Form 0920-0978 FoodNet HUS CRF

Form Approved OMB No. 0920-0978 Exp. Date xx/xx/xxxx

Case ID_____________p1

A

A

CDC’s FoodNet Hemolytic Uremic Syndrome (HUS) Surveillance
Case Report Form
YYYYYearXXFipscode001Record

1A. Case ID

_________________________________________________________

2A. State ID

_________________________________________________________

3A. FoodNet Person ID (if applicable)

_________________________________________________________

4A. Site

_________________________________________________________

5A. Date entered

________/________/________

Demographic Information
Instructions: Complete the following demographic information as it pertains to the patient diagnosed with HUS.
6A. Date of Birth

________/________/________

7A. State of Residence

_________________________________________________

8A. County of residence

_________________________________________________

9A. Sex

 Male  Female  Unknown

10A. Ethnicity

 Hispanic  Non-Hispanic  Unknown

11A. Race

 Black

 White

 Asian

 American Indian / Alaska Native
 Pacific Islander / Native Hawaiian
 Multi-Racial  Other  Unknown
Clinical Information
Instructions: Complete the following by interviewing the attending physician and/or reviewing patient's medical record.
12A. Is the date of HUS diagnosis known?

 yes  no

13A. Date of HUS diagnosis?

________/________/________

14A. Did the patient have diarrhea in the 3 weeks before HUS diagnosis?

 yes  no  unknown

if yes

17A.

15A.

Date of diarrhea onset

________/________/________

16A.

Did stools contain visible blood at the time?

 yes  no  unknown

Was diarrhea treated with antimicrobial medications?
if yes

18A.

 yes  no  unknown

Types of antimicrobials used to treat diarrhea: (check all that apply)












Azithromycin (Zithromax, Z-Pak)
Ceftriaxone (Rocephin)
Ciprofloxin (Cipro)
Levofloxacin (Levaquin)
Metronidazole (Flagyl)
Piperacillin
Tazobactam
Trimethoprim Sulfamethoxazole (Bactrim, Septra)
Vancomycin (Vancocin)
Other ____________________________________
Unknown

Last updated 7/06/2016
Public reporting burden of this collection of information is estimated to average 132 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 30333; ATTN: PRA (0920-0978).

Case ID_____________p2

A

A
Clinical Information Continued

19A. Did the patient have contact with another person with
diarrhea or HUS during the 3 weeks before HUS diagnosis
(include daycare, household, etc)?

 yes  no

 unknown

20A. Was the patient treated with an antimicrobial medication
(ANY antibiotic) for any other reason than diarrhea during
the 3 weeks before HUS diagnosis?

 yes  no

 unknown

if yes

21A. Reason treated with antimicrobial

22A.

Types of antimicrobials used to treat conditions other than diarrhea: (check all that apply)












_______________________________

Azithromycin (Zithromax, Z-Pak)
Ceftriaxone (Rocephin)
Ciprofloxin (Cipro)
Levofloxacin (Levaquin)
Metronidazole (Flagyl)
Piperacillin
Tazobactam
Trimethoprim Sulfamethoxazole (Bactrim, Septra)
Vancomycin (Vancocin)
Other ______________________________
Unknown

Other medical conditions present during 3 weeks before HUS diagnosis:
23A.

Other gastrointestinal illnes

 yes  no

 unknown

24A.

Urinary tract infection

 yes  no

 unknown

25A.

Respiratory tract infection

 yes  no

 unknown

26A.

Other acute illness

 yes  no

 unknown

if yes

Describe ____________________________________________________________________________

27A.

Pregnancy

 yes  no  unknown

28A.

Kidney disease

 yes  no  unknown

29A.

Immune compromising condition or medication

 yes  no  unknown

if yes

30A. Malignancy

 yes  no  unknown

31A. Transplanted organ or bone marrow

 yes  no  unknown

32A. HIV infection

 yes  no  unknown

33A. Steroid Use (parenteral or oral)

 yes  no  unknown
 yes  no  unknown

Other
Describe

_____________________________

Laboratory values within 7 days before and 3 days after HUS diagnosis
Instructions: Record the correct unites or convert to the correct units before entering into the HUS database, especially for platelet
count (e.g., enter a platelet count of 33,700/mm3 as 33.7)
34A.

Highest serum creatinine

_______________

mg/dL (suggested range: 0.10-30.00)

35A.

Highest serum BUN

_______________

mg/dL (suggested range: 4.0-100.0)

36A.

