Form 0920-0978 COVID-19 Invasive Methicillin-Resistant Staphylococcus a

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

Invasive Methicillin-Resistant Staphylococcus aureus
Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2020
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

9. AGE

1

Check if transgendered

1

Female

Male 2

1

oz. OR

Mos. 3

Years

1

Yes

2

No

9

Not Hispanic or Latino

9

Unknown

Asian

1

White

Black or African American

1

Unknown

-

15. DATE OF INCIDENT SPECIMEN COLLECTION
(DISC):

is not available)

cm. 1

1

Unknown

IF YES, date of admission:

Unknown

2

1

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

Native Hawaiian or Other Pacific Islander 1

1

in. OR

Hispanic or Latino

1

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

ft.

kg.

Unknown

6. FACILITY ID WHERE
PATIENT TREATED:

13. ETHNIC ORIGIN:

American Indian or Alaska Native

13. HEIGHT:

lbs.

5. LABORATORY ID WHERE INCIDENT
SPECIMEN INDENTIFIED:

10. RACE: (Check all that apply)

-

12. WEIGHT:

1

4. PATIENT ID:

8. DATE OF BIRTH:

7. SEX AT BIRTH:
2

3. STATE ID:

Unknown

-

-

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

Bone 1

1

Pericardial fluid 1

CSF 1

Internal body site (specify):

Peritoneal fluid 1

Pleural fluid 1

1

Outpatient

Facility
ID:
3

20. WERE CULTURES OS THE SAME OR OTHER STERILE SITES(S) POSITIVE WITHIN 29 DAYS
AFTER DISC?

Inpatient

1

1

Yes

2

No

9

Unknown

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

ICU

13

Date:

Date:

Date:

Facility
ID:

1

1

1

6

OR

15

Dialysis center

7

Radiology

11

Surgery

2

Other Inpatient

16

Observation/Clinical
decision unit

4

1

Facility
ID:

Clinic/doctor’s office

8

LTCF

5

Facility
ID:
Emergency room

Muscle

Other normally sterile site (specify):

19. LOCATION OF SPECIMEN COLLECTION:
1

Joint/Synovial fluid 1

Other outpatient

Blood

1

LTACH

14

Autopsy

10

Other (specify):

9

Unknown

1

Internal body site

Bone

1

Joint/Synovial fluid

CSF

Muscle

Date:

Date:

Date:

1

1

1

Peritoneal fluid

Date:
1

Pericardial fluid

Date:

Pleural fluid

Date:

Other normally sterile site (specify):

Date:
-

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

-

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

1

S 2

I

3

R 9

U

Cefoxitin

1

S 3

R 9

U

Clindamycin

1

S 2

I

3

R 9

U

Nafcillin

1

S

2

I 3

R 9

U

Oxacillin

1

S 3

R 9

U

Trimethoprim-Sulfamethoxazole

1

S 2

I

3

R 9

U

Vancomycin

1

S

2

I 3

R 9

U

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

Private residence

1

1

LTCF Facility ID:

1

1

LTACH Facility ID:

Hospital Inpatient Facility ID:

1

Homeless

1

Incarcerated

1

Other (specify):

1

Unknown

Was patient transferred from this hospital?
1

Yes

2

No

NICU/SCN

2

Well Baby Nursery

9

Unknown

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

9

Unknown

1

Yes

2

No

IF YES, birth weight:

9

Unknown
lbs.

IF YES, estimated gestational age:

oz. OR

weeks OR 1

g. OR 1

Unknown birth weight

Unknown gestational age

Public reporting burden of this collection of information is estimated to average 20 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 —

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

1

2

No

9

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

Unknown

IF YES, date of ICU admission:

Yes

1
-

-

OR 1

No

9

Unknown

IF YES, date of ICU admission:

Date Unknown

28. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply) 1

2

None

1

-

-

OR 1

Date Unknown

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
MALIGNANCY

RENAL DISEASE

1

Malignancy, hematologic

1

AIDS/CD4 count <200

1

Malignancy, solid organ (non-metastatic)

Lowest serum creatinine:

1

Primary immunodeficiency

1

Malignancy, solid organ (metastatic)

1

1

Transplant, hematopoetic stem cell

1

Transplant, solid organ

CHRONIC LUNG DISEASE

IMMUNOCOMPROMISED CONDITION

1

Cystic fibrosis

1

1

Chronic pulmonary disease

1

CHRONIC METABOLIC DISEASE
1

Diabetes mellitus
1

HIV infection

With chronic complications

CARDIOVASCULAR DISEASE
1

CVA/Stroke/TIA

1

Congenital heart disease

1

Congestive heart failure

1

Myocardial infarction

1

Peripheral vascular disease (PVD)

