Form 0920-0978 HAIC Multi-site Gram-Negative Bacilli Case Report Form (

PATIENT ID: ___ ___ ___ ___ ___ ___ ___ ___ ___

DATE REPORTED TO EIP SITE:

___ ___ - ___ ___ - ___ ___ ___ ___

2019 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem Resistant A. baumannii (CRAB)
Multi-site Gram-Negative Surveillance Initiative (MuGSI)

Form Approved
OMB No. 0920-0978
Exp. Date: XX-XX-XXXX

Healthcare-Associated Infections Community Interface (HAIC) Case Report
Patient’s Name:

Phone no. (

Address:

)

MRN:

City:

State

ZIP:

Hospital:

----Patient Identifier information is not transmitted to CDC---DEMOGRAPHICS
1. STATE:

2. COUNTY:

3. STATE ID:

____ ____

_____________

___ ___ ___ ___ ___ ___ ___ ___ ___

___ ___ - ___ ___ - ___ ___ ___ ___

6. AGE:

8a. ETHNIC ORIGIN:

7. SEX AT BIRTH:

5. DATE OF BIRTH:

____ ____ ____

□ Days □ Mos. □ Yrs.

4a. LABORATORY ID WHERE
INCIDENT SPECIMEN IDENTIFIED:
________________________

□
□ MALE □ FEMALE □
□ Unknown
□ Check if transgender □

□

___ ___ - ___ ___ - ___ ___ ___ ___

□ American Indian or Alaska □ Native Hawaiian or
Native

Other Pacific Islander

□ White
□ Asian
□ Black or African American □ Unknown

Not Hispanic or Latino
Unknown

□Escherichia coli
□Enterobacter cloacae
□Klebsiella aerogenes

_______________________________

8b. RACE: (Check all that apply)

Hispanic or Latino

10. ORGANISM:
Carbapenem-resistant:
Enterobacteriaceae (CRE):

9. DATE OF INCIDENT SPECIMEN COLLECTION (DISC):

4b. FACILITY ID WHERE PATIENT TREATED:

□Klebsiella pneumoniae
□Klebsiella oxytoca

□ A. baumannii (CRAB)

11. INCIDENT SPECIMEN COLLECTION SITE:

□ Blood □ Bone □ CSF □ Internal body site (specify):___________ □ Joint/synovial fluid □ Muscle
□ Peritoneal fluid □ Pericardial fluid □ Pleural fluid □ Urine □ Other normally sterile site (specify): ______________
12. LOCATION OF SPECIMEN COLLECTION:

□ OUTPATIENT:

Facility
ID:____________

□ Emergency room
□ Clinic/Doctor's office
□ Dialysis center
□ Surgery
□ Observational/

□ INPATIENT:

□ LTCF

Facility
ID:____________

Facility
ID:____________

□ ICU
□ OR
□ Radiology
□ Other inpatient

□ LTACH

Facility
ID:____________

□ Autopsy
□ Other (specify):
_______________

Clinical decision unit

□ Unknown

□ Other outpatient

14. WAS THE PATIENT HOSPITALIZED ON THE DAY OF OR IN THE
29 CALENDAR DAYS AFTER THE DISC?

□ Yes □ No □ Unknown
IF YES, DATE OF ADMISSION:

16. PATIENT OUTCOME:

___ ___ - ___ ___ - ___ ___ ___ ___

□ Survived

DATE OF DISCHARGE: ___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

IF SURVIVED, DISCHARGED TO:

□ Left against medical advice (AMA)

13. WHERE WAS THE PATIENT LOCATED ON THE 3RD CALENDAR DAY BEFORE THE
DISC?

□ Private residence
□ LTCF

Facility ID: _______________

□ Hospital inpatient

Facility ID: _______________
Was the patient transferred from
this hospital?

□ LTACH

Facility ID: ___________________

□ Homeless
□ Incarcerated
□ Other (specify):________________
□ Unknown

□ Yes □ No □ Unknown
15a. WAS THE PATIENT IN AN ICU IN THE 7 DAYS BEFORE THE DISC?

□ Yes □ No □ Unknown

IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

15b. WAS THE PATIENT IN AN ICU ON THE DAY OF INCIDENT SPECIMEN COLLECTION
OR IN THE 6 DAYS AFTER THE DISC?

□ Yes □ No □ Unknown

IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Died

DATE OF DEATH:

□ Private residence □ LTCF Facility ID:______ □ LTACH Facility ID: ______
□ Other (specify): ________ □ Unknown

□ Date unknown

□ Unknown

___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

ON THE DAY OF OR IN THE 6 CALENDAR DAYS BEFORE DEATH, WAS THE PATHOGEN
OF INTEREST ISOLATED FROM A SITE THAT MEETS THE CASE DEFINITION?

□

Yes

□ No □ Unknown

Public reporting burden of this collection of information is estimated to average 25 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 Review Office, 1600 Clifton Road NE, MS
D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).

Version Date: 07/29/2018

PAGE 1 OF 4

Form Approved
OMB No. 0920-0978
Exp. Date: XX-XX-XXXX

17. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)
□
□
□
□
□

Abscess, not skin
AV fistula/graft infection
Bacteremia
Bursitis
Catheter site infection (CVC)

□
□
□
□
□

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

18. UNDERLYING CONDITIONS: (Check all that apply)

□ AIDS/CD4 count < 200

□ Primary immunodeficiency
□ Transplant, hematopoietic stem cell
□ Transplant, solid organ

CHRONIC METABOLIC DISEASE

□

Diabetes mellitus
□ With chronic complications

LIVER DISEASE

□ Chronic liver disease
□ Ascites
□ Cirrhosis
□ Hepatic encephalopathy
□ Variceal bleeding
□ Hepatitis C
□ Treated, in SVR
□ Current, chronic

CARDIOVASCULAR DISEASE

□
□
□
□
□

CVA/Stroke/TIA
Congenital heart disease
Congestive heart failure
Myocardial infarction
Peripheral vascular disease (PVD)

GASTROINTESTINAL DISEASE

□
□
□
□

□
□
□

19. SUBSTANCE USE, CURRENT
(Check all that
apply) □ None

□ Unknown

□ Tobacco
□ E-nicotine delivery system
□ Marijuana

ALCOHOL
ABUSE:

□ Yes
□ No
□ Unknown

20. RISK FACTORS: (Check all that apply)

NEUROLOGIC CONDITION

□
□
□
□
□
□
□
□

□
□
□

□

□ None □ Unknown

DAYS AFTER HOSPITAL ADMISSION?

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC:

□ Yes □ No □ Unknown

IF YES, DATE OF DISCHARGE CLOSEST TO DISC :___ _____ - ___ ___ - ___ ___ ___ ___

□

Connective tissue disease
Obesity or morbid obesity
Pregnant

□

□ None □ Unknown

□
□

Urinary tract problems/
abnormalities
Premature birth
Spina bifida

MODE OF DELIVERY:
(Check all that apply)

□ DUD or abuse
□ DUD or abuse
□ DUD or abuse
□ DUD or abuse
□ DUD or abuse
□ DUD or abuse

□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU

□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping
□ Skin popping

□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU
□ Non-IDU

COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR
DAYS BEFORE DISC:
□ Yes □

OVERNIGHT STAY IN LTCF IN THE YEAR BEFORE DISC:

□ Yes □ No □ Unknown

Facility ID: __________

OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC:

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

□ Unknown
Check here if central line in place for > 2 calendar days: □
No

URINARY CATHETER IN PLACE ON THE DISC (UP TO

THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2
CALENDAR DAYS BEFORE DISC:
□ Yes □ No

Facility ID: __________

□ Yes □ No □ Unknown

Facility ID: __________

SURGERY IN THE YEAR BEFORE DISC:

□ Yes □ No □ Unknown

CURRENT CHRONIC DIALYSIS:

□ Yes □ No □ Unknown

IF YES, TYPE:

