Form 0920-0978 ABC H. Influenzae Neonatal Sepsis Expanded Surveillance

Person Filling Out Form:

__________________________________________
(Last, First, M.I.)

Culture date: __ __ /__ __ /__ __ __ __
month / day / year (4 digits)

Infant’s Name: ________________________________________________ Estimated
(Last, First, M.I.)
__ /__ __ /__ __ __ __
Infant’s Chart No.:_____________________________________________ Due Date: __month
/ day / year (4 digits)

Infant

STATE ID:___ ___ ___ ___ ___ ___ ___

Mother

Mother’s Prenatal Care Provider: ____________________________________________
Clinic Name: _____________________________________________

Clinic Phone Number: _____________________________________________
Mother’s Name: ______________________________________________ Mother's
(Last, First, M.I.)
__ /__ __ /__ __ __ __ Hospital Name: ___________________________________________________
Mother’s Chart No.: ___________________________________________ Date of Birth: __
month / day / year (4 digits)
- Patient identifier information is
NOT transmitted to CDC -

2019 ABCs H. Influenzae Neonatal Sepsis Expanded Surveillance Form

Indicate type of HiNSES case:

Maternal cases: pregnant or post-partum (sterile isolates only)
Live Birth (hospitalized) - complete #1-31
Stillbirth (hospitalized)- complete #1-3,12-31
Spontaneous Abortion - complete #1-2b,12-18, and 28-31
Home delivery (any outcome) - end form
Induced Abortion - end form
Pregnancy outcome unknown - end form

Neonatal: infant
(sterile isolates only)
- complete #1-31

Infant Information

Fetal Cases (any gestational age - specify isolate/outcome):
Hi from a sterile site in stillbirth - complete #1-3, 12-31
Fetal deathHi isolated from placenta/amniotic fluid:
Stillbirth - complete #1-3,12-31
Spontaneous abortion - complete #1-2b,12-18, and 28-31

Were labor & delivery records available?

1. Date of live birth/stillbirth/spontaneous abortion: __ __ /__ __ /__ __ __ __ Time : ___ ___ ___ ___
month

day

year (4 digits)

Yes (1)

No (0)

Unknown (9)

(times in military format)

2. Gestational age of infant live birth/stillbirth/spontaneous abortion in completed weeks: __ __ (do not round up)
2a. Determined by:

Dates

Physical Exam

Unknown

Ultrasound

2b. Date of maternal last menstrual period (LMP): __ __ /__ __ /__ __ __ __

month / day / year (4 digits)

Unknown (9)

3. Birth weight: ___ lbs ___oz OR __ __ __ __ grams
4. Date & time of newborn discharge from hospital of birth: __ __ /__ __ /__ __ __ __
month

day

5. Was the infant transferred to another hospital following birth?

year (4 digits)

Yes (1)

month

Yes (1)

__ __ __ __

time
year (4 digits)
__ month / day / year (4 digits)

day

AND date of discharge __ __ /__ __ /__ __ __

Unknown (9)

Unknown (9)
Unknown (9)

6. Was the infant discharged to home and readmitted to the birth hospital?
__ __ /__ __ /__ __ __ __

Unknown (9)

time

No (0)

If YES, Hospital where infant was transferred__ __ __ __ __ ID
AND date of transfer __ __ /__ __ /__ __ __ __ month / day / year (4 digits)
AND date of discharge __ __ /__ __ /__ __ __ __ month / day / year (4 digits)
If YES, date & time of readmission:

__ __ __ __

Unknown (9)

No (0)
Unknown (9)
Unknown (9)

Yes (1)
7. Was the infant discharge to home and readmitted to a different hospital?
No (0)
If YES, hospital ID: __ __ __ __ __
AND date & time of admission: __ __ /__ __ /__ __ __ __ month / day / year (4 digits) __ __ __ __ time
AND date of discharge __ __ /__ __ /__ __ __ __

Unknown (9)
Unknown (9)

Unknown (9)

month / day / year (4 digits)

8. Outcome of infant :

Unknown (9)
Survived (1) Died (2)
If infant Died, specify Date of Death _ _ / _ _/ _ _ _ _ month / day / year (4 digits)
Unknown (9)
8a. If survived, did the infant have the following neurologic or medical sequelae evident on discharge (Check all that apply)
Requiring oxygen
None
Seizure disorder
Hearing impairment
9. Was the infant admitted to the NICU during hospitalization following birth?

Yes (1)

No (0)

Unknown (9)

9a. If infant readmitted, was infant admitted to NICU during rehospitalization?

Yes (1)

No (0)

Unknown (9)

Unknown (9)
9b. If yes, to either 9 or 9a, total number of days in the NICU. __ __ __
10. From time of birth to date of discharge, did the infant have a
Yes (1)
temperature ˜ 100.4 F/38 C?
* Questions 10a-c: Only for live births of pregnant and post-partum HiNSES cases
10a. Were any bacterial cultures performed on infant from time of birth to date of discharge?

