Form 0920-0978 Carbapenem-resistant Pseudomonas aeruginosa Multi-Site G

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

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

2017–2018 Carbapenem-resistant Pseudomonas aeruginosa
Multi-Site Gram-Negative Surveillance (MuGSI) Case Report

Patient’s Name____________________________________________________________________________ Phone no. (________)___________________________________
(Last, First, MI)

Address__________________________________________________________________________________________ MRN_________________________________________
City____________________________________________________ State___________ Zip__________________ Hospital__________________________________________

­— Patient identifier information is NOT transmitted to CDC —
1. STATE

2. COUNTY:

3. STATE ID:

4. L ABORATORY ID WHERE CULTURE
IDENTIFIED:

6. DATE OF BIRTH:

5. FACILITY ID WHERE PATIENT TREATED:

7a. AGE:

7b. Is age in day/mo/year?

❑
8a. SEX:

8b. ETHNIC ORIGIN:

8c. RACE (check all that apply):

❑
❑
❑

❑
❑
❑

❑
❑
❑

Male
Female
Unknown

Hispanic or Latino
Not Hispanic or Latino
Unknown

Days ❑ Mos

Asian

Black or African American

❑
❑

 merican Indian or
A
Alaska Native

❑

Unknown

White

❑

Yrs

 ative Hawaiian or Other
N
Pacific Islander

9c. Where was the patient located on the 4th calendar day prior to the date of initial culture?

9a. DATE OF INITIAL CULTURE:

❑
❑
❑
❑
❑

Private residence
LTCF
Facility ID: ________________
LTACH Facility ID: ________________
Homeless
Incarcerated

❑


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

9b. LOCATION OF CULTURE COLLECTION:
Hospital Inpatient
ICU
Surgery/OR
Radiology
Other Unit

Outpatient
Clinic/Doctors Office
Surgery
Other Outpatient
Dialysis Center

Emergency Room

LTCF
Facility ID: _____________________
LTACH Facility ID: _____________________
Autopsy
Unknown

Observational Unit/Clinical Decision Unit

10. W
 AS PATIENT HOSPITALIZED AT THE TIME OF, OR WITHIN 30 CALENDAR DAYS
AFTER, INITIAL CULTURE?
❑ Yes
❑ No
❑ Unknown
If YES:

11a. Was the patient in the ICU in the 7 days prior to their initial culture?

❑ Yes

❑ No

❑ Unknown

Date of admission

11b. W
 as the patient in the ICU on the date of or in the 7 days after the date
of initial culture?

Date of discharge

❑ Yes

12a. PATIENT OUTCOME:

12c. If died, date of death:

❑ Survived

❑ Died

❑ No

❑ Unknown

❑ Unknown

12b. If survived, transferred to:

❑
❑
❑

Private residence
LTCF

Facility ID: _______________

LTACH Facility ID: _______________

❑
❑

Unknown

Other (specify):
_______________________

13. INITIAL CULTURE SITE:

❑
❑
❑
❑
❑

Blood
Bone
Bronchoalveolar lavage (LRT site, complete Q19a–d)
CSF
Internal abscess (specify site) _______________________

❑
❑
❑
❑
❑
❑

12d. Was CR-PA cultured from a normally sterile site, urine, wound, CF throat
swab, or LRT site, ≤ calendar day 7 before death (Day 1 = date of initial culture)?

❑ Yes

❑ No

Pleural fluid
Peritoneal fluid
Pericardial fluid
Joint/synovial fluid
Sputum (LRT site, complete Q19a–d)
Tracheal aspirate (LRT site, complete Q19a–d)

❑
❑
❑
❑
❑

❑ Unknown
Urine (complete Q18a–c)
Wound (specify site) _____________________________
Throat swab (CF patient only, complete Q19a–d)
Other LRT site (specify site) ________________________
(complete Q19a–d)
Other normally sterile site (specify site) _______________

Public reporting burden of this collection of information is estimated to average 45 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).

PAGE 1 OF 4

14a. Was the initial culture polymicrobial?

❑
❑
❑

14b. Were any of the following organisms cultured from the initial culture
(check all that apply)?

Yes

❑
❑
❑
❑
❑
❑

No
Unknown


>1 CR P. aeruginosa with two distinct antibiograms
Vancomycin-resistant Enterococci (VRE)
Methicillin-resistant Staphylococcus aureus (MRSA)
Carbapenem-resistant Enterobacteriaceae (CRE)
Carbapenem-resistant Acinetobacter (CRAB)
None of the listed organisms cultured

15. Susceptibility Results (please complete the table below based on the information found in the indicated data source). Shaded antibiotics are required to have the MIC
entered into the MuGSI-CM system, if available.
Data Source
Antibiotic

Medical Record
MIC

Interp

Microscan
MIC

Vitek

Interp

MIC

Interp

Phoenix
MIC

Interp

Kirby-Bauer
Zone
Diam

Interp

E-test
MIC

Interp

Amikacin
Aztreonam
CEFEPIME
CEFTAZIDIME
Ceftazidime-avibactam
Ceftolozane-tazobactam
Ciprofloxacin
COLISTIN
DORIPENEM
Gentamicin
IMIPENEM
Levofloxacin
MEROPENEM
Piperacillin-Tazobactam
POLYMYXIN B
Tobramycin
16. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S) (check all that apply):

❑
❑
❑
❑
❑
❑
❑
❑

Abscess, not skin
AV fistula/graft infection
Bacteremia
Bronchitis (Acute/Chronic)
Bursitis
Catheter site infection (CVC)
Cellulitis
CF exacerbation

❑
❑
❑
❑
❑
❑
❑
❑

Chronic ulcer/wound (not decubitus)
Decubitus/pressure ulcer
Ecthyma gangrenosum
Empyema
Endocarditis
Epidural abscess
Meningitis
Osteomyelitis

17. UNDERLYING CONDITIONS (check all that apply):

❑ AIDS/CD4 count < 200
❑ Alcohol abuse
❑ Chronic Bronchiectasis
❑ Chronic Liver Disease
❑ Chronic Pulmonary Disease
❑ Chronic Renal Insufficiency
❑ Chronic Skin Breakdown
(Check all that apply):
❑ Burn
❑ Prolonged surgical wound
❑ Other (specify) ____________
❑ Unknown

❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑

❑

❑

None

❑

None

❑

Unknown

❑
❑
❑
❑
❑
❑
❑
❑

Peritonitis
Pneumonia (complete Q19a–d)
Pyelonephritis
Septic arthritis
Septic emboli
Septic shock
Skin abscess
Surgical incision infection

❑
❑
❑
❑
❑

Surgical site infection (internal)
Traumatic wound
Upper respiratory infection
Urinary tract infection
Other ______________________

❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑

IVDU
Inflammatory Bowel Disease/Crohns
Liver Failure
Metastatic Solid Tumor
Myocardial Infarct
Neurological Problems
Obesity or Morbid Obesity
Peptic Ulcer Disease
Peripheral Vascular Disease (PVD)
Premature Birth
Solid Tumor (non metastatic)

❑
❑
❑

Spina bifida
Transplant Recipient
Urinary Tract Problems/Abnormalities

Unknown

Congestive Heart Failure
Connective Tissue Disease
Current Smoker
CVA/Stroke
Cystic Fibrosis
Decubitus/Pressure Ulcer
Dementia/Chronic cognitive deficit
Diabetes
Hemiplegia/Paraplegia
HIV
Hematologic Malignancy

PAGE 2 OF 4

Complete questions 18a–18d for URINE cultures ONLY.

Complete questions 19a-19d ONLY for LRT site cultures, CF throat swabs, or
for non-LRT cultures where pneumonia is marked in question 16.

URINE Cultures ONLY:

URINE Cultures ONLY:

19a. Chest Radiology source of results:

18a. W
 as the urine collected through
an indwelling urethral catheter?

18b. R
 ecord the colony count for
P. aeruginosa:

❑
❑
❑

_____________________________

Yes
No
Unknown

❑

CT

❑

❑

X-Ray

Not Done

19b. Chest Radiology Findings (check all that apply):

❑
❑
❑
❑
❑
❑
❑
❑

None

❑

Not available

Air space density/opacity
Bronchopneumonia/pneumonia
Cannot rule out pneumonia
Cavitation
Consolidation
Interstitial infiltrate

❑
❑
❑
❑
❑
❑

Multiple lobar infiltrate (bilateral)
New or changed infiltrate
No evidence of pneumonia
Pleural effusion
Single lobar infiltrate
Other (specify): ____________

Multiple lobar infiltrate (unilateral)

18c. Signs and Symptoms associated with urine culture.

19c. Signs and Symptoms associated with lower respiratory tract 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. Then go to question 18d.

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. Then go to question 19d.

❑
❑

❑
❑
❑
❑
❑
❑
❑

None

❑

Unknown

 ostovertebral angle pain or
C
tenderness

❑ Dysuria
❑

❑ Frequency
❑ Suprapubic tenderness
❑

Urgency


Fever [temperature ≥100.4 °F
(38 °C)]

Symptoms for patients ≤ 1 year of age only.

❑
❑
❑
❑

Apnea

❑
❑
❑
❑

Bradycardia
Lethargy
Vomiting

18d. W
 as a blood culture positive in the 3 calendar days before through the 3
calendar days after the initial urine culture?