Highest WBC

_______________

K/mm3 (suggested range: 0.50-125.00)

Last updated 7/06/2016

Case ID_____________p3

A

A
Laboratory Values Continued

37A.

Lowest hemoglobin

_______________

38A.

Lowest hematocrit

_______________

%

(suggested range: 0.0-100.0)

_______________

K/mm3

(suggested range: 3.0-600.0)

39A.

Lowest platelet count

40A.

Microangiopathic changes

g/dL

(suggested range: 2.0-30.0)

 yes  no  unknown  not tested

Other laboratory findings within 7 days before and 3 days after HUS diagnosis:
41A. Blood (or heme) in urine

 yes  no  unknown  not tested

42A. Protein in urine

 yes  no  unknown  not tested

43A. RBC in urine by microscopy

 yes  no  unknown  not tested

Epi Information
Instructions for Hospital Discharge Data: All records meeting the ICD9-or ICD10-CM codes specified in the surveillance protocol should
be reviewed even if the case had already been identified through Active Surveillance in order to obtain potentially missing information.
If a case is captured through HDD and was previously identified through the network of practitioners, sites should check that the
abstracted information from active surveillance is current and complete. In the event that additional information is available, this should
be included in the FoodNet HUS surveillance system. If a discrepancy is identified, the most current information should be used.
44A. How was patient’s illness first identified by public health (state or local health department or EIP)?













Report of HUS case by a physician or service participating in the FoodNet HUS active surveillance network
Report of HUS case by a non-participating physician or service
Routine STEC infection active surveillance
Retrospective review of hospital discharge data
Other (please specify) ___________________________________________________________________________
Unknown

45A. Date reported to public health or identified
by hospital discharge data review

________/________/________

46A. Was hospital discharge data review completed
for this case (to verify or supplement information)?

 yes  no  unknown

47A. Date of HDD (hospital discharge data) review

________/________/________

48A. Is this case epidemiologically linked to a confirmed
or probable Shiga toxin-producing E.coli (STEC) case?

 yes  no  unknown

49A. Is this case outbreak related?

 yes  no  unknown

Form A Comments, Composite Variables, and Status
50A. Completed by (initials):

_________________________________________________________

51A. Comments

_________________________________________________________
_________________________________________________________
_________________________________________________________

55A. Complete?

 incomplete  unverified  complete

Last updated 7/06/2016

Case ID_____________p4

B

B
CDC’s Foodnet Hemolytic Uremic Syndrome Surveillance
Microbiology Report Form

Instructions: Enter the most relevant microbiology tests associated with this HUS case by specimen source. If multiple positive stool
specimens were tested, prioritize specimens tested by the SPHL or CDC. Include positive stool with any evidence of STEC, and, if
applicable, serum sent to CDC for testing of abxbodies against STEC and/or one other positive specimen if additional results are
available. In addition, you will be prompted to enter negative results (if applicable) only for evidence of STEC.

Stool Specimen
1B. Was stool collected?

 yes  no

 unknown

2B. Date stool specimen collected

________/________/________

3B. State Lab ID:

_____________________________

Instructions: Answer below questions as they pertain to the stool specimen collected at each lab. You will be asked about other
specimens in the other pathogens section.
4B. Questions
Clinical Lab
State or Local PHL
CDC Lab (Federal)
Was this specimen forwarded
N/A
 yes  no  unk
 yes  no  unk
to the lab?
Was testing performed at lab?
 yes  no  unk
 yes  no  unk
 yes  no  unk
Was a Shiga toxin test
N/A
 yes  no  unk
 yes  no  unk
performed? (e.g. PCR, EIA)
Shiga toxin test result
 positive  negative
 positive  negative
 positive  negative
Shiga toxin type

Was a CIDT for E. coli O157
performed? (e.g. Immunocard Stat)
CIDT result?
Did the test include H7?
Was a culture for E.coli O157
performed?
Was E.coli O157 isolated?
Was a culture for E.coli nonO157 performed?
Was E.coli non-O157
isolated?
O Antigen

H Antigen

 stx1  stx2  stx1 &
stx2 undifferentiated

 stx1  stx2  stx1 &
stx2 undifferentiated

 yes  no  unk

 yes  no  unk

 positive  negative
 yes  no  unk
 yes  no  unk
 yes  no  unk

 stx1  stx2  stx1 & stx2
undifferentiated
N/A

 positive  negative

N/A

N/A

N/A
N/A

 yes  no  unk
 yes  no  unk
 yes  no  unk

 yes  no  unk

N/A
N/A

 yes  no  unk

 yes  no  unk

N/A

O26 O111 O103
 O121 O45  O145
rough und not found

N/A

 H7 pos  H7 neg
 non-motile not tested

5B. Was immunomagnetic separation (IMS) used to
identify common STEC serogroups?
6B. What serogroup(s) did the IMS procedure target?
(check all that apply)
7B. Was whole genome sequencing (WGS) performed on this isolate? (at state or CDC)
8B. Sequencing ID:

 yes  no

 unknown

 O157  O26  O45
 O103  O111  O121
 O145

 yes  no

 unknown
_____________________________

Last updated 7/06/2016

Case ID_____________p5

B

B
CDC Serology Tests
 yes  no

9B. Has patient serum or plasma been sent to CDC for testing
for antibodies to O157 or other STEC?

 unknown

10B. Date serology specimen collected?

________/________/________

11B. State laboratory ID for serum

_____________________________

12B. Was there more than one serology result for this case?

 yes  no  unknown

13B. Questions
LPS type

Titer IgG

Interpretation of IgG
Positive
Negative

Interpretation of IgM
Positive
Negative

Titer IgM

 O157  O111
 O157  O111
 O157  O111
Other Pathogens (co-infections) and Other Specimens
14B. Questions
Were any other pathogens
identified?
Specimen source
Test type

Clinical Lab

State or Local PHL

CDC Lab (federal)

yes no  unk

yes no  unk

yes no  unk

Same stool used for STEC
testing
culture CIDT

Same stool used for STEC
testing
culture CIDT

Same stool used for STEC
testing
culture CIDT

Pathogen
Other Specimens (second specimen)

yes no  unk

Was any other specimen
collected?
Date other specimen
collection
Specimen source

________/________/________

culture non-culture (CIDT)

Test type 1
Pathogen 1

culture non-culture (CIDT)

Test type 2
Pathogen 2
Where positive? (check
all that apply)
Other specimen
State lab id



clinic 

State or local 

CDC

Form B Comments, Composite Variables, and Status
15B. Completed by (initials)

__________________________________________________________

16B. Comments

__________________________________________________________
__________________________________________________________
__________________________________________________________

20B. Complete?

 incomplete  unverified

 complete
Last updated 7/06/2016

Case ID_____________p6

C

C
CDC’s Foodnet Hemolytic Uremic Syndrome Surveillance
Chart Review Form

Instructions: Complete after patient has been discharged; use hospital discharge summary, consultation notes and DRG coding sheet.
Complete one composite form for all institution where hospitalized.

Hospitals
1C. Was patient hospitalized?

 yes  no  unknown

2C. Date of first admission:

________/________/________

3C. Date of last discharge:

________/________/________

Complications
Did any of the following complications occur during this admission:
4C.
6C.
8C.
10C.
12C.

Pneumonia
Seizure
Paralysis or hemiparesis
Blindness
Other major neurologic
sequelae
if yes, Describe:

 yes  no
 yes  no
 yes  no
 yes  no
 yes  no

 unknown
 unknown
 unknown
 unknown
 unknown

if yes
If yes
If yes
if yes
if yes

Date of onset
5C. ____/____/____
7C. ____/____/____
9C. ____/____/____
11C. ____/____/____
13C. ____/____/____

________________________________________________________

Were any of the following procedures performed during this admission:
14C.
15C.

19C.
20C.

Peritoneal dialysis
Hemodialysis

 yes  no  unknown
 yes  no  unknown

Transfusion with:
16C. packed RBC or whole blood
17C. platelets
18C. fresh frozen plasma

 yes  no  unknown
 yes  no  unknown
 yes  no  unknown

Plasmapheresis
 yes  no  unknown
 yes  no  unknown
Laparotomy or other abdominal surgery*
(*other than insertion of dialysis catheter)
if yes Describe:
_________________________________________________________

Discharge
 dead alive

21C. Condition at discharge
if dead

22C. Date deceased

________/________/________

if alive

23C. Requiring dialysis

 yes  no

 unknown

24C. With neurologic deficits

 yes  no

 unknown

Form C Comments, Composite Variables, and Status
25C. Completed by (initials):

_________________________________________________________

26C. Comments

_________________________________________________________

28C. Complete?

 incomplete  unverified

 complete
Last updated 7/06/2016