Form 0920-0978 Surveillance for Extended-Spectrum Beta- Lactamase-Produ

Patient ID: _______________________________________________

Surveillance for Extended-Spectrum Beta- Lactamase-Producing Enterobacteriaceae
Multi-Site Gram-Negative Bacilli Surveillance (MuGSI)
Healthcare Associated Infection Community Interface (HAIC) Case Report

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

Patient’s name: ______________________________________________________________________________

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

Phone no. (______)_____________________

Address: ____________________________________________________________________________________

MRN: ________________________________

City: _______________________________________________

Hospital: _____________________________

State: _____________ Zip: ______________

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

2. COUNTY:

3. STATE ID:

_____ _____

_________________

___________________________

5. Where was the patient located on the 4th calendar day prior to the date of initial culture?
Private residence
LTCF Facility ID: ____________
LTACH Facility ID: ____________
Homeless
Incarcerated
8a. SEX:
Male
Female
Unknown
8b. ETHNIC ORIGIN:
Hispanic or Latino
Not Hispanic or Latino
Unknown

Hospital Inpatient
Was the patient transferred from
this hospital? Yes
No Unknown
Facility ID: ___________________
Other (specify): _______________
Unknown

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

4a. LABORATORY ID WHERE CULTURE
IDENTIFIED:
__________________________

4b. FACILITY ID WHERE
PATIENT TREATED:
_____________________

6. DATE OF BIRTH:

7a. AGE:
_____ _____ _____

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

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 the initial
culture date?

___ ___ - ___ ___ - ___ ___ ___ ___
Yes
No
Unknown
11b. Was the patient in the ICU on the date of or in the 7 days after
the initial culture date?

10b. LOCATION OF CULTURE COLLECTION:
Hospital Inpatient
Emergency Room
LTCF
Facility ID: ____________
LTACH Facility ID: ____________
Observational Unit/Clinical Decision Unit
Unknown
12. PATIENT OUTCOME:

Survived

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

Died

Outpatient:
Clinic/Doctors Office
Surgery
Other Outpatient
Dialysis Center
Unknown

If died, date of death:
___ ___ - ___ ___ - ___ ___ ___ ___

14a. INITIAL CULTURE SITE:
Blood
Bone
Brain
CSF
Heart
Joint/synovial fluid
Kidney
Liver
Lymph node
Ovary
Pancreas

Pericardial fluid
Peritoneal fluid
Pleural fluid
Spleen
Urine
Vascular tissue
Vitreous
Other fluid (sterile)
Deep tissue
Other normally sterile site
_________________________________

Yes

No

Unknown

13. ORGANISM ISOLATED FROM INITIAL NORMALLY STERILE SITE OR
URINE:
Extended-Spectrum Cephalosporin-resistant:
Escherichia coli
Klebsiella pneumoniae
Klebsiella oxytoca

URINE Cultures ONLY:
14b. 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 date of initial culture.
None
Unknown
Costovertebral angle pain or
Frequency
tenderness
Suprapubic tenderness
Dysuria
Urgency
Fever [temperature ≥ 100.4⁰F
(38⁰C)]

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

VERSION: 10/2017 CS 283662-A

IMPORTANT— PLEASE COMPLETE THE BACK OF THIS FORM

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15a. Susceptibility Results: Please complete the table below based on the primary antibiotic testing report. Shaded antibiotics are required to have the MIC
entered into the ESBL Case Management system, if available.
Kirby-Bauer
Data Source
Microscan
Vitek
Phoenix
E-test
Antibiotic

MIC

Interp

MIC

Interp

MIC

Interp

Zone
Diam

Interp

MIC

Interp

Amikacin
Amoxicillin/Clavulanate
Ampicillin
Ampicillin/Sulbactam
Ampicillin/Sulbactam
Aztreonam
Cefazolin
Cefepime
CEFOTAXIME
CEFTAZIDIME
CEFTRIAXONE
Ceftazidime/Avibactam
Ceftolozane/Tazobactam
Cephalothin
Ciprofloxacin
Colistin
DORIPENEM
ERTAPENEM
Fosfomycin
Gentamicin
IMIPENEM
Levofloxacin
MEROPENEM
Moxifloxacin
Nitrofurantoin
Piperacillin-Tazobactam
Polymyxin B
Tigecycline
Tobramycin
Trimethoprim-sulfamethoxazole
Other (Specify) _______________
15b. Did clinical laboratory
identify isolate as ESBL
producer?
Yes

