CDC 52.15B Rev 10- Healthcare-Associated Infections Community Interface (HA

Patient ID: _____ _____ _____ _____ _____ _____ _____ _____
–Healthcare-Associated Infections Community Interface (HAIC) Case Report–

Phone No.: (

Patient's Name:

(Last, First, M.I.)

Address:

)

Patient
Chart No.:

(Number, Street, Apt. No.)

Hospital:

(Zip Code)

(City, State)

– Patient identifier information is NOT transmitted to CDC –

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

Invasive Methicillin-Resistant Staphylococcus aureus
Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2016
– SHADED AREAS BELOW INDICATE CORE VARIABLES –

1. STATE:
2. COUNTY:
(Residence of patient)
(Residence of Patient)

3. STATE I.D.:

6. DATE OF BIRTH:

5. SEX:
1

Male

2

Female

Mo.

Day

4a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:

8. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY
ISOLATED: (Check all that apply)
1
Pericardial fluid
1
Blood

7a. AGE:
Year

7b. Is age in day/mo/yr?
1

Mo.

Day

Days 2

Mos. 3

Yrs.

Year

1

2

Yes

No

9

1

CSF

1

Pleural fluid

1

Bone

1

Peritoneal fluid

1

Muscle

1

Unknown

Day

Yes (HO-MRSA case) 2

1

Hispanic or Latino

2

Not Hispanic or Latino

10b. IF PATIENT WAS HOSPITALIZED, WAS THIS PATIENT
ADMITTED TO THE ICU DURING HOSPITALIZATION?

9

1

12c. WEIGHT: 1

Unknown

12b. RACE: (Check all that apply)
1
White
1
1
1
1

2

Yes

No

Unknown

12e. BMI: 1

Unknown

Radiology

2

Other Unit

4

Emergency Room

3

Surgery
LTACH
13
Dialysis/Renal Clinic
Facility ID
__________________________
Other
Outpatient
Autopsy
14

Observational Unit/Clinical Decision Unit

16

18. PATIENT OUTCOME:
1

Survived

No (Complete CRF, CA-MRSA or HACO-MRSA case)

Yes (Complete CRF) 2

No (STOP data abstraction)
15. Where was the patient located on the
4th calendar day prior to the date of
initial culture?

1

Pregnant

2

Post-partum

3

Neither

9

Unknown

1
2

NICU/SCN

9

Unknown

Well Baby Nursery

_______ (do not calculate, only if available in the MR)

16. LOCATION OF CULTURE COLLECTION: (Check one)
Hospital Inpatient Outpatient
5
LTCF
8
Clinic/
1
ICU
Facility ID
__________________________
Doctors Office
6
Surgery/OR

9
Mo.

9
10

Unknown
Other

Other sterile site (specify)
______________________

14. If case is ≤12 months of age,
type of birth hospitalization:

_______ ft _______ in OR _______ cm

Native Hawaiian
or Other Pacific Islander

11
15

Unknown

Unknown

12d. HEIGHT: 1

_____________________
1

13. At time of first positive
culture, patient was:

_______ lbs _______ oz OR _______ kg

Black or
African American
American Indian
or Alaska Native
Asian

7

9

Internal body site (specify)

If yes, was the case selected for full CRF based on
sampling frame 1:10?

Year

1
12a. ETHNIC ORIGIN:

1

11. WAS CULTURE COLLECTED >3 CALENDAR DAYS
AFTER HOSPITAL ADMISSION?

If YES: Date of admission
Mo.

Joint/Synovial fluid

1

10a. WAS THE PATIENT HOSPITALIZED AT THE TIME OF,
OR WITHIN 30 CALENDAR DAYS AFTER, INITIAL CULTURE?

9. DATE OF INITIAL CULTURE:

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

1

Private Residence

1

Long Term Care Facility
Facility ID __________________________

1

Long Term Acute Care Hospital
Facility ID __________________________
Homeless

1
1

Incarcerated

1

Hospital Inpatient
Facility ID __________________________

1

Other __________________________

1

Unknown

17. Were cultures of the SAME or OTHER sterile site(s) positive within 30 days after initial culture date?
1

Yes

2

No

9

Unknown

If yes, indicate site and date of last positive culture:
1

Blood, Date:________

1

Pericardial fluid, Date:________

1

CSF, Date:________

1

Joint/Synovial fluid, Date:________

1

Pleural fluid, Date:________

1

Bone, Date:________

1

Peritoneal fluid, Date:________

1

Muscle, Date:______

1

Internal body site
Date:________

1

Other sterile site
(specify)____________
Date:________

Unknown
Day

2

Year

Died

Mo.

Day

Year

Date of death

Date of discharge
1

Yes 2

No If Yes, Facility ID __________________________

If survived, was the patient transferred to a LTACH? 1

Yes 2

No If Yes, Facility ID __________________________

If survived, was the patient transferred to a LTCF?

Was MRSA cultured from a normally sterile site < calendar day 7 before death?
1

Yes 2

No 9

Unknown

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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978)

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

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19. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)

1

None

1

Unknown

1

Abscess (not skin)

1

Cellulitis

1

Meningitis

1

Septic Emboli

1

Traumatic Wound

1

AV Fistula/Graft Infection

1

Chronic Ulcer/Wound (non-decubitus)

1

Peritonitis

1

Septic Shock

1

Urinary Tract

1

Bacteremia

1

Decubitus/Pressure Ulcer

1

Pneumonia

1

Skin Abscess

1

1

Bursitis

1

Empyema

1

Osteomyelitis

1

Surgical Incision

_______________________

1

Catheter Site Infection

1

Endocarditis

1

Septic Arthritis

1

Surgical Site (Internal)

_______________________

20. UNDERLYING CONDITIONS: (Check all that apply) (if none or no chart available, check appropriate box)

1

None

1

Other: (specify)

Unknown

Abscess/Boil (Recurrent)

1

Connective Tissue Disease

1

Hemiplegia/Paraplegia

1

Other Drug Use

1

AIDS

1

Current Smoker

1

HIV

1

Peptic Ulcer Disease

1

Chronic Cognitive Deficit

1

CVA/Stroke

1

1

Peripheral Vascular Disease (PVD)

1

Chronic Liver Disease

1

Cystic Fibrosis

Influenza
(within 10 days of initial culture)

1

Chronic Pulmonary Disease

1

Decubitus/Pressure Ulcer

1

Premature Birth

1

IVDU

1

Chronic Kidney Disease

1

Dementia

1

Metastatic Solid Tumor

1

Chronic Skin Breakdown

1

Diabetes

1

1

1

Congestive Heart Failure

Hematologic Malignancy

1

Myocardial Infarct

1

Obesity

21. PRIOR HEALTHCARE EXPOSURE – Healthcare-associated and Community-associated: (Check all that apply)
1

Previous documented MRSA infection or colonization
Month
Year
OR previous STATE I.D.:

1

Hospitalized within year before initial culture date.
Date of discharge
Mo.

If YES:

Day

Year

1

None

Solid Tumor (non metastatic)

1

Other: (specify only for cases ≤ 12 months
of age) _____________________________

1

Unknown

Surgery within year before initial culture date.
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:

If YES:
1

1

1

Unknown

_____/ _____ / _____

2. __________________________________________

_____/ _____ / _____

3. __________________________________________

_____/ _____ / _____

4. __________________________________________

_____/ _____ / _____

1

Dialysis within year before initial culture date.
(Hemodialysis or Peritoneal dialysis)

1

Current chronic dialysis
Peritoneal
Type
Unknown
Hemodialysis
Type of vascular access
AV fistula / graft
Hemodialysis CVC
Unknown

If known, Facility ID __________________________

Date

Surgery
1. __________________________________________

1

Residence in a long-term care facility
within year before initial culture date.
If known, Facility ID __________________________

1

Admitted to a LTACH within year
before initial culture date.
If known, Facility ID __________________________

1

Central vascular catheter in place at
any time in the 2 calendar days prior
to initial culture.

– THIS SHADED AREA FOR OFFICE USE ONLY –
22. Was case first
identified through
audit?
1

Yes 2

9

Unknown

No

23. CRF status:
1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

24. Does this case have
recurrent MRSA
disease?
1

Yes 2

9

Unknown

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

No

25. Date reported to EIP site:
Mo.

Day

26. Initials of
S.O:

Year

27 COMMENTS:_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 10-2015

CS260005

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