Form 17AHK Att. 3 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) Neona

NEONATAL INFECTION EXPANDED TRACKING FORM

Infant’s Name: _______________________________________________________________________________

(Last, First, M.I.)
Mother’s Name: _______________________________________________________________________________
(Last, First, M.I.)

Mother’s Date of Birth: __ __ /__ __ /__ __ __ __

Culture date: _________________________

month day year (4 digits)

-

Infant’s Chart No.: ________________________________________________
Mother’s Chart No.: ______________________________________________

Hospital Name: ____________________________________________________________

2017 ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)
NEONATAL INFECTION EXPANDED TRACKING FORM

STATEID __ __ __ __ __ __ __
Infant Information

HOSPITAL ID (of birth; if home birth leave blank) __ __ __ __ __

Were labor & delivery records available?

1. Date of Birth: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

Time of birth: ___ ___ ___ ___

(times in military format)

Unknown (1)

3a. Gestational age of infant at birth in
completed weeks:
__ __ (do not round up)

Yes (1)

2. Did this birth occur outside of the hospital?
Yes (1)
No (0)
Unknown (9)
IF YES, please check one:
Home Birth (1)
En route to hospital (3)
Other (4)

3b. Date of maternal last menstrual period
(LMP): __ __ /__ __ /__ __ __ __
month

day

OR __ __ __ __ grams

Unknown (1)

month

Survived (1)

Birthing Center (2)
Unknown (9)

4. Birth weight: ___ lbs ___oz

year (4 digits)

5. Date & time of newborn discharge from hospital of birth: __ __ /__ __ /__ __ __ __
6. Outcome:

OMB No. 0920-0978

No (0)

Died (2)

day

__ __ __ __
time

year (4 digits)

Unknown (9)

7. Was the infant discharged to home and readmitted to the birth hospital? (for GBS cases only):
IF YES, date & time of readmission: __ __ /__ __ /__ __ __ __
month

day

AND date & time of admission: __ __ /__ __ /__ __ __ __
day

year (4 digits)

Yes (1)

__ __ __ __

__ __ __ __
time

No (0)

Unknown (1)

time

year (4 digits)

8. Was the infant admitted to a different hospital from home? (for GBS cases only):
IF YES, hospital ID: ___ ___ ___ ___ ___
month

Unknown (1)

Yes (1)

No (0)

Unknown (1)

9a. Were any ICD-9 codes reported in the discharge diagnosis of the infant’s chart?
Yes (1)

No (0)

Unknown (9)

9b. IF YES, Were any of the following ICD-9 codes reported in the discharge diagnosis of the chart? (Check all that apply)
041.02: Streptococcus group b (1)

038.0: Streptococcus septicemia (1)
320.2: Streptococcal meningitis (1)

9c. Were any ICD-10 codes reported in the discharge diagnosis of the infant’s chart?
Yes (1)
No (0)
Unknown (9)
9d. IF YES, were any of the following ICD-10 codes reported in the discharge diagnosis of the chart?
(Check all that apply)
A40.1: Sepsis due to streptococcus, group B (1)

P36.1: Sepsis of newborn to other unspecified streptococci (1)

A40.8: Other Streptococcal sepsis (1)

B95.1: Streptococcus, group b as the cause of disease classified
elsewhere (1)

A40.9: Streptococcus sepsis, unspecified (1)
A49.1: Streptococcal infection, unspecified site (1)
P36: Bacterial sepsis of newborn (1)
P36.0: Sepsis of newborn due to streptococcus,
group B (1)

B95.5: Unspecified streptococcus as the cause of disease classified
elsewhere (1)
G00.2: Streptococcal meningitis (1)

10. Did the baby receive breast milk from the mother? (for late-onset GBS cases only):
IF YES, did the baby receive breast milk before onset of GBS

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

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,
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30329, ATTN: PRA(0920-0978). Do not send the completed form to this address.
6/2015

Page 1 of 4

Maternal Information
11. Maternal admission date & time: __ __ /__ __ /__ __ __ __
month

day

__ __ __ __

12. Maternal age at delivery (years): __ __ years

13. Maternal blood type:

14. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
15. Date & time of membrane rupture: __ __ /__ __ /__ __ __ __
month

Unknown (1)

time

year (4 digits)

day

A (1)

Yes (1)

No (0)

Yes (1)

No (0)

__ __ __ __

AB (3)

O (4)

Unknown (1)

time

year (4 digits)

B (2)

16. Was duration of membrane rupture >18 hours?

Yes (1)

No (0)

Unknown (9)

17. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?

Yes (1)

No (0)

Unknown (9)

18. Type of rupture:

Spontaneous (1)

Artificial (2)

19. Type of delivery: (Check all that apply)
Vaginal (1)

Vaginal after previous C-section (1)

Primary C-section (1)

Forceps (1)

Vacuum (1)

Unknown (1)

If delivery was
by C-section:

Did labor begin before C-section?

Yes (1)

No (0)

Unknown (9)

Did membrane rupture happen before C-section?

Yes (1)

No (0)

Unknown (9)

20. Intrapartum fever (T > 100.4 F or 38.0 C):

Yes (1)

No (0)

Unknown (9)

IF YES, 1st recorded T > 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month

21.

Were antibiotics given to the mother intrapartum?

day

year (4 digits)

Yes (1)

No (0)

__ __ __ __

month

b) Antibiotic 1: ___________________________
Start date: __ __ /__ __ /__ __ __ __

Unknown (9)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 6: ___________________________
Start date: __ __ /__ __ /__ __ __ __

Unknown (9)

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 5: ___________________________
Start date: __ __ /__ __ /__ __ __ __

time

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 4: ___________________________
Start date: __ __ /__ __ /__ __ __ __

__ __ __ __

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 3: ___________________________
Start date: __ __ /__ __ /__ __ __ __

IM (2)

year (4 digits)

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 2: ___________________________
Start date: __ __ /__ __ /__ __ __ __

IV (1)

day

Unknown (1)

time

IF YES, answer a-b and Questions 22-23
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __

6/2015

Repeat C-section (1)

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

Stop date (if applicable): __ __ /__ __ /__ __ __ __
Page 2 of 4

22.

Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)

___ ___ (minutes) ___ ___ (days)*

*Day variable should only be completed if the number of hours >24

23.

What was the reason for administration of intrapartum antibiotics? (Check all that apply)
GBS prophylaxis (1)
Suspected amnionitis/
chorioamnionitis (1)

Prolonged latency (1)
C-section prophylaxis (1)

Mitral valve prolapse prophylaxis (1)
Other (1)
Unknown (1)
Yes (1)

24. Did mother have chorioamnionitis or suspected chorioamnionitis?

No (0)

***Questions 25–33 should only be completed for early- and late-onset GBS cases***
25. Did mother receive prenatal care?

Yes (1)

No (0)

Unknown (9)

26. Please record the following: the total number of prenatal visits AND the first and last visit dates to the prenatal
as recorded in the labor and delivery chart
No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
Unknown (1)
month

day

year (4 digits)

month

day

year (4 digits)

27. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
28. GBS bacteriuria during this pregnancy?
Yes (1)
No (0)
Unknown (9)
IF YES, what order of magnitude was the colony count?
0 (1)
<10,000 (2)
10k–<25,000 (3)
25k–<50,000 (4)
50k–<75,000 (5)
>100,0000 (7)
Unknown (9)
29. Previous infant with invasive GBS disease?

Yes (1)

No (0)

Unknown (9)

30. Previous pregnancy with GBS colonization?

Yes (1)

No (0)

Unknown (9)

75k–<100,000 (6)

31a. Was maternal group B strep colonization screened for BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, list dates, test type, and test results below:
Test date

:

1. __ __ /__ __ /__ __ __ __

2. __ __ /__ __ /__ __ __ __

Test Result
(Do not include urine here!)

Test type:
Culture (1)

PCR (2)

Rapid antigen (3)

Positive (1)

Other (4)

Unknown (9)

Unknown (9)

Culture (1)

PCR (2)

Other (4)

Unknown (9)

Positive (1)
Unknown (9)

Rapid antigen (3)

Negative (0)

Negative (0)

31b. If the most recent test was GBS positive was antimicrobial susceptibility performed BEFORE admission (in prenatal care)?
Yes (1)

No (0)

Unknown (9)

IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

32a. Was maternal group B strep colonization screened for AFTER admission (before delivery)?

Yes (1)

No (0)

Unknown (9)

IF YES, list date of most recent test, test type and test results below:
Test date
__ __ /__ __ /__ __ __ __

6/2015

:

Test type:
Culture (1)

PCR (2)

Rapid antigen (3)

Other (4)

Unknown (9)

Page 3 of 4

Test Result
(Do not include urine here!)
Positive (1)
Unknown (9)

Negative (0)

32b. If the most recent test was GBS positive, was antimicrobial susceptibility performed AFTER admission?
Yes (1)

No (0)

Unknown (9)

IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
33.

Yes (1)
Yes (1)

Were GBS test results available to care givers at the time of delivery?

No (0)
No (0)

Unknown (9)
Unknown (9)

Yes (1)

No (0)

Unknown (9)

34. COMMENTS: ______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
35.

6/2015

Neonatal Infection Expanded Form Tracking Status:
Complete (1)
Partial (2)
Chart unavailable (3)

Page 4 of 4

Edited & corrected (4)