Form 0920-0978 2023 MuGSI Extended-Spectrum Beta-Lactamase (ESBL)-Produ

[NCEZID] Emerging Infections Program

Att13_HAIC_2023 MuGSI ESBL_iEC CRF

HAIC Multi-Site Gram-Negative Surveillance Initiative - Extended Spectrum Beta-Lactamase Producing Enterobacteriaceae (MuGSI-ESBL)

OMB: 0920-0978

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0978 can be found here:
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PATIENT ID:

DATE REPORTED TO EIP SITE: (mm/dd/yyyy)

202 EExtended-Spectrum Beta-Lactamase
Beeta Lactamase (ESBL)-Producing
(ESBL) Pro
Enterobacterales *OWBTJWF
*OWBTJWF &TDIFSJDIJ
&TDIFSJDIJBDPMJ
B DPMJ
Multi-site Gram-Negative Surveillance Initiative (MuGSI)
Healthcare-Associated Infections Community Interface (HAIC) Case Report
Patient’s Name:

Form Approved
OMB No. 0920-0978

Phone no.:

Address:

MRN:

"EESFTT5ZQF:

Hospital:
----Patient Identifier information is not transmitted to CDC----

DEMOGRAPHICS
2. COUNTY:

1. STATE:

3. STATE ID:

4a. LABORATORY ID WHERE
INCIDENT SPECIMEN IDENTIFIED:

7. SEX AT BIRTH:

5. DATE OF BIRTH: (mm/dd/yyyy)

8a. ETHNIC ORIGIN:

Male
Female
Unknown

6. AGE:
Days

Mos

4b. FACILITY ID WHERE PATIENT TREATED:

8b. RACE: (Check all that apply)

Hispanic or Latino
Not Hispanic or Latino
Unknown

American Indian or Alaska Native
Asian
Black or African American

Native Hawaiian or Other Pacific Islander
White
Unknown

Check if transgender

Yrs

9B. DATE OF INCIDENT SPECIMEN
COLLECTION (DISC): (mm/dd/yyyy)

10. ORGANISM:

9C. 5*.&0'%*4$
5*.&0'%*4$	))...JMJUBSZ'PSNBU


Escherichia coli
&YUFOEFETQFDUSVNDFQIBMPTQPSJOSFTJTUBOU
*G&DPMJ
TFMFDUPOFPGUIFGPMMPXJOH
*G&DPMJ
TFMFDUPOFPGUIFGPMMPXJOH
&YUFOEFETQFDUSVNDFQIBMPTQPSJOSFTJTUBOUKlebsiella pneumoniae
&YUFOEFETQFDUSVNDFQIBMPTQPSJOSFTJTUBOU
&YUFOEFETQFDUSVNDFQIBMPTQPSJOSFTJTUBOU
K
&YUFOEFETQFDUSVNDFQIBMPTQPSJOSFTJTUBOUKlebsiella
oxytoca

/POFYUFOEFETQFDUSVNDFQIBMPTQPSJOSFTJTUBOU

11. INCIDENT SPECIMEN COLLECTION SITE:
Blood
Bone
CSF

Internal body site (specify):
Joint/synovial fluid
Muscle

12. LOCATION OF SPECIMEN COLLECTION:
OUTPATIENT
Facility ID:

INPATIENT
Facility ID:

Emergency room
Clinic/Doctor’s office
Dialysis center
Surgery
Observational/
Clinical decision unit
Other outpatient

ICU
OR
Radiology
Other inpatient

Urine
Other normally sterile site (specify):

Peritoneal fluid
Pericardial fluid
Pleural fluid

13. WHERE WAS THE PATIENT LOCATED ON THE 3RD CALENDAR DAY BEFORE THE DISC?
LTCF
Facility ID:
LTACH
Facility ID:

Private residence
LTCF
Facility ID:

LTACH
Facility ID:
Homeless
Incarcerated
Other (specify):

Hospital inpatient
Facility ID:

Autopsy
Other (Specify):

Was the patient transferred from
this hospital?
Yes

No

Unknown

Unknown

Unknown

14. WAS THE PATIENT HOSPITALIZED ON THE DAY OF OR IN THE
29 CALENDAR DAYS AFTER THE DISC?
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: (mm/dd/yyyy)

OR

15b. WAS THE PATIENT IN AN ICU ON THE DAY OF INCIDENT SPECIMEN
COLLECTION OR IN THE 6 DAYS AFTER THE DISC?