□
□
□

CENTRAL LINE IN PLACE ON THE DISC (UP TO THE TIME OF

□ Yes □ No

DATE UNKNOWN

OTHER

MuGSI CONDITIONS

DOCUMENTED USE
DISORDER (DUD)/ABUSE:
Marijuana/cannabinoid (other than smoking)
Opioid, DEA schedule I (e.g., heroin)
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
Cocaine or methamphetamine
Other (specify): _____________
Unknown substance

Burn
Decubitus/pressure ulcer
Surgical wound
Other chronic ulcer or chronic
wound
Other (specify):___________

□

Chronic kidney disease
Lowest serum creatinine: ________mg/DL

WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR

OR,

SKIN CONDITION

Hemiplegia
Paraplegia
Quadriplegia

OTHER SUBSTANCES: (Check all that apply)

Surgical incision infection
Surgical site infection (internal)
Traumatic wound
Urinary tract infection
Other (specify): ____________

□
□
□
□

Cerebral palsy
Chronic cognitive deficit
Dementia
Epilepsy/seizure/seizure disorder
Multiple sclerosis
Neuropathy
Parkinson’s disease
Other (specify): ________________

RENAL DISEASE

Malignancy, hematologic
Malignancy, solid organ (non-metastatic)
Malignancy, solid organ (metastatic)

□
□
□
□
□
□

□
□
□
□
□

Pyelonephritis
Septic arthritis
Septic emboli
Septic shock
Skin abscess

PLEGIAS/PARALYSIS

MALIGNANCY

Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome

SMOKING:

□ None □ Unknown

□ HIV infection

Cystic fibrosis
Chronic pulmonary disease

□
□
□
□
□

Epidural Abscess
Meningitis
Osteomyelitis
Peritonitis
Pneumonia

IMMUNOCOMPROMISED CONDITION

CHRONIC LUNG DISEASE

□
□

□
□
□
□
□

□ None □ Unknown

□ Hemodialysis □ Peritoneal □ Unknown

□ Unknown

IF YES, CHECK ALL THAT APPLY:
□ Indwelling Urethral Catheter □ Suprapubic Catheter

□ Condom Catheter

□ Other (specify):__________

ANY OTHER INDWELLING DEVICE IN PLACE ON THE DISC (UP
TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2
CALENDAR DAYS BEFORE DISC:

IF YES, CHECK ALL THAT APPLY:

□ Yes □ No □ Unknown

□ ET/NT Tube □ Gastrostomy Tube
□ Tracheostomy □ Nephrostomy Tube

□ NG Tube
□ Other (specify):

_____________

IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:

□ AV fistula/graft □ Hemodialysis central line □ Unknown
21a. WEIGHT:
_________lbs. ______ oz. OR

21b. HEIGHT:
_________ft. _______ in. OR

_____kg

_____cm

□ Unknown

□ Unknown

PATIENT TRAVELED INTERNATIONALLY
IN THE YEAR BEFORE DISC:

21c. BMI:
_________

□ Unknown

□ Yes □ No □ Unknown

COUNTRY: ____________, ____________, ____________

PATIENT HOSPITALIZED WHILE VISITING
COUNTRY(IES) ABOVE:

□ Yes □ No □ Unknown

Version Date: 07/29/2018
PAGE 2 OF 4

Form Approved
OMB No. 0920-0978
Exp. Date: XX-XX-XXXX
URINE CULTURES ONLY:
22a. WAS THE URINE

COLLECTED THROUGH AN
INDWELLING URETHRAL
CATHETER?

