Form 0920-0978 HAIC Multi-site Gram-Negative Surveillance Initiative –

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

DATE REPORTED TO EIP SITE:

___ ___ - ___ ___ - ___ ___ ___ ___

2019 Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacteriaceae
Form Approved
OMB No. 0920-0978
Exp. Date: XX-XX-XXXX

Multi-site Gram-Negative Surveillance Initiative (MuGSI)
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

□
□
□

4b. FACILITY ID WHERE PATIENT TREATED:
_______________________________

8b. RACE: (Check all that Apply)

□ American Indian or Alaska □ Native Hawaiian or

Hispanic or Latino
Not Hispanic or Latino
Unknown

Native

Other Pacific Islander

□ White
□ Asian
□ Black or African American □ Unknown

10. ORGANISM:
Extended-Spectrum Cephalosporin-resistant:

9. DATE OF INCIDENT SPECIMEN COLLECTION (DISC):
___ ___ - ___ ___ - ___ ___ ___ ___

□Escherichia coli
□Klebsiella pneumoniae
□Klebsiella oxytoca

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:

□ INPATIENT:

Facility
ID:____________
Emergency room

Facility
ID:____________

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

□ ICU
□ OR
□ Radiology
□ Other inpatient

Clinical decision unit

□ LTCF

Facility
ID:____________

□ LTACH

Facility
ID:____________

□ Autopsy
□ Other (specify):
_______________

□ 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

___ ___ - ___ ___ - ___ ___ ___ ___ OR

□ Date unknown

□ Unknown
□ 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: 01/2019

PAGE 1 OF 4

FormForm
Approved
Approved
OMBOMB
No. No.
0920-0978
0920-0978
Exp.
Date:
XX-XX-XXXX
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

19. UNDERLYING CONDITIONS: (Check all that apply)

□ AIDS/CD4 count < 200

Chronic pulmonary disease

□ 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

□
□
□
□

□
□
□

SMOKING:

(Check all that
apply) □ None

□ Tobacco
□ E-nicotine delivery system
□ Marijuana

□
□
□
□
□
□

□ Yes
□ No
□ Unknown

21. RISK FACTORS: (Check all that apply)

□
□
□
□
□
□
□
□

□

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

□ None □ Unknown

Facility ID: __________

OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC:

□ Yes □ No
□ Yes □ No □ Unknown

□ Yes □ No □ Unknown
□ Yes □ No □ Unknown

SURGERY IN THE YEAR BEFORE DISC:

□ Yes □ No □ Unknown

CURRENT CHRONIC DIALYSIS:

□ Yes □ No □ Unknown

□ Hemodialysis □ Peritoneal □ Unknown

□ Unknown

Version Date: 01/2019

22b. HEIGHT:

_________ft. _______ in. OR
_____cm

□ None □ Unknown
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

DAYS BEFORE DISC:

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

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

□ Yes □ No □ Unknown

□ Unknown

□

URINARY CATHETER IN PLACE ON THE DISC (UP TO

THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2

□ Yes □ No □ Unknown
IF YES, CHECK ALL THAT APPLY:
□ Indwelling Urethral Catheter □ Suprapubic Catheter

CALENDAR DAYS BEFORE DISC:

□ 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: □ Yes □ No □ Unknown

IF YES, CHECK ALL THAT APPLY:

□ ET/NT Tube □ Gastrostomy Tube
□ Tracheostomy □ Nephrostomy Tube
PATIENT TRAVELED INTERNATIONALLY
IN THE YEAR BEFORE DISC:

□ AV fistula/graft □ Hemodialysis central line □ Unknown

_____kg

□
□

Urinary tract problems/
abnormalities
Premature birth
Spina bifida

□ NG Tube
□ Other (specify):
_____________

IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:

_________lbs. ______ oz. OR

□

Check here if central line in place for > 2 calendar days:

Facility ID: __________

22a. WEIGHT:

Connective tissue disease
Obesity or morbid obesity
Pregnant

CENTRAL LINE IN PLACE ON THE DISC (UP TO THE TIME OF
COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR

□

OVERNIGHT STAY IN LTCF IN THE YEAR BEFORE DISC:

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

MuGSI CONDITIONS

Chronic kidney disease
Lowest serum creatinine: ________mg/DL

Facility ID: __________

IF YES, TYPE:

□
□
□

Hemiplegia
Paraplegia
Quadriplegia

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

□

RENAL DISEASE

WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR
DAYS AFTER HOSPITAL ADMISSION?

