Form 0920-0978 2020 Carbapenem Resistant Enterobacteriaceae (CRE) Carba

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

DATE REPORTED TO EIP SITE:

___ ___ - ___ ___ - ___ ___ ___ ___

2020 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. (

)
MRN:

Address:
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.

9. DATE OF INCIDENT SPECIMEN
COLLECTION (DISC):

4a. LABORATORY ID WHERE
INCIDENT SPECIMEN IDENTIFIED:
________________________

___ ___ - ___ ___ - ___ ___ ___ ___

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

_______________________________

8b. RACE: (Check all that apply)

□ American Indian or Alaska □ Native Hawaiian or

□ Hispanic or Latino
□ MALE □ FEMALE □ Not Hispanic or Latino
□ Unknown
□ Check if transgender □ Unknown
10. ORGANISM: □ CRE □ CRAB
If CRE, select one of
the following and
specify species for less
common genera:

4b. FACILITY ID WHERE PATIENT TREATED:

Native

Other Pacific Islander

□ Asian
□ White
□ Black or African American □ Unknown

Citrobacter spp. _______________________________________________________
Serratia spp.

_______________________________________________________

Proteus spp.

_______________________________________________________

Morganella spp. _______________________________________________________
Providencia spp. _______________________________________________________
Raoutella spp.

_______________________________________________________

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): ___________ □ Respiratory site (specify): ___________ □ Other non-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: 01/2019

PAGE 1 OF 4

Form Approved

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

17a. 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

17c. WAS THE PATIENT TREATED FOR THE MUGSI ORGANISM?
18. UNDERLYING CONDITIONS: (Check all that apply)

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

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

□
□
□
□

Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome

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

□
□
□
□
□
□
□
□

□
□
□

□ Unknown

□ Yes
□ Tobacco
□ No
□ E-nicotine delivery system □ Unknown
□ Marijuana

□

□

□ No

□ Yes □ No □ Unknown

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

DATE UNKNOWN

□
□
□

□

Lowest serum creatinine: ________mg/DL
□ Unknown or not done

□

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC:

OTHER

Chronic kidney disease

□

Connective tissue disease
Obesity or morbid obesity
Pregnant

□
□

Urinary tract problems/
abnormalities
Premature birth
Spina bifida

□ None □ Unknown

Marijuana, cannabinoid (other than smoking)
Opioid, DEA schedule I (e.g., heroin)
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
Opioid, NOS
Cocaine
Methamphetamine
Other (specify): _____________
Unknown substance

None
Unknown
WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR
□ Yes
DAYS AFTER HOSPITAL ADMISSION?

□

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

MuGSI CONDITIONS

□
□
□
□
□
□
□
□

DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse
DUD or abuse

DURING THE CURRENT HOSPITALIZATION, DID THE PATIENT RECEIVE
MEDICATION ASSISTED TREATMENT (MAT) FOR OPIOID USE DISORDER?

20. RISK FACTORS: (Check all that apply)

□
□
□
□

Hemiplegia
Paraplegia
Quadriplegia

DOCUMENTED USE DISORDER (DUD)/ABUSE:

□
□
□
□
□
□
□
□

MODE OF DELIVERY: (Check all that apply)
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU
□ IDU

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

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

OVERNIGHT STAY IN LTCF IN THE YEAR BEFORE DISC:

□ Yes □ No □ Unknown

Facility ID: __________

OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC:

□ Yes □ No □ Unknown

Facility ID: __________

□ Yes □ No □ N/A (patient not hospitalized or did not have DUD)

CENTRAL LINE 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
□

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

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

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

□ Yes □ No □ Unknown

IF YES, CHECK ALL THAT APPLY:

CURRENT CHRONIC DIALYSIS:

□ Yes □ No □ Unknown

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

□ Hemodialysis □ Peritoneal □ Unknown

IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:

PATIENT TRAVELED INTERNATIONALLY
IN THE YEAR BEFORE DISC:

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

21b. HEIGHT:
_________ft. _______ in. OR

_____kg

_____cm

Version Date: 01/2019

□ Unknown

□ Indwelling Urethral Catheter □ Suprapubic Catheter
□ Condom Catheter
□ Other (specify):__________

SURGERY IN THE YEAR BEFORE DISC:

□ Unknown

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

IF YES, CHECK ALL THAT APPLY:

Facility ID: __________

IF YES, TYPE:

□ Yes
□ No
□ Unknown

SKIN CONDITION

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)

ALCOHOL
ABUSE:

17b. RECURRENT UTI

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

NEUROLOGIC CONDITION

OTHER SUBSTANCES: (Check all that apply)

SMOKING:

□
□
□
□
□

PLEGIAS/PARALYSIS

MALIGNANCY

□
□
□

Pyelonephritis
Septic arthritis
Septic emboli
Septic shock
Skin abscess

□ None □ Unknown

□ AIDS/CD4 count < 200

CHRONIC METABOLIC DISEASE

□

□
□
□
□
□

□ Yes □ No □ Unknown

□ HIV infection

Cystic fibrosis
Chronic pulmonary disease

□ None □ Unknown □ Colonized

Epidural Abscess
Meningitis
Osteomyelitis
Peritonitis
Pneumonia

IMMUNOCOMPROMISED CONDITION

CHRONIC LUNG DISEASE

□
□

□
□
□
□
□

□ Unknown

21c. BMI:
_________

□ Unknown

□ NG Tube
□ Other (specify):

_____________

□ 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
Date: XX-XX-XXXX
Exp. 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: ________________

23. WAS THE

INCIDENT
SPECIMEN
POLYMICROBIAL?

