Form 0920-0978 2020 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 –

2020 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.:

Mo.

Day

7b. HOSPITAL I.D. WHERE 8. DATE OF BIRTH:
Mo.
Day
PATIENT TREATED:

6. COUNTY: (Residence of Patient)

5. CRF Status: 1

4. Date reported to EIP site:

3. PATIENT I.D.:

Year

4

Complete 2
Chart unavailable 7
after 3 requests

1

9b. Is age in day/mo/yr?
Mos. 3
Yrs.
Days 2
1
11b. RACE: (Check all that apply) 1

Lab Repeating Group Section (T1-T10)
T1
Test Type

T2
Date of Specimen Collection
Day

Mo.

White 1

T3
T3a
Test Method Hospital/Lab I.D.
(non-culture) where test identified

Year

American Indian 1
or Alaska Native

Black 1

2

11a. ETHNIC ORIGIN:

Male

1

Hispanic or Latino

Female

2

Not Hispanic or Latino

9

Unknown

Asian 1

Native Hawaiian
1
or Other Pacific Islander

T5
Bacterial Species
Isolated*

T4
Site from which
organism isolated

Edited & Correct

QA Review Change

10. SEX:

9a. AGE:

Year

Incomplete 3

Unknown

T6
Test Result

1
2
3


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

Yes

If YES, date of admission:
Mo.

2

Day

Date of discharge:

Year

Mo.

Day

T8
T10
T7
T9
Isolate/ Specimen Isolate/ specimen Shipped to If shipped,
N/A, why not?
Available?
accession #
CDC?

Year

1

No

2

17. If patient was hospitalized, was this patient admitted to the
ICU during hospitalization?
1

Yes

2

No

9

3


Unknown

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

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

22. OUTCOME: 1

Unknown

OR

Survived 2

Died 9

Unknown

24a. At time of first positive culture, patient was:
Postpartum 3
1
Pregnant 2
Neither 9

Unknown

Private

1

Military

1

Other(specify) _________________

Medicare

1

Indian Health Service (IHS)

1

Uninsured

1

Medicaid/state assistance program

1

Incarcerated

1

Unknown

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
Live birth/neonatal death

1

Bacteremia
without Focus

1

Meningitis

1

Peritonitis

1

Endometritis

1

Pericarditis

1

STSS

Septic abortion

1

Necrotizing fasciitis

1

Otitis media

1

Mark if this is a HiNSES fetal death with placenta and/or amniotic fluid isolate, a
stillbirth, or neonate <22 wks gestation.

1

Pneumonia

1

Chorioamnionitis

1

Puerperal sepsis

1

Cellulitis

Mark if this is a GBS Blood Spot Study case that lives outside ABCs catchment area

1

Septic arthritis

1

Septic shock

1

Epiglottitis

1

Osteomyelitis

1

Other (specify)

1

Hemolytic uremic
syndrome (HUS)

1

Empyema

1

Abscess (not skin)

1

Endocarditis

1

Unknown

Abortion/stillbirth

24d.

9

1

22a. If survived, patient discharged to: 1

24b. If pregnant or postpartum, what was the outcome of fetus:
Survived, clinical infection 3
1
Survived, no apparent illness 2
24c.

No

1

23. If patient died, was the culture obtained on autopsy?
1
Yes 2
No
9
Unknown

4

Yes 2

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

20b. HEIGHT:

20c. BMI: ___ ___ . ___

Facility ID:

