2021 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carb

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

DATE REPORTED TO EIP SITE:

___ ___ - ___ ___ - ___ ___ ___ ___

2021 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem Resistant A. baumannii (CRAB)
Multi-site Gram-Negative Surveillance Initiative (MuGSI)

Form Approved
OMB No. 0920-0978

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):

___ ___ - ___ ___ - ___ ___ ___ ___

If CRE, select one of
the following:

□ Blood
□ Bone
□ Bronchoalveolar lavage (CRAB only, complete Q23c)
□ CSF
□ Internal body site (specify):_______________
□ Muscle
12. LOCATION OF SPECIMEN COLLECTION:
Facility
ID:____________

□ Emergency room
□ Clinic/Doctor's office
□ Dialysis center
□ Surgery
□ Observational/

□ LTCF
Facility
ID:____________

□ LTACH

Facility
ID:____________

□ Autopsy
□ Other (specify):
_______________

□ 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:

□ American Indian or Alaska □ Native Hawaiian or
Native

Other Pacific Islander

□ Asian
□ White
□ Black or African American □ Unknown

□ Peritoneal fluid
□ Pericardial fluid
□ Pleural fluid
□ Joint/synovial fluid
□ Sputum (CRAB only, complete Q23c)
□ Tracheal aspirate (CRAB only, complete Q23c)

Facility
ID:____________

Clinical decision unit

_______________________________

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

□ INPATIENT:
□ ICU
□ OR
□ Radiology
□ Other inpatient

4b. FACILITY ID WHERE PATIENT TREATED:

8b. RACE: (Check all that apply)

□ Hispanic or Latino
□ MALE □ FEMALE □ Not Hispanic or Latino
□ Unknown
□ Check if transgender □ Unknown
10. ORGANISM: □ CRE □ CRAB

11. INCIDENT SPECIMEN COLLECTION SITE:

□ OUTPATIENT:

4a. LABORATORY ID WHERE
INCIDENT SPECIMEN IDENTIFIED:
________________________

□ Left against medical advice (AMA)

□ Urine
□ Wound (specify):_______________
(CRAB only)
□ Other LRT site (specify):_______________
(CRAB only, complete Q23c)
□ Other normally sterile site (specify):_______________

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 28 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: 10/2020

PAGE 1 OF 4

Form Approved

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

17a. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S) (Check all that apply): □ None □ Colonized □ Unknown
□ Abscess, not skin
□ Epidural abscess
□ Cellulitis
□ Pyelonephritis
□ AV fistula/graft infection
□ Chronic ulcer/wound (not decubitus) □ Meningitis
□ Septic arthritis
□ Bacteremia
□ Osteomyelitis
□ Decubitus/pressure ulcer
□ Septic emboli
□ Bursitis
□ Peritonitis
□ Empyema
□ Septic shock
□ Catheter site infection (CVC) □ Endocarditis
□ Pneumonia (CRAB cases, complete Q23c) □ Skin abscess
17b. RECURRENT UTI □ Yes □ No □ Unknown

□
□
□
□
□

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

17c. WAS THE PATIENT TREATED FOR THE MUGSI ORGANISM? □ Yes □ No □ Unknown
18. UNDERLYING CONDITIONS: (Check all that apply)

□
□

□ AIDS/CD4 count < 200

□ 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

□
□
□
□

□ Unknown

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

□

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

□

□

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC:

□ No

□ Yes □ No □ Unknown

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

DATE UNKNOWN

□

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?

□
□
□

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)

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

OTHER

Hemiplegia
Paraplegia
Quadriplegia

DOCUMENTED USE DISORDER (DUD)/ABUSE:

□
□
□
□
□
□
□
□

□

RENAL DISEASE

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

ALCOHOL
ABUSE:

□
□
□
□

Cerebral palsy
Chronic cognitive deficit
Dementia
Epilepsy/seizure/seizure disorder
Multiple sclerosis
Neuropathy
Parkinson’s disease
Other (specify): ________________

OTHER SUBSTANCES: (Check all that apply)

SMOKING:

(Check all that
apply) □ None

□
□
□
□
□
□
□
□

PLEGIAS/PARALYSIS

MALIGNANCY

□
□
□

SKIN CONDITION

NEUROLOGIC CONDITION

□ HIV infection

Cystic fibrosis
Chronic pulmonary disease

CHRONIC METABOLIC DISEASE

□

□ None □ Unknown

IMMUNOCOMPROMISED CONDITION

CHRONIC LUNG DISEASE

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

□ 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

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: __________

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

SURGERY IN THE YEAR BEFORE DISC:

□ 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

□ Unknown

Version Date: 10/2020

□ Unknown

IF YES, CHECK ALL THAT APPLY:

Facility ID: __________

IF YES, TYPE:

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

□ 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
Exp. Date: XX-XX-XXXX

URINE CULTURES ONLY:
22a. WAS THE URINE
COLLECTED THROUGH AN
INDWELLING URETHRAL
CATHETER?

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.

□ None
□ Costovertebral angle pain or tenderness
□ Dysuria
□ Fever [temperature ≥ 100.4 °F (38 °C)]

□ Yes □ No □ Unknown
URINE CULTURES ONLY:
22b. RECORD THE COLONY
COUNT: ________________

Symptoms for patients
□ Unknown
≤ 1 year of age only:
□ Frequency
□
Apnea
□ Lethargy
□ Suprapubic tenderness
□
Bradycardia
□ Vomiting
□ Urgency

Complete question 23c ONLY for A. BAUMANNII cases from
LRT site cultures or for non-LRT cultures where pneumonia is
marked in question 17a.

