HomeMy WebLinkAboutcase-report-form-archiveCalifornia Department of Public Health DRAFT
Surveillance and Statistics Section February 28, 2008
MS 7306, P.O. Box 997413
Sacramento, CA 95899-7413
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SEVERE STAPHYLOCOCCUS AUREUS INFECTION IN A PREVIOUSLY HEALTHY PERSON*
CASE REPORT
*A Previously Healthy Person is defined as a person “who has not been hospitalized or had surgery, dialysis, or residency in a
long-term care facility in the past year, and did not have an indwelling catheter or cutaneous medical device at the time of culture.”
SECTION 1. INITIAL SCREENING FOR CASE DEFINITION
Did the patient’s infection result in: ICU admission Yes No Death Yes No
If No to both of the above, patient does not meet the case definition. Please do not complete or submit this form.
Does the patient have ANY of the following? Yes No Unknown
If yes, check all that apply
Hospitalized within the past year (including >48 hours prior to first S. aureus positive culture)
Surgery within past year
Dialysis (hemo or peritoneal) within past year
Residence in long-term care within the past year
Percutaneous device or indwelling catheter
(e.g. BROVIAC®, foley, tracheostomy, gastrostomy)
If ANY risk factor is checked, patient does not meet the case definition. Please do not complete or submit this form.
SECTION 2. DEMOGRAPHIC INFORMATION
Patient Name – Last First Middle Initial Date of Birth
_____/_____/_____
Age
________ years
Sex
Male Female
Address (number, street) City State ZIP code County Telephone Number
Race (check all that apply)
African-American White Native American Asian/Pacific Islander Other______________
Ethnicity (check one)
Hispanic/Latino Non-Hispanic/Non-Latino
If Asian/Pacific Islander, check all that apply: Asian Indian Cambodian Chinese Filipino Guamanian Hawaiian
Japanese Korean Laotian Samoan Vietnamese Other______________
Occupation
SECTION 3. CLINICAL INFORMATION
Patient Hospitalized?
Yes No Unk
If Yes, Hospital Name City ZIP code
Admit Date _____/_____/__________ Medical Record #
Illness Onset Date
_____/_____/__________
Physician Name – Last First Telephone Number
Chest X-ray Yes No Unknown
If Yes, Normal Abnormal describe ____________________
Was a clinically-relevant infection associated with the positive culture? Yes No Unknown
If Yes, type of infection (check all that apply)
Bacteremia
Bursitis
Pyomyositis Meningitis
Septic arthritis
Septic emboli
Wound infection
Osteomyelitis Pneumonia
Necrotizing Hemorrhagic
Endocarditis
Skin or soft tissue infection (specify if known) __________________________
Necrotizing fasciitis Other infection (specify)_________________________________
Toxic shock syndrome (see Instructions)
Underlying condition(s) (check all that apply):
Alcohol abuse
Asthma
Eczema
Psoriasis
Folliculitis
Other chronic dermatologic condition
(specify) ______________________________
HIV/AIDS
IVDU
Diabetes mellitus
Emphysema/COPD
Heart failure/CHF
Immunosuppressive therapy
Liver disease
Malignancy – hematologic
Malignancy – solid organ
Chronic renal insufficiency
Current smoker
Other (specify) _________________________________
None
Past Medical History Staphylococcal disease MRSA infection or colonization
Patient Outcome Survived (as of _____/_____/_____) Died (Date _____/_____/_____) Unknown
California Department of Public Health
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SECTION 4. LABORATORY INFORMATION
Is the isolate: MRSA MSSA Culture date: _____/_____/_____ Hospital/clinic where culture obtained:
Site from which S. aureus was isolated (check all that apply)
Blood
Bone
Nares
Joint
Sputum/trach
Eye
Skin (swab/aspirate)
Ear (drainage/aspirate)
Peritoneal fluid
Urine
Pleural fluid
Wound
Cerebrospinal fluid
Surgical specimen
specify _________________________
Other (specify) ____________________________________________________________________________
Susceptibility Results (or attach laboratory
report of antibiotic susceptibilities) Susceptible Intermediate Resistant Not tested or unknown
Ciprofloxacin
Clindamycin
Daptomycin
Erythromycin (or other macrolide)
Gentamicin
Oxacillin
Linezolid
Rifampin
Synercid
Tetracycline
Trimethoprim-sulfamethoxazole
Telithromycin
Vancomycin
Other (specify)
Laboratory-confirmed influenza? A B Type of test ____________________ Date _____/_____/__________
SECTION 5. EPIDEMIOLOGIC INFORMATION
Did the patient reside in or participate in any of the following in the year prior to the culture? (Check all that apply.)
Correctional facility Residential care facility Indian reservation Pre-school/child care Team sports
SECTION 6. ASSOCIATION WITH OTHER CASES
Was this patient’s illness associated with other cases of S. aureus illness? Yes No Unknown
If Yes, specify nature of other illness _______________________________________________________________________________________________
Specify nature of association with other case(s) Household Sexual Other _____________________________
ADDITIONAL INFORMATION
Comments/Remarks:
Attachments/Reports:
Please attach laboratory report of antibiotic susceptibilities unless Susceptibility Results have been provided above.
REPORTING AGENCY
Investigator Name Local Health Jurisdiction Telephone Number Date
STATE USE ONLY
Case Counted Yes No Reason for case classification