
Blood
Joint/synovial fluid
CSF
Bone
Pleural fluid
Urine
Peritoneal fluid
Other normally sterile site
Pericardial fluid
_____________________________

13b. Was the initial culture polymicrobial?
Yes

No

Unknown

13c. Was the initial
isolate tested for
carbapenemase?
Yes
No
Labortory Not Testing
Unknown

If yes, what testing method was used
(check all that apply):
Automated Molecular Assay
(specify): _________________
CarbaNP
E Test
PCR
Modified Hodge Test (MHT)
Other (specify): ___________
Unknown

URINE Cultures ONLY:
14a. How was the urine collected?
Clean Catch
In and Out Catheter
Indwelling Catheter
Condom Catheter
Other: ___________________
Unknown

If tested, what was
the testing result?
Positive
Negative
Indeterminate
Unknown

URINE Cultures ONLY:
14b. Record the colony count for the
organism indicated in Q13a:
_________________________
Unknown

URINE Cultures ONLY:
14c. Signs and Symptoms associated with urine culture. Please indicate if any of the following symptoms were reported during the 5 day time period including
the 2 calendar days before and the 2 calendar days after the day of initial culture:
Altered mental status
Fever
Pyuria
None
Acute pain, swelling or tenderness of the
Frequency
Retention
testes, epididymis or prostate
Hematuria
Suprapubic tenderness
Chills
Incontinence
Unspecified abdominal pain/tenderness
Cloudy
Leukocytosis
Urgency
Costovertebral angle pain or tenderness
Malodorous
Unknown
Dysuria
Purulent discharge
Other (specify): _________________
15. Was the same organism (Q13a) cultured from a different sterile site or urine in the 30 days after the date of initial culture (of this current episode)?
Yes

No

Unknown

If yes, source (check all that apply):
Blood
Joint/synovial fluid
CSF
Bone
Pleural fluid
Urine
Peritoneal fluid
Other normally sterile site _____________________________
Pericardial fluid
16. Enterobacteriaceae ONLY:
Were cultures of sterile site(s) or urine positive in the 30 days prior to the date of
initial culture, for a DIFFERENT organism (Q13a)?
Yes

No

Unknown

NA

If yes, source (check all that apply):
Blood
Joint/synovial fluid
CSF
Bone
Pleural fluid
Urine
Peritoneal fluid
Other normally sterile site _________________________
Pericardial fluid

If yes, indicate organism type and associated State ID for the incident closest to
the date of initial culture:
Organism

State ID

E. coli
Enterobacter cloacae
Enterobacter aerogenes
Klebsiella pneumoniae
Klebsiella oxytoca

16a. A. baumannii Cultures ONLY:
Were cultures of OTHER sterile site(s) or urine positive in the 30 days prior to the
date of initial culture, for another A. baumannii?
Yes

No

Unknown

NA

If yes, source (check all that apply):
Blood
Joint/synovial fluid
CSF
Bone
Pleural fluid
Urine
Peritoneal fluid
Other normally sterile site _________________________
Pericardial fluid
17a. Was this patient positive for the SAME organism in the year prior to the date
of the initial culture (Q10a):
Yes

No (GO TO Q17c)

If yes, State ID for the organism closest to the date of initial culture:
________________________________________________________________

17b. If yes, specify date of culture and State ID for the first positive culture
in the year prior:

Unknown (GO TO Q17c)
State ID: ________________________________________________________

17c. Enterobacteriaceae ONLY:
Was this patient positive for a MuGSI Enterobacteriaceae in the year prior to the date of initial culture (Q10a)?
Yes

No (GO TO Q18)

VERSION:01/2016

Unknown (GO TO Q18)

NA (GO TO Q18)

IMPORTANT­— PLEASE COMPLETE THE NEXT PAGE OF THIS FORM

PAGE 2 OF 4

17d. If yes, specify organism, date of culture and State ID for the first positive
Enterobacteriaceae culture in the year prior to the date of initial culture (Q10a):
Carbapenem-resistant Enterobacteriaceae (CRE):
E. coli
Enterobacter cloacae
Enterobacter aerogenes
Klebsiella pneumoniae
Klebsiella oxytoca

Date of Culture:

State ID: ____________________________________

18. Susceptibility Results: (please complete the table below based on the information found in the indicated data source). Shaded antibiotics are required to
have the MIC entered into the MuGSI-CM system, if available.
Data Source
Antibiotic

Medical Record
MIC

Interp

Microscan
MIC

Interp

Vitek
MIC

Phoenix

Interp

MIC

Interp

Kirby-Bauer
Zone
Diam

Interp

E-test
MIC

Interp

Amikacin
Amoxicillin/Clavulanate
Ampicillin
Ampicillin/Sulbactam
Aztreonam
Cefazolin
CEFEPIME
CEFOTAXIME
CEFTAZIDIME
CEFTRIAXONE
Cephalothin
Ciprofloxacin
COLISTIN
DORIPENEM
ERTAPENEM
Gentamicin
IMIPENEM
Levofloxacin
MEROPENEM
Moxifloxacin
Nitrofurantoin
Piperacillin/Tazobactam
POLYMYXIN B
TIGECYCLINE
Tobramycin
Trimethoprim-sulfamethoxazole
19. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S) (check all that apply):
Abscess, not skin
AV fistula/graft infection
Bacteremia
Bursitis
Catheter site infection (CVC)
Cellulitis

Chronic ulcer/wound (not decubitus)
Decubitus/pressure ulcer
Empyema
Endocarditis
Meningitis
Osteomyelitis

20. UNDERLYING CONDITIONS (check all that apply):
AIDS/CD4 count < 200
Alcohol abuse
Chronic Liver Disease
Chronic Pulmonary Disease
Chronic Renal Insufficiency
Chronic Skin Breakdown
Congestive Heart Failure
Connective Tissue Disease
Current Smoker
CVA/Stroke
VERSION:01/2016

None

None

Unknown

Peritonitis
Pneumonia
Pyelonephritis
Septic arthritis
Septic emboli
Septic shock

Skin abscess
Surgical incision infection
Surgical site infection (internal)
Traumatic wound
Urinary tract infection
Other ______________________

Unknown

Cystic Fibrosis
Decubitus/Pressure Ulcer
Dementia/Chronic Cognitive Deficit
Diabetes
Hemiplegia/Paraplegia
HIV
Hematologic Malignancy
IVDU
Liver failure
Metastatic Solid Tumor

Myocardial Infarct
Neurological Problems
Obesity or Morbid Obesity
Peptic Ulcer Disease
Peripheral Vascular Disease (PVD)
Premature Birth
Solid Tumor (non metastatic)
Spina bifida
Transplant Recipient
Urinary Tract Problems/Abnormalities

IMPORTANT­— PLEASE COMPLETE THE NEXT PAGE OF THIS FORM

PAGE 3 OF 4

21. RISK FACTORS OF INTEREST (check all that apply):

None

Unknown

Culture collected > calendar day 3 after hospital admission

Central venous catheter in place on the day of culture (up to time of culture) or at
any time in the 2 calendar days prior to the date of culture

Hospitalized within year before date of initial culture:

If yes, enter mo/yr

If known, prior hospital ID:____________________

OR

Unknown

Surgery within year before date of initial culture
Current chronic dialysis:

Peritoneal

Hemodialysis Access:

Hemodialysis

AV fistula/graft

CVC

Residence in LTCF within year before date of initial culture
If known, facility ID: ______________________
Admitted to a LTACH within year before initial culture date
If known, facility ID: ______________________

Unknown
Unknown

Urinary catheter in place on the day of culture (up to time of culture) or at any
time in the 2 calendar days prior to the date of culture
If checked, indicate all that apply:
Indwelling Urethral Catheter
Suprapubic Catheter
Condom Catheter
Other: _____________
Any OTHER indwelling device in place on the day of culture (up to time of culture)
or at any time in the 2 calendar days prior to the date of culture
If checked, indicate all that apply:
ET/NT Tube
Gastrostomy Tube
NG Tube
Tracheostomy
Nephrostomy Tube
Other: _____________
Patient traveled internationally in the two months prior to the date of initial
culture.
Country:__________________, ___________________, __________________
Patient was hospitalized while visiting country (ies) listed above

SURVEILLANCE OFFICE USE ONLY
22. Was case first identified
through audit?
Yes
No
Unknown

23. CRF status:
Complete
Pending
Chart unavailable

24. Date reported to EIP site:

25. SO initials:
______

26. Comments:

VERSION:01/2016

CS250882-A

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