Clostridium Difficile Infection (CDI) Surveillance Emerg

Form approved OMB No. 0920-0978
Specimen ID: _____ _____ _____ _____ _____ _____ _____ _____ _____

Patient ID: _____ _____ _____ _____ _____ _____ _____ _____ _____

– CLOSTRIDIUM DIFFICILE INFECTION (CDI) SURVEILLANCE EMERGING INFECTIONS PROGRAM CASE REPORT FORM –
Patient's Name:

Phone No.: (

)

(Last, First, M.I.)

Chart Number:

Address:

(Number, Street, Apt. No.)

Hospital:
(City)

– Patient identifier information is NOT transmitted to CDC –

U.S. DEPARTMENT OF
HEALTH and HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

CLOSTRIDIUM DIFFICILE INFECTION (CDI) SURVEILLANCE
EMERGING INFECTIONS PROGRAM CASE REPORT

1. STATE:

2. COUNTY:

(Residence of Patient)

(Residence of Patient)

5. DATE OF BIRTH:
Mo.

Day

3. STATE ID:

6. AGE:

7a. SEX:

Year

8a. DATE OF INCIDENT STOOL
COLLECTION POSITIVE FOR C. diff:
Mo.

Day

Year

4a. LAB/HOSPITAL WHERE
TOXIN ASSAY PERFORMED:

1

Male

2

Female

2

No

7

White

1

Unknown

2

Not Hispanic or Latino

1

7

Unknown

1

GDH

Culture 1
Cytotoxin
Other (specify):

8c. Location of stool collection: (Check one)
4
Long Term Care/
Hospital Inpatient
Skilled Nursing Facility
2
Long Term Acute
5
Outpatient
Care Hospital
1

1

NAAT

1

Unknown

Unknown
Day

1

Black or African American

American Indian or Alaska Native

1

Mo.

Asian

1

EIA

1

Native Hawaiian or Other
Pacific Islander

Hispanic or Latino

1

4b. PROVIDER ID WHERE
PATIENT TREATED:

1

1

9. Was patient hospitalized at the time of, or within 7 days after,
stool collection?
Yes

7c. RACE: (Check all that apply)

7b. ETHNIC ORIGIN:

8b. Positive diagnostic assay for C. diff:
(Check all that apply)

1

1

(Zip Code)

(State)

Emergency Room

3

7

Unknown

8

Observation
Unit/CDU

Other (specify):

6

10. Where was the patient a resident 4 days prior to stool collection? (Check one)
Long Term Care/
Skilled Nursing Facility

1

Hospital Inpatient

2

Long Term Acute
Care Hospital

5

Homeless

Home

6

Incarcerated

Year

4

7

Unknown

8

Other (specify):

If YES, Date of Admission:

3

11. HCFO classification questions:
a. Was stool collected ≥ 4 days after hospital admission?

12. Was patient admitted due to CDI: (is CDI listed in the medical record as the reason
for admission?)

1

Yes (HCFO)

2

No (go to 11b.)

1

b. If no, was stool collected at LTCF/SNF/LTACH?
1

Yes (HCFO)

2

No (go to 11c.)

c. If no, was the patient admitted from LTCF/SNF or another acute
care setting?
1

Yes (HCFO)

2

No (CO – complete CRF)

d. If HCFO, was this case selected for full CRF based on sampling
frame (1:10)?
1

Yes (Complete CRF)

2

No (STOP data abstraction here!)

14. Exclusion criteria for CA-CDI: (Check all that apply)
None
Unknown
1
Hospitalized (overnight) at any time in the 12 weeks prior to stool
collection date.
If yes, Date of most recent discharge:
Mo.

Day

Year

Overnight stay in LTACH at any time in the 12 weeks prior to stool
collection date

Residence in LTCF/SNF at any time in the 12 weeks prior to
stool collection date
CO cases: not eligible for health interview if any of these boxes are
checked. HCFO and Prisoners: not eligible for health interview.
1

16. Patient outcome:
1

Survived

7

2

No

Not Admitted

3

7

Unknown

13. Were other enteric pathogens detected from stool at the same date incident
C. diff + stool was collected?
1
5
9
None
Campylobacter
Norovirus
10
6
2
Rotavirus
No other
Salmonella
pathogens tested
3
Shiga Toxin-Producing
4

Unknown
Other (specify):

7

E. coli
Shigella

8

15. Exposures to healthcare:
a. Chronic Hemodialysis prior to incident C. diff + stool:
1

Yes

2

No

7

Unknown

b. Surgical procedure in the 12 weeks prior to incident C. diff + stool:
Unknown

1

Yes

1

Yes

2

No

7

Unknown

c. ER visits in the 12 weeks prior to incident C. diff + stool:
1

Yes

2

No

7

Unknown

d. Observation/CDU stay in the 12 weeks prior to incident C.diff + stool:
1

Yes

2

No

7

Unknown

Unknown
Mo.

Day

Year

2

Date of Discharge:

Died

Mo.

Day

Year

Date of Death:

If survived, patient was discharged to:
2

Long Term Acute Care Hospital

4

Long Term Care/ Skilled Nursing Facility

3

Home

5

Other

7

Unknown

Public reporting burden of this collection of information is estimated to average 20 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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17a. Colectomy (related to CDI):
Yes 2

1

No

If YES, Date of Procedure
Mo.

