Elizabethkingia Meningoseptica Case Investigation Form

Appendix 1: Case Investigation Form

Elizabethkingia Meningoseptica

Case Investigation Form

This form is intended to interview patients in Wisconsin with:

• Bloodstream isolates of Elizabethkingia meningoseptica.

AND

• The blood specimen was collected after November 1, 2015

When initiating an interview, please use the script appropriate to a participant as a case or control in the case-control investigation.

Was consent given: Yes No (DO NOT PROCEED)

Contact Information

Patient contact information (gather at least State and Zip Code, even if proxy was interviewed): Name: ___________________________________ Address: __________________________________ City, State, Zip: ____________________________ Phone: ( ) ___________________________

Proxy contact information (if applicable): Name: ________________________ Relation to patient: Relative: _________________ Clinician Other: ___________________ Address: Same as patient __________________________________ City, State, Zip: ____________________________ Phone: ( ) ___________________________

I nterview Information

Date reported to health department: ___/___/_____ (MM/DD/YYYY) Not applicable, why? ________________________

Date interview completed: ___/___/_____ (MM/DD/YYYY) Not applicable. Why? ________________________

Interviewer: Name: __________________________

Affiliation (state health dept. or CDC): __________________________________

State Epi ID:_______________________________________________ State Lab ID: ________________________________________________

For interviewer use only:

Information on this report was collected through (check all that apply): Patient/proxy interview Medical Record Review

Review of health department notes Other: ______________________________________

Must be filled BEFORE faxing to DPH:

Does this patient have laboratory-confirmation of Elizabethkingia meningoseptica bloodstream infection? Yes No (STOP interview)

Patient Provider (Patient interview or Medical Record Review)

1. Primary care provider name: ­­­­­­­­­­­­­_______________________________________________________________________________________

2. Location and phone number of Primary care provider: __________________________________________________________________

Demographic Information (Medical Record Review and Patient Interview)

3. Date of birth: ____/____/_____ (MM/DD/YYYY)

4. What state do you live in? _____________________

5. What is your race: (check all that apply) White Asian American Indian/Alaska Native

Black Native Hawaiian/Other Pacific Islander

6. What is your ethnicity: Hispanic or Latino Not Hispanic or Latino

7. What is your sex: Male Female

Facility at time of first positive culture (Medical Record Review)

8. Date of admission: ____/____/_____ (MM/DD/YYYY)

9. Name of current facility: ­­­­­­­­­­­­­____________________

10. Facility type: __________________

11. Unit patient located at time of culture collection:

Facility at time of Exposure (Medical Record Review)

12. Date of admission/outpatient visit: ____/____/_____ (MM/DD/YYYY)

13. Name of facility: ­­­­­­­­­­­­­____________________

14. Facility type: __________________

Incident E. meningoseptica (Medical Record Review)

15. Date of Culture: ____/____/_____ (MM/DD/YYYY)

16. Source of culture: ______________

17. Susceptibility_____________

18. List antibiotic exposure before positive culture during the inpatient admission _____________________________

19. Indwelling devices at time of culture _______________________________________________

Laboratory Information (Medical Record Review)

20. PFGE pattern (specify):

Risk factors (Medical Record Review)

21. Inpatient Antimicrobial history: List antibiotics used during past 3 months, indication and duration.

Antibiotics	Indication	Start date (MM/DD/YYYY)	End date (MM/DD/YYYY)	Total number of days receiving antibiotics

22. Outpatient Antimicrobial history: List of antibiotics used during the past 3 months, indication and duration.

Antibiotics	Indication	Start date (MM/DD/YYYY)	End date (MM/DD/YYYY)	Total number of days receiving antibiotics

Multidrug Resistant Organism (MDRO) Medical Record Review

23. During the past year have has the patient had infection with a multidrug resistant organism (MDRO) Yes No (Skip to Question 27)

Organism	Antibiotic Susceptibility Testing	Site of Infection	Facility (name and location) at time of Diagnosis	Incident Date (MM/DD/YYYY)

Medical History – Comorbidity Scale (Patient Interview and Medical Record Review)

24. Females only: Were you pregnant or ≤6 weeks postpartum when the illness began?

Yes, pregnant (weeks pregnant at onset)______ Yes, postpartum (delivery date) ___/___/____ (MM/DD/YYYY) No Unknown

Do you have any of the following medical conditions? Please ask about each condition and specify ALL conditions that are present.

