PATIENT ID: ____ ____ ____ ____ ____ ____ ____ ____
Invasive Methicillin-resistant Staphylococcus aureus
Active Bacterial Core Surveillance (ABCs) Case Report
Patient Name:___________________________________________________________________ Phone: ( ) _____________-_____________
(Last, First, M.I.)
Address: _______________________________________________________________________ Chart number:_____________________________________
(Number, Street, Apt#)
_______________________________________________ ___________ ___________ Hospital: _________________________________________
(City) (State) (Zip)
- Patient Identifier Information Is Not Transmitted to CDC - -SHADED AREAS FOR OFFICE USE ONLY-
1. STATE:
(Residence of patient)
2. COUNTY:
(Residence of Patient)
________________________
3. STATE I.D.:
4a. HOSPITAL/LAB WHERE CULTURE IDENTIFIED:
4b. HOSPITAL ID WHERE PATIENT TREATED:
5. DATE OF BIRTH:
Mo Day Year
6a. AGE:
6b. Is age in
day/mo/yr?
1 Days
2 Mos.
3 Yrs.
7a. SEX:
1 Male
2 Female
7b. ETHNIC ORIGIN:
1 Hispanic or Latino
2 Not Hispanic or Latino
9 Unknown
7c. RACE: (Check ALL that apply)
1 American Indian or Alaska Native
1 Asian
1 Black or African American
1 Native Hawaiian or Other Pacific Islander
1 White
1 Unknown
7d. WEIGHT: ________lb ________oz OR ________ kg Unk
7e. HEIGHT: ________ft ________ in OR ________cm Unk
7f. TYPE OF INSURANCE: (Check ALL that apply)
1 Medicare
1 Military/VA
1 Medicaid/state assistance program
1 No health coverage
1 Unknown
1 Indian Health Service (HIS)
1 Private/HMO/PPO/managed care plan
1 Other: (specify)__________________________________
8. WAS PATIENT HOSPITALIZED?
1 Yes 2 No 9 Unknown
If YES: Date of Admission
Mo Day Year
Date of Discharge
Mo Day Year
10. LOCATION OF CULTURE COLLECTION: (Check ONE)
9. WAS AN INFECTION RELATED TO THE INITIAL CULTURE INCLUDED IN THE ADMISSION DIAGNOSIS? (Was MRSA infection the reason for hospital admission?)
1 Yes
2 No
9 Unknown
0 Hospital Inpatient
3 Emergency Room
4 Outpatient
5 Long Term Care
Facility
9 Unknown
10 Other (specify)
__________________
12. DATE OF INITIAL CULTURE: Mo Day Year
11. PATIENT OUTCOME: 9 UNKNOWN
1 SURVIVED Mo Day Year
2 DIED
Was MRSA contributory or causal? 1 Yes 2 No
9 Unknown
Date of Death:
13. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY ISOLATED: (Check ALL that apply)
1 Blood
1 CSF
1 Pleural fluid
1 Peritoneal fluid
1 Pericardial fluid
1 Joint/Synovial fluid
1 Bone
1 Internal body site (specify)
_________________________
1 Other sterile site (specify)
_________________________
14. Were cultures of the SAME sterile site(s) positive between 7 and 30 days after initial culture?
1 Yes 2 No 9 Unknown
15. Were cultures of OTHER sterile site(s) positive within
30 days of initial culture?
1 Yes 2 No 9 Unknown
If YES, list site(s):
16. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S):
(Check ALL that apply) 1 NONE 1 UNKNOWN
15. Were cultures of OTHER sterile site(s) positive within 30 days of initial culture?
1 Yes 2 No 9 Unknown
If YES, list site(s):
1 Bacteremia
1 Empyema
1 Meningitis
1 Peritonitis
1 Pneumonia
1 Osteomyelitis
1 Urinary Tract
1 Endocarditis
1 Surgical Incision
1 Surgical Incision
1 Pressure Ulcer
1 Skin Abscess
1 Abscess (not skin)
1 Surgical site (internal)
1 Septic Arthritis
1 Bursitis
1 Septic Shock
1 Cellulitis
1 Traumatic Wound
1 Pressure Ulcer
1 Other: (specify)
________________
________________
________________
1 Blood
1 CSF
1 Pleural fluid
1 Peritoneal fluid
1 Pericardial fluid
1 Joint/Synovial fluid
1 Bone
1 Internal body site (specify)
_____________________
1 Other sterile site (specify)
_____________________
1 Blood
1 CSF
1 Pleural fluid
1 Peritoneal fluid
1 Pericardial fluid
Public reporting burden of this collection of information is estimated to average 10 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0009). Rev 12-2006
17. UNDERLYING CONDITIONS: (Check ALL that apply) (If none or no chart available, check appropriate box) 1 NONE 1 UNKNOWN
1 Current Smoker
1 Alcohol Abuse
1 IVDU
1 Other Drug Use
1 HIV
1 AIDS or CD4 count<200
1 Solid Organ Malignancy
1 Hematologic Malignancy
1 Peripheral Vascular Disease
(PVD)
1 Heart Failure/CHF
1 Atherosclerotic Cardiovascular
Disease (ASCVD)/CAD
1 CVA/Stroke (Not TIA)
1 Emphysema/COPD
1 Asthma
1 Systemic Lupus
Erythematosus
1 Sickle Cell Anemia
1 Diabetes
1 Chronic Renal Insufficiency
1 Chronic Liver Disease
1 Rheumatoid Arthritis
1 Obesity
1 Immunosuppressive 1 Influenza (within 10
Therapy days of initial culture)
1 Decubitus Ulcer 1 Abscess/Boil
1 Eczema 1 Psoriasis
1 Other Dermatological Condition(s): (specify)
_______________________________________
1 Other condition(s): (specify)
_______________________________________
18. CLASSIFICATION – Healthcare-associated and Community-associated: (Check ALL that apply) 1 NONE 1 UNKNOWN
1 Previous documented MRSA infection or colonization 1 Surgery within year before index
If YES: Month Year OR previous STATEID: culture date.
1 Dialysis within year before index
1 Culture collected > 48 hours after hospital admission. Culture date.
1 Hospitalized within year before index culture date. (Hemodialysis or Peritoneal dialysis)
1 Residence in a long-term care facility
within year before index culture date
1 Central vascular catheter in place at
time of admission/evaluation
19. SUSCEPTIBILITY RESULTS: [S=Sensitive (1), I=Intermediate (2), R=Resistant (3), U=Unknown/Not Reported (9)]
Ciprofloxacin:
Clindamycin:
Daptomycin:
Doxycycline:
Erythromycin:
Gatifloxacin:
Gentamicin:
Levofloxacin:
Linezolid:
Oxacillin:
Penicillin:
Quinupristin/Dalfopristin:
Rifampin:
Tetracycline:
Trimethoprim-sulfamethoxazole:
Vancomycin:
Other:
___________________________________
Cefazolin:
Chloramphenicol:
Moxifloxacin:
Nafcillin:
Ampicillin:
Imipenem:
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
S I R U
-
20. Was case first identified through audit?
1 Yes
2 No
9 Unknown
21. CRF status:
1 Complete
2 Incomplete
3 Edited & Corrected
4 Chart unavailable
after 3 requests
22. Does this case If YES, previous
have recurrent (1st) STATEID:
MRSA disease?
1 Yes
2 No
9 Unknown
23. DATE REPORTED TO EIP SITE:
Mo Day Year
24. Initials of S.O.:
_________
25. COMMENTS: _________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________
File Type | application/msword |
File Title | PATIENT ID:___ ___ ___ ___ ___ ___ ___ ___ |
Author | CDC |
Last Modified By | skf0 |
File Modified | 2007-02-14 |
File Created | 2007-02-14 |