Complete questions 23a-23b ONLY for A. BAUMANNII cases:
23a. DID THE PATIENT HAVE A SPUTUM CULTURE POSITIVE
FOR CRAB IN THE 30 DAYS BEFORE THE DISC?

23c. Chest Radiology Findings (check all that apply):

□ Yes □ No □ Unknown □ N/A

□ No report available
□ Not done
□ Acute respiratory distress syndrome (ARDS)
□ Air space density/opacity
□ Ground glass opacities/infiltrates
□ Bronchopneumonia/pneumonia
□ Cannot rule out pneumonia

23b. RISK FACTORS IN THE 7 DAYS BEFORE THE DISC:

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

□ Cavitation
□ Consolidation
□ Infiltrate
□ Pleural effusion
□ Nodules

24b. IF YES, COMPLETE TABLE BELOW:

24a. DID THE PATIENT HAVE A POSITIVE
TEST(S) FOR SARS-CoV-2 (MOLECULAR
ASSAY, SEROLOGY OR OTHER
CONFIRMATORY TEST) ON OR BEFORE
THE DISC?

Test type

Specimen collection date
FIRST positive test for
SARS-CoV-2 on or before the
DISC:

□ Yes □ No □ Unknown

MOST RECENT positive
test for SARS-CoV-2 on
or before the DISC:

/
Unknown

/
Unknown

/

□
□
□
□
□

Molecular assay
Antigen
Serology
Unknown
Other (specify): ____________

/

□
□
□
□
□

Molecular assay
Antigen
Serology
Unknown
Other (specify): ____________

24c.COVID-NET CASE ID:_______________
24d. NNDSS IDs (please provide at least one of the following when applicable):
Local case ID:_______________

Local record ID:_______________

State case identifier:_______________

Legacy case identifier:_______________

CDC 2019-nCOV ID:_______________
25. WAS THE INCIDENT SPECIMEN POLYMICROBIAL?

□ Yes □ No □ Unknown
26b. IF YES, WHAT TESTING METHOD WAS USED? (Check all that apply):
Non-Molecular Test Methods:

Molecular Test Methods:

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

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

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

□ PCR
□ Streck ARM-D
□ Other

Method (mCIM)

Sequencing

(specify):_____________

□ Unknown

27a. WAS THE INCIDENT SPECIMEN
TESTED FOR ESBL PRODUCTION OR
OTHER BETA-LACTAMASE GENES?

□ Yes □ No □ Laboratory not testing □ Unknown
27b. IF TESTED, WHAT TESTING METHOD
WAS USED? (Check all that apply):

Version Date: 10/2020

26a. WAS THE INCIDENT SPECIMEN TESTED FOR
CARBAPENEMASE GENES?

□ Yes □ No □ Laboratory not testing □ Unknown
26c. IF TESTED, WHAT WAS THE TESTING RESULT?
Non-Molecular Test Results:

□ Positive □ Indeterminate □ Negative □ Unknown
Molecular Test Results:

□ NDM
□ KPC
□ OXA (specify):_______________
□ VIM
□ IMP
□ Other carbapenemase gene (specify):_______________

□ Broth Microdilution (ATI detection)
□ ESBL well
□ Expert rule (ATI flag)
□ Unknown
□ Broth Microdilution (Manual)
□ Disk Diffusion
□ E-test
□ Molecular test (specify):_____________
□ Gene variant (specify):______________
□ Other non-molecular test (specify):______________

□ Pos
□ Pos
□ Pos
□ Pos
□ Pos
□ Pos

□ Neg
□ Neg
□ Neg
□ Neg
□ Neg
□ Neg

□ Ind
□ Ind
□ Ind
□ Ind
□ Ind
□ Ind

□ Unk
□ Unk
□ Unk
□ Unk
□ Unk
□ Unk

27c. IF TESTED, WHAT WAS THE RESULT?

□ Positive
□ Positive
□ Positive
□ Positive
□ Positive
□ Positive
□ Positive
□ Positive

□ Negative
□ Negative
□ Negative
□ Negative
□ Negative
□ Negative
□ Negative
□ Negative

□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate
□ Indeterminate

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
PAGE 3 OF 4

Form Approved
OMB No. 0920-0978
Form Approved
OMB No. 0920-0978

28. 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 Source
Antibiotic

Medical Record
MIC

Interp

Microscan
MIC

Interp

Vitek

Phoenix

MIC Interp MIC

Interp

Sensititre
MIC

Interp

Kirby-Bauer

E-test

Zone Diam Interp MIC

Interp

Amikacin
Amoxicillin/Clavulanate
Ampicillin
Ampicillin/Sulbactam
Aztreonam
Cefazolin
CEFEPIME
Cefiderocol
CEFOTAXIME
Cefoxitin
CEFTAZIDIME
Ceftazidime/Avibactam
Ceftolozane/Tazobactam
CEFTRIAXONE
Cephalothin
Ciprofloxacin
COLISTIN
DORIPENEM
Doxycycline
Eravacycline
ERTAPENEM
Fosfomycin
Gentamicin
IMIPENEM
Imipenem-relebactam
Levofloxacin
MEROPENEM
Meropenem-vaborbactam
Minocycline
Nitrofurantoin
Omadacycline
Piperacillin/Tazobactam
Plazomicin
POLYMYXIN B
Rifampin
Tetracycline
TIGECYCLINE
Tobramycin
Trimethoprim-sulfamethoxazole
29a. WAS THE CASE FIRST
IDENTIFIED THROUGH AN AUDIT?
Yes
No

29b. CRF STATUS:
Complete
Pending
Chart unavailable after 3 requests

29c. SO INITIALS:

29d. DATE OF ABSTRACTION:
___ ___ - ___ ___ - ___ ___ ___ ___

29e. COMMENTS:

CS295460-A

PAGE 4 OF 4