Form 0920-0978 CANDIDEMIA - CASE REPORT FORM

Form approved OMB 0920-0978
State ID: ______________________ Date of Initial Culture (mm/dd/yyyy): ___/___/________ Surveillance Office Initials ________

CANDIDEMIA 2017 CASE REPORT FORM
Patient name: ________________________________________________

Medical Record No.: _______________________________________

(Last, First, MI)

Address: ____________________________________________________
(Number, Street, Apt. No.)

________________________________ ___________________
(City, State)

(Zip Code)

Hospital: ________________________________________________
Acc No. (incident isolate): __________________________________
Acc No. (subseq isolate): __________________________________

……………………………………………………………………cut/tear here and retain portion above at EIP site…………………………………………………………………………
Check if not a case:
Reason not a case:

Out of catchment area

Duplicate entry

Not candidemia

Unable to verify address

Other (specify):_____________

SURVEILLANCE OFFICER INFORMATION
1. Date reported to EIP site:

/

/

2. Date review completed:

/

/

3. Was case first
5. Previous candidemia episode?
identified through audit? 1 Yes 0 No 9 Unknown
1 Yes 0
No
5a. If yes, enter state IDs:

6. CRF status: 7. SO’s
initials:
1 Complete
______
2 Pending

4. Isolate available?
1 Yes 0
No

4 Chart
unavailable

DEMOGRAPHICS
8. State ID:

9. State: _________________

10. County: ______________________

11. Lab ID where positive culture was identified:
12. Date of birth (mm/dd/yyyy):

/

13. Age:

14. Sex:

/

1

days 2

mos 3

yrs

Native Hawaiian/Pacific Islander

Female
Male
16. Ethnic origin:
1 Hispanic/Latino

Black/African American

American Indian/Alaska Native

2

Not Hispanic/Latino

Asian

Unknown

9

Unknown

15. Race (check all that apply):
White

Check if transgender

LABORATORY DATA

/

17. Date initial positive Candida blood culture was drawn (mm/dd/yyyy):

/

18. Source of initial positive Candida blood culture
(check all that apply):
1 Blood, from CVC

19. Candida species from initial positive blood culture (check all that apply):
1

Candida albicans (CA)

6

Candida tropicalis (CT)

2

Blood, from peripheral stick

2

Candida glabrata (CG)

7

Candida, other (CO) specify: ______________

3

Blood, not specified

3

Candida krusei (CK)

8

Candida, gram tube negative/non albicans (CGN)

4

Other (specify): _____________________

4

Candida lusitaniae (CL)

9

Candida species (CS)

9

Unknown

5

Candida parapsilosis (CP)

10

Pending

20. Antifungal susceptibility testing (check here
Date of culture

Species
1
2
3
4
5
6
7
8
9
10

CA
CG
CK
CL
CP
CT
CO
CGN
CS
Pending

1
2
3
4
5
6
7
8
9
10

CA
CG
CK
CL
CP
CT
CO
CGN
CS
Pending

if no testing done/no test reports available):
Drug

MIC

Interpretation

Amphotericin B

S

SDD

I

R

NS

Anidulafungin (Eraxis)

S

SDD

I

R

NS

Caspofungin (Cancidas)

S

SDD

I

R

NS

Fluconazole (Diflucan)

S

SDD

I

R

NS

Flucytosine (5FC)

S

SDD

I

R

NS

Itraconazole (Sporanox)

S

SDD

I

R

NS

Micafungin (Mycamine)

S

SDD

I

R

NS

Posaconazole (Noxafil)

S

SDD

I

R

NS

Voriconazole (Vfend)

S

SDD

I

R

NS

Amphotericin B

S

SDD

I

R

NS

Anidulafungin (Eraxis)

S

SDD

I

R

NS

Caspofungin (Cancidas)

S

SDD

I

R

NS

Fluconazole (Diflucan)

S

SDD

I

R

NS

Flucytosine (5FC)

S

SDD

I

R

NS

Itraconazole (Sporanox)

S

SDD

I

R

NS

Micafungin (Mycamine)

S

SDD

I

R

NS

Posaconazole (Noxafil)

S

SDD

I

R

NS

Voriconazole (Vfend)

S

SDD

I

R

NS

Page 1 of 5

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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-0978).

State ID: ______________________ Date of Initial Culture (mm/dd/yyyy): ___/___/________ Surveillance Office Initials ________
21. Additional non-Candida organisms isolated from blood cultures on the same day as initial culture date: 1

Yes 0

No 9

Unknown

21a. If yes, additional organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________
22. Any subsequent positive Candida blood cultures in the 30 days after initial culture date? 1 Yes 0 No 9
Unknown
22a. If yes, provide dates of all subsequent positive Candida blood cultures and select the species:
Date Drawn (mm/dd/yyyy)
Species identified*

/
/
/
/

/
/
/
/

CA

CG

CK

CL

CP

CT

CO:_________

CGN

CS

Pending

CA

CG

CK

CL

CP

CT

CO:_________

CGN

CS

Pending

CA

CG

CK

CL

CP

CT

CO:_________

CGN

CS

Pending

CA

CG

CK

CL

CP

CT

CO:_________

CGN

CS

Pending

*Attach additional MIC page if additional Candida species (different from original), if another C. glabrata (even if original was C. glabrata), or if
same Candida species (if no AFST results available for original)

