CDC Rev.10-2015 Clostridium Difficile Infection (CDI) Surveillance Emerg

Form approved OMB No. 0920-0978
Patient ID: ______________________________________________________

Expires 8/31/2016

Specimen ID: ____________________________________________________

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

Phone No.: (

) ___________-___________________

(Last, First, M.I.)

Address: _______________________________________________________________________________

Chart Number: ____________________________________

(Number, Street, Apt. No.)

________________________________________________ ________________ ___________________
(City)

(State)

– 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

Hospital: ______________________________________________

(Zip Code)

3. STATE ID:

_________________________________________

6. AGE:

Year

7a. SEX:

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

£££££££££

1 £ Male
2 £ Female

7b. ETHNIC ORIGIN:
1 £ Hispanic or Latino
2 £ Not Hispanic or Latino
7 £ Unknown

4a. LAB/HOSPITAL WHERE
TOXIN ASSAY PERFORMED:
_______________________

4b. PROVIDER ID WHERE
PATIENT TREATED:
___________________

7c. RACE: (Check all that apply)
1 £ Native Hawaiian or Other Pacific Islander
1 £ American Indian or Alaska Native
1 £ White
1 £ Black or African American

1 £ Asian
1 £ Unknown

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

8c. Location of stool collection: (Check one)
1 £ Hospital Inpatient
4 £ Long Term Care/
7 £ Unknown
Facility ID _____________ Skilled Nursing Facility
1 £ EIA
1 £ GDH
1 £ NAAT
Facility ID ___________
Mo.
Day
Year
1 £ Culture 1 £ Cytotoxin
1 £ Unknown
2 £ Long Term Acute Care 5 £ Outpatient
8 £ Observation
1 £ Other (specify):
Hospital
Unit/CDU
Facility ID _____________
________________________
3 £ Emergency Room
6 £ Other (specify): ___________________
9. Was patient hospitalized at the time of, or within 7 days after,
10. Where was the patient a resident 4 days prior to stool collection? (Check one)
stool collection?
1 £ Hospital Inpatient
3 £ Home
6 £ Incarcerated
1 £ Yes 2 £ No 7 £ Unknown
Facility ID ______________
4 £ Long Term Care/ Skilled Nursing 7 £ Unknown
If YES, Date of Admission:
Mo.
Day
Year
2 £ Long Term Acute Care Hospital Facility
8 £ Other (specify):
Facility ID _____________
Facility ID ______________
_______________
5 £ Homeless

££ ££
££££

££ ££
££££

11. HCFO classification questions:
a. Was stool collected ≥ 4 days after hospital admission?
1 £ Yes (HCFO)
2 £ No (go to 11b.)

12. Was CDI a primary or contributing reason for patient’s admission?
1 £ Yes

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)
Facility ID ______________
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

££ ££ £
£££

£ Unknown

Facility ID ______________
1 £ Overnight stay in LTACH at any time in the 12 weeks prior to stool collection date
Facility ID ______________
1 £ Residence in LTCF/SNF at any time in the 12 weeks prior to stool collection date
Facility ID ______________
16. Patient outcome: 7 £ Unknown
1 £ Survived
Date of Discharge:
Mo.
Day

3 £ Not Admitted

7 £ Unknown

13. Were other enteric pathogens detected from stool at the same date
incident C. diff + stool was collected?
1 £ Campylobacter 5 £ None
8 £ Other (specify):
2 £ Salmonella 6 £ No other pathogens tested ______________
3 £ Shiga Toxin-Producing E. coli 9 £ Norovirus
4 £ Shigella
7 £ Unknown
10 £ Rotavirus

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:
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

Year

££ ££ ££££

If survived, patient was discharged to:
2 £ Long Term Acute Care Hospital
Facility ID ______________
3 £ Home

2 £ No

4 £ Long Term Care/ Skilled Nursing Facility
Facility ID ______________
5 £ Other

2 £ Died
Date of Death:

Mo.

Day

Year

££ ££ ££££

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 D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).

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17a. Colectomy (related to CDI):
1 £ Yes 2 £ No 7 £ Unknown
If YES, Date of Procedure
Mo.
Day

Year

££ ££ £
£££

17b. ICU Admission (on the day of or after incident stool collection):
1 £ Yes 2 £ No 7 £ Unknown
If YES, Date of ICU Admission
Mo.
Day
Year

££ ££
££££

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

17c. Any additional positive stool test for C. diff ≥ 2 and ≤ 8
weeks after the last C. diff + stool specimen?
1 £ Yes 2 £ No
If YES, Date of first recurrent specimen
Mo.
Day
Year

£ Unknown

££ ££
££££

19. Was pseudomembranous colitis listed in the
surgical pathology, endoscopy, or autopsy report
(within 7 days before or after incident C. diff + stool)?
1 £ Yes
3 £ Not Done
2 £ No
7 £ Information not available

