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Cases of bacterial pulmonary infections diagnosed in hospitalized patients with COVID-19


          Clinician's Information:
    Your name:
    Your email address:
    State location of institution/hospital:   
    5-digit zip code of institution/hospital:
    Patient's Demographic Information :
  1. Age group in years:  0-12   13-17   18-44   45-64   65-74   75-84   >=85
  2. Sex:   Male      Female
  3. Underlying medical conditions:                           NONE
    Asthma Coronary artery disease
    COPD Hypertension
    Lung cancer Heart failure
    Cirrhosis Sickle cell disease
    Cerebrovascular disease Chronic kidney disease
    Solid organ transplant HIV
    Bone marrow/stem cell transplant Obesity (BMI>30)
    Type 1 diabetes Smoking
    Type 2 diabetes Pregnancy
    Use of corticosteroids/other immunosuppressants Other, specify:

    4. SARS CoV-2 Diagnosis and COVID-19 Illness:
  4. Month of first positive SARS-CoV-2 test result:  

  5. Which test type(s) was positive?   RT-PCR      Serology     Antigen

  6. Illness severity:
    Mild to moderate (up to mild pneumonia; SpO2>94%, respiratory rate<24 breaths per minute without supplemental oxygen requirement)
    Severe (at least one criterion: dyspnea, >=24 breaths per minute; hypoxia, SpO2 <=94% on room air; requiring invasive or non-invasive mechanical ventilation; >50% lung involvement on imaging)
    Critical (respiratory failure, sepsis, multi-organ system dysfunction)
    7.   
  7. Month of hospital admission:  
    8.   
  8. Was the patient in the ICU?     No     Yes, admitted to ICU on hospital day#:
                                                                           [Hospital admission day = day 0, etc]
  9. Did the patient require:
    a. non-invasive ventilation/high flow oxygen device?    No    Yes
    b. invasive mechanical ventilation?    No     Yes
    c. ECMO support?    No     Yes

  10. a. Did the patient experience any of the complications listed due to progression of COVID-19 disease? [Select all that apply]                   NONE
    Shock/sepsis (requiring pressor support)   Heart failure
    Kidney failure Liver failure
    Respiratory failure Thrombotic events
    Other, specify:
    b. Shock/sepsis (requiring pressor support) diagnosed on hospital day#:

  11. Did patient receive any treatments for COVID-19? [Select all that apply]
    IL-6 receptor inhibitor (e.g., tocilizumab)   NONE
    IL-1 receptor inhibitor Remdesivir
    Convalescent plasma Dexamethasone
    Other, specify: Hydroxychloroquine

    12. Bacterial Infection:
  12. Infection diagnosed on hospital day#:

  13. How was the bacterial infection diagnosed? [Select all that apply]
    Blood culture Sputum culture
    ET culture BAL culture
    Radiologic findings Laboratory findings (e.g. procalcitonin)
    Other, specify:

  14. What type of infection did the patient have?
    Community-acquired pneumonia (not associated with ventilator)
    Hospital-acquired pneumonia (not associated with ventilator)
    Ventilator-associated pneumonia
    Other, specify:

  15. a. Was an infecting organism identified?      No     Yes
    b. If yes, organism identified:

  16. a. At initial identification, what was the susceptibility profile for the organism:
    Piperacillin/tazobactam:S     R    Not done   
    Vancomycin:S     R    Not done
    Levofloxacin:S     R    Not done
    Azithromycin:S     R    Not done
    Gentamicin:S     R    Not done
    Meropenem:S     R    Not done
    Cefepime:S     R    Not done
    Ceftriaxone:S     R    Not done
    Other, specify:      S     R    Not done
    b. If cultures were repeated at a later date, did the susceptibility profile for this organism change?     Not repeated    No    Yes, details:

  17. a. Did the patient receive empiric antibiotic treatment before bacterial infection was diagnosed?     No     Yes
    b. If yes, empiric therapy started because of suspected:
    c. If yes, when did empiric therapy begin?  
    d. If yes, what was the duration in days of this empiric therapy?  
    e. If yes, what antibiotics were given empirically?
       Piperacillin/tazobactam   Vancomycin
       Levofloxacin Azithromycin
       Gentamicin Meropenem
       Cefepime Ceftriaxone
       Other, specify:
    f. Comments:   

  18. a. How was the diagnosed infection treated? (not empiric antibiotics)
    Piperacillin/tazobactam   Started on hospital day#:  
    Vancomycin Started on hospital day#:  
    Levofloxacin Started on hospital day#:  
    Azithromycin Started on hospital day#:  
    Gentamicin Started on hospital day#:  
    Meropenem Started on hospital day#:  
    Cefepime Started on hospital day#:  
    Ceftriaxone Started on hospital day#:  
    Other 1, specify:    Started on hospital day#:  
    Other 2, specify:    Started on hospital day#:
    b. How many total days was the diagnosed infection treated?

  19. a. Did the infection resolve with treatment?     No     Yes
    b. If no, was it due to lack of antimicrobial activity?     No     Yes     Not sure

  20. Did the patient have another infecting organism or syndrome identified?
    No     Yes (e.g. UTI, CLABSI, C. difficile), specify:

    21. Outcome:
  21. The outcome for this patient is:
    Death, on hospital day#:
    Discharged to hospice, on hospital day#:
    Survived and discharged as recovering, on hospital day#:
    Ongoing hospitalization

  22. If the outcome was death, the major contributing factor(s) to the patient's cause of death were:    [check all that apply]
    Complications due to COVID-19 infection
    Complications due to bacterial infection
    Other, specify: