SevereStaphylococcus aureus Community-Acquired Pneumonia

Report Form

Name of data abstracter______Affiliation:______

Tel (_____)______-______Date abstracted: ___/____/______(MM/YY/YYY)

I. Patient Information

  1. Age:______
  2. Date of birth: _____/______/______(MM/DD/YYYY)
  3. Sex: __Male __ Female
  4. Race: __ White __ Black__ American Indian/Alaskan Native

__ Asian __ Native Hawaiian/Pacific Islander __Other

  1. Ethnicity: __ Non-Hispanic __Hispanic___ Unknown
  2. State of residence (or Country if non-US) ______

II. Onset Classification

  1. Was the patient hospitalized >48 hours prior to firstS. aureus culture? __ Yes __ No__ Don’t know
  2. Did the patient ever have previous MRSA infection or colonization? __ Yes__ No__ Don’t know

In the past year, did the patient have: (Check all that apply)

SurgeryDialysis (hemo or peritoneal)Any hospitalization

Residence in long-term care Invasive device in place at least 1 day before S. aureus culture

 Unknown

III. Past Medical History (Please see appendix A for definitions)

  1. Please check all that apply

 AsthmaCurrent Smoker HIV/AIDSCongestive heart failure

Neoplastic disease Cystic fibrosisETOH abuse Diabetes mellitus

Injecting drug useRenal diseaseCOPDCerebrovascular disease

Other drug abuse DialysisLiver diseasePostSplenectomyState

Neurologic or neuromuscular diseaseGastroesophageal reflux disease(GERD)

Use of therapy to decrease stomach acid Other______

9.Does the patient have a history of any of the following skin conditions? (please check all that apply)

 Eczema Atopic dermatitisPsoriasisSkin infections

 Other, please describe:______

10.Was the patient vaccinated for influenza during the current season? ___Yes ___No ___Don’t know
  1. If Yes, which vaccine was administered? ___IM ___Nasal
  2. Date of vaccination: ___/____/______(mm/dd/yyyy)

IV. Culture Results(Please attach microbiology report with patient names excluded)

  1. Date of first positive S. aureusculture? _____/______/______(mm/dd/yyyy)
  2. Was the culture result polymicrobial? __Yes__No
  3. If YES, list other organsisms______
  4. Site from which S. aureus was isolated: (check all that apply)

Blood / Joint / Skin (swab/aspirate) / Urine
CSF / Bone / Sputum/trach/BAL / Ear (drainage/aspirate)
Pleural fluid / Surgical specimen / Nares / Eye
Peritoneal fluid / Post-op wound / Other (specify)
  1. Was this isolate reported as resistant to oxacillin (i.e., MRSA)? __ Yes __ No
V. Signs and Symptoms (In the week before the date of S. aureusculture from Question 11)
  1. Date of S. aureus pneumonia symptom onset: _____/_____/______(mm/dd/yyyy)
  2. Symptoms/Signs (check all that apply)

 Altered mental status Sore throat CoughMyalgias Hemoptysis

 Cardiac arrhythmia Fever Headache Chills Rales

Shortness of breath Nausea Vomiting Chest pain Fatigue/malaise

 CyanosisOther, please describe______

  1. Was this infection following influenza-like illness (ILI)? ___Yes ___No ___Don’t know

(If NO go to question 20)

  1. If Yes, what were the ILIsymptoms (please check all that apply)

 Sore throatFeverCoughFatigue/malaiseChills

Chest painMyalgiasHeadache Shortness of breathRhinorrhea

 Nausea Other, please describe______

  1. Date of ILI symptom onset:____/_____/______(mm/dd/yyyy)
  1. Was the patient tested for influenza? ___Yes ____No ___Don’t know
  2. If yes, was influenza virus infection confirmed by a laboratory test? ___Yes ___No ___Don’t know

(If NO, go to question 20)