20.2 CLINICAL FINDINGS (within 7 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)
2 £ Diarrhea documented, but unable to determine if it is by definition
3 £ No Diarrhea documented
4 £ “Asymptomatic” documented in medical record
7 £ Information not available

1 £ Nausea
2 £ Vomiting
3 £ Neither
4 £ Both
7 £ Information not available

20.1 LABORATORY FINDINGS (within 7 days
before or after incident C. diff + stool):
a. Albumin ≤ 2.5g/dl:
1 £ Yes 2 £ No 3 £ Not Done
7 £ Information not available
b. White blood cell count ≤ 1,000/µl:
1 £ Yes 2 £ No 3 £ Not Done
7 £ Information not available
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 1 £ Unknown
1 £ AIDS
1 £ Connective Tissue Disease
1 £ Inflammatory Bowel Disease
1 £ Chronic Cognitive Deficit
1 £ CVA/Stroke
1 £ Myocardial Infarct
1 £ Chronic Kidney Disease
1 £ Dementia
1 £ Peptic Ulcer Disease
1 £ Chronic Liver Disease
1 £ Diabetes
1 £ Peripheral Vascular Disease
1 £ Chronic Pulmonary Disease
1 £ Diverticular Disease
1 £ Primary Immunodeficiency
1 £ Congenital Heart Disease
1 £ Hemiplegia/Paraplegia
1 £ Short Gut Syndrome
1 £ Congestive Heart Failure
1 £ HIV
1 £ Solid Organ Transplant
22. Was ICD-9 008.45 or ICD-10 A04.7 listed on the discharge form?
1 £ Yes 2 £ No 3 £ Not Admitted 7 £ Unknown
If YES, what was the POA code assigned to it?
1 £ Y,Yes
3 £ U, Unknown
2 £ N, No 4 £ W, Clinically Undetermined

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

23. At time of incident C. diff + stool, patient was:
1 £ Pregnant 2 £ Post-partum 3 £ Neither
Delivery Date:

5 £ Missing
6 £ Not Applicable

Mo.

Day

7 £ Unknown

Year

££ ££ ££££

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)
a. Proton pump inhibitor 1 £ Yes
2 £ No
(e.g. Esomeprazole, Omeprazole, Lansoprazole, Pantoprazole, Rabeprazole)

7 £ Unknown

b. H2 Blockers (e.g. Famotidine, Ranitidine, Cimetidine) 1 £ Yes

2 £ No

c. Immunosuppressive therapy (Check all that apply) 1 £ None
1 £ Steroids
1 £ Chemotherapy

1 £ Unknown
1 £ Other agents (specify): ____________________________

d. Antimicrobial therapy (Check all that apply) 1 £ Yes, name unknown
1 £ Amikacin
1 £ Cefazolin
1 £ Ceftriaxone
1 £ Doxycycline
1 £ Amoxicillin
1 £ Cefdinir
1 £ Cefuroxime
1 £ Ertapenem
1 £ Amoxicillin/Clavulanic Acid 1 £ Cefepime
1 £ Cephalexin
1 £ Gentamicin
1 £ Ampicillin
1 £ Cefotaxime
1 £ Ciprofloxacin
1 £ Imipenem
1 £ Amp/sulb
1 £ Cefoxitin
1 £ Clarithromycin 1 £ Levofloxacin
1 £ Azithromycin
1 £ Cefpodoxime 1 £ Clindamycin
1 £ Linezolid
1 £ Aztreonam
1 £ Ceftazidime
1 £ Daptomycin
1 £ Meropenem

7 £ Unknown

1 £ None
1 £ Metronidazole
1 £ Moxifloxacin
1 £ Nitrofurantoin
1 £ Penicillin
1 £ Piperacillin-Tazobactam
1 £ Rifampin
1 £ Rifaximin

1 £ Unknown
1 £ Tetracycline
1 £ Tigecycline
1 £ Tobramycin
1 £ Trimethoprim -Sulfamethoxazole
1 £ Vancomycin (IV)
1 £ Other (specify):
____________________

e. Was patient treated for previous suspected or confirmed CDI in the prior 12 weeks?
£ Yes
£ No
£ Unknown
If YES, which medication was taken (check all that apply, or unknown if applicable):
£ Metronidazole
£ Vancomycin
£ Fidaxomicin
£ Other, specify:______________

£ Unknown

– SURVEILLANCE OFFICE USE ONLY –
25. CRF status:
1 £ Complete 3 £ Edited & Correct
2 £ Incomplete 4 £ Chart unavailable
after 3 requests

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

27. Initials of S.O:

1 £ Yes

_______________

2 £ No

If yes, Previous STATEID:

£££££££££

29. Identified through
audit
1 £ Yes

2 £ No

28. COMMENTS: _______________________________________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
CDC Rev. 10-2015

CS259114

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