In strict medical confidence
Surveillance of Listeriosis, England and Wales
If cultures are available but have not been sent, please forward to:
Dr Corinne Amar. Gastrointestinal Bacterial Reference Unit, Public Health England, 61 Colindale Avenue, London,
NW9 5EQ. Tel. 020 8327 7341
1.
Your details
Microbiologist: __________________________
Date of completion: ____ /____ /____
Laboratory: _____________________________________________________________________
2.
Specimen details
Specimen reference no.: ______________________
Source of culture:
3.
Blood

CSF

HVS


(please specify) _____________________
Patient details (‘patient’ refers to positive isolate)
First Name: _________________________
Town:
Surname: ________________________________
_________________________
Date of Birth: _______________
Ethnicity:
4.
Other
Specimen date: ____ /____ /_____
Postcode
Age ____ years
___________________________
Gender: Male

Female

_____________________________________________________________________
Clinical details
Date of onset of illness: ____ /____ /____
Did the patient die?
Yes

No

Hospital of original admission: __________________________ Admission date: ____ /____ /____
Principal Listeria illness (tick all that apply):
Meningitis

Septicaemia

Gastroenteritis

Other
 (specify):
______________________
What antibiotics have been used to treat this Listeria infection?
_________________________________________________________________________________
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In strict medical confidence
Symptoms experienced (please tick):
Nausea

Vomiting

Diarrhoea

Myalgia

Arthralgia

Backache

Nuchal rigidity

Confusion
Abdominal pain
Seizures


Fever
Ataxia


Chills
Tremors


Headache

Myoclonus

 Other  (specify)_________________________ _______________
Does the patient have an underlying illness/condition?
No

Yes
 (specify): ____________________________________________________________
Was the patient taking any (please tick):
immunosuppressives

cytotoxics

steroids

or No

or Unknown

(if yes specify): _____________________________________________________________________
Does the patient have reduced Gastric Acid secretion?
Yes

No

Unknown

If yes, please give details: ___________________________________________________________
5.
Pregnancy-associated cases (for non-pregnancy cases please go to section 6, page 3)
i) Mother’s details (if not recorded above)
First Name:
________________________
Surname: _____________________________
Town:
_____ ___________________
Postcode: _____________________________
Date of Birth: ___ /___ /___
Age ___ years
Hospital of original admission: ______________________________________________________
ii) Details of the pregnancy.
Outcome of pregnancy:
Live birth

Still birth

Miscarriage

Still pregnant

Date of Delivery / Miscarriage: ____ /____ /____
Expected Date of Delivery (EDD): ___ /___ /___
Gestation at pregnancy end: _____ weeks
During pregnancy did the mother have symptoms suggestive of Listeriosis?
Yes

No

If yes, what were the main features of this illness (tick all that apply):
Flu-like (pyrexia / myalgia / headache / fatigue)
Other


Gastroenteritis

Abdominal pain

Night sweats

please specify___________________________________________________________
Date of onset of this illness: ____ /____ /____ Gestational stage of first onset of this illness: _____ weeks
Was Listeria infection in the mother confirmed microbiologically?
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Yes

No

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iii) Details of the infant (if applicable)
First Name: ___________________________
Surname: _______________________________
Date of Birth: ____ /____ /____
Gender of infant:
If a live birth, did the infant survive?
Yes

If a live birth, was the infant ill with Listeriosis?
Please state age of infant at onset of illness?
No
Male

Female


Yes

No

______ days
Nature of the infant’s Listeria illness:
Meningitis

Septicaemia

Other
 (specify) ______________________________________
Was the infant’s infection (if present) due to or thought to be due to vertical transmission from the mother?
Yes

No

Was the infant’s infection (if present) due to or thought to be due to cross contamination? Yes
6.

No

Linked cases
Is it thought that this case could be linked to any other case(s)?
If yes, please give their full Name(s):
Yes

No

1. _________________________________________
2. _________________________________________
Please tick if culture(s) have been sent to the reference laboratory for typing for:
7.
case 1

case 2

Food history
Was the Listeria infection linked to suspect food Item(s) eaten by the patient?
Yes

No

If yes, please specify: _____________________________________________________________
Thank you for completing this questionnaire
Please return it in the pre-paid envelope provided.

If you have any specific questions about this questionnaire or Listeria surveillance please call or write to:
Adedoyin Awofisayo, Centre for Infectious Disease Surveillance and Control, Public Health
England, 61 Colindale Avenue, London, NW9 5EQ. Email: EEDD@phe.gov.uk Tel. 020 8327 7925

If you have any specific questions about Listeria typing please call or write to:
Dr Corinne Amar. Gastrointestinal Bacterial Reference Unit, Public Health England, 61 Colindale
Avenue, London, NW9 5EQ. Tel. 020 8327 7341
Version 2 – 2012
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