IF YES, DATE OF ADMISSION: (mm/dd/yyyy)

Yes

No

Unknown

IF YES, DATE OF ICU ADMISSION: (mm/dd/yyyy)

16. PATIENT OUTCOME:

Survived

Date unknown
IF SURVIVED, DISCHARGED TO:
Private residence
LTCF, Facility ID:
LTACH, Facility ID:

OR

Died

DATE OF DISCHARGE: (mm/dd/yyyy)

OR
Left against medical advice (AMA)

Other (specify):

Date unknown

Date unknown

Unknown

DATE OF DEATH: (mm/dd/yyyy)

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

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).
CS322168

04/09/2021

Page 1 of 4

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)

17b. RECURRENT UTI:

Yes

Decubitus/pressure ulcer
Empyema
Endocarditis
Epidural abscess
Meningitis
Osteomyelitis
Peritonitis
No

None

GASTROINTESTINAL DISEASE
Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome

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

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

OTHER SUBSTANCES: (Check all that apply)

OTHER
Connective tissue disease
Obesity or morbid obesity
Pregnant
MuGSI CONDITIONS
Urinary tract problems/abnormalities
Premature birth
Spina bifida

RENAL DISEASE
Chronic kidney disease
Lowest serum creatinine:
Unknown or not done

None

mg/DL

Unknown
DUD/ ABUSE

ALCOHOL ABUSE
Yes
No
Unknown

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

PLEGIAS/PARALYSIS
Hemiplegia
Paraplegia
Quadriplegia

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

SMOKING:
(Check all that apply)
None
Unknown
Tobacco
E-nicotine delivery system
Marijuana

Unknown

Unknown

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)

19. SUBSTANCE USE

Pneumonia
Pyelonephritis
Septic arthritis
Septic emboli
Septic shock
Skin abscess
Surgical incision infection

IMMUNOCOMPROMISED CONDITION
HIV infection
AIDS/CD4 count < 200
Primary immunodeficiency
Transplant, hematopoietic stem cell
Transplant, solid organ

CHRONIC METABOLIC DISEASE
Diabetes mellitus
With chronic complications

Colonized

Unknown

18. UNDERLYING CONDITIONS: (Check all that apply)
CHRONIC LUNG DISEASE
Cystic fibrosis
Chronic pulmonary disease

None

MODE OF DELIVERY (Check all that apply)

Marijuana, cannabinoid (other than smoking)

DUD or abuse

IDU

Skin popping

Non-IDU

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

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown
Unknown

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

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

Opioid, NOS

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

Cocaine

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

Methamphetamine

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

Other (specify):

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

Unknown substance

DUD or abuse

IDU

Skin popping

Non-IDU

Unknown

DURING THE CURRENT HOSPITALIZATION, DID THE PATIENT RECEIVE MEDICATION ASSISTED TREATMENT (MAT) FOR OPIOID USE DISORDER?
No
N/A (patient not hospitalized or did not have DUD)
Yes

20. RISK FACTORS: (Check all that apply)

None

Unknown

WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR
DAYS AFTER HOSPITAL ADMISSION?

Yes

No

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC

Yes

No

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

IF YES, DATE OF DISCHARGE CLOSEST TO DISC: (mm/dd/yyyy)

OR,

Unknown

No

Unknown

IF YES, CHECK ALL THAT APPLY:
Indwelling Urethral Catheter
Suprapubic Catheter

DATE UNKNOWN

Condom Catheter
Other (specify):

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

Yes

No

Unknown

Yes

No

Unknown

SURGERY IN THE YEAR BEFORE DISC:

Yes

No

Unknown

CURRENT CHRONIC DIALYSIS:

Yes

No

Unknown

Facility ID:

Yes

OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC:
Facility ID:

IF YES, TYPE
Hemodialysis

Peritoneal

Yes
Unknown

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

kg

Unknown

OR

Tracheostomy
Nephrostomy Tube
Other (specify):

No

Unknown

PATIENT HOSPITALIZED WHILE VISITING COUNTRY(IES) ABOVE:
Yes

21b. HEIGHT:
oz.

Unknown

COUNTRY(IES):

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

lbs.

No

IF YES, CHECK ALL THAT APPLY:
ET/NT Tube
Gastrostomy Tube
NG Tube

PATIENT TRAVELED INTERNATIONALLY IN THE YEAR BEFORE DISC:

Unknown

IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:
AV fistula/graft
Hemodialysis central line

21a. WEIGHT:

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:

No

Unknown

21c. BMI:
ft.
cm

in.
Unknown

OR
Unknown
Page 2 of 4

URINE CULTURES ONLY:

URINE CULTURES ONLY:

22. RECORD THE
COLONY COUNT:

23. SIGNS AND SYMPTOMS ASSOCIATED WITH URINE CULTURE

Symptoms for patients
≤ 1 year of age only:

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
Unknown
Costovertebral angle pain or tenderness

Dysuria
Fever [temperature ≥ 100.4 °F (38 °C)]
Frequency

24a. IS ANTIMICROBIAL USE (IV OR ORAL) IN THE 30 DAYS BEFORE THE DISC DOCUMENTED?