Unknown

1

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

5

Induced abortion

6

Still pregnant

9

Unknown

25. If patient <1 month of age, indicate gestational age and birth weight. If pregnant, indicate
gestational age of fetus, only.
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 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
AIDS or CD4 count <200
Immunosuppressive
Therapy
(Steroids,
etc.)
1
1
Connective Tissue Disease (Lupus, etc.)
1
Eculizumab (Soliris) - N.men. only
1
Asthma
1
CSF
Leak
1
Atherosclerotic CVD (ASCVD)/CAD
Ravulizumab (Ultomiris) - N.men. only
1
1
Deaf/Profound Hearing Loss
1
1
Bone Marrow Transplant (BMT)
Leukemia
1
Dementia
1
1
CVA/Stroke/TIA
1
Multiple Myeloma
Diabetes Mellitus,
1
1
Chronic Hepatitis C
1
Multiple Sclerosis
HbA1C ______(%), Date ___/___/______
1
1
Chronic Kidney Disease
Myocardial Infarction
1
Emphysema/COPD
1
1
Chronic Liver Disease/cirrhosis
Nephrotic Syndrome
1
Heart Failure/CHF
1
1
Current Chronic Dialysis
1
Neuromuscular Disorder
HIV Infection
1
1
Chronic Skin Breakdown
1
Obesity
Hodgkin’s
Disease/Lymphoma
1
1
Cochlear Implant
1
Parkinson’s Disease
Immunoglobulin Deficiency
1
1
Complement Deficiency
Peptic Ulcer Disease
1

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

27b. 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

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

1

Marijuana/cannibinoid (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

1

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

1

DUD or Abuse

1

Opioid, NOS

1

DUD or Abuse

1

Cocaine

1
1

Methamphetamine

1
1

Other* (specify): _______________

1

Unknown substance

9

No

Unknown

non-IDU

1

Unknown

IDU

1

Skin popping 1

non-IDU

1

Unknown

1

IDU

1

1

Unknown

IDU

1

Skin popping 1
Skin popping 1

non-IDU

1

non-IDU

1

Unknown

DUD or Abuse
DUD or Abuse

1
1

IDU

Skin popping 1
Skin popping 1

non-IDU
non-IDU

1
1

Unknown

IDU

1
1

1

DUD or Abuse

1

IDU

1

non-IDU

1

Unknown

1

DUD or Abuse

1

IDU

1

Skin popping 1
Skin popping 1

non-IDU

1

Unknown

Unknown

– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISM –
HAEMOPHILUS INFLUENZAE
28a. What was the serotype?

1

b

2

Not Typeable
ypeable

3

a

4

c

5

d

6

e

7

Yes 2 No 9
Unknown
28b. If <15 years of age and serotype ‘b’ or ‘unknown’ did 1
patient receive Haemophilus influenzae b vaccine? If YES, please complete the list below.
VACCINE NAME / MANUFACTURER
DOSE
DATE GIVEN
DOSE
Mo.

Day

Year

1

3

2

4

NEISSERIA MENINGITIDIS
29. What was the serogroup?
1
6

A

2

B

3

Not Groupable 8

C

4

Y

5

W135
9

31.Did patient receive meningococcal vaccine?
Type Codes:
1= ACWY conjugate
(Menactra,
Menveo, MenHibrix)
2= ACWY
polysaccharide
(Menomune)
3= B (Bexsero,
Trumenba)
9= Unknown

Other (specify)

8

TYPE

1

Unknown
1

Yes 2

No 9

DATE GIVEN
Mo.

Day

Yes 2

No 9

Day

Unknown If YES, complete the table

1
2

Not tested or Unknown

VACCINE NAME / MANUFACTURER

Year

STREPTOCOCCUS PNEUMONIAE
32. Did patient receive pneumococcal vaccine?
1

Unknown

VACCINE NAME / MANUFACTURER

Year

9

DATE GIVEN

Mo.

30. Is patient currently attending college?

Other

DOSE

f

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
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
Sterile Sites
1=Blood
2=Bone
3=Brain
4=CSF
5=Heart
6=Joint
7=Kidney
8=Other Sterile Site
9=unknown
10=Liver
11=Lymph node
12=Muscle/Fascia/Tendon
13=Ovary
14=Pancreas
15=Pericardial Fluid

16=Peritoneal Fluid
17=Pleural fluid
18=Spleen
19=Vascular Tissue
20=Vitreous fluid
Non-Sterile Sites
21=Amniotic fluid
24=Placenta
27=Wound

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 Available
1=Yes
2=No
T8 - No Isolate, 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)
6=Isolate N/A for collection
T9 - Shipped to CDC?
1=Yes
0=No

* 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