  1. If YES, what laboratory test was used? (Please check all that apply)

ImmunofluorescenceRapid antigenViral cultureRT-PCR

 SerologyOther (please describe)______

  1. What was the type of influenza detected:  ABBoth A and B
  2. Date of influenza test:____/____/______(mm/dd/yyyy)

VI. Clinical and Laboratory Findings (On day of S. aureus culture [+/- 1day], most abnormal value)

  1. Temperature: ______oC or _____oF__ Not obtained
  2. Blood pressure:
  3. Systolic: ______Not obtained
  4. Diastolic:______Not obtained
  5. Respiratory rate: ______per minute__ Not obtained
  6. Pulse rate:______per minute__ Not obtained
  7. WBC count ______mm3 __ Not obtained
  8. Neutrophils:______%
  9. Platelets: ______mm3__ Not obtained
  10. Hematocrit:______Not obtained
  11. Arterial pH:______Not obtained
  12. Sodium:______mmol/liter__ Not obtained
  13. Glucose:______mg/dl__ Not obtained
  14. Blood urea nitrogen (BUN):_____mg/dl__ Not obtained
  15. Serum Creatinine: ______mg/dl__ Not obtained
  16. PO2:_____mm Hg__ Not obtained
  17. PCO2:: _____mm Hg__ Not obtained
  1. Chest X-Ray:__Normal__ Abnormal
  2. If abnormal, please check all that apply:(If available, please attach copy of report)

Single lobar infiltrateMultiple lobar infiltrate Interstitial infiltrate

Pleural effusionEmpyemaCavitation

 Other, please describe______

VII. Infection Hospitalization

Was the patient hospitalized as a result of the infection? __Yes__ No __Unknown

If not admitted, go to question 39

  1. Date admitted____/____ /______(mm/dd/yyyy)
  2. Date discharged____/____ /______(mm/dd/yyyy)
  1. Was the patient admitted to the ICU? ___Yes ___No ___Unknown
  2. If yes, number of ICU days:______
  3. Was the patient placed on mechanical ventilation? ___Yes ___No ___Unknown
  4. If yes, number of ventilator days:______
VIII. Treatment
  1. Were antibiotics prescribed? __Yes__ No __Unknown
  2. If Yes, list antibiotics prescribed beforeS. aureusculture results known: ______
  3. List antibiotics prescribed afterS. aureus culture results known: ______
  1. Were antivirals, including influenza antivirals, prescribed?__Yes__ No __Unknown
  2. If Yes, please list antivirals:______
  1. Were other treatment modalities used (e.g., surgical intervention)? __Yes__ No __Unknown
  2. What were the other treatment modalities: (please check all that apply)

 Thoracentesis Chest tubes Other, please describe:______

IX. Patient Outcome
  1. Date outcome was recorded:____/_____/______(mm/dd/yyyy)
  2. What was the patient’s outcome: __survived__died__unknown
  3. If patient died, date of death: ____/______/______(mm/dd/yyyy)
  4. If the patient died, cause of death:______
  5. Was S. aureus causal or contributory to death? ___Yes___No ___Unknown

Note:If laboratory printouts, radiology reports or discharge summaries available, please remove identifiers and fax along with this report form.

End of Form. Thank you for your assistance.

Appendix A: Definitions and Clarifications

  • Question 8: Examples of invasive devices or percutaneous catheters are foley, gastrostomy, broviac, tracheostomy)
  • Question 10: Past medical history definitions
  • Cerebrovascular disease: clinical diagnosis of stroke or transient ischemic attack or stroke documented by magnetic resonance imaging or computed tomography (CT)
  • Congestive heart failure: systolic or diastolic ventricular dysfunction documented by history, physical examination, and chest radiograph, echocardiogram, multiple gated acquisition scan, or left ventriculogram.
  • Liver disease: clinical or histological diagnosis of cirrhosis or another form of chronic liver disease, such as chronic active hepatitis
  • Neoplastic disease: any cancer except basal- or squamous-cell cancer of the skin that was active at the time of presentation or diagnosed within one year of presentation.
  • Renal disease: history of chronic renal disease or abnormal blood urea nitrogen (BUN) and creatinine concentrations documented in the medical record.
  • Question 16 and 17: Signs and symptoms
  • Altered mental status: disorientation with respect to person, place and time that is not known to be chronic, stupor, or coma.
  • Myalgias:Muscular pain or tenderness
  • Hemoptysis:The expectoration of blood or of blood-streaked sputum from the larynx, trachea, bronchi, or lungs.
  • Rales:wheezy and raspy sounds originating from a compromise
  • Cyanosis: A bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood.
  • Rhinorrhea:persistent watery mucus discharge from the nose (as in the common cold)

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