OR,

□
□
□
□

OTHER

DOCUMENTED USE
DISORDER (DUD)/ABUSE:

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC:

□ Yes
□ No
□ Unknown

SKIN CONDITION

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

OTHER SUBSTANCES: (Check all that apply)

ALCOHOL
ABUSE:

□ Unknown

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

NEUROLOGIC CONDITION

□
□
□

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

20. SUBSTANCE USE, CURRENT

18. RECURRENT UTI
□
□
□
□
□

PLEGIAS/PARALYSIS

MALIGNANCY

Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome

Pyelonephritis
Septic arthritis
Septic emboli
Septic shock
Skin abscess

□ None □ Unknown

□ HIV infection

Cystic fibrosis

□ Unknown
□
□
□
□
□

Epidural Abscess
Meningitis
Osteomyelitis
Peritonitis
Pneumonia

IMMUNOCOMPROMISED CONDITION

CHRONIC LUNG DISEASE

□
□

□
□
□
□
□

□ None

22c. BMI:
_________

□ Unknown

□ Yes □ No □ Unknown

COUNTRY: ____________, ____________, ____________

PATIENT HOSPITALIZED WHILE VISITING
COUNTRY(IES) ABOVE:

□ Yes □ No □ Unknown
PAGE 2 OF 4

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

URINE CULTURES ONLY:
23a. RECORD THE

COLONY COUNT:
________________

URINE CULTURES ONLY:
23b. 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 through the 2 calendar days after the DISC.
Symptoms for patients
≤ 1 year of age only:
□ Unknown
□ None

□ Costovertebral angle pain or tenderness
□ Dysuria
□ Fever [temperature ≥ 100.4 °F (38 °C)]

24a. WAS THE
INCIDENT
SPECIMEN
POLYMICROBIAL?

□ Yes
Yes
□ No
□ Unknown
Unknown

□ Frequency
□ Suprapubic tenderness
□ Urgency

24b. WHAT SCREENING/ CONFIRMATORY
METHOD WAS USED FOR ESBL
IDENTIFICATION?
(Check all that apply):
None
Unknown

□

□

24c. IF SCREENING/ CONFIRMATORY
METHOD WAS USED, WHAT WAS THE
RESULT?

□ Broth Microdilution (ATI detection)
□ ESBL well
□ Expert rule (ATI flag)
□ Unknown
□ Broth Microdilution (Manual)
□ Disk Diffusion
□ E-test
□ Molecular test (specify):_____________
□ Other non-molecular test (specify):_______

□ Positive
Positive
□ Positive
Positive
□ Positive
Positive
□ Positive
Positive
□ Positive
Positive
□ Positive
Positive
□ Positive
Positive
Positive
□ Positive

25a. IS ANTIMICROBIAL USE (IV OR ORAL) IN THE 30 DAYS BEFORE THE DISC DOCUMENTED?
25b. IF YES, CHECK ALL ANTIMICROBIALS USED IN THE 30 DAYS BEFORE THE DISC: (Check all that apply)

□ Amikacin
□ Amoxicillin
□ Amoxicillin/clavulanic acid
□ Ampicillin
□ Ampicillin/sulbactam
□ Azithromycin
□ Aztreonam
□ Cefazolin
□ Cefdinir
□ Cefepime
□ Cefixime
□ Cefotaxime
□ Cefoxitin
□ Cefpodoxime
□ Ceftaroline

□ Ceftazidime
□ Ceftazidime/avibactam
□ Ceftizoxime
□ Ceftolozane/tazobactam
□ Ceftriaxone
□ Cefuroxime
□ Cephalexin
□ Ciprofloxacin
□ Clarithromycin
□ Clindamycin
□ Dalbavancin
□ Daptomycin
□ Delafloxacin
□ Doripenem
□ Doxycycline

