Case Report Form - English

Undetermined risk factors and modes of transmission for Candida auris infection — Colombia, 2016

Appendix 1a. Case Report Form for Cases of Candida auris and Candidemia [English]

Appendix 1a. Case Report Form for cases of Candida auris and Candidemia
Case ID: ________________ Sex (M)(F) Age: _____ (years)(months)(days) Address:_________________________ Location: Country: ____________________ City: ___________________ Institution:_____________________________ Date of admission (DD)(MM)(YY) Reason for admission: _______________________________________ Date of discharge (DD)(MM)(YY) Condition at discharge: Alive ( ) Dead ( ) Hospitalized ( ) Unknown ( )
Location During Hospitalization:
Was the patient transferred from another facility? (Yes)(No)(UNK) Name and City of Hospital: _____________________________________________ Date of transfer: (DD)(MM)(YY) Admitted to the ICU: (Si)(No)(ND) Date of admission to the ICU (DD)(MM)(YY) Date of discharge from the ICU (DD)(MM)(YY) Locations of patient during hospitalization: Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY) Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY) Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY) Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY) Unit: ________________ room: ______ Date of arrival: (DD)(MM)(YY) Date leaving: (DD)(MM)(YY) Was the patient in the Operating Room? (Yes)(No)(UKN), If yes, please complete the following: Operating room:____________ Date: (DD)(MM)(YY) Procedure/Operation:__________________________ Operating room:____________ Date: (DD)(MM)(YY) Procedure/Operation:__________________________ Operating room:____________ Date: (DD)(MM)(YY) Procedure/Operation:__________________________
Risk Factors
Previous Hospitalizations: Has the patient been hospitalized in the past 90 days? (Yes)(No)(UNK) Hospital and City: ______________ Date of Admission: (DD)(MM)(YY) Reason for hospitalization: _____________ Date of discharge: (DD)(MM)(YY) Hospital and City: ______________ Date of Admission: (DD)(MM)(YY) Reason for hospitalization: _____________ Date of discharge: (DD)(MM)(YY) Has the patient ever been previously diagnosed with candida? (Yes)(No)(UNK) Date:(DD) (MM) (YY) What species was isolated? _____________________ Has the patient ever previously received an antifungal? (Yes)(No)(UNK) Which?_________________ Began: (DD)(MM)(YY) Stopped: (DD)(MM)(YY) Indication for treatment: _______________________________________						Comorbilities: Diabetes: (Yes)(No)(UNK) Solid tumor: (Yes)(No)(UNK) Hematologic Malignancy: (Yes)(No)(UNK) Bone Marrow Transplant: (Yes)(No)(UNK) Chronic renal failure: (Yes)(No)(UNK) Hemodialysis (Yes)(No)(UNK) Liver disease:(Yes)(No)(UNK) Immunosuppressed: (Yes)(No)(UNK) Please select:(Autoimmune)(Transplant) (Corticosteroids)(Cancer) HIV/AIDS: (Yes)(No)(UNK) CD4: ________ Viral load: ______________ Others:(Yes)(No)(UNK) Which?: _____________
Current Hospitalization
Procedure: Hemodialysis: (Yes)(No)(UNK) Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY) Central venous catheter (Yes)(No)(UNK) Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY) Respiratory support: (BiPAP) (Intubation) Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY) Bronchoscopy: (Yes)(No)(UNK) Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY) Physical Therapy: (Yes)(No)(UNK) Begin date: (DD) (MM) (YY) End date: (DD) (MM) (YY)
Treatments: Chemotherapy: (Yes)(No)(UNK) Begin:(DD)(MM)(YY) End:(DD)(MM)(YY) TPN: (Yes)(No)(UNK) Begin:(DD)(MM)(YY) End:(DD)(MM)(YY) Corticosteroides: (Yes)(No)(UNK) ¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY) ¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY) Vasopressors: (Yes)(No)(UNK) ¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY) ¿Which? ________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY) ¿Other treatments? ___________________________________________ Begin:(DD)(MM)(YY) End:(DD)(MM)(YY)					Antimicrobials: ¿What treatment was used for this candidemia?:_________dose:______ Begin:(DD) (MM) (YY) End:(DD) (MM) (YY) Other antimicrobials: Name and dose:_____________________________ Begin:(DD) (MM) (YY) End:(DD) (MM) (YY) Name and dose:_____________________________ Begin:(DD) (MM) (YY) End:(DD) (MM) (YY) Name and dose:_____________________________ Begin:(DD) (MM) (YY) End:(DD) (MM) (YY) Name and dose:_____________________________ Begin:(DD) (MM) (YY) End:(DD) (MM) (YY) Name and dose:_____________________________ Begin:(DD) (MM) (YY) End:(DD) (MM) (YY)
