Form HAIC.400.1 2024 Multi-site Gram-Negative Surveillance Initiative (M

PATIENT ID:

DATE REPORTED TO EIP SITE:

2024 Multi-site Gram-Negative Surveillance Initiative (MuGSI)
Healthcare-Associated Infections Community Interface (HAIC) Case Report

Form Approved
OMB No. 0920-0978

NOTE: Enter all dates as mm/dd/yyyy

PATIENT’S NAME:

PHONE NO.:
MRN:

ADDRESS:
ADDRESS TYPE:

HOSPITAL:

----Patient Identifier information is not transmitted to CDC---DEMOGRAPHICS
1. STATE: 2a. COUNTY:

2b. PLANNING REGION:

4b. FACILITY ID WHERE PATIENT TREATED:

4a. LABORATORY ID WHERE INCIDENT SPECIMEN IDENTIFIED:
7. SEX AT BIRTH:

5. DATE OF BIRTH:

8a. ETHNIC ORIGIN:

● Male
● Female
● Unknown

6. AGE:
● Days ● Mos

3. STATE ID:

8b. RACE: (Check all that apply)
■ American Indian or
Alaska Native
■ Asian
■ Black or African American

● Hispanic or Latino
● Not Hispanic or Latino
● Unknown

■ Check if transgender

● Yrs

■ Native Hawaiian or
Other Pacific Islander
■ White
■ Unknown

10. ORGANISM:

9a. DATE OF INCIDENT
SPECIMEN COLLECTION
(DISC):

■ Carbapenem-Resistant Enterobacterales (CRE)
■ Escherichia coli
■ Klebsiella pneumoniae
■ Klebsiella oxytoca
■ Klebsiella aerogenes
■ Enterobacter cloacae

9b. TIME OF DISC:

■ Extended-Spectrum Beta-Lactamaseproducing Enterobacterales (ESBL-E)

■ Carbapenem-Resistant
A. baumannii (CRAB)

■ Escherichia coli
■ Klebsiella pneumoniae
■ Klebsiella oxytoca

■ Invasive Escherichia coli
(iEC) (not CRE or ESBL-E)

11. SPECIMEN COLLECTION SITE(S):
■ Muscle
■ Peritoneal fluid
■ Pericardial fluid
■ Pleural fluid
■ Joint/synovial fluid
■ Sputum (CRAB only, complete Q23c)
■ Tracheal aspirate (CRAB only, complete Q23c)

■ Blood
■ Bone
■ Bronchoalveolar lavage
(CRAB only, complete Q23c)
■ CSF
■ Internal body site (specify):

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 (complete 22a–22c)
■ 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?

● LTCF

● Private residence
● LTCF
Facility ID:

Facility ID:
● LTACH
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

IF YES, DATE OF ADMISSION:

15a. WAS THE PATIENT IN AN ICU IN THE 7 DAYS BEFORE THE DISC?
IF YES, DATE OF ICU ADMISSION:

OR

● Yes

● No

● Unknown

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

Date 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-XXXX).
CS342262-A 09/20/2023

Page 1 of 6

16. PATIENT OUTCOME:
DATE OF DISCHARGE:
● Date unknown
● Left against medical advice (AMA)

● Survived
● Died
● Unknown
DATE OF DEATH:

OR

IF SURVIVED, DISCHARGED TO:

OR

● Private residence

■ Decubitus/pressure ulcer
■ Empyema
■ Endocarditis
■ Epidural abscess
■ Meningitis
■ Osteomyelitis
■ Peritonitis

● No

● None

● Colonized

■ Pneumonia (CRAB cases, complete Q23c)
■ Pyelonephritis (complete 22a–22c)
■ Sepsis
■ Urosepsis
■ Septic arthritis
■ Septic emboli
■ Septic shock

17b. RECURRENT UTI:
● Yes

● Unknown

● LTACH, Facility ID:

Date unknown

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)

● Other (specify):

● LTCF, Facility ID:

● Unknown
■ Skin abscess
■ Surgical incision infection
■ Surgical site infection (internal)
■ Traumatic wound
■ Urinary tract infection
(complete 22a–22c)
■ Other (specify):

17c. WAS THE PATIENT TREATED FOR THE MUGSI ORGANISM?
● Unknown

● Yes

18. UNDERLYING CONDITIONS: (Check all that apply)
CHRONIC LUNG DISEASE
■ Cystic fibrosis
■ Chronic pulmonary disease
CHRONIC METABOLIC DISEASE
■ Diabetes mellitus
■ With chronic complications
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

● None

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

LIVER DISEASE
■ Chronic liver disease
■ Ascites
■ Cirrhosis
■ Hepatic encephalopathy
■ Variceal bleeding
■ Hepatitis C
■ Treated, in SVR
■ Current, chronic

PLEGIAS/PARALYSIS
■ Hemiplegia
■ Paraplegia
■ Quadriplegia

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

■ None
■ Unknown

OTHER SUBSTANCES: (Check all that apply) ● None

● Unknown

● Unknown

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

RENAL DISEASE
■ Chronic kidney disease
Lowest serum creatinine:

■ Tobacco
■ E-nicotine delivery system

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

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

mg/DL
■ Unknown or not done

19. SUBSTANCE USE
SMOKING: (Check all that apply)

● No

■ Marijuana

ALCOHOL ABUSE:
● Yes
● No

● Unknown

● Unknown
DUD/ ABUSE

MODE OF DELIVERY (Check all that apply)

Marijuana, cannabinoid (other than smoking)

DUD or abuse

IDU

Skin popping Non-IDU Unknown

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

DUD or abuse

IDU

Skin popping Non-IDU 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?
Yes No
N/A (patient not hospitalized or did not have DUD)

Page 2 of 6

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 Unknown

IF YES, DATE OF DISCHARGE CLOSEST TO DISC:

OR,

DATE UNKNOWN

Facility ID:

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:

SURGERY IN THE YEAR BEFORE DISC:

Yes No Unknown

INVASIVE OR DIAGNOSTIC UROLOGIC PROCEDURE IN THE YEAR BEFORE DISC:

Yes No Unknown

IF YES, CHECK ALL THAT APPLY:

Prostate procedure Cystoscopy Other

CURRENT CHRONIC DIALYSIS:
IF YES, TYPE:

Yes No Unknown

Hemodialysis

Peritoneal

IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:

Unknown
AV fistula/graft

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

Yes No Unknown

URINARY CATHETER IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION),
OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC:
IF YES, CHECK ALL THAT APPLY:

Yes No Unknown

■ Indwelling Urethral Catheter

■ Condom Catheter

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

■ Tracheostomy

Yes No Unknown

■ Other (specify):

PATIENT TRAVELED INTERNATIONALLY IN THE YEAR BEFORE DISC:

Yes No Unknown

COUNTRY(IES):
PATIENT HOSPITALIZED WHILE VISITING COUNTRY(IES) ABOVE:

21a. WEIGHT:
lbs.

Yes No Unknown

21b. HEIGHT:
oz. OR kg Unknown

ft.

21c. BMI:
in. OR

cm

Unknown

Unknown

Complete questions 22a-22c for all MuGSI cases from urine cultures or where UTI or pyelonephritis is marked in question 17a:

22a. WAS THE URINE COLLECTED THROUGH AN INDWELLING URETHRAL CATHETER? Yes No Unknown
22b. RECORD THE COLONY COUNT:
22c. ASSOCIATED SIGNS AND SYMPTOMS:
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:
■ None
■ Fever [temperature ≥ 100.4 °F (38 °C)]
■ Unknown

■ Frequency

■ Apnea

■ Lethargy

■ Costovertebral angle pain or tenderness

■ Suprapubic tenderness

■ Bradycardia

■ Vomiting

■ Dysuria

■ Urgency

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?

Yes No Unknown N/A

23b. RISK FACTORS PRIOR TO CRAB DISC: (Check all that apply)
■ 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
■ Visited a wound care clinic at any time in the year before the DISC
■ None of the above
Page 3 of 6

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

23c. CHEST RADIOLOGY FINDINGS: (Check all that apply)
■ Not done
■ No report available
■ Acute respiratory distress syndrome (ARDS)
■ Air space density/opacity

■ Ground glass opacities/infiltrates
■ Bronchopneumonia/pneumonia
■ Cannot rule out pneumonia
■ Cavitation

■ Consolidation
■ Infiltrate
■ Pleural effusion

■ Nodules
■ No evidence of pneumonia

24a. IS ANTIMICROBIAL USE (IV OR ORAL) IN THE 30 DAYS BEFORE THE DISC DOCUMENTED? Yes No Unknown
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
■ Cefadroxil
■ Cefazolin
■ Cefdinir
■ Cefepime
■ Cefiderocol
■ Cefixime
■ 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
■ Imipenem/cilastatin
■ Levofloxacin
■ Linezolid
■ Meropenem
■ Meropenem/vaborbactam
■ Metronidazole
■ Moxifloxacin
■ Nitrofurantoin
■ Omadacycline
■ Oritavancin
■ Penicillin
■ Piperacillin/tazobactam
■ Polymyxin B
■ Polymyxin E (colistin)

Unknown

■ 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 SARS-CoV-2 (MOLECULAR ASSAY, ANTIGEN, OR OTHER VIRAL TEST,
EXCLUDING SEROLOGY) IN THE 90 DAYS BEFORE OR DAY OF THE DISC?
Yes No Unknown

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

or

Date unknown

25c.COVID-NET CASE ID IN THE YEAR BEFORE OR DAY OF DISC:

Most recent positive test:

or

Date unknown

None or N/A

26. WAS THE INCIDENT SPECIMEN POLYMICROBIAL? Yes No Unknown
27a. WAS THE INCIDENT SPECIMEN TESTED FOR CARBAPENEMASE GENES? Yes No

Laboratory not testing Unknown

27b. IF YES, WHAT TESTING METHOD WAS USED? (Check all that apply)
Non-Molecular Test Methods:
■ CarbaNP
■ Carbapenemase Inactivation
Method (CIM)
■ CPO Detect
■ Disk Diffusion/ROSCO Disk
■ E-test
■ Modified Carbapenemase
Inactivation Method (mCIM)

Molecular Test Methods:
■ Modified Hodge Test (MHT)
■ RAPIDEC
■ Other (specify):
■ Unknown

■ Automated Molecular Assay
■ Carba-R
■ Check Points
■ MALDI-TOF MS
■ Next Generation Nucleic
Acid Sequencing
■ PCR

■ Streck ARM-D
■ Other (specify):
■ Unknown

27c. IF TESTED, WHAT WAS THE TESTING RESULT?
Non-Molecular Test Results:
● Positive
● Indeterminate
● Negative
● Unknown

Molecular Test Results:
■ NDM Pos Neg Ind Unk
■ KPC Pos Neg Ind Unk
■ OXA (specify): Pos Neg Ind Unk
■ VIM Pos Neg Ind Unk
■ IMP Pos Neg Ind Unk
■ Other carbapenemase gene (specify): Pos Neg Ind Unk

Page 4 of 6

28a. WAS THE INCIDENT SPECIMEN TESTED FOR ESBL PRODUCTION OR OTHER BETA-LACTAMASE GENES?
● Yes
● No
● Laboratory not testing
● Unknown

28b. IF TESTED, WHAT TESTING METHOD WAS USED? (Check all that apply):

28c. 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

■ Molecular test (specify):

Pos Neg Ind Unk

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

Pos Neg Ind Unk

Page 5 of 6

29. SUSCEPTIBILITY RESULTS:
Please complete the table below based on the information found in the indicated data source.

Antibiotic

No susceptibility data from the medical record are available

Data source:

Data source:

Data source:

Data source:

Data source:

Data source:

MIC or zone diameter

Interpretation

APS
VK
SEN
PX
MS
MR
KB
ET
MIC or
zone diameter

APS
VK
SEN
PX
MS
MR
KB
ET
Interpretation

APS
VK
SEN
PX
MS
MR
KB
ET
MIC or
zone diameter

APS
VK
SEN
PX
MS
MR
KB
ET
Interpretation

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
Moxifloxacin
Nitrofurantoin
Omadacycline
Piperacillin/Tazobactam
Plazomicin
Polymyxin B
Rifampin
Tetracycline
Tigecycline
Tobramycin
Trimethoprimsulfamethoxazole

30a. WAS THE CASE FIRST
IDENTIFIED THROUGH AN AUDIT?
● Yes
● No

30b. CRF STATUS:

30c. SO INITIALS:

30d. DATE OF ABSTRACTION:

● Complete
● Pending
● Chart unavailable after 3 requests
● Complete – pending data

30e. COMMENTS:

Page 6 of 6