EIP CDI Surveillance: CDI Case Treatment Questionnaire

Form approved OMB No. 0920-0978

EIP CDI Surveillance: CDI Case Treatment Questionnaire

DEPARTMENT OF
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

Patient ID:

State ID:
Incident C.difficile Specimen Collection Date:

No Treatment

______/______/______

Unknown Treatment

The objective of this form is to capture the use of the antimicrobial agents listed below for the treatment of an incident C.difficile episode (CDI case). For each therapy used, please select the route (when appropriate), enter the
start and stop dates (select N/A if date is not available), and select the dosage. If patient is on taper, please select the initial dose of the taper and check taper=YES. Please note: The treatment of C.difficile usually lasts 10-14 days
and it may start +/- 7 days of incident stool collection date.
If >7 days have elapsed between the last dose and the subsequent dose of an antimicrobial therapy, only the first antimicrobial therapy course should be documented.
Vancomycin (Vancocin) (Do NOT Record Vancomycin IV)
PO

Route:

Rectal

PO

Route:

Unknown

Rectal

PO

Route:

Unknown

Rectal

PO

Route:

Unknown

Rectal

Unknown

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Dosage:

500mg

Dosage:

500mg

Dosage:

500mg

Dosage:

500mg

125mg

250mg

Other ______________
Frequency:

Once a Day

Taper:

TID

BID

Other ______________

QID
YES

125mg

Unknown

NO

250mg

Other ______________

Unknown
Frequency:

Once a Day

BID

Taper:

YES

NO

Route:

PO

IV

250mg

Other ______________
Frequency:

TID

Other ______________

QID

125mg

Unknown

Once a Day

QID

Unknown

TID

BID

Other ______________

Taper:

YES

NO

Route:

PO

IV

125mg

Unknown

250mg

Other ______________

Unknown
Frequency:

Once a Day

Unknown

BID

TID

Other ______________

QID
Taper:

YES

NO

Route:

PO

IV

Unknown

Metronidazole (Flagyl)
PO

Route:

IV

Unknown

Start Date: ______/______/______

N/A

Stop Date: ______/______/______
Dosage:

125mg

250mg

Other ______________
Frequency:

Once a Day

Taper:

BID

Other ______________

QID
YES

Unknown

Unknown

Unknown

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

500mg

Dosage:

500mg

Dosage:

500mg

Dosage:

500mg

125mg

Other ______________

Unknown
TID
Unknown

Frequency:

Once a Day

BID

Other ______________

QID
Taper:

NO

250mg

YES

125mg

Other ______________

Unknown
Frequency:

TID

Once a Day

QID

Unknown

Taper:

NO

250mg
BID

Other ______________
YES

125mg

Other ______________

Unknown
TID
Unknown

Frequency:

Once a Day

BID

Other ______________

QID
Taper:

NO

250mg

YES

Unknown
TID
Unknown

NO

Fidaxomicin (Dificid) - PO
Start Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Dosage:

QID

Once a Day

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Dosage:

200mg
Other ______________

Frequency:

Start Date: ______/______/______

BID

Other ______________

Other ______________

Unknown
TID
Unknown

Dosage:

200mg

Frequency:
QID

Once a Day

BID

Other ______________

Other ______________

Unknown
Frequency:

TID

Dosage:

200mg

Unknown

QID

Once a Day

BID

Other ______________

Other ______________

Unknown
TID
Unknown

200mg

Frequency:
QID

Once a Day

BID

Other ______________

Unknown
TID
Unknown

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).
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State ID:

Patient ID:

Probiotics
YES

/

Specimen Collection Date:

/

Stool Transplant
NO

YES

If yes, specify: ____________________________________________________________

NO

Start Date:

N/A

______/______/______

Stop Date:

______/______/______

N/A

Rifaximin (Xifaxan) – PO
Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Dosage:

Dosage:

400mg
Other ______________

Frequency:

Once a Day

QID

Other ______________

Unknown
Frequency:

TID

BID

Other ______________

Dosage:

400mg

QID

Unknown

Once a Day

BID

Other ______________

Other ______________

Unknown
Frequency:

TID

Dosage:

400mg
Once a Day

QID

Unknown

Other ______________

Unknown
Frequency:

TID

BID

Other ______________

400mg

QID

Unknown

Once a Day

BID

Other ______________

Unknown
TID
Unknown

Nitazoxanide (Alinia, Annita) – PO
Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Start Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Stop Date: ______/______/______

N/A

Dosage:

Dosage:

500mg
Other ______________

Frequency:

Once a Day

QID

Frequency:

TID

BID

Other ______________

Dosage:

500mg
Other ______________

Unknown
QID

Unknown

Once a Day

BID

Other ______________

Other ______________
Frequency:

TID

Dosage:

500mg

Unknown

Once a Day

QID

Unknown

Frequency:

TID

BID

Other ______________

500mg
Other ______________

Unknown
QID

Unknown

Once a Day

BID

Other ______________

Unknown
TID
Unknown

Other
Specify: ________________________________
Route:
Start Date:
Dosage:

PO

Rectal

IV

IM

Route:

Unknown
N/A

______/______/______
_________________

Specify: ________________________________

Unknown

Stop Date:

______/______/______

Frequency:

_________________

N/A
Unknown

Start Date:
Dosage:

PO

Rectal

IV

IM

_________________

Route:

Unknown
N/A

______/______/______

Unknown

Stop Date:

______/______/______

Frequency:

_________________

N/A
Unknown

Start Date:
Dosage:

PO

Rectal

IV

______/______/______
_________________

IM

IV

IM

Unknown
N/A

______/______/______
_________________

Unknown

Stop Date:

______/______/______

Frequency:

_________________

N/A
Unknown

Start Date:
Dosage:

PO

Rectal

IV

IM

Unknown
N/A

______/______/______
_________________

Unknown

Stop Date:

______/______/______

Frequency:

_________________

N/A
Unknown

Specify: ________________________________

Specify: ________________________________
Route:

Dosage:

Rectal

Specify: ________________________________

Specify: ________________________________
Route:

Start Date:

PO

Route:

Unknown
N/A

Unknown

Stop Date:

______/______/______

Frequency:

_________________

N/A
Unknown

Start Date:
Dosage:

PO

Rectal

IV

IM

______/______/______
_________________

Unknown
N/A

Unknown

Stop Date:

______/______/______

Frequency:

_________________

N/A
Unknown

comments

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