No (0)

Unknown (9)

Yes (1)

No (0)

10b. If cultures performed from time of birth to date of discharge+, list the culture date(s), source(s), and result(s).
+For neonates hospitalized for > 7 days, list cultures from time of birth through day 7 of life

Culture Date

#1. __ __ / __ __ / __ __ __ __

Culture Source
Blood

CSF

Other (specify)
_____________

#2. __ __ / __ __ / __ __ __ __

8/2018

Blood

CSF

Other (specify)
_____________
Page 1 of 4

Results
Positive (specify organism) _____________
Negative
Result unknown
Positive (specify organism) _____________
Negative
Result unknown

10c. If any sterile site culture positive for Hi, list ABCs State ID assigned to infant case.
11. Were any ICD-9 codes reported in the discharge diagnosis of the infant’s chart?

__ __ __ __ __ __ __
Yes (1)

No (0)

Unknown (9)

11a. If YES, Were any of the following ICD-9 codes reported in the discharge diagnosis of the chart? (Check all that apply)
None of the codes listed were found in chart
320.0: Haemophilus meningitis
762.7: Chorioamnionitis affecting fetus or newborn
771.81: Septicemia of newborn
670.22 Puerperal sepsis, delivered w/ postpartum
995.91: Sepsis
038.41 Septicemia due to H. influenzae
482.2: Pneumonia due to H. influenzae

Other ICD-9 codes (specify) _________________

11b. Were any ICD-10 codes reported in the discharge diagnosis of the infant’s chart?

Yes (1)

No (0)

Unknown (9)

11c. IF YES, were any of the following ICD-10 codes reported in the discharge diagnosis of the chart? (Check all that apply)
P36.9: Bacterial sepsis of newborn, unspecified
None of the codes listed were found in the chart
P02.7:
Chorioamnionitis
A41.3: Sepsis due to H. influenzae
O85: Puerperal sepsis
J14: Pneumonia due to H. influenzae
O75.3: Sepsis during labor
G00.0: Haemophilus meningitis
B96.3 H. influenzae as cause of disease classd elswhr
P36.8: Other bacterial sepsis of newborn
Other ICD-10 codes (specify) _________________

Maternal Information
12. Maternal admission date & time: __ __ /__ __ /__ __ __ __ __ __ __ __
month

day

Not Applicable/
Patient not hospitalized

Unknown (9)

time

year (4 digits)

13. Maternal age at delivery / spontaneous abortion (years): __ __ years
14. Number of prior pregnancies __ __

Unknown (9)

15. Any prior history of preterm births? (< 37 weeks gestation al age)
Yes (1)

16. Did mother receive prenatal care?

No (0)

Yes (1)

No (0)

Unknown (9)

Unknown (9)

17. Please record: the total number of prenatal visits AND the first and last visit dates to the prenatal provider as
recorded in the chart
Unknown (9)
No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

month

day

year (4 digits)

Unknown (9)

18. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
19. Date & time of membrane rupture: __ __ /__ __ /__ __ __ __
month

20. Was duration of membrane rupture

day

year (4 digits)

˜ 18 hours?

time

Yes (1)

21. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?
22. Type of rupture:

Spontaneous (1)

Unknown (9)

__ __ __ __

Artificial (2)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

Unknown (9)

22a. If artificial rupture, reason for rupture (check all that apply)
Unknown (9)

Fetal distress
Suspected chorioamnionitis
Preclampsia/eclampsia/hypertension
Maternal bleeding

Gestational diabetes
Severe fetal growth restriction
Post-term pregnancy
Other, specify ___________________

23. Type of delivery: (Check all that apply)
Unknown (9)

8/2018

Vaginal
Forceps

Vaginal after previous C-section (VBAC)
Vacuum
Page 2 of 4

Primary C-section
Repeat C-section

Yes (1)

23a. If delivery was by C-section: Did labor begin before C-section?

23b. If delivery was by C-section: Did membrane rupture happen before C-section?
23c. If delivery by C-section was it scheduled or emergency?

Emergency (2)

Scheduled (1)

24. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
Yes (1)

No (0)

Yes (1)

23d. If emergency C-section. What was the reason? (check all that apply)
Cord prolapse
Placenta previa/abruption
Unknown (9)
Fetal distress
Uterine rupture
Failure to progress
Breech position

25. Were antibiotics given to the mother intrapartum?

Unknown (9)

No (0)

Unknown (9)

Eclampsia/preclampsia/hypertension
Diabetes
Maternal infection
Other(specify) ________________

Yes (1)

No (0)

Yes (1)

No (0)

No (0)

Unknown (9)

Unknown (9)

IF YES, answer 25. a-b and Questions 26-27
a) Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

__ __ __ __
time

Unknown (9)

b)

26.

Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)

___ ___ (minutes) ___ ___ (days)*

*Day variable should only be completed if the number of hours >24

27.

What was the reason for administration of intrapartum antibiotics? (Check all that apply)
Unknown (9)

Intrapartum fever (≥ 100.4 F/38 C)
Prolonged latency
C-section prophylaxis
GBS prophylaxis

28. Did mother have chorioamnionitis or suspected chorioamnionitis during
the intrapartum period or in the week prior to spontaneous abortion?

Suspected amnionitis/chorioamnionitis
Mitral valve prolapse prophylaxis
Other (specify) _____________
Yes (1)

No (0)

Unknown (9)

29. During the intrapartum period or in the week prior to spontaneous abortion did the mother have any of the following
symptoms or diagnoses? (check all that apply)
Maternal tachycardia (>100 beats/min)
Uterine tenderness
Fetal
tachycardia (>160 beats/min)
Unknown (9)
Foul smelling amniotic fluid
Intrapartum fever (≥ 100.4 F/38 C)
None listed
Urinary tract infection
Maternal WBC >20 or 20,000
8/2018

Page 3 of 4

30. Maternal Intrapartum fever (T ˜ 100.4 F or 38.0 C):
IF YES, 1 recorded T
st

Yes (1)

No (0)

˜ 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month

day

year (4 digits)

Unknown (9)
Unknown (9)

__ __ __ __
time

30a. Were any bacterial cultures performed on mother during labor/end of pregnancy?

Yes (1)

No (0)

30b. If cultures performed during labor/end of pregnancy, list the culture date(s) during labor, source(s), and result(s)?
Culture Date
Culture Source
Results
#1. __ __ / __ __ / __ __ __ __

Blood
Vaginal
Urine Cervical
Placental Amniotic Fluid
Other (specify) _____________

Positive (specify organism)
_____________
Negative
Result unknown

#2. __ __ / __ __ / __ __ __ __

Blood
Vaginal
Urine Cervical
Placental Amniotic Fluid
Other (specify) _____________

Positive (specify organism)
Negative
_____________
Result unknown

30c. If any sterile site cultures collected during labor/end of pregnancy were positive for H. Influenzae,
list ABCs State ID assigned to maternal case. __ __ __ __ __ __ __
31. Maternal post-partum fever (temperature ˜ 100.4 F/38 C)?

Yes (1)

No (0)

Unknown (9)

31a. Were any bacterial cultures performed on mother post-partum/post pregnancy loss?

Yes (1)

No (0)

31b. If cultures performed post-partum/post pregnancy loss, list the culture date(s), source(s) and result(s).
Results
Culture Date
Culture Source
Blood
Vaginal
Urine Cervical Positive (specify organism) _____________
#1. __ __ / __ __ / __ __ __ __
Negative
Placental Amniotic Fluid
Result unknown
Other (specify) _____________
#2. __ __ / __ __ / __ __ __ __

Blood
Placental

Vaginal
Urine
Amniotic Fluid

Cervical

Other (specify) _____________
31c.

Positive (specify organism) _____________
Negative
Result unknown

If any sterile site cultures collected post-partum/post pregnancy loss were positive for
+LQIOXHQ]DH, list ABCs State ID assigned to maternal case. __ __ __ __ __ __ __

31d. Were any ICD-9 or ICD-10 codes reported in the discharge diagnoses of the mother’s chart?
Yes (1)
(
No (0)
Unknown (9)
31e. If any ICD-9 or ICD-10 codes reported in the discharge diagnoses of the mother’s chart: (Check all that apply)
ICD-9
ICD-10
None of the listed ICD-9 codes found in chart
None of the listed ICD-10 codes found in chart
A41.3: Sepsis due to H. influenzae
995.91: Sepsis
J14: Pneumonia due to H. influenzae
038.41 Septicemia due to H. influenzae
G00.0: Haemophilus meningitis
482.2: Pneumonia due to H. influenzae
P02.7: Chorioamnionitis
320.0: Haemophilus meningitis
O85: Puerperal sepsis
762.7: Chorioamnionitis affecting fetus or newborn
O75.3: Sepsis during labor
670.22: Puerperal sepsis, delivered, w/ postpartum
B96.3 H. influenzae as cause of disease classd elswhr
670.20: Puerperal sepsis, unspecified
Other ICD-10 codes (specify) _________________
670.24: Puerperal sepsis, postpartum
Other ICD-9 codes (specify)____________________
32. COMMENTS: ______________________________________________________________________

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
33. HiNSES Form Tracking Status
8/2018

Complete (1)

Partial (2)
Page 4 of 4

Chart unavailable (3)

Edited & corrected (4)