Form 0920-0978 ABC Surveillance Case Report

– 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 –

2019 Active Bacterial Core
Surveillance (ABCs) CASE REPORT

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

)

Form Approved
0920-0978

A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM
– SHADED AREAS FOR OFFICE USE ONLY –

1. STATE:
( Patient Residence )

2. STATE I.D.:

5. CRF Status:
1
Complete

4. Date reported to EIP site:

3. PATIENT I.D.:

Mo.

Day

Year

4

9a. AGE:

8. DATE OF BIRTH:
Mo.

Day

Year

9b. Is age in day/mo/yr?
1

T1
Test Type

Days 2

T2
Date of Specimen
Collection
Day

Mo.

Mos. 3

1

Male

2

Female

Yrs.

T3

T4

Test Method
(non-culture)

Site from which
organism isolated

Year

Edited & Correct

QA Review Change

11b. RACE: (Check all that apply)

11a. ETHNIC ORIGIN:

10. SEX:

3

Incomplete

Chart unavailable 7
after 3 requests

7b. HOSPITAL I.D. WHERE
PATIENT TREATED:

7a. HOSPITAL/LAB I.D. WHERE
CULTURE IDENTIFIED:

6. COUNTY: (Residence of Patient)

2

1

Hispanic or Latino

2

Not Hispanic or Latino

9

Unknown

T5
Bacterial Species
Isolated*

1

White

1

Asian

1

Black

1

1

American Indian
or Alaska Native 1

Native Hawaiian
or Other Pacific Islander
Unknown

T7
Isolate/Specimen
Available?

T6
Test Result

T8
If isolate/specimen
not available,
why not?

1
2
3


* For other bacterial pathogens (i.e. non-ABCs), write-in pathogen name
16. WAS PATIENT
HOSPITALIZED?
1

Yes

2

If YES, date of admission:
Mo.

Day

Date of discharge:

Year

Mo.

Day

1

No

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) ____________

Long term acute care facility 6
3
20a. WEIGHT:
______lbs______ oz OR ______ kg

College dormitory 9
OR

Unknown

______ft ______ in OR ______ cm OR

Unknown

20c. BMI: ___ ___ . ___

Survived 2

Died 9

Unknown

No

9

Unknown

18b. If resident of a facility, what 19a.Was patient transferred
was the name of the facility?
from another hospital?
1

Yes 2

9

Unknown

19b. If YES, hospital I.D.:

No

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

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

2

21. TYPE OF INSURANCE: (Check all that apply)

Unknown

OR

Yes

Facility ID:

Unknown

20b. HEIGHT:

22. OUTCOME: 1

17. If patient was hospitalized, was this patient admitted to the
ICU during hospitalization?

Year

Home 2

LTC/SNF 3

LTACH 5

If discharged to LTC/SNF or LTACH, list Facility ID

Left AMA
4

9

Unknown

Other, Specify

26. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
Unknown

1

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

Bacteremia
without Focus

1

Peritonitis

1

Endometritis

1

Pericarditis

1

STSS

1

Meningitis

1

Otitis media

1

Septic abortion

1

Necrotizing fasciitis

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

24c.

Gestational age:
CDC 52.15A REV. 2018

(wks) Birth weight:

(gms)

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

Page 1 of 3

Public reporting burden to collect this information is estimated to average 15
20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering/maintaining the data
needed, and completing/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 information, including suggestions for reducing this burden to CDC,

Do not send the completed form to this address.

27. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE,check appropriate box) 1
None 1
Immunoglobulin
Deficiency
1
AIDS or CD4 count <200
1
Complement Deficiency
1
Immunosuppressive Therapy (Steroids, etc.)
1
Asthma
1
Connective Tissue Disease (Lupus, etc.) CSF
1
Eculizumab (Soliris) - N.men. only
1
Atherosclerotic CVD (ASCVD)/CAD 1
1
Leak
Leukemia
1
Marrow
Transplant
(BMT)
Bone
1
Deaf/Profound Hearing Loss
1
Multiple Myeloma
1
CVA/Stroke/TIA
1
Dementia
1
Multiple Sclerosis
1
Chronic Hepatitis C
1
Diabetes Mellitus,
1
Myocardial Infarction
1
Chronic Kidney Disease
1
HbA1C ______(%), Date ___/___/______
1
1
Nephrotic Syndrome
Chronic Liver Disease/cirrhosis
1
Emphysema/COPD
1
Neuromuscular Disorder
1
Current Chronic Dialysis
1
Heart Failure/CHF
1
1
Obesity
1
Chronic Skin Breakdown
HIV Infection
1
1
Parkinson’s Disease
1
Cochlear Implant
Hodgkin’s Disease/Lymphoma
1
1
Peptic Ulcer Disease

Unknown
1
1
1

1

Peripheral Neuropathy
Peripheral Vascular Disease
Plegias/Paralysis
Premature Birth (specify gestational
age at birth)
(wks)
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Other prior illness (specify):

Yes

0

1
1
1
1
1
1

SUBSTANCE USE, CURRENT
27c. SMOKING:

1

1

None

(check all that apply)

Tobacco 1

Unknown 1

27d. OTHER SUBSTANCES: (check all that apply) 1

None

E-Nicotine Delivery System 1

1

Unknown

27c. ALCOHOL ABUSE: 1

Marijuana

1

Marijuana/cannabinoid (other than smoking)

Documented Use Disorder (DUD)/Abuse?
1
DUD or Abuse

1

Opioid, DEA schedule I (e.g., heroin)

1

DUD or Abuse

1

Opioid, DEA schedule II - IV (e.g., methadone, oxycodone)

1

1
1

Cocaine or methamphetamine

1
1

DUD or Abuse
DUD or Abuse

1

No

9

Unknown

Mode of delivery: (check all that apply)
1
IDU 1
Skin popping 1

non-IDU

1

Unknown

1

Skin popping 1

non-IDU

1

Unknown

1

IDU

1

IDU

1

1

Unknown

IDU

non-IDU

IDU

1
1

Skin popping 1
Skin popping 1
Skin popping 1

non-IDU

1
1

non-IDU

1
1

Unknown

DUD or Abuse
1
1
Unknown substance
*Includes hallucinogens (LSD, mushrooms, etc.), club drugs (MDMA, GHB, etc.), dissociative drugs (ketamine, etc.), inhalants

IDU

1

Skin popping 1

non-IDU

1

Unknown

Other* (specify): _______________

DUD or Abuse

Unknown

– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISM –
Yes 2 No 9
Unknown
28b. If <15 years of age and serotype ‘b’ or ‘unknown’ did 1
patient receive Haemophilus influenza b vaccine? If YES, please complete the list below.
VACCINE NAME / MANUFACTURER
DOSE
DATE GIVEN

HAEMOPHILUS INFLUENZAE
28a. What was the serotype?
1

b

2

Not Typeable 3

4

c

5

d

8

Other (specify)

6

e

7

Mo.

a

Day

28c. Were records obtained to verify
vaccination history? (<5 years of age
with Hib/unknown serotype, only)
1
Yes
2
No
If YES, what was the source of the
information? (Check all that apply)

Year

1

f

2
3

9

Not Tested or Unknown

4

NEISSERIA MENINGITIDIS
29. What was the serogroup?
1
6

A

2

B

3

Not Groupable 8

30. Is patient currently attending college?

C

4

Y

5

W135

Other

9

31.Did patient receive meningococcal vaccine?
Type Codes:

TYPE

DOSE

1= ACWY conjugate
(Menactra,
Menveo, MenHibrix)
2= ACWY
polysaccharide
(Menomune)
3= B (Bexsero,
Trumenba)
9= Unknown

1

Unknown
1

Yes 2

No 9

DATE GIVEN
Mo.

Day

Yes 2

No 9

Unknown If YES, complete the table
VACCINE NAME / MANUFACTURER

Year

1
2

Medical Chart

1

Vaccine Registry

1

Healthcare Provider

1

Other (specify)

STREPTOCOCCUS PNEUMONIAE
32. Did patient receive pneumococcal vaccine?
1

Unknown

1

Yes

2

No 9

Unknown

If YES, please note which pneumococcal vaccine was received:
(Check all that apply)

®

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 IPD in Children expanded form.

3
4

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

Unknown
Year

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:
Varicella
1
1
Yes 2 No 9 Unknown
Penetrating trauma
1
Blunt trauma
1
Mo.

If YES,
date of delivery:

If YES, date of surgery or skin incision:

Unknown

Unknown date

9

Day

Year

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. 2018

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:

/

/
Page 2 of 3

VALUE SETS for LAB REPEATING GROUP
T1 - Test Type
1=PCR
2=Culture
3=Antigen
4=Immunohistochemistry
5=Latex agglutination
7=Other
9=unknown
T3 - Test Method (if non-culture)
1=Biofire Filmarray Meningitis/Encephalitis Panel
2=other
3=Biofire Filmarray Blood Culture ID (BCID) Panel
4=Verigene Gram + Blood Culture (BCT) Test
5=Bruker MALDI Biotyper CA System
6=BD Directigen Meningitis Combo Test Kit
7=ThermoFisher Wellcogen Bacterial Antigen Rapid
8=Alere BinaxNOW Antigen Card
9=Unknown

T4 - Site of organism isolation
19=Peritoneal Fluid
1=Amniotic fluid
20=Placenta
2=Blood
21=Pleural fluid
3=Bone
22=Respiratory secretion
4=Brain
23=Sinus
5=CSF
24=Spleen
6=Heart
25=Sputum
7=Other Sterile Site
26=Vitreous
8=Joint
27=Wound
9=unknown
28=Unknown
10=Kidney
11=Liver
12=Lung
13=Lymph node
14=Middle ear
15=Muscle/Fascia/Tendon
16=Ovary
17=Pancreas
18=Pericardial Fluid

T5 - Bacterial Species Isolated*
1=Neisseria meningitidis
2=Haemophilus influenzae
3=Group B Streptococcus
5=Group A Streptococcus
6=Streptococcus pneumoniae
T6 -Test Result
1=Positive
0=Negative

T7 - Isolate/Specimen Available
1=Yes
2=N0
T8 - No Isolate/Specimen, why not
1=N/A at Hospital Lab 2=N/A at
State Lab
3=Hospital refuses
4=Isolate Discrepancy (2x)
5=No DNA (non-viable)

* For other bacterial pathogens (i.e. non-ABCs) write-in pathogen name

CDC 52.15A REV. 2018

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Page 3 of 3