1

Inflammatory bowel disease

1

Peptic ulcer disease

1

Short gut syndrome

Unknown or not done

SKIN CONDITION

1

Cerebral palsy

1

Burn

LIVER DISEASE

1

Chronic cognitive deficit

1

Decubitus/pressure ulcer

1

1

Dementia

1

Surgical wound

Chronic liver disease
1

Ascites

1

Epilepsy/seizure/seizure disorder

1

Other chronic ulcer or chronic wound

1

Cirrhosis

1

Multiple sclerosis

1

Other skin condition (specify):

1

Hepatic encephalopathy

1

Neuropathy

1

Variceal bleeding

1

Parkinson’s Disease

1

Other (specify):

Hepatitis C

1

OTHER

Treated, in SVR

1
1

Diverticular disease

mg/DL

NEUROLOGIC CONDITION

GASTROINTESTINAL DISEASE
1

Chronic kidney disease

1

Connective tissue disease

1

Obesity or morbid obesity

PLEGIAS/PARALYSIS

1

Pregnant

1

Hemiplegia

1

Other (specify only for cases

1

Paraplegia

1

Quadriplegia

Current, chronic

30. WAS THE PATIENT HOMELESS IN THE YEAR BEFORE DISC? 1

Yes

2

No

9

≤12 months of age):

Unknown

31. SUBSTANCE USE:
SMOKING:

1

None

1

Unknown

OTHER SUBSTANCES (CHECK ALL THAT APPLY):

1
1

Tobacco
None

1
1

E-nicotine delivery system

1

ALCOHOL ABUSE: 1

Marijuana

Yes

2

No

9

Unknown

Unknown
DOCUMENTED USE DISORDER (DUD/ABUSE):

MODE OF DELIVERY (Check all that apply):

1

Marijuana, cannabinoid (other than smoking)

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

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

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

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

1

DUD or abuse

1

1

Opioid, NOS

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

Cocaine

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

Methamphetamine

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

Other (specify):

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

Unknown substance

1

DUD or abuse

1

IDU 1

Skin popping

1

Non-IDU

1

Unknown

1

Yes

No

9

 /A (patient not hospitalized
N
or did not have DUD)

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

CDC 52.15B Rev. 07-2019

CS309520

2

Page 2 of 3

32. PRIOR HEALTHCARE EXPOSURE(S):
PREVIOUS DOCUMENTED MSSA INFECTION OR COLONIZATION

OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC

1

1

Yes

2

No

9

Unknown
OR previous STATE I.D.:

If YES:
Month

Yes

2

No

9

No

9

Unknown

Facility ID
OVERNIGHT STAY IN LTCF IN THE YEAR BEFORE DISC
1

Unknown
-

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

2

Year

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC
1

Yes

Yes

2

No

9

Unknown

Facility ID

-

Date unknown

Facility ID:
SURGERY IN THE YEAR BEFORE DISC

1

Yes

2

No

9

Unknown

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

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

CURRENT CHRONIC DIALYSIS 1

1

TYPE: 1

Yes

2

No

9

Unknown

CHECK HERE if central line in place for >2 calendar days 1

Yes

2

No

9

33. PATIENT OUTCOME

Peritoneal

No

9

1

Unknown

Unknown

1

AV fistual/graft

2

Hemodialysis central line

9

Unknown

Unknown
1

Survived

DATE OF DISCHARGE:
1

1

2

IF HEMODIALYSIS, type of vascular access:

DIALYSIS IN THE YEAR BEFORE DISC (Hemodialysis or Peritoneal dialysis)
1

Hemodialysis

Yes

-

2
-

OR 1

Date Unknown

Left against medical advice (AMA)

Private Residence

2

LTCF Facility ID:

3

LTACH Facility ID:

2
-

-

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?

IF SURVIVED, DISCHARGED TO:
1

Died

DATE OF DEATH:

4

Other (specify):

9

Unknown
IF YES, WHAT TYPE OF TEST WAS USED?

34a. WAS THE PATIENT TESTED FOR SARSIF YES, DATE OF TEST:
CoV-2 (MOLECULAR ASSAY, SEROLOGY OR
OTHER CONFIRMATORY TEST) ON OR BEFORE
THE DISC?
OR 1
Date Unknown
1 Yes 2 No 9 Unknown

IF YES, TEST RESULT:

Molecular assay

Positive

Serology
Method unknown
Other (specify):________________

Indeterminate

COVID-NET CASE ID

Negative

NNDSS IDs (please provide at least one of the following when applicable:
Local case ID:____________________

Local record ID:____________________

State case identifier:____________________

Legacy case identifier:____________________

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

Yes

2

9

Unknown

No

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

36. DOES THIS CASE
HAVE RECURRENT
MRSA DISEASE?1
Yes 2 No
9

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

37. DATE REPORTED TO EIP SITE:
-

38. DATE ABSTRACTION:
-

Unknown

39. S.O. INITIALS:

-

-

40. COMMENTS:

CDC 52.15B Rev. 07-2019

CS309520

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