Form 17AHK Att. 1 - 2017 ACTIVE BACTERIAL CORE SURVEILLANCE CASE RE

– 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 –

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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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