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pdfPATIENT ID:
DATE REPORTED TO EIP SITE: (mm/dd/yyyy)
2022 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem Resistant A. baumannii (CRAB)
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:
Address Type:
Hospital:
----Patient Identifier information is not transmitted to CDC----
DEMOGRAPHICS
1. STATE:
2. COUNTY:
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
9a. DATE OF INCIDENT SPECIMEN
COLLECTION (DISC): (mm/dd/yyyy)
10. ORGANISM:
CRE
CRAB
If CRE, select one of
the following:
9b. TIME OF DISC: (HH:MM-Military Format)
Escherichia coli
Enterobacter cloacae
Klebsiella aerogenes
Klebsiella pneumoniae
Klebsiella oxytoca
11. INCIDENT SPECIMEN COLLECTION SITE:
Blood
Bone
Bronchoalveolar lavage (CRAB only, complete Q23c)
CSF
Internal body site (specify):
Muscle
Peritoneal fluid
Pericardial fluid
Pleural fluid
Joint/synovial fluid
Sputum (CRAB only, complete Q23c)
Tracheal aspirate (CRAB only, complete Q23c)
12. LOCATION OF SPECIMEN COLLECTION:
OUTPATIENT
Facility ID:
INPATIENT
Facility ID:
ICU
OR
Radiology
Other inpatient
Emergency room
Clinic/Doctor’s office
Dialysis center
Surgery
Observational/
Clinical decision unit
Other outpatient
Urine
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
Facility ID:
LTACH
Facility ID:
Private residence
LTCF
Facility ID:
LTACH
Facility ID:
Homeless
Incarcerated
Other (specify):
ospital inpatient
H
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
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)
Unknown
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 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 (0920-0978).
CS322168
04/16/2021
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
CHRONIC LUNG DISEASE
Cystic fibrosis
Chronic pulmonary disease
None
GASTROINTESTINAL DISEASE
Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome
Yes
No
Unknown
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
PLEGIAS/PARALYSIS
Hemiplegia
Paraplegia
Quadriplegia
OTHER SUBSTANCES: (Check all that apply)
RENAL DISEASE
Chronic kidney disease
Lowest serum creatinine:
Unknown or not done
None
MuGSI CONDITIONS
Urinary tract problems/abnormalities
Premature birth
Spina bifida
mg/DL
Unknown
DUD/ ABUSE
ALCOHOL ABUSE
Yes
No
Unknown
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):
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 (CRAB cases, complete Q23c)
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
17c. WAS THE PATIENT TREATED FOR THE MUGSI ORGANISM?
Unknown
18. UNDERLYING CONDITIONS: (Check all that apply)
None
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?
N/A (patient not hospitalized or did not have DUD)
Yes No
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
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 No Unknown
IF YES, DATE OF DISCHARGE CLOSEST TO DISC: (mm/dd/yyyy)
OR,
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:
OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC:
Facility ID:
IF YES, TYPE
Hemodialysis
Peritoneal
oz. OR
kg Unknown
Tracheostomy
Nephrostomy Tube
Other (specify):
COUNTRY(IES):
Yes No Unknown
PATIENT HOSPITALIZED WHILE VISITING COUNTRY(IES) ABOVE:
Yes No Unknown
21b. HEIGHT:
lbs.
Unknown
IF YES, CHECK ALL THAT APPLY:
ET/NT Tube
Gastrostomy Tube
NG Tube
Yes No Unknown
Check here if central line in place for > 2 calendar days
21a. WEIGHT:
Yes No
PATIENT TRAVELED INTERNATIONALLY IN THE YEAR BEFORE DISC:
Unknown
IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS:
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:
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:
21c. BMI:
ft.
in. OR
cm Unknown
Unknown
Page 2 of 4
URINE CULTURES ONLY:
URINE CULTURES ONLY:
22a. WAS THE URINE COLLECTED THROUGH
AN INDWELLING URETHRAL CATHETER?
22c. SIGNS AND SYMPTOMS ASSOCIATED WITH URINE CULTURE
Yes
No Unknown
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
URINE CULTURES ONLY:
22b. RECORD THE COLONY COUNT:
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 IN THE 7 DAYS BEFORE THE DISC:
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
24a. DID THE PATIENT HAVE A POSITIVE TEST(S) FOR
SARS-CoV-2 (MOLECULAR ASSAY, SEROLOGY OR
OTHER CONFIRMATORY TEST) IN THE YEAR BEFORE OR
DAY OF THE DISC?
Yes
Symptoms for patients ≤ 1 year
of age only:
Apnea
Lethargy
Bradycardia
Vomiting
Fever [temperature ≥ 100.4 °F (38 °C)]
Frequency
Suprapubic tenderness
Urgency
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
24b. IF YES, COMPLETE THE TABLE BELOW FOR THE MOST
RECENT POSITIVE SARS-COV-2 TEST IN THE YEAR BEFORE OR
DAY OF THE DISC:
SPECIMEN
COLLECTION DATE
No Unknown
TEST TYPE
Molecular assay
Antigen
Serology
Unknown
Other (specify):
Unknown
24c.COVID-NET CASE ID:
24d. NNDSS IDs: (please provide at least one of the following when applicable)
Local case ID:
Local record ID:
Legacy case identifier:
CDC 2019-nCOV ID:
State case identifier:
26a. WAS THE INCIDENT SPECIMEN TESTED FOR CARBAPENEMASE GENES?
25. WAS THE INCIDENT SPECIMEN POLYMICROBIAL?
Yes No
Yes No Unknown
26b. 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)
Modified Hodge Test (MHT)
RAPIDEC
Other (specify):
Unknown
Molecular Test Methods:
Automated Molecular Assay
Carba-R
Check Points
MALDI-TOF MS
Next Generation Nucleic
Acid Sequencing
PCR
Streck ARM-D
Other (specify):
26c. 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
Unknown
27a. WAS THE INCIDENT SPECIMEN TESTED FOR ESBL
PRODUCTION OR OTHER BETA-LACTAMASE GENES?
Yes
No
Laboratory not testing
Unknown
Laboratory not testing Unknown
27b. IF TESTED, WHAT TESTING METHOD WAS USED?
(Check all that apply):
27c. 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
28. SUSCEPTIBILITY RESULTS:
Please complete the table below based on the results from the data source (Accelerate Pheno System, E-test, Kirby Bauer, Microscan, Phoenix, Sensititre, Vitek, or Medical Record).
Data source:
Antibiotic
MIC or zone
diameter
Data source:
Interpretation
MIC or zone
diameter
Data source:
Interpretation
MIC or zone
diameter
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
Tigcycline
Tobramycin
Trimethoprimsulfamethoxazole
29a. WAS THE CASE FIRST
IDENTIFIED THROUGH AN AUDIT?
Yes
No
29e. COMMENTS:
29b. CRF STATUS:
29c. SO INITIALS:
29d. DATE OF ABSTRACTION: (mm/dd/yyyy)
Complete
Pending
Chart unavailable after 3 requests
Complete - pending data
Page 4 of 4
File Type | application/pdf |
File Title | 2021 Carbapenem Resistant Enterobacterales (CRE)/ Carbapenem Resistant A. baumannii (CRAB) Multi-site Gram-Negative Surveillance |
Subject | MuGSI CRECRAB, CS 322168, Carbapenem ResistantEnterobacterales (CRE), Carbapenem Resistant A. baumannii (CRAB), ulti-site Gram-N |
Author | Centers for Disease Control and Prevention |
File Modified | 2022-03-24 |
File Created | 2021-07-20 |