Myocardial Infarction	Yes	(If YES, specify) _______________________________	No	Unknown
Congestive Heart Failure	Yes	(If YES, specify) _______________________________	No	Unknown
Peripheral Vascular Disease	Yes	(If YES, specify) _______________________________	No	Unknown
Cerebrovascular Disease	Yes	(If YES, specify) _______________________________	No	Unknown
Dementia	Yes	(If YES, specify) _______________________________	No	Unknown
Chronic Obstructive Pulmonary Disease (COPD)	Yes	(If YES, specify) _______________________________	No	Unknown
Peptic Ulcer Disease	Yes	(If YES, specify) _______________________________	No	Unknown
Diabetes Mellitus, uncomplicated	Yes	(If YES, specify) _______________________________	No	Unknown
Diabetes Mellitus, complicated (end-organ damage)	Yes	(If YES, specify) _______________________________	No	Unknown
Moderate to Severe Chronic Kidney Disease	Yes	(If YES, specify) _______________________________	No	Unknown
Hemiplegia	Yes	(If YES, specify) _______________________________	No	Unknown
Leukemia	Yes	(If YES, specify) _______________________________	No	Unknown
Malignant Lymphoma	Yes	(If YES, specify) _______________________________	No	Unknown
Solid Tumor	Yes	(If YES, specify) _______________________________	No	Unknown
Liver Disease	Yes	(If YES, specify) _______________________________	No	Unknown
AIDS	Yes	(If YES, specify) _______________________________	No	Unknown
History of decubitus ulcers	Yes	(If YES, specify location) ________________________	No	Unknown

Height

______

Weight

______

Other (please specify)

Yes

(If YES, specify) _______________________________

No

Unknown

Dialysis (Medical Record Review)

45. List dialysis in the past year. If chronic, list dialysis days, and dialysis center (facility name, and phone number).

Type of dialysis (i.e. hemodialysis, peritoneal dialysis)	Indication	Type, and date of access (i.e. fistula, line) (MM/DD/YYYY)	Dialysis days (MM/DD/YYYY)	Location (for chronic dialysis name dialysis center)

Inpatient and Outpatient Surgical or Procedure History (Medical Record Review)

46. List surgical procedures in the past year.

Surgery/Procedure	Indication	Date of Surgery (MM/DD/YYYY)	Hospitalization Admission and Discharge (MM/DD/YYYY)	Total number of days receiving antibiotics

Immunosuppressant use (Medical Record Review)

47. Immunosuppressant history: List immunosuppressant used in past 6 months, indication and duration (prednisone 20 mg administered daily for ≥ 2 weeks would be considered an immunosuppressant), include chemotherapy and radiation therapy.

Immunosuppressant	Indication	Start date (MM/DD/YYYY)	End date (MM/DD/YYYY)	Total number of days receiving drug

Activities (Patient Interview)

48. In the past year have you been to the dentist? Yes No (Skip to Question 52)

49. List types of procedures (cleaning, tooth extraction)? _________________________________________________

50. What is your water supply? Well City or Municipal water Other, specify _______________

51. Do you have a humidifier at home? Yes No

52. In the past year before you became ill, did you do any of the following activities either at home or while traveling:

Exposure	Yes	No	Location	Date(s) (MM/DD/YYYY)
Swimming
Water aerobics
Snorkeling
Scuba diving
Splash pad, water park
Steam room, or wet sauna
Hot tub or whirlpool/spa

Healthcare Exposure (Patient Interview)

53. In the past year before you became ill, did you receive any intravenous infusions (infusions through the vein) for medicines, vitamins? Yes No (Skip to Question 56)

Medication/Vitamin or Substance	Facility or Location (Address/Phone number)	Date(s) (MM/DD/YYYY)

54. In the past three months before you became ill, were any central, peripheral lines or catheters inserted (for example, intravenous line, dialysis line)

Yes No (Skip to Question 57)

Intravenous Line	Facility or Location (Address/Phone number)	Date of Insertion (MM/DD/YYYY)

55. In the past year have you been admitted to long term care facility, long term acute care hospital or an acute care hospital in Wisconsin, out of state or outside the country?

Yes No (Skip to Question 59)

56. List facilities in Wisconsin and out of state or country that you have been admitted to with location and dates in the last year (including multiple stays or admissions).

Name and Type of Facility (LTCF, LTACHs, Acute Care Hospital)	Location (Address and phone number)	Indication	Start date (MM/DD/YYYY)	End date (MM/DD/YYYY)	Total number of days

57. Any travel outside of the U.S. in the last year? Yes No (Skip to Question 61)

58. If yes, please list countries visited in the last year. ­­­­­­­­­­­­______________________________________________________________________________

59. In the last year have you had any medical devices (i.e. peripheral intravenous catheter, pacemaker, PEG/J)? Yes No

60. In the last year have you received home health services? Yes No

61. Any additional comments or notes (e.g. travel details, additional visits to healthcare providers, other diagnostic testing, and information)?

This is the end of the interview. Thank you very much for your time.

If you have any questions please feel free to contact Wisconsin Division of Public Health at 608-267-9003.

Interviewer: Please fax completed forms to 608-261-4976

Public reporting burden of this collection of information is estimated to average 75 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)