HAIC 400.4 Invasive Staphylococcus aureus Healthcare-Associated Inf

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

Invasive Staphylococcus aureus
Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2025
Patient’s Name:

Phone No.: (
Address Type:

Address:
City:

State:

January, 2024

)

MRN:

ZIP:

Hospital:

— PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC —

1. STATE:

2.a PLANNING REGION:

2. COUNTY:

-

1

Male

Female

9

Unknown

9. AGE

1

Check if transgender

1

-

Days 2

lbs.

oz. OR

Mos. 3

Years

1

Hispanic or Latino

1

Asian

1

Middle Eastern or North African

1

Black or African American

1

Native Hawaiian or Pacific Islander

in. OR

cm. 1

1

Yes

2

No

9

IF YES, date of admission:

Unknown

-

1

White

1

Unknown
15. IS THE ISOLATE
MRSA OR MSSA?
MRSA
MSSA

14. DATE OF INCIDENT
SPECIMEN COLLECTION (DISC):

and/or wt. is not available)

Unknown

-

Unknown

-

Unknown

17. WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR DAYS AFTER
HOSPITAL ADMISSION?
Yes (HO case)
2 No (CA or HACO case)
1

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

6. FACILITY ID WHERE
PATIENT TREATED:

American Indian or Alaska Native 1

13. BMI (record only if ht.

ft.

kg.

Unknown

5. LABORATORY ID WHERE INCIDENT
SPECIMEN INDENTIFIED:

1

12. HEIGHT:

11. WEIGHT:

1

4. PATIENT ID:

10. RACE AND/OR ETHNICITY: (Check all that apply)

8. DATE OF BIRTH:

7. SEX AT BIRTH:
2

3. STATE ID:

-

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

1

Pleural fluid 1

Outpatient

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

Facility
ID:
3

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

LTACH

14

Autopsy

10

Other

9

Other outpatient

Blood

1

1

Internal body site

1

Joint/Synovial fluid

CSF

Muscle

Date:

Date:

Date:

1

1

1

Peritoneal fluid

Date:
1

Unknown

Bone

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 13 DAYS:

-

-

22. SUSCEPTIBILITY RESULTS [S=Sensitive (1), I=Intermediate (2), R=Resistant (3), NS=Non-susceptible (4), SDD=Susceptible dose-dependent (5), U=Unknown/Not Reported (9)]
Cefazolin

1

S

I

3

9

U

Daptomycin

1

S

4

NS

9

Oxacillin

1

S

3

R

9

2

R

Cefoxitin

1

S

U

Doxycycline

1

S

2

I

U

Tetracycline

1

S

2

I

3

R

9

U

3

R

9

3

R

9

Ceftaroline

1

U

Linezolid

1

S

U

TMP-SMX

1

S

S

SDD

5

2

3

3

R

I

3

R
R

9

U Clindamycin 1

9

U Nafcillin

9

S

9

U

2

I

3

R

9

U

U Vancomycin 1

S

2

I

3

R

9

U

24. IF CASE IS ≤12 MONTHS OF AGE, TYPE OF BIRTH HOSPITALIZATION:

1

Private residence

1

1

LTCF Facility ID:

1

Hospital Inpatient Facility ID:

Yes

2

No

NICU/SCN

2

Well Baby Nursery

9

3

Unknown

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

Was patient transferred from this hospital?
1

LTACH Facility ID:

R

S

23. WHERE WAS THE PATIENT LOCATED ON THE 3RD CALENDAR DAY BEFORE THE DISC?
1

I

1

2

9

Unknown

1

Homeless

1

Correctional or detention facility

1

Drug/alcohol rehabilitation

1

Other

1

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 29 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 —

Page 1 of 3

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 INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)

2

1

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
IF YES, is it associated with the MRSA/MSSA infection?

28a. DOES THE PATIENT HAVE:
Implanted cardiac device (e.g., prosthetic heart valve, pacemaker, AICD, LVAD)? 1

Yes

2

No

9

Unknown

1

Yes
Yes

2
2

No

9

Unknown

Implanted orthopedic device (e.g., prosthetic joint or orthopedic hardware)?
Non-dialysis vascular graft?

1

No

9

1

Unknown

29. UNDERLYING CONDITIONS: (Check all that apply) 1

None

1

1

Yes, specify:___________

1

Yes, specify:___________

1

28b. Does the patient have another type of implanted prosthetic device associated with the infection?

Yes, specify:___________
Yes

IMMUNOCOMPROMISED CONDITION

MALIGNANCY

RENAL DISEASE

1

1

1

1

1

1
1

With chronic complications

CARDIOVASCULAR DISEASE
1

HIV infection

Malignancy, hematologic

2

No

9

Unknown

2

No

9

Unknown
Unknown

Malignancy, solid organ (non-metastatic)

1

1

Malignancy, solid organ (metastatic)

1

1

Transplant, hematopoetic stem cell

NEUROLOGIC CONDITION

1

Transplant, solid organ:

1

Cerebral palsy

SKIN CONDITION
1 Blistering disease

__________________

1

Chronic cognitive deficit

1

Burn

1

Dementia

1

Decubitus/pressure ulcer

1

Epilepsy/seizure/seizure disorder

1

Eczema

Multiple sclerosis

1

Psoriasis
Surgical wound
Other chronic ulcer or chronic wound

1

Chronic liver disease
Ascites

1

Congestive heart failure

1

Cirrhosis

1

Neuropathy

1

1

Myocardial infarction

1

Hepatic encephalopathy

1

Paresis

1

1

Peripheral vascular disease (PVD)

1

1

Parkinson’s Disease

OTHER

1

Spinal cord injury

1

1

Variceal bleeding
Hepatitis C
Treated, in SVR

1
1

1

Connective tissue disease

1

Obesity or morbid obesity

PLEGIAS/PARALYSIS

1

Pregnant

1

Hemiplegia

1

1

Diverticular disease

1

Inflammatory bowel disease

1

Peptic ulcer disease

1

Paraplegia

1

Short gut syndrome

1

Quadriplegia

Current, chronic

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

Yes

2

No

9

mg/DL

Unknown or not done

Congenital heart disease

GASTROINTESTINAL DISEASE

Unknown

9

Chronic kidney disease

1

1

9

1

LIVER DISEASE

CVA/Stroke/TIA

No

AIDS/CD4 count <200
Primary immunodeficiency

1

Diabetes mellitus

No

Lowest serum creatinine:

Chronic pulmonary disease

CHRONIC METABOLIC DISEASE

2

Unknown

CHRONIC LUNG DISEASE
Cystic fibrosis

2

Other (specify only for cases
≤12 months of age):

Unknown

31. SUBSTANCE USE:
SMOKING: 1

None documented 1

Unknown 1

OTHER SUBSTANCES (CHECK ALL THAT APPLY):

1

Tobacco 1

E-nicotine delivery system 1

None documented

1

Marijuana ALCOHOL ABUSE: 1

Yes

2

None documented

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 MRSA/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

Unknown

Facility ID

No

9

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

1

Survived
-

2
-

OR 1

1

3

Date Unknown

DATE OF DEATH:

Correctional or detention facility

2

LTCF Facility ID:

3

LTACH Facility ID:

4

Other

Homeless

9

Unknown

No

9

2

9

Unknown

No

Unknown

Hemodialysis central line

Hospitalized >1 year
-

9
-

OR 1

1

Unknown

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?
1
9 Unknown
Yes 2 No

First positive test: ___ ___-___ ___- ___ ___ ___ ___

Unknown

34. WAS CASE FIRSTIDENTIFIED
THROUGH AUDIT?
Yes

1

Unknown

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

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

1

Unknown

Most recent positive test: ___ ___-___ ___- ___ ___ ___ ___

1

Unknown

None or N/A

COVID-NET CASE ID in the year before or day of the DISC:

1

Peritoneal

9

Drug/alcohol rehabilitation

34a. 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 2

1

AV fistula/graft

Died

Left against medical advice (AMA)

IF SURVIVED, DISCHARGED TO:
1 Private Residence

1

No

Unknown

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

36. DOES THIS CASE
HAVE RECURRENT
MRSA/MSSA
DISEASE?
1

Yes

9

Unknown

2

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

No

37. DATE REPORTED TO EIP SITE:
-

39. S.O. INITIALS:

-

38. DATE ABSTRACTION:
-

-

40. COMMENTS:

CDC 52.15B Rev. 07-2019

CS309520

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