Cpo Surveillance Form Page 3
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3Surveillance Protocol for CPO in BC
Appendix D – Addendum Form for Carbapenemase Producing Organisms (CPO) Infections
NB: This form should be complete if a) the case was identified as a CPO infection; b) the case was initially reported
as colonization, and subsequently developed into a CPO infection within a year from initial identification. Please
ensure that the CPO surveillance form (Appendix C) has been completed for this case.
Name of the Facility: ____________________________
1
Unique Identifier (assigned by BCPMHRL) ___________________________________
2
Patients’ status
Inpatient
Haemodialysis clinic patient
Other, please specify ____________________________
3
Date of admission or visiting (dd/mmm/yyyy) __________________________
4
Date of CPO infection identification (dd/mmm/yyyy) __________________________
5
Site(s) of infection
Bloodstream
Urinary tract
Respiratory tract
Wound
Surgical site
Other, please specify ____________________________
6
Organism(s) isolated (Check all that apply)
Acinetobacter spp.
Serratia spp.
Klebsiella pneumonia
Enterobacter spp.
Escherichia coli
Proteus spp.
Morganella morganii
Citrobacter spp.
Pseudomonas spp.
Other Entero-bacteriaceae, please specify ____________________________
7
CPO gene(s) detected:
NDM
KPC
OXA-48
VIM
IMP
SME
Other, please specify __________________________
8a
Was the patient treated with an antibiotic for CPO infection?
Yes
No
Unknown
8b
(Optional) If Yes, which antibiotic(s) was / were used? (Check all that apply)
Colistin
Tigecycline
Other, please specify ____________________________
9
Was ICU admission required due to CPO infections or the complications associated with CPO infection?
Yes
No
N/A – patient was already in ICU
Unknown
10
Patient outcome 30 days
or up until discharge after identification of CPO infection
Patient alive, still in hospital 30 days after diagnosis
Patient survived and discharged
Patient survived and transferred
Patient died
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
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