Form HAIC.400.4 Invasive Staphylococcus aureus Healthcare-Associated Inf

Form Approved
OMB No. 0920-0978
Expires xx/xx/xxxx
June 2025

Invasive Staphylococcus aureus
Healthcare-Associated Infections Community Interface (HAIC) Case Report – 2026
Patient’s Name:

Phone No.: (

Address:

Address Type:

MRN:

City:

State:

ZIP:

)

Hospital:

— PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC —

1. STATE:

2. COUNTY:

2.a PLANNING REGION:

3. STATE ID:

8. DATE OF BIRTH:

7. SEX:
1

Male

2

Female

9

Missing Value

-

-

Days 2

5. LABORATORY ID WHERE
6. FACILITY ID WHERE
INCIDENT SPECIMEN IDENTIFIED:
PATIENT TREATED:

10. RACE AND/OR ETHNICITY: (Check all that apply)

9. AGE
1

4. PATIENT ID:

Mos. 3

Years

1

American Indian or Alaska Native

1

Hispanic or Latino

1

White

1

Asian

1

Middle Eastern or North African

1

Unknown

1

Black or African American

1

Native Hawaiian or Other Pacific Islander

10a. WHAT TYPE OF HEALTH INSURANCE DID THE PATIENT HAVE AT THE TIME OF THE DISC? (Check all that apply)
1

Medicaid 1

9

Unknown

Medicare 1

Private Insurance (including TRICARE) 1

oz. OR

kg.

11. WEIGHT:

12. HEIGHT:

lbs.

1

VA Care 1

13. BMI (record only if

ft.

Unknown

1

Self-pay (includes uninsured) 1

in. OR

Unknown

1

Other (specify):

14. DATE OF INCIDENT SPECIMEN
COLLECTION (DISC):

ht. and/or wt. is not
available)

cm.

No charge 1

-

Unknown

15. IS THE ISOLATE MRSA
OR MSSA?
MRSA
MSSA
Unknown

-

16. WAS THE PATIENT HOSPITALIZED AT THE TIME OF OR IN THE 29 CALENDAR DAYS AFTER THE DISC?

17. WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR DAYS
AFTER HOSPITAL ADMISSION?

1

1

Yes

2

No

9

Unknown

IF YES, date of admission:

-

-

Yes (HO case)

2

No (CA or HACO case)

18. INCIDENT SPECIMEN COLLECTION SITE: (Check all that apply)
1

Blood 1

Bone 1

1

Pleural fluid 1

CSF 1

Internal body site (specify):

1

Muscle 1

Pericardial fluid 1

Peritoneal fluid

Other normally sterile site (specify):

19. LOCATION OF SPECIMEN COLLECTION:
1
Outpatient
Facility
ID:

20. WERE CULTURES OF THE SAME OR OTHER STERILE SITES(S) POSITIVE WITHIN 29 DAYS
AFTER DISC?

1
Inpatient
Facility
ID:

5
LTCF
Facility
ID:

3

Emergency room

1

ICU

8

Clinic/doctor’s office

6

OR

15

Dialysis center

7

Radiology

11

Surgery

2

Other Inpatient

16

Observation/Clinical
decision unit

4

Joint/Synovial fluid 1

1

2

No

9

Unknown

IF YES, INDICATE SITE AND DATE OF LAST POSITIVE CULTURE:

13
LTACH
Facility
ID:

Other outpatient

Yes

14

Autopsy

10

Other

9

Unknown

1 Blood
Date:

1 Bone
Date:

1 CSF
Date:

1 Internal body site
Date:

1 Joint/Synovial fluid
Date:

1 Muscle
Date:

1 Peritoneal fluid
Date:

1 Pericardial fluid
Date:

1 Pleural fluid
Date:

1 Other normally sterile site (specify):
Date:
21. DATE OF FIRST SA BLOOD CULTURE AFTER WHICH SA NOT ISOLATED FOR 13 DAYS:
-

-

22. SUSCEPTIBILITY RESLULTS [S=Sensitive (1), I=Intermediate (2), R=Resistant (3), NS=Non-susceptible (4), SDD=Susceptible dose-dependent (5), U=Unknown/Not Reported (9)]
Cefazolin

9

U

Cefoxitin

3

R 9

U

Ceftaroline 1

S 5

Daptomycin 1

1

S

4

NS 9

U

Doxycycline 1

S 2

I 3

R 9

U

Linezolid

1

S

Oxacillin

S

3

R

U

Tetracycline 1

S 2

I 3

R 9

U

TMP-SMX

1

S 2

1

S 2

I 3

R

9

1

S

SDD 3

R 9

U

Clindamycin 1

S 2

I 3

R 9

U

3

R 9

U

Nafcillin

1

S 2

I 3

R 9

U

3

R 9

U

Vancomycin 1

S 2

I 3

R 9

U

I

23. WHERE WAS THE PATIENT LOCATED ON THE 3RD CALENDAR DAY BEFORE THE DISC?

24. IF CASE IS ≤12 MONTHS OF AGE, TYPE OF BIRTH HOSPITALIZATION:

1 Private residence
1 LTCF
Facility ID:
1 Hospital Inpatient
Facility ID:
Was patient transferred from this hosptial?
1 Yes 2 No 9 Unknown

1

1

LTACH

NICU/SCN

2

Well Baby Nusery

9

Unknown

Facility ID:

25. IF PATIENT <2 YEARS OF AGE WERE THEY BORN PREMATURE (<37 WEEKS GESTATION)?

1

Homeless

1

Correctional or detention facility

1

1

Drug/alcohol rehabilitation

1

Other

1

Unknown

Yes

2

No

IF YES, birth weight:

9

Unknown
lbs.

IF YES, estimated gestational age:

oz. OR

weeks OR 1

g. OR 1

Unknown birth weight

Unknown gestational age

Public reporting burden of this collection of information is estimated to average 29 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 30329; ATTN: PRA (0920-0978).

CS309520-B

— IMPORTANT — PLEASE COMPLETE THE BACK OF THIS FORM —

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26. WAS THE PATIENT IN AN ICU IN THE 2 DAYS BEFORE THE DISC?

27. WAS THE PATIENT IN AN ICU ON THE DISC OR IN THE 2 DAYS AFTER THE DISC?

1

1

Yes

2

No

9

Unknown

IF YES, date of ICU admission:

-

-

OR 1

None

2

No

9

Unknown

IF YES, date of ICU admission:

Date Unknown

28. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply) 1

Yes

1

-

-

OR 1

Date Unknown

Unknown

1

Abscess (not skin)

1

Cellulitis

1

Epidural Abscess

1

Septic Arthritis

1

Surgical Site (Internal)

1

AV Fistula/Graft Infection

1

Chronic Ulcer/Wound (non-decubitus)

1

Meningitis

1

Septic Emboli

1

Traumatic Wound

1

Bacteremia

1

Decubitus/Pressure Ulcer

1

Peritonitis

1

Septic Shock

1

Urinary Tract

1

Bursitis

1

Empyema

1

Pneumonia

1

Skin Abscess

1

Other: (specify)

1

Catheter Site Infection

1

Endocarditis

1

Osteomyelitis

1

Surgical Incision

28a. DOES THE PATIENT HAVE:
IMPLANTED CARDIAC DEVICE (E.G., PROSTHETIC HEART VALVE, PACEMAKER, AICD, LVAD)?
1 Yes 2 No 9 Unknown
IF YES, is it associated with the MRSA/MSSA infection?
1 Yes 2 No 9 Unknown

IMPLANTED ORTHOPEDIC DEVICE (E.G., PROSTHETIC JOINT OR ORTHOPEDIC
HARDWARE)?
1 Yes 2 No 9 Unknown
IF YES, is it associated with the MRSA/MSSA infection?
1

If associated with the infection, specify type (check all that apply):

1

CIED pocket/generator infection

1

LVAD driveline infection

1

CIED lead infection

1

LVAD pump/pump pocket infection

1

CIED unspecified infection location

1

LVAD unspecified infection location

1

Prosthetic heart valve

1

Other, specify:

NON-DIALYSIS PROSTHETIC VASCULAR GRAFT? 1

Yes 2

No 9

IF YES, is it associated with the MRSA/MSSA infection?

Yes 2

No 9

Unknown

If associated with the infection, specify type (check all that apply):

1

Prosthetic joint, hip

1

Hardware, spine

1

Prosthetic joint, knee

1

Hardware, other

1

Prosthetic joint, other

1

Other, specify:

Unknown

1

Yes 2

No 9

Unknown

28b. DOES THE PATIENT HAVE ANOTHER TYPE OF IMPLANTED PROSTHETIC DEVICE ASSOCIATED WITH THE INFECTION?
1

Yes 2 No 9 Unknown
IF YES, specify type (check all that apply):
1

CSF shunt/drain

1

Percutaneous drain/tube (non-CSF)

29. UNDERLYING CONDITIONS: (Check all that apply) 1
CHRONIC LUNG DISEASE
1 Cystic fibrosis
1 Chronic pulmonary disease
CHRONIC METABOLIC DISEASE
1 Diabetes mellitus
1 With chronic complications
CARDIOVASCULAR DISEASE
1 CVA/Stroke/TIA
1 Congenital heart disease
1 Congestive heart failure
1 Myocardial infarction
1 Peripheral vascular disease (PVD)
GASTROINTESTINAL DISEASE
1 Diverticular disease
1 Inflammatory bowel disease
1 Peptic ulcer disease
1 Short gut syndrome

None

1

1

Urinary catheter or stent

Other, specify:

Unknown

IMMUNOCOMPROMISED CONDITION
1 HIV infection
1 AIDS/CD4 count <200
1 Primary immunodeficiency
1 Transplant, hematopoetic stem cell
1 Transplant, solid organ
LIVER DISEASE
1 Chronic liver disease
1 Ascites
1 Cirrhosis
1 Hepatic encephalopathy
1 Variceal bleeding
1 Hepatitis C
1 Treated, in SVR
1 Current, chronic
MALIGNANCY
1 Malignancy, hematologic
1 Malignancy, solid organ (non-metastatic)
1 Malignancy, solid organ (metastatic)

30. WAS THE PATIENT HOMELESS IN THE YEAR BEFORE DISC? 1

1

Yes 2

No 9

NEUROLOGIC CONDITION
1 Cerebral palsy
1 Chronic cognitive deficit
1 Dementia
1 Epilepsy/seizure/seizure
disorder
1 Multiple sclerosis
1 Neuropathy
1 Paresis
1 Parkinson’s Disease
1 Spinal cord injury
PLEGIAS/PARALYSIS
1 Hemiplegia
1 Paraplegia
1 Quadriplegia

RENAL DISEASE
1 Chronic kidney disease
Lowest serum creatinine:

mg/DL

1 Unknown or not done
SKIN CONDITION
1 Blistering disease
1 Burn
1 Decubitus/pressure ulcer
1 Eczema
1 Psoriasis
1 Surgical wound
1 Other chronic ulcer or chronic wound
OTHER
1 Connective tissue disease
1 Obesity or morbid obesity
1 Pregnant
1 Other (specify only for cases
≤12 months of age):

Unknown

31. SUBSTANCE USE:
SMOKING 1
1

None documented 1

Unknown 1

Tobacco 1

E-Nicotine delivery system

ALCOHOL ABUSE: 1

Yes 2

None documented 9

Unknown

Marijuana

INJECTION DRUG USE (IDU): 1

Yes

2

None documented

9

Unknown

If IDU, which substance(s) (check all that apply)

If IDU, did the patient receive medication assisted treatment (MAT)/ medication for opioid use

1
1
1
1

disorder (MOUD) during the current hospitalization?

Opioid, schedule I
Opioid, schedule II-IV
Opioid, NOS
Cocaine

CDC 52.15B Rev. 07-2019

1
1
1

Methamphetamine
Other (specify):
Unknown substance

1

CS309520-B

Yes 2

No 9

NA (not hospitalized or does not inject opioids)

Page 2 of 2

32. PRIOR HEALTHCARE EXPOSURE(S):
PREVIOUS DOCUMENTED MRSA/MSSA INFECTION OR COLONIZATION

OVERNIGHT STAY IN LTACH IN THE YEAR BEFORE DISC

1

1 Yes 2
Facility ID

Yes 2 No 9 Unknown
IF YES:
Month
Year

OR previous STATE I.D.:

No 9

Unknown

PREVIOUS HOSPITALIZATION IN THE YEAR BEFORE DISC?

OVERNIGHT STAY IN LTCF IN THE YEAR BEFORE DISC

1

1 Yes 2
Facility ID

Yes 2 No 9 Unknown
IF YES, DATE OF DISCHARGE CLOSEST TO DISC: __ __-__ __-__ __ __ __
OR, 1 Date unknown
Facility ID:

SURGERY IN THE YEAR BEFORE DISC 1

Yes 2

No 9

No 9

Unknown

Unknown

IF YES, list the surgeries and dates of surgery that occurred within 90 days prior to the DISC:
Surgery

Date

1.

__ __-__ __-__ __ __ __

2.

__ __-__ __-__ __ __ __

3.

__ __-__ __-__ __ __ __

4.

__ __-__ __-__ __ __ __

CENTRAL LINE IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION),
OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC
1

Yes 2

No 9

CURRENT CHRONIC DIALYSIS

Unknown

TYPE: 1

CHECK HERE if central line in place for >2 calendar days 1

Yes 2

No 9

33. PATIENT OUTCOME 1

Unknown
Survived

2

Died

DATE OF DISCHARGE: __ __-__ __-__ __ __ __ OR 1
1 Left against medical advice (AMA)
IF SURVIVED, DISCHARGED TO:
1 Private Residence
2 LTCF Facility ID:
3 LTACH Facility ID:
5 Homeless

6
7
4
9

Date Unknown

Yes 2

No 9

Correctional or detention facility
Drug/alcohol rehabilitation
Other
Unknown

Unknown

1
9

Yes

2

No

Unknown

35. CRF STATUS:
1 Complete
2 Incomplete
3 Edited & Correct
4 Chart unavailable
after 3 requests

Peritoneal 1

Unknown

Unknown

1

AV fistula/graft 1

Hemodialysis central line 1

3

Hospitalized > 1 year

9

Unknown

Unknown

1

Yes

2

No

9

Unknown

SPECIMEN COLLECTION DATES FOR POSITIVE TESTS IN THE 90 DAYS BEFORE OR
DAY OF DISC:
First positive test: __ __-__ __-__ __ __ __ 1

Unknown

Most recent positive test: __ __-__ __-__ __ __ __ 1

COVID-NET CASE ID in the year before or day of the DISC:
34. WAS CASE FIRST IDENTIFIED
THROUGH AUDIT?

No 9

DATE OF DEATH: __ __-__ __-__ __ __ __ OR 1 Date Unknown
ON THE DAY OF OR IN THE 6 CALENDAR DAYS BEFORE DEATH, WAS THE PATHOGEN OF
INTEREST ISOLATED FROM A SITE THAT MEETS THE CASE DEFINITION?

34a. DID THE PATIENT HAVE A POSITIVE TEST(S) FOR SARS-COV-2 (MOLECULAR ASSAY,
ANTIGEN OR OTHER VIRAL TEST; EXCLUDING SEROLOGY) IN THE 90 DAYS BEFORE OR DAY
OF THE DISC?
1

Yes 2

IF HEMODIALYSIS, type of vascular access:

DIALYSIS IN THE YEAR BEFORE DISC (Hemodialysis or Peritoneal dialysis)
1

Hemodialysis 1

1

Unknown

None or N/A
36. DOES THIS CASE HAVE
RECURRENT MRSA/MSSA
DISEASE?
1

Yes

2

9

Unknown

IF YES, PREVIOUS
(1ST) STATE I.D.

37. DATE REPORTED TO EIP SITE:
-

No

39. S.O. INITIALS:

-

38. DATE ABSTRACTION:
-

-

40. COMMENTS:

CDC 52.15B Rev. 07-2019

CS309520-B

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