Form ABC.100.4 ABCs Severe GAS Infection: Supplemental Form

ABCs Severe GAS Infection: Supplemental Form
State ID: ___ ___ ___ ___ ___ ___ ___

REV. 7/2019

Symptom onset date: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

Unknown symptom onset date (check if unknown)
Please enter clinical finding and/or laboratory information requested below;
Form Approved
0920-0978
record HIGH or LOW values within 48 hours or 2 days of culture or admission

1. Soft-tissue necrosis (necrotizing fasciitis, necrotizing myositis, or necrotizing gangrene)?

1 Y 2 N 9 DK

If yes, a. Location on body:__________________________________________________
b. Surgery?
1 Y 2 N 9 DK
c. Amputation? 1 Y 2 N 9 DK
d. Debridement 1 Y 2 N 9 DK
2. Did the case have any of the following sequelae from the GAS infection? (Select all that apply)
1
1
1
1

a. Dialysis?
b. Impaired renal function?
c. Rehabilitation?
d. Other

Y
Y
Y
Y

2
2
2
2

N
N
N
N

3. Hypotension? 1 Y 2 N 9 DK

9
9
9
9

DK
DK
DK
DK

If yes to 2c., please indicate rehab type:
1 Inpatient 2 Outpatient 3 Rehab facility
(If yes to 2d., specify)_______________________

Low systolic BP __ __ __mmHg or

(Systolic BP≤ 90mmHg; for children <10yrs, see Lab Values Table)

not available

(Enter abnormal or lowest hypotensive systolic BP found during this illness)

***IF PATIENT DID NOT HAVE HYPOTENSION AT ANY TIME WITHIN 48 HOURS OR 2 DAYS OF CULTURE OR ADMISSION,
PLEASE STOP HERE***

4. a. Renal impairment? 1 Y 2 N 9 DK

Highest creatinine __ __. __mg/dL or

(Creatinine ≥2.12 mg/dL; for children <15yrs, see Lab
Values Table)

(If no chronic kidney disease, enter creatinine ≥2x upper limit of normal found during this illness. If no

lab value unavailable

abnormal value found or if chronic kidney disease, enter highest creatinine recorded during this illness.)

b. Was chronic kidney disease specifically listed in the chart?
Baseline or lowest creatinine: __ __. __mg/dL or

lab value unavailable

(Enter baseline (from old or current charts) or lowest creatinine recorded during this illness)

Date of baseline value if obtained from current hospitalization: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
3
lab value unavailable
5 a. Coagulopathy? 1 Y 2 N 9 DK Low platelets __ __ __(000)/mm or
3
(Platelets ≤ 100,000/mm )

(Enter platelet count ≤100,000/mm3 or lowest platelet count recorded during this illness.)

b. Disseminated intravascular coagulation (DIC)?
6a. Liver involvement? 1 Y

1 Y

2 N 9 DK

(If no chronic liver disease, enter lab value that is ≥2x upper limit of normal found
during this illness. If no abnormal value found or if chronic liver disease,enter highest
values recorded during this illness below.)

2 N

9 DK

b. Was chronic liver disease specifically listed
in the chart?

(Enter baseline (from old or current charts) or lowest values
recorded during this illness below. Enter dates of baseline values if
obtained from current hospitalization.)

Highest

Baseline or lowest

AST (SGOT) _ _ _ _U/L

AST (SGOT) _ _ _ _U/L

or

or

lab value unavailable

lab value unavailable

Date of baseline
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

ALT (SGPT) _ _ _ _U/L
or lab value unavailable

ALT (SGPT) _ _ _ _U/L
or lab value unavailable

Bilirubin __ __.__ mg/dL
or lab value unavailable

Bilirubin __ __ .__ mg/dL
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
or
lab value unavailable
)

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

7. a. Acute respiratory distress syndrome (ARDS)?
b. Acute onset of generalized edema?
c. Pleural or peritoneal effusions with hypoalbuminemia?(Serum albumin <3 g/dL or < 30 g/L)
Low albumin __ __ . __g/dL or
lab value unavailable

)

1
1
1

Y 2 N 9 DK
Y 2 N 9 DK
Y 2 N 9 DK

(Enter albumin <3 g/dL or < 30 g/L or lowest albumin recorded during this illness)

8. Generalized erythematous rash?
Form completed by (initials): ___ ___ ___

2 N 9 DK
1 Y
Date form completed: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

Public reporting burden of this collection of information is estimated to average 20 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 information, including suggestions for reducing this burden to CDC,
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30329, ATTN: PRA(0920-0978). Do not send the completed form to this address.

Table. Laboratory values
Age

Limit of normal range
Systolic Blood Pressure

0 – 28 days

<60 mm Hg

1 month – 12 months

<70 mm Hg

1 – 9 years

<70+(2x age in years)

10 + years

<91 mm Hg
Platelets

All

≤100x109/L or ≤100,000/mm3
Albumin

.
All
Age

<3g/dL or <30g/L
Normal range
Twice upper limit of
normal range
Creatinine1

0 – 3 years

0.03 – 0.5 mg/dL

≥1 mg/dL

4 – 9 years

0.03 – 0.59 mg/dL

≥1.18 mg/dL

10 – 14 years

0.31 – 0.88 mg/dL

≥1.76 mg/dL

15+ years

0.5 – 1.06 mg/dL

≥2.12 mg/dL

Normal range

Twice upper limit of
normal range

Age

Alanine Aminotransferase1 (ALT) or SGPT
0 – 7 days

6 – 40 U/L

≥80 U/L

8 – 30 days: Males
Females

10 – 40 U/L
8 – 32 U/L

≥80 U/L
≥64 U/L

1 – 12 months

12 – 45 U/L

≥90 U/L

1 – 19 years

5 – 45 U/L

≥90 U/L

20+ years

7 – 40 U/L

≥80 U/L

Normal range

Twice upper limit of
normal range

Age

Aspartate Aminotransferase1 (AST) or SGOT
0 – 7 days: Male
Female

30 – 100 U/L
24 – 95 U/L

≥200 U/L
≥190 U/L

8 – 30 days

22 – 71 U/L

≥142 U/L

1 – 12 months

22 – 63 U/L

≥126 U/L

1 – 3 years

20 – 60 U/L

≥120 U/L

4 – 9 years

15 – 50 U/L

≥100 U/L

10-15 years

10 – 40 U/L

≥80 U/L

16-19 years: Male
Female

15 – 45 U/L
5 – 30 U/L

≥90 U/L
≥60 U/L

20 + years
Age

12 – 38 U/L

≥76 U/L

Normal range

Twice upper limit of
normal range

Total Bilirubin1 (TBILI)
1 month – adult

<1 mg/dL

≥2 mg/dL

1 Kratz A, Pesce MA, Basner RC, Einstein AJ. Appendix: Laboratory Values of Clinical Importance. In: Longo DL, Fauci AS, Kasper DL, Hauser
SL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine, 18e. New York, NY: The McGraw-Hill Companies; 2012. Local
laboratories may have slightly different reference values.