No

Unknown

15c. What confirmatory testing method was used? (check all that apply):
Broth microdilution (ATI)
Disk diffusion
Other (specify): _____________________________________

16. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S) (check all that apply):
Abscess, not skin
Appendicitis
AV fistula/graft infection
Bacteremia
Catheter site infection (CVC)
Cholangitis

Chronic ulcer/wound (not decubitus)
Decubitus/pressure ulcer
Diverticulitis
Empyema
Endocarditis
Epididymitis

17. UNDERLYING CONDITIONS (check all that apply) :
None
Unknown
AIDS/CD4 count < 200
Connective Tissue Disease
Alcohol abuse
CVA/Stroke
Chronic Liver Disease
Cystic Fibrosis
Chronic Pulmonary Disease
Decubitus/Pressure Ulcer
Chronic Renal Insufficiency
Dementia/Chronic Cognitive Deficit
Chronic Skin Breakdown
Diabetes
Congestive Heart Failure
Hemiplegia/Paraplegia
VERSION: 10/2017

None

⃞ None
Unknown

15d. If TESTED, what was the
test result?
Positive
Negative
Indeterminate
Unknown

Unknown
Epidural abscess
Meningitis
Osteomyelitis
Peritonitis
Pneumonia
Prostatitis

Pyelonephritis
Septic arthritis
Surgical incision infection
Surgical site infection (internal)
Traumatic wound
Urinary tract infection
Other ______________________

HIV
Hematologic Malignancy
IVDU
Liver Failure
Metastatic Solid Tumor
Myocardial Infarct
Neurological Problems

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

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18. RISK FACTORS OF INTEREST (Check all that apply):

None

Unknown

Hospitalized within year before date of initial culture:
Yes
No
Unknown
If yes, enter mo/yr ___ ___ - ___ ___ ___ ___ OR

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 initial culture
Unknown

If known, prior hospital ID: __________________________
Surgery within year before date of initial culture

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 initial culture
If checked, indicate all that apply:
Indwelling Urethral Catheter
Suprapubic Catheter
Condom Catheter
Other: _____________

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

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

19a. Is antimicrobial use (IV or oral) in the 30 days before the date of initial culture collection documented in the H&P or medical administration record?
Yes (complete 19b)
No
Unknown
19b. If yes, indicate all antibiotics given in the 30 days before the date of initial culture collection:
Amikacin
Ceftazidime
Doxycycline
Amoxicillin
Ceftazidime/Avibactam
Ertapenem
Amoxicillin/Clavulanic Acid
Ceftizoxime
Fosfomycin
Ampicillin/Sulbactam
Ceftolozane/Tazobactam
Gentamicin
Azithromycin
Ceftriaxone
Imipenem
Aztreonam
Cefuroxime
Levofloxacin
Cefaclor
Cephalexin
Linezolid
Cefazolin
Ciprofloxacin
Meropenem
Cefdinir
Clarithromycin
Metronidazole
Cefepime
Clindamycin
Moxifloxacin
Cefotaxime
Colistin
Nitrofurantoin
Cefpodoxime
Daptomycin
Ofloxacin
Cefprozil
Doripenem
Penicillin
20. CRF status:
Complete
Pending
Chart unavailable

21. Date reported to EIP site:

___ ___ - ___ ___ - ___ ___ ___ ___

Piperacillin-Tazobactam
Polymyxin B
Rifampin
Tetracycline
Ticarcillin/Clavulanic Acid
Tigecycline
Tobramycin
Trimethoprim-Sulfamethoxazole
Vancomycin, IV
Vancomycin, oral
Unknown
Other (specify):________________
Other (specify):________________
22. SO initials:
_______

23. Comments:
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

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