Day

Yes

1

Unknown

7

17c. Any additional positive stool test for C. diff ≥ 2
and ≤ 8 weeks after the last C. diff + stool specimen?
Yes
No
1
2

17b. ICU Admission (on the day of or after incident stool collection):
No

2

Unknown

7

If YES, Date of ICU Admission
Mo.

Year

Day

If YES, Date of first recurrent specimen

Year

Mo.

Day

Year

Unknown
18. RADIOGRAPHIC FINDINGS (within 5 days before or after
incident C. diff + stool):
Both
4
Toxic megacolon
1
lleus
Not Done
2
5
Neither
3
Information not available
7

19. Was pseudomembranous colitis listed in the
surgical pathology, endoscopy, or autopsy report
(within 5 days before or after incident C. diff + stool)?
Yes
No

1
2

20.1 LABORATORY FINDINGS (within 5 days before
or after incident C. diff + stool):
a. Albumin ≤ 2.5g/dl:
Yes
Not Done
1
3
No
2
Information not available
7

Not Done
Information not available

3
7

20.2 CLINICAL FINDINGS (within 5 days before and up to 1 day after incident C. diff + stool):
d. Diarrhea:
e. Upper GI Symptoms:
1
Diarrhea by definition (unformed or watery stool, ≥ 3/day for ≥ 1 day)
Nausea
1
2
Vomiting
Diarrhea documented, but unable to determine if it is by definition
2
3
Neither
No Diarrhea documented
3
“Asymptomatic” documented in medical record
4
4
Both
Information not available
7
7
Information
not available

b. White blood cell count ≤ 1,000/µl:
1
Yes 2 No 3 Not Done
7

c. White blood cell count ≥ 15,000/µl:
1
Yes 2 No 3 Not Done
7
Information not available

21. UNDERLYING CONDITIONS: (Check all that apply) If none or no chart available, check appropriate box 1 None
AIDS
Connective Tissue Disease
Inflammatory Bowel Disease
1
1
1
CVA/Stroke
Chronic
Cognitive
Deficit
Myocardial Infarct
1
1
1
Dementia
Chronic
Kidney
Disease
Peptic Ulcer Disease
1
1
1
Diabetes
Chronic
Liver
Disease
1
Peripheral
Vascular Disease
1
1
Diverticular
Disease
Chronic
Pulmonary
Disease
Primary
Immunodeficiency
1
1
1
Hemiplegia/Paraplegia
Congenital Heart Disease
Short Gut Syndrome
1
1
1
Congestive Heart Failure

1

HIV

1

Yes 2

No 3

Not Admitted 7

Unknown

Y,Yes 3

U, Unknown

2

N, No

W, Clinically Undetermined 6

4

5

Unknown
Stem Cell Transplant
1
Solid Tumor (non metastatic)
1
Hematologic Malignancy
1
Metastatic Solid Tumor
1

23. At time of incident C. diff + stool, patient was:
1

If YES, what was the POA code assigned to it?
1

1

Solid Organ Transplant

1

22. Was ICD-9 008.45 or ICD-10 A04.7 listed on the discharge form?
1

Information not available

Pregnant

Mo.

Missing

Neither

Post-partum 3

2

Day

7

Unknown

Year

Delivery Date:

Not Applicable

24. MEDICATIONS TAKEN 12 WEEKS PRIOR TO INCIDENT STOOL COLLECTION DATE (including current hospital stay if collection date > admission date):
(If none or no chart available, check appropriate box)
1
a. Proton pump inhibitor
(e.g. Esomeprazole, Omeprazole, Lansoprazole, Pantoprazole, Rabeprazole)

Yes

2

No

7

Unknown

b. H2 Blockers (e.g. Famotidine, Ranitidine, Cimetidine)

Yes

2

No

7

Unknown

1

None

1

Unknown

1

None

1

Unknown

1

c. Immunosuppressive therapy (Check all that apply)
1

Steroids

1

Chemotherapy

Other agents (specify):

1

d. Antimicrobial therapy (Check all that apply)

1

Yes, name unknown

1

Amikacin

1

Cefazolin

1

Ceftazidime

1

Clarithromycin

1

Imipenem

1

Nitrofurantoin

1

Tigecycline

1

Amoxicillin

1

Cefdinir

1

Ceftizoxime

1

Clindamycin

1

Levofloxacin

1

Ofloxacin

1

Tobramycin

1
1

Trimethoprim
-Sulfamethoxazole
Vancomycin (IV)

1

Other (specify):

Cefepime

1

Ceftriaxone

1

Daptomycin

1

Linezolid

1

Penicillin

1

Cefotaxime

1

Cefuroxime

1

Doxycycline

1

Meropenem

1

Piperacillin-Tazobactam

Cefpodoxime

1

Cephalexin

1

Ertapenem

1

Metronidazole 1

Tetracycline

Cefprozil

1

Ciprofloxacin

1

Gentamicin

1

Moxifloxacin

Ticarcillin/Clavulanic Acid

1

1
Amoxicillin/
Clavulanic Acid

1

Amp/sulb

1

Azithromycin

1

1

Cefaclor

1

1

– SURVEILLANCE OFFICE USE ONLY –
25. CRF status:
1
2

Complete
Incomplete

26. Previous unique CDI episode ( >8 weeks prior to this episode):
3
4

Edited & Correct
Chart unavailable after
3 requests

1

Yes

2

No

If yes, Previous STATEID:

27. Initials
of S.O:

29. Identified
through audit
1

Yes 2

No

28. COMMENTS:

CDC Rev. 11-2014

CS253103

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