Form 0920-0978 2022 ABC Surveillance Case Report

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Patient’s Name:

Phone No.:(

(Last, First, MI.)

Address:

)

Patient Chart No.:
(Number, Street, Apt. No.)
(City, State)

– Patient Identifer information is not transmitted to CDC –
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
A
ATLANTA, GA 30333

1. STATE:

2022 Active Bacterial Core
Surveillance (ABCs) Case Report
– SHADED AREAS FOR OFFICE USE ONLY –

Mo.

Day

Year

Year

9b. Is age in day/mo/yr?
Mos. 3

Days 2

Lab Repeating Group Section T1-T10
T2
T1
Date of Specimen Collection
Mo. Day Year

Yrs.

6. COUNTY:

1

Complete 2

4

 hart unavailable
C
after 3 requests

10.SEX:

9a. AGE:

1

Test Type

5. CRF Status:

3. PATIENT I.D.: 4. Date reported to EIP site:

7a. HOSPITAL/LAB I.D. 8. DATE OF BIRTH:
WHERE PATIENT
TREATED::
Mo.
Day

Form Approved
0920-0978

CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM

2. STATE I.D.:

(Patient Residence)

Hospital:

(Zip Code)

1

Male

2

Female

Incomplete
7

3

Edited & Correct

(Residence of Patient)

QA Review Change

11a. ETHNIC ORIGIN:

11b. RACE: (Check all that apply)

1

Hispanic or Latino

1

White

1

Asian

2

Not Hispanic or Latino

1

Black

1

9

Unknown

1

Unknown

Native Hawaiian
or Other Pacific Islander
American Indian or Alaska Native

1

T3

T3a

T4

T5

T6

Test Method
(non-culture)

Hospital/Lab I.D.
where test identified

Site from which
organism isolated

Bacterial Species
Isolated*

Test Result

1

1=Positive
0=Negative

2

1=Positive
0=Negative

3

1=Positive
0=Negative

4

1=Positive
0=Negative

T7

T8

T9

T10

Isolate/Specimen
Available?

If isolate/specimen
N/A, why not?

Shipped to
CDC?

If shipped,
accession#

1

1=Yes
2=No

1=Yes
0=No

2

1=Yes
2=No

1=Yes
0=No

3

1=Yes
2=No

1=Yes
0=No

4

1=Yes
2=No

1=Yes
0=No

Yes

1

2

8=Other Sterile Site
9=Unknown
10=Liver
11=Lymph Node
12=Muscle/Fascia/Tendon
13=Ovary
14=Pancreas

Date of discharge:

Mo. Day Year

Mo.

Day

No

1

1

Private residence

4

Homeless

7

Non-medical ward

2

Long term care facility

5

Incarcerated

8

Other (specify): __________

3

Long term acute care facility 6

College dormitory

9

Unknown

20a. WEIGHT:_____ lbs ______oz OR ______ kg OR

Unknown

20b. HEIGHT:______ ft _______in OR ______ cm OR

Unknown

20c. BMI: ___ ___ . ___
22. OUTCOME: 1

Survived

2

Died 9

Unknown

No

9

Pregnant

2

3

(wks)

Birth weight:

9

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 Not Needed

Unknown

19a. Was patient transferred
from another hospital?

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

1

Yes 2

9

Unknown

1

Other (specify)_____________________________

1

Private

1

Miltary

1

Medicare

1

Indian Health Service (IHS) 1

1

 edicaid/state
M
assistance program

1

Incarcerated

Home 2

1

No

Uninsured
Unknown

LTC/SNF 3

24b. If pregnant or postpartum, what was the outcome of fetus:

Neither 9

Unknown

1

25. If patient <1 month of age, indicate gestational age and birth weight.
If pregnant, indicate gestational age of fetus, only.
Gestational age:

No

LTACH 5

If discharged to LTC/SNF or LTACH, list Facility ID: ________________

Unknown

Postpartum

2

18b. If resident of a facility, what
was the name of the facility?

22a. If survived, patient discharged to: 1

24a.At time of first positive culture, patient was:
1

* For other bacterial
pathogens (i.e. non-ABCs),
write in pathogen name

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

23. If patient died, was the culture obtained on autopsy?
Yes 2

Yes

Facility ID: _______________

Unknown

OR

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

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

Year

18a. Where was the patient a resident at time of initial culture?

1

T3 - Test Method (if non-culture)
1=Biofire Filmarray Meningitis/Encephalitis Panel 7=ThermoFisher Wellcogen
2=Other
Bacterial Antigen Rapid
3=Biofire Filmarray Blood Culture ID (BCID) Panel 8=Alere Binax
4=Verigene Gram + Blood Culture (BCT) Test
NOW Antigen Card
5=Bruker MALDI Biotyper CA System
9=Unknown
6=BD Directigen Meningitis Combo Test Kit

T4 - Site
1=Blood
2=Bone
3=Brain
4=CSF
5=Heart
6=Joint
7-Kidney

If YES, date of admission:

16. WAS PATIENT
HOSPITALIZED?

#T1 - Test Type
1=PCR
2=Culture
3=Antigen
7=Other
9=Unknown

(gms)

Survived, no apparent illness

2

Survived, clinical infection

3

Live birth/neonatal death

4

Abortion/stillbirth

5

Induced abortion

6

Still pregnant

9

Unknown

24c.

4

Left AMA 9

Unknown

Other, Specify: _________________
Mark if this is a GBS Blood Spot
Study case that lives outside ABCs
catchment area.

– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
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,
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Rd. MS D-74, Atlanta, GA, 30333, ATTN: PRA(0920-0978) Do not send the completed form to this address.
CDC 52.12A REV 2019

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Page 1 of 2

26. TYPES OF INFECTION CAUSED BY ORGANISM: (Check all that apply)
1

Abscess (not skin) 1

Chorioamnionitis 1

Empyema

1

Necrotizing fasciitis

1

Peritonitis

1

Puerperal sepsis

1

Septic shock

1

B
 acteremia
without Focus

1

Endocarditis

1

Osteomyelitis

1

Pericarditis

1

Septic abortion

1

STSS

Cellulitis

1

Epiglottitis

 emolytic uremic
H
syndrome (HUS)

1

Otitis media

1

Pneumonia

1

Septic arthritis

1

Other (specify): ____________________

1

Endometritis

1

1

Meningitis

1

Unknown

1

27. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE, check appropriate box) 1
1

None

Immunosuppressive Therapy (Steroids, etc.)

1

Unknown

1

Peripheral Neuropathy
Peripheral Vascular Disease

1

AIDS or CD4 count <200

1

Connective Tissue Disease (Lupus, etc.)

1

Asthma

1

CSF Leak

1

Eculizumab (Soliris) - N.men. only

1

1

Atherosclerotic CVD (ASCVD)/CAD 1

Deaf/Profound Hearing Loss

1

Ravulizumab (Ultomiris) - N.men. only

1

Plegias/Paralysis

1

Bone Marrow Transplant (BMT)

1

Dementia

1

Leukemia

1

Premature Birth (specify gestational

1

CVA/Stroke/TIA

1

Diabetes Mellitus,

1

Multiple Myeloma

1

Chronic Hepatitis C

Multiple Sclerosis

1

Seizure/Seizure Disorder

1

Chronic Kidney Disease

1

HbA1C ______(%), Date ___/___/______ 1
1
Emphysema/COPD

Myocardial Infarction

1

Sickle Cell Anemia

1

Chronic Liver Disease/cirrhosis

1

Heart Failure/CHF

1

Nephrotic Syndrome

1

Solid Organ Malignancy

1

Current Chronic Dialysis

1

HIV Infection

1

Neuromuscular Disorder

1

Solid Organ Transplant

1

Chronic Skin Breakdown

1

Hodgkin’s Disease/Lymphoma

1

Obesity

1

Splenectomy/Asplenia

1

Cochlear Implant

1

Immunoglobulin Deficiency

1

Parkinson’s Disease

1

1

Complement Deficiency

1

Peptic Ulcer Disease

Other prior illness (specify):
_____________________________

1

age at birth)______ (wks)

SUBSTANCE USE, CURRENT
27b. SMOKING:

1

(check all that apply)

None

1

Unknown

1

27d. OTHER SUBSTANCES: (check all that apply) 1

Tobacco 1
None 1

E-Nicotine Delivery System 1

Unknown

27c. ALCOHOL ABUSE:

Marijuana

Documented Use Disorder (DUD)/Abuse

1

Yes

0

No

9

Unknown

Mode of delivery: (check all that apply)

1

Marijuana/cannibinoid (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

1

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

1

DUD or Abuse

1

IDU

1

Skin popping

1

non-IDU

1

Unknown

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

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

1

b 2

Not Typeable

3

a 4

c

5

d 6

e 7

f 8

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

Year

Other (specify): _______________________ 9

DATE GIVEN
Mo. Day

1

3

2

4

NEISSERIA MENINGITIDIS
A

6

Not Groupable 8

2

B 3

C

30. Is patient currently attending college?
4

Y 5

W135

Other: ______________ 9

31. Did patient receive meningococcal vaccine?
DOSE TYPE

2= ACWY
polysaccharide
(Menomune)

3= B (Bexsero,
Trumenba)
9= Unknown

1

Unknown

1
Yes 2
DATE GIVEN

Mo. Day

Type Codes:
1= ACWY conjugate,
(Menactra, Menveo,
MenHibrix)

VACCINE NAME/MANUFACTURER
Year

STREPTOCOCCUS PNEUMONIAE

29. What was the serogroup?
1

No 9
Year

Yes 2

No

9

Unknown

Unknown If YES, complete the table
VACCINE NAME/MANUFACTURER

1

32. Did patient receive pneumococcal vaccine?
1
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

2
3

If between 2 months and < 5 years of age and an isolate is available
for serotyping, please complete the IPD in Children expanded

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 1

Hearing deficits 1

Amputation (digit)

1

Amputation (limb)

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?
Yes 2
No 9
Unknown
1
If YES, date of surgery or skin incision:
Mo. Day

9

Unknown

Seizures 1

1

Yes 2

No 9

Year

38. Does this case have
1
recurrent disease with
the same pathogen? 9

Yes 2

No

Other (specify): _____________________

1

Varicella

1

Penetrating trauma

1

Blunt trauma

Submitted By:
1

 urgical would
S
(post operative)

1

Burns

If YES to any of the above, record the number
of days prior to the first positive culture
(if > 1, use the most recent skin injury)
1

Unknown date

Unknown

35. Did patient have:

Unknown

Mo. Day

No

Paralysis or spasticity 1

If YES, date of delivery:

9
Yes 2

1

34. Did the patient deliver a baby
(vaginal or C-section)

Year

Unknown date

37. Was case
1
first identified
through audit? 9

Not tested or Unknown

0-7 days 2

8-14 days 9

If YES, previous (1st) state I.D.:

Unknown

Unknown days
39. I nitials
of S.O.
_____________

____________________________
Phone No.:(

) _____________

Date: ____/____/____
Physician’s Name:
____________________________
Phone No.:(

) _____________

36. COMMENTS:

CDC 52.12A REV 2019

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Page 2 of 2