Form 0920-0978 Invasive Methicillin-Sensitive Staphylococcus aureus Hea

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-Sensitive Staphylococcus aureus
Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2018
– 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 MSSA 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

Hispanic or Latino

2

Not Hispanic or Latino

9

Unknown

1

12c. WEIGHT: 1

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

2

Yes

No

1
1

Unknown

Unknown

2

Other Unit

4

Emergency Room

3

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

18. PATIENT OUTCOME:

9

Survived

Mo.

1

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

NICU/SCN

2

Well Baby Nursery

9

Unknown

1

Private Residence

1

Long Term Care Facility
Facility ID __________________________

1

Long Term Acute Care Hospital
Facility ID __________________________

1

Homeless

1

Incarcerated

1

Hospital Inpatient
Facility ID __________________________

1

Other __________________________

1

Unknown

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

Observational Unit/Clinical Decision Unit

16

Other sterile site (specify)

No

Unknown

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

Radiology

2

Yes (HO case)

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

_______ ft _______ in OR _______ cm
12e. BMI: 1

_____________________

______________________

Unknown

12d. HEIGHT: 1

Native Hawaiian
or Other Pacific Islander

11
15

Unknown

_______ lbs _______ oz OR _______ kg

Black or
African American
American Indian
or Alaska Native
Asian

7

9

Internal body site (specify)

1

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

Year

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

12a. ETHNIC ORIGIN:
1

Day

1

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

Unknown

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:

9
10

Unknown
Other

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:________

17b. Date of first SA blood culture after which SA not isolated for 14 days: __________________________

Unknown
Day

2

Year

Died

Mo.

Day

Year

Date of death

Date of discharge
1

Yes 2

No 9

Unknown If Yes, Facility ID __________________________

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

Yes 2

No 9

Unknown If Yes, Facility ID __________________________

If survived, was the patient transferred to a LTCF?

Was MSSA 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 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)

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

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

1

None

1

Unknown

1

Abscess (not skin)

1

Cellulitis

1

Epidural Abscess

1

Septic Arthritis

1

Surgical Site (Internal)

1

AV Fistula/Graft Infection

1

Chronic Ulcer/Wound (non-decubitus)

1

Meningitis

1

Septic Emboli

1

Traumatic Wound

Septic Shock

1

Urinary Tract

1

Other: (specify)

1

Bacteremia

1

Decubitus/Pressure Ulcer

1

Peritonitis

1

1

Bursitis

1

Empyema

1

Pneumonia

1

Skin Abscess

1

Catheter Site Infection

1

Endocarditis

1

Osteomyelitis

1

Surgical Incision

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

1

None

1

Unknown

1

Abscess/Boil (Recurrent)

1

CVA/Stroke

1

Solid Tumor (non metastatic)

AIDS

1

Cystic Fibrosis

1
1

IVDU

1

Metastatic Solid Tumor

1

1

Chronic Cognitive Deficit

1

Decubitus/Pressure Ulcer

1

Myocardial Infarct

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

1

Chronic Liver Disease

1

Dementia

1

Obesity

1

Chronic Pulmonary Disease

1

Diabetes

1

Other Drug Use

1

Chronic Kidney Disease

1

Hematologic Malignancy

1

Peptic Ulcer Disease

1

Chronic Skin Breakdown

1

Hemiplegia/Paraplegia

1

Peripheral Vascular Disease (PVD)

1

Congestive Heart Failure

1

HIV

1

Premature Birth

1

Connective Tissue Disease

1

1

Current Smoker

Influenza
(within 10 days of initial culture)

Birth Weight _______________________ lb _______________________ oz OR _______________________ g
Estimated gestational age _______________________ weeks

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

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

1

Hospitalized within year before initial culture date.
Date of discharge
If YES:

Mo.

Day

Year

1

None

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

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.

22. SUSCEPTIBILITY RESULTS [S=Sensitive (1), I=Intermediate (2), R=Resistant (3), U=Unknown/Not Reported (9)]
Cefoxitin

S

R

U

Clindamycin

S

I

R

U

Oxacillin

S

R

U

Trimethoprim-Sulfamethoxazole

S

I

R

Vancomycin

S

I

R

U

U

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

Yes 2

9

Unknown

No

24. CRF status:
1
2
3
4

Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests

25. Does this case have
recurrent MSSA
disease?
1

Yes 2

9

Unknown

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

No

26. Date reported to EIP site:
Mo.

Day

27. Initials of
S.O:

Year

28 COMMENTS:_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 09-2016

CS270050

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