□ Yes
□ No
□ Unknown

URINE CULTURES ONLY:
22c. 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
□ Apnea
□ Costovertebral angle pain or tenderness □ Frequency
□ Bradycardia
□ Suprapubic tenderness
□ Dysuria
□ Lethargy
□ Fever [temperature ≥ 100.4 °F (38 °C)] □ Urgency
□ Vomiting

24a. WAS THE

INCIDENT SPECIMEN
TESTED FOR
CARBAPENEMASE?

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

□ Yes
□ No
□ Laboratory not
testing

Non-Molecular Tests

Molecular Tests

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

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

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

Method (mCIM)

□ Unknown

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

25. WAS THE SAME ORGANISM (Q10)

26. ENTEROBACTERIACEAE ONLY: WERE
CULTURES OF STERILE SITE(S) OR URINE
POSITIVE FOR A DIFFERENT ORGANISM
(Q10) IN THE 30 DAYS BEFORE THE DISC?

CULTURED FROM A DIFFERENT
STERILE SITE OR URINE IN THE 30
DAYS AFTER THE DISC?

□ Yes □ No □ Unknown

□ Blood
□ Bone
□ CSF
□ Internal body site (specify): ___________
□ Joint/synovial fluid
□ Muscle
□ Peritoneal fluid
□ Pericardial fluid
□ Pleural fluid
□ Urine
□ Other normally sterile site (specify): ___________
□ Respiratory site (specify): ___________
□ Other non-sterile site (specify): ___________

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): ___________
□ Respiratory site (specify): ___________
□ Other non-sterile site (specify): ___________

□ 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
□ Other

□ Pos
□ Pos
□ Pos
□ Pos
□ Pos
□ Pos
□ Pos

□ Neg
□ Neg
□ Neg
□ Neg
□ Neg
□ Neg
□ Neg

(specify)___________

□ Ind
□ Ind
□ Ind
□ Ind
□ Ind
□ Ind
□ Ind

□ Unk
□ Unk
□ Unk
□ Unk
□ Unk
□ Unk
□ Unk

□ Escherichia coli
□ Enterobacter cloacae
□ Klebsiella aerogenes
□ Klebsiella pneumoniae
□ Klebsiella oxytoca
□ Citrobacter spp. ____________________________________________
□ Serratia spp. ____________________________________________
□ Proteus spp. ____________________________________________
□ Morganella spp. ____________________________________________
□ Providencia spp. ____________________________________________
□ Raoutella spp. ____________________________________________
STATE ID: ________________________

27a. A. BAUMANNII CULTURES ONLY:WERE CULTURES OF OTHER

27b. A. BAUMANNII CULTURES ONLY:

□ Yes □ No □ Unknown □ N/A IF

□ Yes □ No □ Unknown □ N/A

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

POSITIVE IN THE 3 CALENDAR
DAYS BEFORE THROUGH THE
3 CALENDAR DAYS AFTER
THE DISC FOR THE SAME
MuGSI ORGANISM?

IF YES, INDICATE ORGANISM AND
ASSOCIATED STATE ID FOR THE INCIDENT
CLOSEST TO THE DISC:

□ Yes □ No □ Unknown □ N/A

IF YES, SOURCE: (check all that apply)

URINE CULTURES ONLY:
22d. WAS A BLOOD CULTURE

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

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): ___________

IF YES, STATE ID FOR THE
28a. WAS THE PATIENT POSITIVE FOR THE SAME ORGANISM IN THE YEAR
BEFORE THE DISC?

Version Date: 01/2019

28b. IF YES, SPECIFY DATE OF CULTURE AND STATE ID FOR THE
FIRST POSITIVE CULTURE IN THE YEAR BEFORE:
DATE OF CULTURE:

□ Yes □ No □ Unknown

□ Yes □ No □ Unknown □ N/A

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

INCIDENT CLOSEST TO THE DISC:

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

27c. RISK FACTORS IN THE 7 DAYS BEFORE THE DISC:

□ Non-invasive positive pressure ventilation (CPAP or BiPAP) at any time

___ ___ - ___ ___ - ___ ___ ___ ___

STATE ID: ________________________

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

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

□ Citrobacter spp. _____________________
□ Serratia spp. _____________________
□ Proteus spp. _____________________
□ Morganella spp. _____________________
□ Providencia spp. _____________________
□ Raoutella spp. _____________________

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

PAGE 3 OF 4

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

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
Data Source
Source
Antibiotic
Antibiotic

Medical
MedicalRecord
Record
MIC
MIC

Interp
Interp

Microscan
Microscan
MIC
MIC

Interp
Interp

Vitek
Vitek
MIC
MIC

Interp
Interp

Phoenix
Phoenix
MIC
MIC

Interp
Interp

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

E-test
E-test
MIC
MIC

Interp
Interp

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
Cephalothin
Ciprofloxacin
COLISTIN
ERTAPENEM
DORIPENEM
Gentamicin
Doxycycline
IMIPENEM
ERTAPENEM
Levofloxacin
Fosfomycin
MEROPENEM
Gentamicin
Moxifloxacin
IMIPENEM
Nitrofurantoin
Imipenem-relebactam
Levofloxacin
POLYMYXIN B
MEROPENEM
TIGECYCLINE
Meropenem-vaborbactam
Tobramycin
Minocycline
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
31a. WAS CASE FIRST IDENTIFIED THROUGH AUDIT?

Yes
Yes
□ No
No

31b. CRF
31c.
SOINITIALS:
INITIALS:
31b.
CRFSTATUS:
STATUS:
31c. SO
□ Complete
Complete
□ Pending
Pending
□ Chart
Chart unavailable
unavailable after
after33requests
requests

31d. DATE OF ABSTRACTION:
___ ___ - ___ ___ - ___ ___ ___ ___

31e. COMMENTS:

CS295460-A

PAGE 4 OF 4