Cpo Surveillance Form
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3Surveillance Protocol for CPO in BC
Appendix C – Surveillance Form for Carbapenemase Producing Organisms (CPO)
Name of the Facility: ____________________________
1
1
Unique Identifier
(assigned by BCPHMRL) ______________________________________
2
Patient’s status
Inpatient
Haemodialysis clinic patient
Other, please specify ___________________________________
3
Date of admission or visiting (dd/mmm/yyyy) __________________________
4
CPO status
Infection (please also complete appendix D)
Colonization
Unknown
5a
(Optional) Was this patient treated with antimicrobials within TWO weeks prior to CPO detection?
Yes
No
Unknown
5b
(Optional) If Yes, which of these was / were used? (Check all that apply)
Colistin
Tigecycline
Carbapenem
Cephalosporin
Chloramphenicol
β-lactam inhibitor (eg. Pip/tazo)
Aminoglycoside (amikacin, gentamicin, tobramycin)
Other, please specify ____________________________
6
Has the patient had an overnight stay in a hospital or undergone medical/surgical procedure outside
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of Canada within the past 12 months (or 6 months
)?
Yes, please specify the name of the country ____________________________
No
Unknown
2
7
Has the patient had haemodialysis outside Canada within the past 12 months (or 6 months
)?
Yes, please specify the name of the country ____________________________
No
Unknown
8
Was the patient transferred from a unit with a high prevalence of CPO?
Yes, please specify the name of the healthcare facility ____________________________
No
Unknown
2
9
Has the patient had close contact with a known CPO case within the past 12 months (or 6 months
)?
Yes, please specify the nature of contact:
Roommate in a healthcare facility
Same unit in a healthcare facility
Household
Other, please specify ____________________________
No
Unknown
1. Contact BCPHMRL if the unique identifier has not been received
2. Lack of consensus on the timeframe for the look back period. Communicate with PICNet if the reporting facility applies a
different timeframe other than the past 12 months.
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