Blood Infection Case Report
Report a suspected or confirmed blood infection case with patient details, symptoms, possible source, medical background, treatment status, and reporting notes.
Patient and Reporter Information
Patient name
*
First Name
Middle Name
Last Name
Age
Date of birth
-
Month
-
Day
Year
Date
Sex/gender
*
Female
Male
Intersex
Prefer not to say
Other
Patient contact information
Infection Case Details
Date symptoms started
*
-
Month
-
Day
Year
Date
Date case was noticed or diagnosed
*
-
Month
-
Day
Year
Date
Primary symptoms
*
Fever
Chills
Fatigue
Rapid heart rate
Low blood pressure
Shortness of breath
Confusion
Decreased urine output
Nausea or vomiting
Pain at suspected infection site
Other
Current severity
*
Mild
Moderate
Severe
Critical
Improving
Resolved
Case status
*
Confirmed
Suspected
Under evaluation
Possible Source, Risk Factors, and Medical Background
Suspected source or exposure
*
Community-acquired
Hospital-acquired
Healthcare-associated
Foodborne
Waterborne
Animal exposure
Travel-related
Unknown
Other
Recent surgery or procedures
No recent surgery or procedures
Surgery
Invasive procedure
Dental procedure
Endoscopy
Dialysis
Other
Catheter or line currently in place
*
No
Peripheral IV
Central venous line
PICC line
Urinary catheter
Other
Recent hospitalization
*
No
Yes, within the last 30 days
Yes, within the last 90 days
Unknown
Wound or skin infection present
No wound or skin infection
Surgical wound
Pressure injury
Skin abscess
Cellulitis
Burn
Other
Chronic conditions
Diabetes
Chronic kidney disease
Liver disease
Chronic lung disease
Heart disease
Cancer
HIV infection
Other immune disorder
Other
Immune status
Normal
Immunocompromised
Receiving immunosuppressive therapy
Neutropenic
Transplant recipient
Unknown
Current medications, antibiotics, and known allergies
Current antibiotics
Other current medications
Recent antibiotic use
Known drug allergy
Known antibiotic allergy
No known allergies
Other
Treatment, Outcome, and Reporting Details
Current Treatment Being Given
Hospital or Clinic Name
Admission or Referral Status
*
Admitted
Referred
Outpatient
Transferred
Unknown
Complications Observed
Sepsis
Organ dysfunction
Shock
Respiratory distress
Other
Prognosis / Current Outcome
*
Please Select
Improving
Stable
Worsening
Recovered
Deceased
Unknown
Additional Notes
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