Streptococcus pneumoniae, invasive disease

Nonsterile sites from which organism isolated:Amniotic fluid (delivery/post-birth) Middle ear Placenta (delivery/post-birth) Sinus Wound Other, specify: ______________Did the patient have any underlying conditions? No Unknown YesIf yes, underlying conditions:AIDS Alcohol abuse AsthmaAtherosclerotic Cardiovascular Disease (CAD) Burns Cerebral Vascular Accident (CVA)/StrokeCirrhosis/Liver failure Cochlear implant Complement deficiencyCSF Leak (2° trauma/surgery) Current smoker Deaf/Profound hearing lossDiabetes Mellitus Emphysema/COPD Heart Failure/CHFHIV Hodgkin’s disease Immunoglobulin DeficiencyImmunosuppressive Therapy IVDU LeukemiaMultiple Myeloma Nephrotic Syndrome NoneObesity Organ transplant, specify: Other malignancy, specify: ___________Other prior illness, specify: ______________ Renal Failure/Dialysis Sickle Cell AnemiaSplenectomy/Asplenia Systemic Lupus Erythematosus (SLE) UnknownDid the patient die from this illness? No Unknown YesResistance Testing Results (Obtain from Laboratory)Oxacillin Zone Size: _______mm Interpretation: Not Tested R 20mm (susceptible) UnknownAntimicrobial Agent: ______________________ Susceptibility Method: AGAR Broth Disk (KB) StripS/I/R/U Result: Intermediate Not Tested Resistant Susceptible UnknownSign: < ≤ = ≥ > MIC Value: __________Does the patient have persistent disease as defined by positive sterile site cultures 2-7 days after the first positive culture? No Unknown YesVACCINE INFORMATIONHas patient received 23-valent pneumococcal POLYSACCHARIDE vaccine (i.e., Pneumovax 23)? No Unknown YesIf < 15 years of age, did the patient receive pneumococcal CONJUGATE vaccine? No Unknown YesVACCINATION RECORDIf yes for either, please enter dosage data in the Vaccination RecordMust be added via the Events Tab, add new Vaccinations feature after investigation is submitted.Vaccination Record 1: Date Administered: __ __ / __ __ /__ __ __ __ Age at Vaccination: _______ years monthsVaccine Administered (Select): Pneumococcal conjugate vaccine, 13 valent Pneumococcal conjugate vaccine, polyvalent (PCV7,Pneumococcal vaccine, NOSPneumococcal polysaccharide vaccine (PPV23, PneumVaccination Record 2: Date Administered: __ __ / __ __ /__ __ __ __ Age at Vaccination: _______ years monthsVaccine Administered (Select): Pneumococcal conjugate vaccine, 13 valent Pneumococcal conjugate vaccine, polyvalent (PCV7,Pneumococcal vaccine, NOSPneumococcal polysaccharide vaccine (PPV23, PneumVaccination Record 3: Date Administered: __ __ / __ __ /__ __ __ __ Age at Vaccination: _______ years monthsVaccine Administered (Select): Pneumococcal conjugate vaccine, 13 valent Pneumococcal conjugate vaccine, polyvalent (PCV7,Pneumococcal vaccine, NOSPneumococcal polysaccharide vaccine (PPV23, PneumVaccination Record 4: Date Administered: __ __ / __ __ /__ __ __ __ Age at Vaccination: _______ years monthsVaccine Administered (Select): Pneumococcal conjugate vaccine, 13 valent Pneumococcal conjugate vaccine, polyvalent (PCV7,Pneumococcal vaccine, NOSPneumococcal polysaccharide vaccine (PPV23, PneumEPIDEMIOLOGICRecord additional pneumococcal vaccinations at end of investigation and enter into ALNBS.If < 6 years of age, is the patient in daycare (supervised group of ≥ 2 unrelated children for > 4 hours/week)? No Unknown YesIf yes, Day Care Facility: ____________________________________________________________________________________________________Was the patient a resident of a nursing home or other chronic care facility at the time of first positive culture? No Unknown YesIf yes, Chronic Care Facility: _________________________________________________________________________________________________Is this case part of an outbreak? No Unknown Yes If yes, outbreak name:_____________________________________________________Case Status: Confirmed Not a Case Probable Suspect Unknown MMWR Week: ____________ MMWR Year:____________ADPH Invasive Pneumococcal Disease (02/2013) Page 2 of 3

ADMINISTRATIVEGeneral Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CUSTOM FIELDSDate Due: __ __ / __ __ /__ __ __ __ Investigation ready for supervisor review: Reviewed (Complete) Reviewed (Incomplete)Date investigation ready for supervisor review: __ __ / __ __ /__ __ __ __ Reviewed (Not a case) YesReview comments (completed by supervisor):____________________________________________________________________________________CASE CLASSIFICATION1 Isolation of S. pneumoniae from a normally sterile body site†?†blood, cerebrospinal fluid (CSF), synovial/joint fluid, pleural fluid, or pericardial fluidNo Unknown Yes2 Any reported case without confirmation of S. pneumoniae isolation from a normally sterile body site? No Unknown YesConfirmed: 1 Suspect: 2ADPH Invasive Pneumococcal Disease (02/2013) Page 3 of 3