Cpo Surveillance Form Page 2
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3Surveillance Protocol for CPO in BC
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Is there any evidence that this case was associated with the reporting facility?
Yes
No
Unable to determine/No information available
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11
Is there any evidence of transmission within the reporting facility?
Yes
No
Unable to determine/No information available
12
(Optional) Is there evidence that the patient has underlying medical condition(s)?
No evidence of any underlying medical condition
Yes (please check all that apply)
Diabetes
Liver disease
HIV infection
Cancer (active)
Lung disease (e.g., asthma, COPD)
Kidney disease (include all patients on dialysis)
Solid organ transplantation
Bone marrow transplantation
Other immune suppression, please specify __________________________
Heart disease (do NOT include hypertension alone, isolated atrial fib or mitral valve prolapse)
Other, please specify ____________________________
Unknown/No information available
Once completed, please send it to:
Dr. Guanghong Han
Epidemiologist, Provincial Infection Control Network of BC
504 – 1001 West Broadway, Vancouver, BC V6H 4B1
Phone: (604) 875-4844 ext. 22983
Fax: (604) 875-4373
E-mail: Guanghong.Han@phsa.ca
3. The CPO was identified more than 72 hours or 3 days after admission to the reporting facility and the patient did NOT have
any of the following factors*:
a. an overnight stay in the hospital or medical/surgical procedure outside of Canada within the past 12 months
b. haemodialysis outside of Canada within the past 12 months
c. transferred from a healthcare unit or facility with a high prevalence of CPO
d. close contact with a known CPO case in their household or from another healthcare facility within the past 12 months
* Lack of consensus regarding timeframe after admission. Communicate with PICNet if these criteria are not fully applied in
the reporting facility.
4. Same genotype of CPO and epidemiologic link to other CPO cases in the facility in terms of time and space, e.g., stay in the
same unit, shared equipment or nursing staff
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