Invasive Methicillin-Resistant-Staphylococcus Aureus Active Bacterial Core Surveillance (Abcs) Case Report Form - 2015 Page 2
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1
219. TYPES OF MRSA INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply)
1
None
1
Unknown
1
1
Abscess (not skin)
1
Cellulitis
Meningitis
1
Traumatic Wound
1
Septic Emboli
1
1
AV Fistula/Graft Infection
Peritonitis
1
Septic Shock
1
Urinary Tract
1
Chronic Ulcer/Wound (non-decubitus)
1
1
Bacteremia
1
Pneumonia
1
Skin Abscess
1
Decubitus/Pressure Ulcer
Other: (specify)
_______________________
1
Empyema
1
Bursitis
1
Osteomyelitis
1
Surgical Incision
_______________________
1
Endocarditis
1
Surgical Site (Internal)
1
Catheter Site Infection
1
Septic Arthritis
20. UNDERLYING CONDITIONS: (Check all that apply) (if none or no chart available, check appropriate box)
1
None
1
Unknown
1
Abscess/Boil (Recurrent)
1
1
1
Connective Tissue Disease
Hemiplegia/Paraplegia
Other Drug Use
1
AIDS
1
1
1
HIV
Peptic Ulcer Disease
Current Smoker
1
1
Chronic Cognitive Deficit
1
1
Peripheral Vascular Disease (PVD)
CVA/Stroke
Influenza
(within 10 days of initial culture)
1
Chronic Liver Disease
1
1
Cystic Fibrosis
Premature Birth
1
IVDU
1
Chronic Pulmonar Disease
1
1
Decubitus/Pressure Ulcer
Solid Tumor (non metastatic)
1
Metastatic Solid Tumor
1
Chronic Kidney Disease
Other: (specify only for cases less than or
1
1
Dementia
1
equal to12 months of age)
Myocardial Infarct
1
Chronic Skin Breakdown
1
Diabetes
_____________________________
1
Obesity
1
Congestive Heart Failure
1
Hematologic Malignancy
21. PRIOR HEALTHCARE EXPOSURE – Healthcare-associated and Community-associated: (Check all that apply)
1
None
1
Unknown
1
Surgery within year before initial culture date.
1
Previous documented MRSA infection or colonization
OR previous STATE I.D.:
Month
Year
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:
If YES:
Date
Surgery
/
/
1.
__________________________________________
_____
_____
_____
1
Hospitalized within year before initial culture date.
2.
__________________________________________
/
/
_____
_____
_____
Date of discharge
/
/
_____
_____
_____
3.
__________________________________________
Mo.
Day
Year
1
Unknown
If YES:
/
/
_____
_____
_____
4.
__________________________________________
1
Residence in a long-term care facility
1
Dialysis within year before initial culture date.
within year before initial culture date.
(Hemodialysis or Peritoneal dialysis
)
1
Admitted to a LTACH within year
1
Current chronic dialysis
before initial culture date.
Type
Peritoneal
Unknown
Hemodialysis
1
Central vascular catheter in place at
Type of vascular access
any time in the 2 calendar days prior
AV fistula / graft
to initial culture.
Hemodialysis CVC
Unknown
–
THIS SHADED AREA FOR OFFICE USE ONLY
–
25. Date reported to EIP site:
26. Initials of
22. Was case first
23. CRF status:
24. Does this case have
If YES, previous
identified through
recurrent MRSA
S.O:
1
Complete
(1
st
) STATE I.D.:
audit?
disease?
2
Incomplete
Mo.
Day
Year
1
Yes 2
No
1
Yes 2
No
3
Edited & Correct
4
Chart unavailable
9
Unknown
9
Unknown
after 3 requests
27 COMMENTS:_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
CDC 52.15B Rev. 6-2015
Page 2 of 2
CS253065
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