Form 0920-0978 Clostridium Difficile Infection (CDI) Surveillance Emerg

Patient identifier information is NOT transmitted to CDC
Patient ID: ______________________________________________________

Specimen ID:

Patient’s Name:
Address:

Chart Number:
Hospital:

Form Approved
OMB No. 092-0978
Expires xx/xx/xxxx

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

1. STATE:

2. COUNTY:

(Residence of Patient)

(Residence of Patient)

5. DATE OF BIRTH:

3. STATE ID:

6. AGE:

7a. SEX:
Male
Female

______ /______ /______

4a.LABORATORY ID WHERE
INCIDENT SPECIMEN IDENTIFIED

7b. ETHNIC ORIGIN:
Hispanic or Latino
Not Hispanic or Latino
Unknown

7c. RACE: (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American

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

8a. DATE OF INCIDENT C. diff+
STOOL COLLECTION

______ /______ /______

Native Hawaiian or
Other Pacific Islander
White
Unknown

8c. Location of incident C. diff+ stool collection (Check one)

EIA

GDH

NAAT

Hospital inpatient

Facility ID:

Culture

Cytotoxin

Unknown

LTACH

Facility ID:

LTCF

Facility ID:

Other (specify):

9. Was patient hospitalized on the date of or in the 6 calendar days after incident C. diff+ stool collection?
Yes

4b. FACILITY ID WHERE
PATIENT TREATED

No

Emergency Room
Outpatient

Unknown

Observation Unit/CDU
If YES, Date of Admission: ______ /______ /______

Other (specify):
Unknown

10. Where was the patient on the 3 calendar day before the date of incident C. diff+
stool collection? (Check one)
rd

Hospital inpatient

Facility ID:

LTACH

Facility ID:

LTCF

Facility ID:

11. HCFO classification questions:
a. Was incident C. diff+ stool collected at least 3 calendar days after the date of
hospital admission?
Yes (HCFO - go to 11d.)

b. Was incident C. diff+ stool collected at an outpatient setting for a LTCF
resident, or in a LTCF or LTACH?

Private residence

Incarcerated

No

c. Was the patient admitted from a LTCF or a LTACH?

Homeless

Yes (HCFO - go to 11d.)

Other (specify):

No (CO - Complete CRF)

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

Unknown

Yes (Complete CRF)

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

No

No

Not Admitted

No (STOP data abstraction here!)

14. Exclusion criteria for CA-CDI: (Check all that apply)

Unknown

None

Norovirus

Salmonella

No other pathogens tested

Rotavirus

Shiga Toxin-Producing E. coli

Unknown

Shigella

Other (specify):

Unknown

Hospitalized (overnight) in the 12 weeks before the date of incident
C. diff+ stool collection.

13. Were other enteric pathogens isolated from stool collected on the date of incident
C. diff+ stool collection?
Campylobacter

None

Date of most recent discharge: ______ /______ /______
Facility ID
Overnight stay in LTACH in the 12 weeks before the date of incident
C. diff+ stool collection.
Facility ID
Residence in LTCF in the 12 weeks before the date of incident C. diff+ stool collection.
Facility ID

15. Exposures to Healthcare in the 12 weeks before the date of incident C. diff+ stool collection:
a. Chronic Hemodialysis
Yes

No

b. Surgical procedure
Unknown

Yes

No

c. ER visit
Unknown

Yes

d. Observation/CDU stay
No

Unknown

Yes

No

Unknown

Public reporting burden of this collection of information is estimated to average 30 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).

CDC Rev. 09-2017

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16. Patient outcome

17a. Colectomy (related to CDI):

Unknown

Yes

No

Unknown

If YES, Date of Procedure ______ /______ /______

Survived

Died

If survived:

If died:

Date of discharge: ______ /______ /______

Date of death: ______ /______ /______

17b. ICU Admission (in the 2 calendar days before, the day of,
or the 6 calendar days after the date of incident C. diff+ stool
collection):
Yes

Discharged to:

No

Unknown

LTACH

Facility ID:

If YES, Date of ICU Admission ______ /______ /______

LTCF

Facility ID:

17c. Any additional positive stool test for C. diff ≥ 2 and
≤ 8 weeks after the date of incident C. diff+ stool collection?

Private residence

Yes

Other (specify):

No

If YES, Date of first recurrent specimen ______ /______ /______

Unknown

19. Was pseudomembranous colitis listed in the surgical pathology, endoscopy, or
autopsy report in the 6 calendar days before, the day of, or the 6 calendar days after
the date of incident C. diff+ stool collection?

18. RADIOGRAPHIC FINDINGS (in the 6 calendar days before, the day of, or the
6 calendar days after the date of incident C. diff+ stool collection):
Toxic megacolon

Neither toxic megacolon nor ileus

Yes

Not Done

lleus

Radiology not performed

No

Information not available

Both toxic megacolon and ileus

Information not available

20.1 LABORATORY FINDINGS
(in the 6 calendar days before, the day of, or the
6 calendar days after the date of incident C. diff+
stool collection):
a. Albumin ≤ 2.5g/dl:
Yes

No

Not Done

Information not available
b. White blood cell count ≤ 1,000/µl:
Yes

No

Not Done

Diarrhea by definition (unformed or watery stool,
≥ 3/day for ≥ 1 day)