□ Yes □ No □ Unknown
URINE CULTURES ONLY:
22b. RECORD THE COLONY
COUNT: ________________

URINE CULTURES ONLY:
22c. SIGNS AND SYMPTOMS ASSOCIATED WITH URINE CULTURE

Please indicate if any of the following symptoms where reported during the 5 day time period including the
2 calendar days before through the 2 calendar days after the DISC.
Symptoms for patients ≤
1 year of age only:
□ Unknown
□ None
□ Apnea
□ Costovertebral angle pain or tenderness □ Frequency
□ Bradycardia
□ Suprapubic tenderness
□ Dysuria
□ Lethargy
□ Fever [temperature ≥ 100.4 °F (38 °C)] □ Urgency
□ Vomiting

23. WAS THE
INCIDENT
SPECIMEN
POLYMICROBIAL?

24a. WAS THE

□ Yes
□ No
□ Unknown

□ Yes
□ No
□ Laboratory not

INCIDENT SPECIMEN
TESTED FOR
CARBAPENEMASE?

testing
□ Unknown

24b. IF YES, WHAT TESTING METHOD WAS USED? (Check all that apply):
Non-Molecular Tests

Molecular Tests

□ CarbaNP
□ Carbapenemase Incactivation Method (CIM)
□ Disk Diffusion/ROSCO Disk
□ E-test
□ Modified Carbapenemase Incactivation

□ Automated Molecular Assay
□ Carba-R
□ Check Points
□ MALDI-TOF MS
□ Next Generation Nucleic Acid

Method (mCIM)
□ Modified Hodge Test (MHT)
□ RAPIDEC
□ Other (specify):_____________
□ Unknown

25. WAS THE SAME ORGANISM (Q10) CULTURED
FROM A DIFFERENT STERILE SITE OR URINE IN
THE 30 DAYS AFTER THE DISC?

□ Yes □ No □ Unknown
IF YES, SOURCE: (check all that apply)

□ Blood
□ Bone
□ CSF
□ Internal body site

(specify):
____________
□ Joint/synovial fluid

□ Muscle
□ Peritoneal fluid
□ Pericardial fluid
□ Pleural fluid
□ Urine
□ Other normally sterile site
(specify):_____________

Sequencing
□ PCR
□ Other (specify):_____________
□ Unknown

URINE CULTURES ONLY:
22d. WAS A BLOOD CULTURE
POSITIVE IN THE 3 CALENDAR
DAYS BEFORE THROUGH THE
3 CALENDAR DAYS AFTER
THE DISC FOR THE SAME
MuGSI ORGANISM?

□ Yes □ No □ Unknown

24c. IF TESTED, WHAT WAS THE
TESTING RESULT?

Non-Molecular Test Results:

□ Positive □ Indeterminate
□ Negative □ Unknown

Molecular Test Results:

□ NDM
□ KPC
□ OXA
□ OXA-48
□ VIM
□ IMP

□ Pos
□ Pos
□ Pos
□ Pos
□ Pos
□ Pos

□ Neg
□ Neg
□ Neg
□ Neg
□ Neg
□ Neg

□ Ind
□ Ind
□ Ind
□ Ind
□ Ind
□ Ind

□ Unk
□ Unk
□ Unk
□ Unk
□ Unk
□ Unk

26. ENTEROBACTERIACEAE ONLY: WERE CULTURES OF
STERILE SITE(S) OR URINE POSITIVE IN THE 30 DAYS BEFORE
IF YES, INDICATE ORGANISM TYPE AND
THE DISC, FOR A DIFFERENT ORGANISM (Q10)?
ASSOCIATED STATE ID FOR THE INCIDENT
CLOSEST TO THE DISC:
□ Yes □ No □ Unknown □ N/A
IF YES, SOURCE: (check all that apply)
□ Muscle
□ Blood
□ Peritoneal fluid
□ Bone
□ Pericardial fluid
□ CSF
□ Pleural fluid
□ Internal body site □ Urine
(specify):
□ Other normally sterile site
____________
(specify): ____________
□ Joint/synovial fluid

Organism
Escherichia coli
Enterobacter cloacae
Klebsiella aerogenes
Klebsiella pneumoniae
Klebsiella oxytoca

27a. A. BAUMANNII CULTURES ONLY:

27b. A. BAUMANNII CULTURES ONLY:

□ Yes □ No □ Unknown □ N/A

□ Yes □ No □ Unknown □ N/A

WERE CULTURES OF OTHER STERILE SITE(S) OR URINE POSITIVE IN THE
30 DAYS BEFORE THE DISC, FOR ANOTHER A. BAUMANNII?