□ Apnea
□ Bradycardia
□ Lethargy
□ Vomiting

□ Ertapenem
□ Fidaxomicin
□ Fosfomycin
□ Gentamicin
□ Imipenem/cilastatin
□ Levofloxacin
□ Linezolid
□ Meropenem
□ Meropenem/vaborbactam
□ Metronidazole
□ Moxifloxacin
□ Nitrofurantoin
□ Oritavancin
□ Penicillin
□ Piperacillin/tazobactam

□ Negative
Negative
□ Negative
Negative
□ Negative
Negative
□ Negative
Negative
□ Negative
Negative
□ Negative
Negative
□ Negative
Negative
□ Negative
Negative

□ Indeterminate
Indeterminate
□ Indeterminate
Indeterminate
□ Indeterminate
Indeterminate
□ Indeterminate
Indeterminate
□ Indeterminate
Indeterminate
□ Indeterminate
Indeterminate
□ Indeterminate
Indeterminate
Indeterminate
□ Indeterminate

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

□ Yes □ No □ Unknown
□ Unknown
□ Polymyxin B
□ Polymyxin E (colistin)
□ Rifaximin
□ Tedizolid
□ Telavancin
□ Tigecycline
□ Tobramycin
□ Trimethoprim
□ Trimethoprim/sulfamethoxazole
□ Vancomycin
□ IV
□ PO
□ Other (specify): _____________________
□ Other (specify): _____________________

REMINDER: Any prior antimicrobial use that is not noted above should be documented in the other (specify) field.

Version Date: 01/2019

PAGE 3 OF 4

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

26. 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
Data Source
Antibiotic

Antibiotic

Medical Record
Medical Record
MIC
MIC

Interp
Interp

Microscan
Microscan
MIC
MIC

Vitek
Vitek

Interp
Interp

MIC
MIC

Interp
Interp

Phoenix
Phoenix
MIC
MIC

Amikacin
Amikacin
Amoxicillin/Clavulanate
Amoxicillin/Clavulanate
Ampicillin
Ampicillin
Ampicillin/Sulbactam
Ampicillin/Sulbactam
Aztreonam
Aztreonam
Cefazolin
Cefazolin
CEFEPIME
CEFEPIME
CEFOTAXIME
CEFOTAXIME
CEFTAZIDIME
CEFTAZIDIME
Ceftazidime/Avibactam
CEFTRIAXONE
Ceftolozane/Tazobactam
Cephalothin
CEFTRIAXONE
Ciprofloxacin
Cephalothin
COLISTIN
Ciprofloxacin

Interp
Interp

Kirby-Bauer
Kirby-Bauer
Zone
Interp
Zone
Diam
Interp
Diam

E-test
E-test
MIC
MIC

Interp
Interp

DORIPENEM
COLISTIN
ERTAPENEM
DORIPENEM
Gentamicin
Doxycycline
IMIPENEM
ERTAPENEM
Levofloxacin
Fosfomycin
MEROPENEM
Gentamicin
Moxifloxacin
IMIPENEM
Nitrofurantoin
Imipenem-relebactam
Piperacillin/Tazobactam
Levofloxacin
POLYMYXIN B
MEROPENEM
TIGECYCLINE
Meropenem-vaborbactam
Tobramycin
Minocycline
Trimethoprim-sulfamethoxazole
Moxifloxacin
Meropenem-vaborbactam
Nitrofurantoin
Minocycline
Piperacillin/Tazobactam
Doxycycline
Plazomicin
Plazomicin
POLYMYXIN B
Tetracycline
Rifampin
Rifampin
Tetracycline
Ceftazidime/Avibactam
TIGECYCLINE
Ceftolozane/Tazobactam

Tobramycin
Fosfomycin
Imipenem-relebactam
Trimethoprim-sulfamethoxazole

27a. WAS CASE FIRST IDENTIFIED THROUGH AUDIT?
27a. WAS CASE FIRST INDENTIFIED THROUGH AUDIT?
□ Yes
Yes
□ No

No

27d. COMMENTS:

27b. CRF STATUS:

27b. CRF STATUS:
□ Complete
Complete
□ Pending
Pending
□ Chart
unavailable after 3 requests

27c. SO INITIALS:

27c. SO INITIALS:

Chart unavailable after 3 requests

27d. COMMENTS:

CS295460-B

PAGE 4 OF 4