“Asymptomatic” documented in
medical record

Diarrhea documented, but unable to determine
if it is by definition

No diarrhea, nausea, or vomiting documented

Nausea

Information not available

e. Other findings (in the 6 calendar days before, the day of, or the 6 calendar days after the date of
incident C. diff+ stool collection)

c. White blood cell count ≥ 15,000/µl:
No

d. Symptoms (in the 6 calendar days before, the day of, or 1 calendar day after the date of incident
C. diff+ stool collection) (Check all that apply)

Vomiting

Information not available

Yes

20.2 Clinical findings

Not Done

Information not available

Toxic megacolon

Neither toxic megacolon nor ileus

Ileus

Information not available

Both toxic megacolon and ileus
21. UNDERLYING CONDITIONS: (Check all that apply)

None

Unknown

AIDS

Dementia

Primary Immunodeficiency

Chronic Cognitive Deficit

Diabetes

Short Gut Syndrome

Chronic Kidney Disease

Diverticular Disease

Solid Organ Transplant

Chronic Liver Disease

Hemiplegia/Paraplegia

Stem Cell Transplant

Chronic Pulmonary Disease

HIV

Solid Tumor (non metastatic)

Congenital Heart Disease

Inflammatory Bowel Disease

Hematologic Malignancy

Congestive Heart Failure

Myocardial Infarct

Metastatic Solid Tumor

Connective Tissue Disease

Peptic Ulcer Disease

Pregnancy

CVA/Stroke

Peripheral Vascular Disease

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

CDC Rev. 09-2017

No

Not Admitted

Unknown

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

U, Unknown

Missing

N, No

W, Clinically Undetermined

Not Applicable

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23. MEDICATIONS TAKEN in the 12 weeks before the date of incident C. diff+ stool collection:
a. Proton pump inhibitor

Yes

No

Unknown

b. H2 Blockers

Yes

No

Unknown

c. Immunosuppressive therapy
(Check all that apply)

None

Unknown

Steroids

d. Antimicrobial therapy (Check all that apply)

Yes, name unknown

Chemotherapy
None

Other agents (specify):

Unknown

Amikacin

Cefazolin

Ceftriaxone

Doxycycline

Metronidazole

Tetracycline

Amoxicillin

Cefdinir

Cefuroxime

Ertapenem

Moxifloxacin

Tigecycline

Amoxicillin/Clavulanic Acid

Cefepime

Cephalexin

Gentamicin

Nitrofurantoin

Tobramycin

Ampicillin

Cefotaxime

Ciprofloxacin

Imipenem

Penicillin

Trimethoprim -Sulfamethoxazole

Amp/sulb

Cefoxitin

Clarithromycin

Levofloxacin

Piperacillin-Tazobactam

Vancomycin (IV)

Azithromycin

Cefpodoxime

Clindamycin

Linezolid

Rifampin

Other (specify):

Aztreonam

Ceftazidime

Daptomycin

Meropenem

Rifaximin

e. Was patient treated for previous suspected or confirmed CDI in the 12 weeks before the date of incident C. diff+ stool collection?
Yes

No

Unknown

If YES, which medication was taken (Check all that apply):
Metronidazole

Vancomycin

24. Treatment for incident CDI

Fidaxomicin

No treatment

Other, (specify)

Unknown

Unknown treatment

Probiotics (specify):
Stool transplant Date: ______ /______ /______
Course 1

Start Date: ______ /______ /______

Stop Date: ______ /______ /______

Duration (days) ______________________________

OR

Vancomycin (PO)

Metronidazole (PO)

Rifaximin

Vancomycin (Rectal)

Metronidazole (IV)

Nitazoxanide

Vancomycin (Unknown route)

Metronidazole (Unknown route)

Other (specify):

Vancomycin taper (any route)

Fidaxomicin

Course 2

Start Date: ______ /______ /______

Stop Date: ______ /______ /______

Duration (days) ______________________________

OR

Vancomycin (PO)

Metronidazole (PO)

Rifaximin

Vancomycin (Rectal)

Metronidazole (IV)

Nitazoxanide

Vancomycin (Unknown route)

Metronidazole (Unknown route)

Other (specify):

Vancomycin taper (any route)

Fidaxomicin

Course 3

Start Date: ______ /______ /______

Stop Date: ______ /______ /______

Duration (days) ______________________________

OR

Vancomycin (PO)

Metronidazole (PO)

Rifaximin

Vancomycin (Rectal)

Metronidazole (IV)

Nitazoxanide

Vancomycin (Unknown route)

Metronidazole (Unknown route)

Other (specify):

Vancomycin taper (any route)

Fidaxomicin

Course 4

Start Date: ______ /______ /______

Stop Date: ______ /______ /______

Duration (days) ______________________________

OR

Vancomycin (PO)

Metronidazole (PO)

Rifaximin

Vancomycin (Rectal)

Metronidazole (IV)

Nitazoxanide

Vancomycin (Unknown route)

Metronidazole (Unknown route)

Other (specify):

Vancomycin taper (any route)

Fidaxomicin
– SURVEILLANCE OFFICE USE ONLY –

25. CRF status:
Complete
Incomplete
Chart unavailable after 3 requests

26. Previous unique CDI episode
(>8 weeks before the date of incident C. diff+ stool collection):
Yes

27. Initials of S.O:

28. Identified through audit
Yes

No

No

If YES, Previous STATEID:

29. COMMENTS:

CDC Rev. 09-2017

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