Form assigned MRSA

Form Approved
OMB No. 0920-0009

PATIENT ID: ____ ____ ____ ____ ____ ____ ____ ____

Invasive Methicillin-resistant Staphylococcus aureus
Active Bacterial Core Surveillance (ABCs) Case Report
Patient Name:___________________________________________________________________

Phone: (

Address: _______________________________________________________________________

Chart number:_____________________________________

(Last, First, M.I.)

(Number, Street, Apt#)

) _____________-_____________

_______________________________________________ ___________ ___________ Hospital: _________________________________________
(City)

(State)

(Zip)

- Patient Identifier Information Is Not Transmitted to CDC -

1. STATE:

2. COUNTY:

(Residence of patient)

3. STATE I.D.:

4a. HOSPITAL/LAB WHERE
CULTURE IDENTIFIED:

(Residence of Patient)

4b. HOSPITAL ID WHERE
PATIENT TREATED:

________________________

Mo

Day

6b. Is age in
day/mo/yr?

6a. AGE:

5. DATE OF BIRTH:

7a. SEX:

Year

1
2
3

1

Days
Mos.
Yrs.

2

Male
Female

7b. ETHNIC ORIGIN:

7c. RACE: (Check ALL that apply)

1

Hispanic or Latino

1

American Indian or Alaskan Native

1

White

2

Not Hispanic or Latino

1

Asian

1

Unknown

9

Unknown

1

Black or African American

1

Native Hawaiian or other Pacific Islander

7f. TYPE OF INSURANCE: (ICheck ALL that apply)
1

Medicare

1

Indian Health Service (HIS)

1

Military/VA

1

Medicaid/state assistance program

1
1

1 Unknown
Private/HMO/PPO/managed care
Other: (specify)__________________________________

Yes

If YES:

2

No

Date of Admission
Mo

Day

Year

Date of Discharge
Mo

Day

Year

1

Yes

2

No

9

Unknown
9

SURVIVED

1
2

Nursing Home

5

Prison/Jail

3

Rehabilitation

9

Unknown

6

Other (specify):_______________

Date of Death:
Mo

Yes

Emergency Room
Outpatient

2

7
10

Home Health
Other: (specify)__________________
Mo

Day

2

No

Year

9

No

9

Day

Year

13. STERILE SITE(S) FROM WHICH MRSA WAS INITIALLY
ISOLATED: (Check ALL that apply)
1

Blood

1

Joint/Synovial fluid

1

CSF

1

Bone

1

Pleural fluid

1

Internal body site (specify)

1

Peritoneal fluid

_______________________________

1

Pericardial fluid

1

Other sterile site (specify)

Unknown
16. NON-STERILE SITE(S) FROM WHICH MRSA WAS ISOLATED
WITHIN 72 HOURS BEFORE OR AFTER INITIAL STERILE SITE
CULTURE COLLECTION: (Check ALL that apply)
NONE
UNKNOWN

days after initial culture?
Yes

Unk

4

UNKNOWN

14. Were cultures of the SAME sterile site(s) positive between 7 and 30

1

7e. HEIGHT: ________ft ________ in OR ________cm

3

Was MRSA contributory or causal?
1

Unk

10. LOCATION OF CULTURE COLLECTION: (Check ONE)
Hospital Inpatient
8 Prison/Jail
5
Nursing Home
1 ICU
9 Unknown
6
Rehabilitation
Facility
2 Other Unit

DIED

2

Discharged to: (Check ONE)
4 Hospital
Home

7d. WEIGHT: ________lb ________oz OR ________ kg

12. DATE OF INITIAL CULTURE:

11. PATIENT OUTCOME:
1

No health coverage

9. WAS AN INFECTION
RELATED TO THE INITIAL
CULTURE INCLUDED IN THE
ADMISSION DIAGNOSIS? (Was
MRSA infection the reason for
hospital admission?)

8. WAS PATIENT HOSPITALIZED?
1

1

Unknown

15. Were cultures of OTHER sterile site(s) positive within 30 days of initial

1

Sputum

1

Urine

1

Throat/Nasopharynx

culture?

1

Nares

1

Catheter/Device

1

Other

1

Skin

1

Rectal/Stool

1

Yes

2

No

9

Unknown

If YES, list site(s):

1

Blood

1

Pericardial fluid

1

CSF

1

Joint/Synovial fluid

1

Pleural fluid

1

Bone

1

Peritoneal fluid

If SKIN, check culture type(s) below: (Check ALL that apply)

1 Internal body site (specify)
________________________
1 Other sterile site (specify)
_________________________

1

Traumatic Wound

1

Pressure Ulcer

1

Not Specified

1

Surgical Incision

1

Wound

1

Other: (specify)

1

Abscess

1

Exit site

_______________

17. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check ALL that apply)
Bacteremia

1

Meningitis

Primary

1

Peritonitis

2

Secondary

1

Pneumonia

9

Not Specified

1

Osteomyelitis

1

Abscess (not skin)