IF YES, STATE ID FOR THE
IF YES, SOURCE: (check all that apply)
INCIDENT CLOSEST TO THE
□ Muscle
□ Blood
DISC:
□ Peritoneal fluid
□ Bone
□ Pericardial fluid
□ CSF
□ Internal body site (specify): □ Pleural fluid
□ Urine
___________________
□ Other normally sterile site
□ Joint/synovial fluid
(specify):_____________

State ID

DID THE PATIENT HAVE A SPUTUM CULTURE POSITIVE FOR CRAB IN
THE 30 DAYS BEFORE THE DISC?

27c. A. BAUMANNII CULTURES ONLY:

RISK FACTORS IN THE 7 DAYS BEFORE THE DISC:

□ Non-invasive positive pressure ventilation (CPAP or BiPAP) at any time in
the 7 calendar days before the DISC

□ Nebulizer treatment at any time in the 7 calendar days before the DISC
□ Mechanical ventilation at any time in the 7 calendar days before the DISC

28a. WAS THE PATIENT POSITIVE FOR THE SAME ORGANISM IN THE YEAR
BEFORE THE DISC?

28b. IF YES, SPECIFY DATE OF CULTURE AND STATE ID FOR THE

□ Yes □ No □ Unknown

DATE OF CULTURE:

FIRST POSITIVE CULTURE IN THE YEAR BEFORE:

___ ___ - ___ ___ - ___ ___ ___ ___

STATE ID: ________________________

29a. ENTEROBACTERIACEAE ONLY:
WAS THE PATIENT POSITIVE FOR A
MuGSI ENTEROBACTERIACEAE IN THE
YEAR BEFORE THE DISC?

□ Yes □ No □ Unknown □ N/A

Version Date: 07/29/2018

29b. IF YES, SPECIFY ORGANISM, DATE OF
CULTURE, AND STATE ID FOR THE FIRST
POSITIVE ENTEROBACTERIACEAE
CULTURE IN THE YEAR BEFORE THE DISC:

Carbapenem-resistant Enterobacteriaceae (CRE):

□ Escherichia coli
□ Enterobacter cloacae
□ Klebsiella aerogenes
□ Klebsiella pneumoniae
□ Klebsiella oxytoca

DATE OF CULTURE: ___ ___ - ___ ___ - ___ ___ ___ ___
STATE ID: ________________________

PAGE 3 OF 4

Form Approved
OMB No. 0920-0978
Exp. Date: XX-XX-XXXX

30. 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

Interp

Vitek
MIC

Interp

Phoenix
MIC

Interp

Kirby-Bauer
Zone
Diam

Interp

E-test
MIC

Interp

Amikacin
Amoxicillin/Clavulanate
Ampicillin
Ampicillin/Sulbactam
Aztreonam
Cefazolin
CEFEPIME
CEFOTAXIME
CEFTAZIDIME
CEFTRIAXONE
Cephalothin
Ciprofloxacin
COLISTIN
DORIPENEM
ERTAPENEM
Gentamicin
IMIPENEM
Levofloxacin
MEROPENEM
Moxifloxacin
Nitrofurantoin
Piperacillin/Tazobactam
POLYMYXIN B
TIGECYCLINE
Tobramycin
Trimethoprim-sulfamethoxazole
Meropenem-vaborbactam
Minocycline
Doxycycline
Plazomicin
Tetracycline
Rifampin
Ceftazidime/Avibactam
Ceftolozane/Tazobactam
Fosfomycin
Imipenem-relebactam

31a. WAS CASE FIRST IDENTIFIED THROUGH AUDIT?

31b. CRF STATUS:

□ Yes
□ No

□ Complete
□ Pending
□ Chart unavailable after 3 requests

31d. COMMENTS:

31c. SO INITIALS:

PAGE 4 OF 4