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pdf– 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
A CORE
ATLANTA, GA 30333
1. STATE:
(Patient Residence)
2017 Active Bacterial Core
Surveillance (ABCs) CASE REPORT
COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
– SHADED AREAS FOR OFFICE USE ONLY –
3c. DATE FIRST POSITIVE Culture Independent
Diagnostic Test (CIDT, e.g. PCR) COLLECTED
Yes, Negative 3 No
Mo.
Day
Year
Yes, Positive 2
Mo.
Day
9a. AGE:
Day
1
Unknown
2
9b. Is age in day/mo/yr?
Days 2
Mos. 3
1
Male
2
Female
Yrs.
Group A Streptococcus
5
Neisseria meningitidis
3
Group B Streptococcus
2
Haemophilus influenzae
4
Listeria monocytogenes 6
1
Hispanic or Latino
2
Not Hispanic or Latino
9
Unknown
1
1
CSF
Blood
1
Pericardial fluid
1
Peritoneal fluid
1
Bone
Muscle/Fascia/Tendon 1
1
Other normally sterile site (specify)_______________ 1
13b. CIDT STERILE SITE FROM WHICH ORGANISM WAS DETECTED:
CSF
1
1
1
Joint
1
Yes
2
If YES, date of admission:
Mo.
Day
Internal body site (specify) _____________
Other _________________________
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) ____________
______lbs______ oz OR ______ kg
College dormitory 9
OR
______ft ______ in OR ______ cm OR
22. OUTCOME: 1
Survived 2
Died 9
Unknown
White
1
Asian
1
Black
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
Unknown
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
Meningitis
1
Peritonitis
1
Endometritis
1
Pericarditis
1
STSS
Septic abortion
1
Necrotizing fasciitis
1
Otitis media
1
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. 2016
(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:
1
Survived, no apparent illness 4
Abortion/stillbirth 9
Unknown
Survived, clinical infection
Induced abortion
2
5
Live birth/neonatal death
Still pregnant
3
6
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
21. TYPE OF INSURANCE: (Check all that apply)
Unknown
Unknown
OR
1
Facility ID:
Unknown
20b. HEIGHT:
20c. BMI: ___ ___ . ___
Chart unavailable
after 3 requests
17. If patient was hospitalized, was this patient admitted to the
ICU during hospitalization?
Year
No
Long term acute care facility 6
3
20a. WEIGHT:
Incomplete
14. OTHER SITES FROM WHICH ORGANISM
ISOLATED: (Check all that apply)
Pleural fluid
INFLUENZA 15. Did this patient have a positive flu test 10 days prior to or following any
_____________ ABCs positive culture?
16. WAS PATIENT
HOSPITALIZED?
Edited & Correct
4
Streptococcus pneumoniae
13. STERILE SITES FROM WHICH ORGANISM ISOLATED: (Check all that apply)
1
3
12b. OTHER BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
(specify)
12a. BACTERIAL SPECIES ISOLATED FROM ANY NORMALLY STERILE SITE:
1
Complete
11b. RACE: (Check all that apply)
11a. ETHNIC ORIGIN:
10. SEX:
Year
1
Year
7b. HOSPITAL I.D. WHERE
PATIENT TREATED:
7a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:
8. DATE OF BIRTH:
Day
5. CRF Status:
3d. TYPE OF CIDT:
1
Biofire Meningitis Panel 9
2
Other ___________________
Year
6. COUNTY:
(Residence of Patient)
Mo.
4. Date reported
to EIP site:
3b. DATE FIRST POSITIVE CULTURE COLLECTED
2. STATE I.D.:
Mo.
Form Approved
0920-0978
3a. Was a culture performed?
1
)
(gms)
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
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27. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE,check appropriate box) 1
1
1
1
1
1
AIDS or CD4 count <200
1
Alcohol Abuse, Current
Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease
1
1
1
1
(ASCVD)/CAD
Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke/TIA
Chronic Kidney Disease
Chronic Liver Disease/cirrhosis
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Current Chronic Dialysis
Chronic Skin Breakdown
Cochlear Implant
1
1
1
1
1
1
Dementia
Diabetes Mellitus
Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy (Steroids, etc.)
1
Eculizumab (Soliris) - N.men. cases only
1
1
1
IVDU, Current
IVDU, Past
Leukemia
Multiple Myeloma
Multiple Sclerosis
Myocardial Infarction
Nephrotic Syndrome
Neuromuscular Disorder
Obesity
Other Drug Use, Current
Other Drug Use, Past
Parkinson’s Disease
1
Complement Deficiency
Connective Tissue Disease (Lupus, etc.) CSF
Leak
Deaf/Profound Hearing Loss
None 1
1
1
1
1
1
Unknown
Peptic Ulcer Disease
Peripheral Neuropathy
Peripheral Vascular Disease
Plegias/Paralysis
Premature Birth (specify gestational
age at birth)
(wks)
Seizure/Seizure Disorder
Sickle Cell Anemia
Smoker (current)
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Other prior illness (specify):
1
1
1
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
28c. Were records obtained to verify
vaccination history? (<5 years of age
with Hib/unknown serotype, only)
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
31.Did patient receive meningococcal vaccine?
DOSE
Not Tested or Unknown
TYPE
4
Y
1
Yes 2
DATE GIVEN
Mo.
Day
5
6
No 9
Unknown If YES, complete the table
NAME
Year
Not Groupable 8
9
W135
MANUFACTURER
Other
LOT NUMBER
Vaccine Registry
1
Healthcare Provider
1
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
None 1
1
Skin Scarring/necrosis
Hearing deficits 1
Amputation (digit) 1
Amputation (limb) 1
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
Mo.
No 9
Day
Seizures 1
Paralysis or spasticity 1
9
1
Other (specify)
34. Did the patient deliver a baby (vaginal or C-section) ? 35. Did patient have:
Unknown
1
Yes 2
No 9
Year
Unknown date
Unknown
Mo.
If YES,
date of delivery:
If YES, date of surgery or skin incision:
Unknown
9
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)
0-7 days 2
1
8-14 days 9 Unknown days
Unknown date
36. COMMENTS:
37. Was case first
1
identified through
audit?
9
Submitted By:
Physician’s Name:
CDC 52.15A REV. 2016
Yes 2
Unknown
No
38. Does this case have 1
recurrent disease with
the same pathogen? 9
Yes 2
Unknown
No
39. Initials of
S.O.:
If YES, previous
(1st) state I.D.:
Phone No. : (
)
Phone No. : (
)
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Date:
/
/
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |