Form 0920-0978 HAIC Invasive Methicillin-resistant Staphylococcus aureu

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

Invasive Methicillin-Resistant Staphylococcus aureus
Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2019
Patient’s Name:

Phone No.: (

Address:

)

MRN:

City:

State:

ZIP:

Hospital:

— PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC —

1. STATE:

2. COUNTY:

1

Male

9

Unknown

1

Check if transgendered

Female

-

1

-

Male 2

oz. OR

Mos. 3

kg.

Years

13. ETHNIC ORIGIN:

American Indian or Alaska Native

1

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

1

Asian

1

White

Not Hispanic or Latino

1

Black or African American

1

Unknown

Unknown

14. BMI (record only if ht. and/or wt.

ft.

Unknown

in. OR

Yes

2

1

Unknown

No

9

IF YES, date of admission:

Unknown

-

15. DATE OF INCIDENT SPECIMEN COLLECTION
(DISC):

is not available)

cm. 1

Unknown

16. WAS THE PATIENT HOSPITALIZED AT THE TIME OF OR IN THE 29 CALENDAR DAYS AFTER,
THE DISC?
1

6. FACILITY ID WHERE PATIENT
TREATED:

1

13. HEIGHT:

lbs.

5. LABORATORY ID WHERE INCIDENT
SPECIMEN INDENTIFIED:

10. RACE: (Check all that apply)

9. AGE

12. WEIGHT:

1

4. PATIENT ID:

8. DATE OF BIRTH:

7. SEX AT BIRTH:
2

3. STATE ID:

-

-

17. WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR DAYS AFTER
HOSPITAL ADMISSION?
Yes (HO-MRSA case)

1

-

2

No (CA-MRSA or HACO-MRSA case)

18. INCIDENT SPECIMEN COLLECTION SITE: (Check all that apply)
1

Blood 1

1

Pleural fluid 1

Bone 1

CSF 1

Internal body site (specify):

1

Muscle 1

Pericardial fluid 1

Peritoneal fluid

20. WERE CULTURES OF THE SAME OR OTHER STERILE SITES(S) POSITIVE WITHIN 29 DAYS AFTER
DISC?
1 Yes 2 No 9 Unknown

19. LOCATION OF SPECIMEN COLLECTION:
1
Outpatient
Facility
ID:

5
LTCF
Facility
ID:

Inpatient
1
Facility
ID:

3

Emergency room

8

Clinic/doctor’s office

15

Dialysis center

11

Surgery

16

Observation/Clinical
decision unit

4

Joint/Synovial fluid 1

Other normally sterile site (specify):

IF YES, INDICATE SITE AND DATE OF LAST POSITIVE CULTURE:

13
LTACH
Facility
ID:

1

ICU

6

OR

7

Radiology

14

2

Other Inpatient

10 1

Autopsy
Yes

2

No

9

Unknown

Other outpatient

9

1 Blood
Date:

1 Bone
Date:

1 CSF
Date:

1 Internal body site
Date:

1 Joint/Synovial fluid
Date:

1 Muscle
Date:

1 Peritoneal fluid
Date:

1 Pericardial fluid
Date:

1 Pleural fluid
Date:

1 Other normally sterile site (specify):
Date:

Unknown

21. DATE OF FIRST SA BLOOD CULTURE AFTER WHICH SA NOT ISOLATED FOR 14 DAYS:

-

-

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

S

I

R

U

Cefoxitin

S

Nafcillin

S

I

R

U

Oxacillin

S

Vancomycin

S

I

R

U

I

R

U

Clindamycin

S

I

R

U

R

U

Trimethoprim-Sulfamethozazole

S

I

R

U

I

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

24. IF CASE IS ≤12 MONTHS OF AGE, TYPE OF BIRTH HOSPITALIZATION:

1

1 LTACH
Facility ID:

1

1

Homeless

1

1

Incarcerated

1

Other (specify):

1

Unknown

Private residence

1 LTCF
Facility ID:
1 Hospital Inpatient
Facility ID:
Was patient transferred from this hosptial?
1

Yes

2

No

9

Unknown

Yes

2

No

9

-

Yes

2

No

9

9

Unknown

Unknown
lbs.

oz. OR

IF YES, estimated gestational age:

OR 1

weeks OR 1

g. OR 1

Unknown birth weight

Unknown gestational age

27. WAS THE PATIENT IN AN ICU ON THE DISC OR IN THE 2 DAYS AFTER THE DISC?
1

-

Well Baby Nusery

IF YES, birth weight:

Unknown

IF YES, date of ICU admission:

2

25. IF PATIENT <2 YEARS OF AGE WERE THEY BORN PREMATURE (<37 WEEKS GESTATION)?

26. WAS THE PATIENT IN AN ICU IN THE 2 DAYS BEFORE THE DISC?
1

NICU/SCN

Date Unknown

Yes

2

No

9

Unknown

IF YES, date of ICU admission:

-

-

OR 1

Date 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
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 —

Page 1 of 2

28. TYPES OF MRSA 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

1

Bacteremia

1

Decubitus/Pressure Ulcer

1

Peritonitis

1

Septic Shock

1

Urinary Tract

1

Bursitis

1

Empyema

1

Pneumonia

1

Skin Abscess

1

Other: (specify)