Yes

24b. IF YES, CHECK ALL ANTIMICROBIALS USED IN THE 30 DAYS BEFORE THE DISC: (Check all that apply)
Amikacin
Amoxicillin
Amoxicillin/clavulanic acid
Ampicillin
Ampicillin/sulbactam
Azithromycin
Aztreonam
CefaESPYJM
$FGB[PMJO
$FGEJOJS
$FGFQJNF
$FGJEFSPDPM
$FGJYJNF

Cefotaxime
Cefoxitin
Cefpodoxime
Ceftaroline
Ceftazidime
Ceftazidime/avibactam
Ceftizoxime
Ceftolozane/tazobactam
Ceftriaxone
Cefuroxime
Cephalexin
Ciprofloxacin

Clarithromycin
Clindamycin
Dalbavancin
Daptomycin
Delafloxacin
Doripenem
Doxycycline
Ertapenem
Eravacycline
Fidaxomicin
Fosfomycin
Gentamicin

Apnea
Bradycardia
Lethargy
Vomiting

Suprapubic tenderness
Urgency

No

Unknown

Unknown

Imipenem/cilastatin
Levofloxacin
Linezolid
Meropenem
Meropenem/vaborbactam
Metronidazole
Moxifloxacin
Nitrofurantoin
Omadacycline
Oritavancin
Penicillin
Piperacillin/tazobactam

Polymyxin B
Polymyxin E (colistin) Rifaximin
Tedizolid
Telavancin
Tigecycline
Tobramycin
Trimethoprim
Trimethoprim/sulfamethoxazole Vancomycin
IV
PO
Other (specify):
Other (specify):

REMINDER: Any prior antimicrobial use that is not noted above should be documented in the other (specify) field.

25a. DID THE PATIENT HAVE A POSITIVE TEST(S) FOR SARSCoV-2 (MOLECULAR ASSAY, ANTIGEN OR OTHER VIRAL TEST,
EXCLUDING SEROLOGY) IN THE 90 DAYS BEFORE OR DAY OF
THE DISC?
Yes

No

25b. SPECIMEN COLLECTION DATES FOR POSITIVE TESTS IN THE 90
DAYS BEFORE OR DAY OF DISC:

Unknown
First positive test

or

Date unknown

Most recent positive
test:OLLECTION DATE

or

Date unknown

25c.COVID-NET CASE ID:

26a. WAS THE INCIDENT SPECIMEN POLYMICROBIAL?

Yes

No

Unknown

$PNQMFUFRVFTUJPOTCE0/-:GPS&4#-DBTFT
26b. WAS THE INCIDENT SPECIMEN TESTED FOR ESBL
PRODUCTION OR OTHER BETA-LACTAMASE GENES?
Yes
No
Laboratory not testing
Unknown

26c. IF TESTED, WHAT TESTING METHOD WAS USED?
(Check all that apply):

26d. IF TESTED, WHAT WAS THE RESULT?

Broth Microdilution (ATI detection)
ESBL well

Pos

Neg

Ind

Unk

Expert rule (ATI flag)

Pos

Neg

Ind

Unk

Unknown

Pos

Neg

Ind

Unk

Broth Microdilution (Manual)

Pos

Neg

Ind

Unk

Disk Diffusion

Pos

Neg

Ind

Unk

E-test

Pos

Neg

Ind

Unk

Pos

Neg

Ind

Unk

Pos

Neg

Ind

Unk

Molecular test (specify):
Gene variant (specify):
Other non-molecular test (specify):

Page 3 of 4

27. SUSCEPTIBILITY RESULTS:
Please complete the table below based on the information found in the indicated data source. 	"DDFMFSBUF1IFOP4ZTUFN
&UFTU
,JSCZ#BVFS
.JDSPTDBO
1IPFOJY
4FOTJUJUSF
7JUFL
PS.FEJDBM3FDPSE


%BUB4PVSDF

%BUB4PVSDF
Antibiotic

MICPS;POFEJBNFUFS

*OUFSQSFUBUJPO

%BUB4PVSDF

MICPS;POFEJBNFUFS

*OUFSQSFUBUJPO

MICPS;POFEJBNFUFS

*OUFSQSFUBUJPO

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
Trimethoprimsulfamethoxazole

28a. WAS THE CASE FIRST
IDENTIFIED THROUGH AN AUDIT?
Yes
No

28e. COMMENTS:

C$3'45"564

28c. SO INITIALS:

28d. DATE OF ABSTRACTION: (mm/dd/yyyy)

$PNQMFUF
$PNQMFUF1FOEJOH
Pending
Chart unavailable after 3 requests

Page 4 of 4
File Type	application/pdf
File Title	2021 Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacterales Multi-site Gram-Negative Surveillance Initiative (MuGSI)
Subject	MuGSI ESBL, CS 322168_B, Enterobacterales, Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacterales
Author	Centers for Disease Control and Prevention
File Modified	2023-02-28
File Created	2022-03-21