1

Bursitis

1

Urinary Tract

1

Surgical site (internal)

1

Septic Shock

1

1

Empyema

Endocarditis
1
2

Septic Arthritis

Native valve

1

Prosthetic valve

2

1

NONE

1

UNKNOWN

1

Cellulitis

1

Native Joint

1

Traumatic Wound

________________

Other: (specify)

Prosthetic Joint

1

Surgical Incision

________________

1

Pressure Ulcer

________________

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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009). Rev 12-2004

18. UNDERLYING CONDITIONS: (Check ALL that apply)

(If none or no chart available, check appropriate box)

1

NONE

1

UNKNOWN

1

Current Smoker

1

Heart Failure/CHF

1

Diabetes

1

Spider/Insect Bite 1

Abscess/Boil

1

Alcohol Abuse

1

Atherosclerotic Cardiovascular

1

Chronic Renal Insufficiency

1

Eczema

Psoriasis

1

IVDU

Disease (ASCVD)/CAD

1

Chronic Liver Disease

1

Other Dermatological Condition(s): (specify)

1

HIV

1

CVA/Stroke (Not TIA)

1

Rheumatoid Arthritis

_______________________________________

1

AIDS or CD4 count<200

1

Emphysema/COPD

1

Obesity

_______________________________________

1

Solid Organ Malignancy

1

Asthma

1

Influenza (within 10 days of

1

1

Hematologic Malignancy

1

Systemic Lupus Erythematosus

initial culture)

_______________________________________

1

Peripheral Vascular

1

Sickle Cell Anemia

Immunosuppressive Therapy

_______________________________________

1

1

Other condition(s): (specify)

Disease (PVD)
19. CLASSIFICATION – Healthcare-associated and Community-associated: (Check ALL that apply)
1

1

Previous documented MRSA infection or colonization
Month

If YES:

Year

Culture collected > 48 hours after hospital admission.

1

Hospitalized within year before index culture date.

1

Surgery within year before index culture date.

If YES: 1

1

Dialysis within year before index culture date.

Nursing Home

3

2

Rehabilitation Facility

9

Unknown

Resident at time of culture:

1

NONE

1

UNKNOWN

Residence in a long-term care facility within year before index culture date:

OR previous STATEID:

1

1

1

Other: (specify)
____________________________

Yes

2

No

9

Unknown

Invasive device or catheter in place at time of admission/evaluation?
If YES: (Check ALL that apply)

(Hemodialysis or Peritoneal dialysis)

1

Urinary

1

Gastrointestinal

1

Respiratory

1

Central Vascular

1

Other
__________________

20. SUSCEPTIBILITY RESULTS: [S=Sensitive (1), I=Intermediate (2), R=Resistant (3), U=Unknown/Not Reported (9)]
Ciprofloxacin:

S

I

R

U

Oxacillin:

S

I

R

U

Cefazolin:

S

I

R

U

Clindamycin:

S

I

R

U

Penicillin:

S

I

R

U

Chloramphenicol:

S

I

R

U

I

R

U

Moxifloxacin:

S

I

R

U

Daptomycin:

S

I

R

U

Quinupristin/Dalfopristin:

S

Doxycycline:

S

I

R

U

Rifampin:

S

I

R

U

Nafcillin:

S

I

R

U

I

R

U

Ampicillin:

S

I

R

U

Imipenem:

S

I

R

U

Erythromycin:

S

I

R

U

Tetracycline:

S

Gatifloxacin:

S

I

R

U

Trimethoprim-sulfamethoxazole:

S

I

R

U

Gentamicin:

S

I

R

U

Vancomycin:

S

I

R

U

Levofloxacin:

S

I

R

U

Other:

S

I

R

U

Linezolid:

S

I

R

U

22. WAS CULTURE POLYMICROBIAL?

1

Yes

2

No

9

Unknown

If YES, list other bacterial species isolated:

1________________________________
2________________________________

3________________________________
4 ________________________________

23. WAS PATIENT RECEIVING ANTIBIOTICS AT TIME OF CULTURE?

24. WAS PATIENT PRESCRIBED ANTIBIOTICS AT THE TIME OF CULTURE?
(Was antibiotic treatment initiated or changed?)

1

Yes

If YES, please list: (Use codes in appendix 1)

1

Yes

If YES, please list: (Use codes in appendix 1)

2

No

1__________

3__________

5__________

2

No

1__________

3__________

5__________

9

Unknown

2__________

4__________

6__________

9

Unknown

2__________

4__________

6__________

25. Was case first
identified through
audit?
1

Yes

2

No

9

Unknown

26. CRF status:
1

Complete

2

Incomplete

3

Edited & Corrected

4

Chart unavailable
after 3 requests

27. Does this case
have recurrent
MRSA disease?
1

Yes

2

No

9

Unknown

If YES, previous
(1st) STATEID:

28. DATE REPORTED TO EIP SITE:
Mo

Day

Year

29. Initials
of S.O.:

_________

30. COMMENTS: _________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________