1

Catheter Site Infection

1

Endocarditis

1

Osteomyelitis

1

Surgical Incision

29. UNDERLYING CONDITIONS: (Check all that apply) 1

None

1

Unknown

CHRONIC METABOLIC DISEASE
1 Diabetes mellitus
1 With chronic complications

IMMUNOCOMPROMISED CONDITION
1 HIV infection
1 AIDS/CD4 count <200
1 Primary immunodeficiency
1 Transplant, hematopoetic stem cell
1 Transplant, solid organ

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

LIVER DISEASE
1 Chronic liver disease
1 Ascites
1 Cirrhosis
1 Hepatic encephalopathy
1
Variceal bleeding

GASTROINTESTINAL DISEASE
1 Diverticular disease
1 Inflammatory bowel disease
1 Peptic ulcer disease
1 Short gut syndrome

1

CHRONIC LUNG DISEASE
Cystic fibrosis
Chronic pulmonary disease

1

NEUROLOGIC CONDITION
1 Cerebral palsy
1 Chronic cognitive deficit
1 Dementia
1 Epilepsy/seizure/seizure disorder
1 Multiple sclerosis
1 Neuropathy
1 Parkinson’s Disease
1 Other (specify):

mg/DL

SKIN CONDITION
1 Burn
1 Decubitus/pressure ulcer
1 Surgical wound
1 Other chronic ulcer or chronic wound
1 Other skin condition (specify):

PLEGIAS/PARALYSIS
1 Hemiplegia
1 Paraplegia
1 Quadriplegia

Hepatitis C
Treated, in SVR

1

RENAL DISEASE
1 Chronic kidney disease
Lowest serum creatinine:

OTHER
1 Connective tissue disease
1 Obesity or morbid obesity
1 Pregnant
1 Other (specify only for cases
≤12 months of age):

Current, chronic

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

30. SUBSTANCE USE, CURRENT
ALCOHOL ABUSE:

SMOKING: (Check all that apply)
None

1

1

Unknown

1

Tobacco

E-nicotine delivery system

1

OTHER SUBSTANCES: (CHECK ALL THAT APPLY)

1

None

1

1

Marijuana

1

Yes

1

1

No

Unknown

Unknown

DOCUMENTED USE DISORDER (DUD)/ABUSE:

MODE OF DELIVERY (Check all that apply):

1

Marijuana/cannabinoid (other than smoking)

1

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

1

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

1

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

1

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

1

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

1

Cocaine or methamphetamine

1

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

1

Other (specify):__________________________

1

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

1

Unknown substance

1

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

31. PRIOR HEALTHCARE EXPOSURE(S):

SURGERY IN THE YEAR BEFORE DISC

PREVIOUS DOCUMENTED MRSA INFECTION OR COLONIZATION

IF YES, Unknown list the surgeries and dates of surgery that occurred within 90 days prior to the DISC:

1

Yes

2

No

9

Month

Year

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC
1

Yes

2

No

9

Unknown

If YES, DATE OF DISCHARGE CLOSEST TO DISC:
OR, 1

Date unknown

Facility ID:
OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC
1 Yes 2 No 9 Unknown
Facility ID
OVERNIGHT STAY IN LTCF IN THE YEAR BEFORE DISC
1

Yes

2

No

Facility ID

CDC 52.15B Rev. 07-2018

9

Unknown

-

Yes

2

No

Surgery

Unknown
OR previous STATE I.D.:

If YES:

1

-

9

Unknown

Date

1.

-

-

2.

-

-

3.

-

-

4.

-

-

CENTRAL LINE IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2
CALENDAR DAYS BEFORE DISC
1 Yes 2 No 9 Unknown CHECK HERE if central line in place for >2 calendar days 1
DIALYSIS IN THE YEAR BEFORE DISC (Hemodialysis or Peritoneal dialysis)
1 Yes 2 No 9 Unknown
CURRENT CHRONIC DIALYSIS 1
TYPE:

Hemodialysis

Yes

2

Peritoneal

IF HEMODIALYSIS, type of vascular access: 1
9
CS294652

No

9

Unknown

Unknown
AV fistual/graft
Unknown

2

Hemodialysis central line

Page 2 of 3

32. PATIENT OUTCOME

1

Survived

DATE OF DISCHARGE:
1

-

2
-

OR 1

Date Unknown

Left against medical advice (AMA)

IF SURVIVED, DISCHARGED TO:
1 Private Residence
2 LTCF Facility ID:
3 LTACH Facility ID:

Died

2

DATE OF DEATH:

-

-

OR 1

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?
4

Other (specify):

9

Unknown

1

Yes
es

No

Unknown

– THIS SHADED AREA FOR OFFICE USE ONLY –
33. WAS CASE FIRSTIDENTIFIED
THROUGH AUDIT?
1

Yes

2

9

Unknown

38 COMMENTS:

No

34. CRF STATUS:
1 Complete
2 Incomplete
3 Edited & Correct
4 Chart unavailable
after 3 requests

35. DOES THIS CASE HAVE
RECURRENT MRSA
DISEASE ?
1

Yes

2

9

Unknown

IF YES, PREVIOUS
(1ST) STATE I.D.

36. DATE REPORTED TO EIP SITE:

No
-

-

37. S.O. INITIALS: