Form 0920-0978 ABCs - Severe GAS Infection: Supplemental Form

ABCs - Severe GAS Infection: Supplemental Form
State ID: ___ ___ ___ ___ ___ ___ ___

Symptom onset date: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
Unknown symptom onset date (check if unknown)

REV. 2/2017

Please enter clinical finding and/or laboratory information requested below;
record the HIGHEST or LOWEST value within 48 hours of culture or admission

1. Soft-tissue necrosis (necrotizing fasciitis, necrotizing myositis, or necrotizing gangrene)?

Form Approved
0920-0978

1 Y 2 N 9 DK

If yes, a. Location on body:__________________________________________________
b. Surgery?
1 Y 2 N 9 DK
OPTIONAL: e. Is a pathology report available?
c. Amputation? 1 Y 2 N 9 DK
f. Is a surgical report available?
d. Debridement 1 Y 2 N 9 DK
g. Is a CT or MRI report available?
(If yes to any of the questions above, please collect report)

2. Did the case have any of the following sequelae from the GAS infection? (Select all that apply)
a. Dialysis?
b. Impaired renal function?
c. Rehabilitation?
d. Other

1
1
1
1

Y
Y
Y
Y

2
2
2
2

N
N
N
N

9
9
9
9

DK
DK
DK
DK

If yes to 2c., please indicate rehab type:
1 Inpatient 2 Outpatient 3 Rehab facility
(If yes, specify) ________________________

3. If the case died, and was not hospitalized, please indicate date of death: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
4. Hypotension? 1 Y 2 N 9 DK

not available

Lowest systolic BP __ __ __mmHg or

(Enter lowest systolic BP recorded during this illness)

(Systolic BP≤ 90mmHg; for children < 10yrs, see Instructions)

***IF PATIENT DID NOT HAVE HYPOTENSION AT ANY TIME DURING THIS ILLNESS, PLEASE STOP HERE***
5. a. Renal impairment? 1 Y 2 N 9 DK

Highest creatinine __ __. __mg/dL or

(Creatinine ≥ 2.12 mg/dL; for children < 15yrs, see Instructions)

(Enter highest creatinine recorded during this illness)

lab value unavailable

b. Was chronic kidney disease specifically listed in the chart?
Baseline or lowest creatinine: __ __. __mg/dL or lab value unavailable
(Enter lowest creatinine recorded in the chart)

Date of baseline value if obtained from current hospitalization: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
6 a. Coagulopathy? 1 Y
3
(Platelets ≤ 100,000/mm )

2 N

9 DK

Lowest platelets __ __ __(000)/mm3 or

b. Disseminated intravascular coagulation (DIC)?
7a. Liver involvement?
1 Y 2 N 9 DK
Reference Table (2x upper limit)

lab value unavailable

(Enter lowest platelet count recorded during this illness)

1 Y

2 N

9 DK

b. Was chronic liver disease specifically listed in the chart?
Enter baseline (from old or current charts) or lowest value and highest values recorded during
this illness episode below. Enter dates of baseline values if obtained from current
hospitalization.

Baseline or lowest

Highest
AST (SGOT) _ _ _ _U/L
or

AST (SGOT) _ _ _ _U/L

lab value unavailable or

Date of baseline
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

lab value unavailable

ALT (SGPT) _ _ _ _U/L
ALT (SGPT) _ _ _ _U/L
or lab value unavailable or lab value unavailable

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

Bilirubin __ __.__ mg/dL Bilirubin __ __ .__ mg/dL
lab value unavailable
or lab value unavailable or

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

)

8. a. Adult respiratory distress syndrome (ARDS)?
b. Acute onset of generalized edema?
c. Pleural or peritoneal effusions with hypoalbuminemia?(Serum albumin <3 g/dL or < 30 g/L)
Lowest albumin __ __ . __g/dL or
lab value unavailable

)

1
1
1

Y 2 N 9 DK
Y 2 N 9 DK
Y 2 N 9 DK

(Enter lowest albumin recorded during this illness)

9. Generalized erythematous rash?
Form completed by (initials): ___ ___ ___

1 Y

2 N 9 DK

Date form completed: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

Public reporting burden of this collection of information is estimated to average 20 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 information, including suggestions for reducing this burden to CDC,
CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30329, ATTN: PRA(0920-0978). Do not send the completed form to this address.