Clinical and Laboratory Findings
Clinical: Weight:___________ Height:____________ Evidence of severe sepsis(Yes)(No)(UNK) Sepsis: at least 2 of the following (a) temperature >38.3C or <36C, (b) heart rate >90, (c) respiratory rate >20) with evidence of infection Severe sepsis = sepsis plus respiratory failure Did the patient experience a decompensation during the hospital stay? (Yes)(No)(UNK) Date: (DD)(MM)(YY) Details:______________________________________________________________________________________			Laboratory: (closest available to date of positive candida culture) Date:(DD)(MM)(YY) WBC: ________ %PMNs:________ Hb: ________ PLT: ________ Creatine: ________ BUN: ________ Glucose: _________ AST: ________ ALT: ________ Bilirrubin total: _______ Albumin: ________ Lactate: ________				Candida culture First positive Candida or C. auris culture: Date:(DD)(MM)(YY) Type of sample: (blood)(urine) (wound) (BAL) (other) Which? _______________________ MIC: Fluconazole: ____________ Voriconazole: ___________ Amphotericin: ___________ Caspofungin: __________ Anidulafungin: _________ Micafungin: ___________
Radiology: Any findings on imagige: (Yes)(No)(UNK) Which? ______________________________________ Date: (DD)(MM)(YY)
Cultures (1 year before and after positive Candida culture)
Type of Sample	Date of Collection	Date of Report		Results (microrganism isolated)				MICs
	(DD)(MM)(YY)	(DD)(MM)(YY)
	(DD)(MM)(YY)	(DD)(MM)(YY)
	(DD)(MM)(YY)	(DD)(MM)(YY)
	(DD)(MM)(YY)	(DD)(MM)(YY)
	(DD)(MM)(YY)	(DD)(MM)(YY)
	(DD)(MM)(YY)	(DD)(MM)(YY)
Additional Information for Candidemia Cases in those less than one year of age
Born prematurely: (Yes)(No)(UNK) Delivery: (vaginal) (c-section) Gestation at time of birth: ____ (weeks) Birth weight: _________ (Kgs) Select the type of nutrition received: (breastmilk)(formula)(combination)(other) If formula received, what type? ­­­­­­­­­­­­­­­­­­­_______________________________________________________________________ Were any additives, probiotics or thickening agents used (Yes)(No)(UNK): Which?____________________________________ Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months) Was there any skin breakdown (eg. Rash, open wounds)?: (Yes)(No)(UNK) ; What?:____________________________________ Received prophylactic antifungals? (Yes)(No)(UNK) ; Which?: ____________________________________________________ Required an operation? (Yes)(No)(UNK) Which?: ________________________________ Date: (DD)(MM)(YY) Which?: ________________________________ Date: (DD)(MM)(YY) Any additional procedures performed apart from those mentioned previously or above? ( Yes)(No)(UNK) Which?: ________________________________ Date: (DD)(MM)(YY) Which?: ________________________________ Date: (DD)(MM)(YY) Was the patient exposed to any of the following: Incubator (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months) Feeding tube (Yes)(No)(UNK) Specify: (nose) (mouth) (PEG) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months) Cardiac monitor (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months) Phototherapy: (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months) Steroids for respiratory development (Yes)(No)(UNK) Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months) Other: ________________________ Date: (DD)(MM)(YY) For how long? ______ (hours)(days)(weeks)(months)

• Subject to change as investigation reveals additional information about cases