❑
❑
❑

Unknown

❑

None

❑

Culture collected ≥ calendar day 3 after hospital admission
Hospitalized within year before date of initial culture:

 on-invasive positive pressure ventilation (CPAP or BiPAP) at any time in the
N
7 calendar days prior to the date of initial culture

❑

 ebulizer treatment at any time in the 7 calendar days prior to the date of
N
initial culture

Mechanical ventilation at any time in the 7 calendar days prior to the date of
initial culture

❑

 entral venous
C
catheter
❑ Implanted ventricular
assist device
❑ Urinary catheter
❑ ET/NT Tube

Yes
❑ No
❑ Unknown
If YES: Enter number of hospitalizations in year before date of initial culture.
If patient is hospitalized at time of initial culture, do not count that
hospitalization here.
Number of hospitalizations: _________ If known, prior hospital ID: ___________

Surgery within year before date of initial culture

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_________________

❑

 urrent chronic dialysis:
C
Hemodialysis Access:

❑ Peritoneal
❑ Hemodialysis
❑ AV fistula/graft ❑ CVC

I ndwelling device in place at any time in the 2 calendar days prior to the date of
initial culture. If checked, indicate all that apply:

❑

❑

❑

Leukocytosis
Leukopenia

Low body temperature/hypothermia
[≤ 95ºF (35ºC)]
Low O2 desaturation [pulse oximetry
❑ 
<94% or PaO2/FiO2 ≤240]
❑ New onset purulent sputum
❑ Rales/crackles/bronchial breath sounds
❑ Tachypnea (new onset or worsening)

Unknown

❑

❑
❑

Increased ventilator demand

❑

❑

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

❑
❑
❑
❑

19d. Risk factors for LRT or for non-LRT culture where pneumonia is marked in Q16.

Yes
No

None
❑ Unknown
Altered mental status
Apnea (new onset or worsening)
Change in character of sputum
Cough (new onset or worsening)
Dyspnea (new onset or worsening)
Fever [temperature ≥100.4 °F
(38 °C)]
Hemoptysis
Increased O2 requirements
Increased respiratory secretions
Increased suctioning requirements

❑

❑
❑
❑
❑
❑

NG Tube
Tracheostomy
Gastrostomy Tube
Jejunostomy Tube
Nephrostomy Tube

❑ Other:
_________________
❑ Other:
_________________

Patient traveled internationally in the two months prior to the date of initial culture.
Country: ___________________, ___________________, ___________________

❑ Unknown
❑ Unknown

IMPORTANT­— PLEASE COMPLETE ALL PAGES OF THIS FORM

PAGE 3 OF 3
4

Complete 21a-21b for patients who had cultures collected as a hospital inpatient, in the ER, or when at a LTCF or LTACH.
21a. Is antimicrobial use (IV or oral) in the 14 days before the date of initial culture collection documented in the H&P or medical administration record?
❑ Yes (go to Q21b)
❑ No (go to Q22)
❑ Unknown (go to Q22)

21b. If yes, indicate all antibiotics given in the 14 days before the date of initial culture collection:

❑

Amikacin (Amikin)

❑

Cefoxitin

❑

Clarithromycin

❑

Linezolid

❑

Telavancin

❑

Amoxicillin

❑

Cefpodoxime

❑

Clindamycin

❑

Meropenem

❑

Tetracycline

❑

Amoxicillin-Clavulanic Acid

❑

Cefprozil

❑

Colistin

❑

Metronidazole

❑

Ticarcillin-Clavulanic Acid

❑

Ampicillin

❑

Ceftaroline

❑

Dalbavancin

❑

Minocycline

❑

Tigecycline

❑

Ampicillin-sulbactam

❑

Ceftazidime

❑

Daptomycin

❑

Moxifloxacin

❑

Tobramycin

❑

Azithromycin

❑

Ceftazidime-avibactam

❑

Doripenem

❑

Nafcillin/Dicloxcillin/Oxacillin

❑

Trimethoprim-Sulfamethoxazole

❑

Aztreonam

❑

Ceftizoxime

❑

Doxycycline

❑

Nitrofurantoin

❑

Vancomycin

❑

Cefaclor

❑

Ceftriaxone

❑

Ertapenem

❑

Ofloxacin

❑

Other (specify):

❑

Cefazolin

❑

Ceftolozane-tazobactam

❑

Erythromycin

❑

Penicillin

❑

Cefdinir

❑

Cefuroxime

❑

Fosfomycin

❑

Piperacillin-Tazobactam

❑

Cefepime

❑

Cephalexin

❑

Gentamicin

❑

Polymyxin B

❑

Cefixime

❑

Chloroamphenicol

❑

Imipenem

❑

Quinupristin-dalfopristin

❑

Cefotaxime

❑

Ciprofloxacin

❑

Levofloxacin

❑

Rifampin

_________________________

❑

Other (specify):

_________________________

❑

Other (specify):

_________________________

22. Was case identified through an audit?

23. CRF status:

❑
❑
❑

❑
❑
❑

Yes
No
Unknown

24. Date reported to EIP site:

25. SO initials:

Complete
Pending
Chart unavailable

26. Comments:

PAGE 4 OF 4