23. Documented negative Candida blood culture in the 30 days after initial culture date? 1

/

23a. If yes, date of first negative Candida blood culture:

Yes 0

No 9

Unknown

/

24. Other known sites of Candida infection or colonization in the 7 days before or 3 days after initial culture date?
1 Yes 0 No 9 Unknown
24a. If yes, source (check all that apply):
1

Peritoneal fluid or abdominal cavity

4

Pleural fluid

7

Skin

2

Urine

5

CSF

8

Other site (specify):

3

Respiratory specimen

6

Bone

_________________________________

MEDICAL ENCOUNTERS
25. Is patient currently hospitalized or was patient hospitalized in the 7 days after initial culture date? 1
25a. If yes, Treatment hospital ID

Date of admission

/

Unknown

Yes 0

No 9

Unknown

Date of discharge

/

/

Unknown

/

Unknown

26. Where was the patient located prior to admission? (Check one)
1

Private residence

3

LTCF Facility ID: _________

6

Incarcerated

2

Hospital Inpatient (If transferred from

4

LTACH Facility ID: _________

7

Other (specify): _________________________

another hospital, facility ID: _________)
27. Patient outcome: 1 Survived
0

5
Died

Homeless
9
Unknown

9

Unknown

27a. If survived, Date of last patient encounter

/

27b. If died, Date of death

/

/

Unknown

/

Unknown

28. If survived, discharged to:
0 Not applicable (i.e., patient died, or not hospitalized)

3

Long term acute care hospital Facility ID: ___________

1

Private residence

5

Other, specify: _________________________________

4

Another acute care hospital Facility ID: _____________

9

Unknown

2 Long term care facility Facility ID: _________________
29. Did the patient require a prior hospitalization in the 90 days before, initial culture date? 1

UNDERLYING CONDITIONS
30. Underlying conditions (Check all that apply):
Alcohol abuse, current
Chronic Cognitive Deficit/Dementia
Chronic Kidney Disease
Creatinine ≥3
Chronic Liver Disease
Cirrhosis
Ascites
Hepatic Encephalopathy
Variceal Bleeding
Hepatitis C
Chronic Pulmonary Disease
Chronic Ulcer or Chronic Wound
Decubitus/Pressure Ulcer
Surgical Wound
Burn
Other (specify): _________________

Version: Short Form 2017

None

Yes

0

No

9

Unknown

Unknown

Congestive Heart Failure
Connective Tissue Disease
CVA/Stroke/TIA
Cystic Fibrosis
Diabetes Mellitus
With Chronic Complications
HIV
AIDS/CD4 count <200
Injection Drug Use, Current
Inflammatory Bowel Disease
Malignancy, Hematologic
Malignancy, Solid Organ (non-metastatic)
Malignancy, Solid Organ (metastatic)
Myocardial infarction

Last Updated: 11/15/2017

Neurological Condition
Obesity or Morbid Obesity
Pepcid Ulcer Disease
Peripheral Vascular Disease (PVD)
Plegias/Paralysis
Hemiplegia
Paraplegia
Quadriplegia
Pregnant
Primary Immunodeficiency
Smoker, Current
Transplant, Hematopoietic Stem Cell
Transplant, Solid Organ

Page 2 of 5

State ID: ______________________ Date of Initial Culture (mm/dd/yyyy): ___/___/________ Surveillance Office Initials ________

OTHER CONDITIONS
31. For cases ≤ 1 year of age: Gestational age at birth: _______ wks 9 Unknown
AND
Birth weight: __________ gms
32. Infection with Clostridium difficile in the 90 days before or 30 days after initial culture date:
1 Yes
0 No
9 Unknown

/

32a. If yes, date of first C. diff diagnosis:

/

9

Unknown

Unknown

33. Surgeries in the 90 days before initial culture date:

34. Pancreatitis in the 90 days before initial culture date:

Abdominal surgery

1

Yes

Non-abdominal surgery (specify): __________________

0

No

No surgery
35. Was the patient neutropenic* 2 days before, the day before, or on the day of initial culture date?
1

Yes

0

No

9

Unknown (no WBC days -2 or 0, or no differential)

/

35a. If yes, date of neutropenia (mm/dd/yyyy):
*Neutropenia: ANC ≤ 500

OR

/

calculated as: WBC count * (% polys + % bands) ≤500

Laboratory-calculated ANC:_______
__________ * (% _____ + % ______) = _________
36. Was the patient ever in an ICU in the 14 days before initial
37. Was the patient ever in an ICU in the 14 days after initial culture
culture date?
date?
1 Yes
0 No
9 Unknown
1 Yes
0 No
9 Unknown
38. Did the patient have a CVC 2 days before, the day before, or on the day of initial culture date?
1

Yes

2

No

3

Had CVC but can’t find dates

9

Unknown

38a. If yes, CVC type: (Check all that apply)
1 Nontunneled CVCs

3

Implantable ports

6

Other (specify): ________________________

2

4

Peripherally inserted central catheter (PICC)

9

Unknown

Tunneled CVCs

38b. Were CVCs removed or changed in the 7 days after initial culture date?
1 Yes
5

Died or discharged before indwelling catheter replaced

2

Unknown

No

9

3 CVC removed, but can’t find dates
39. Did the patient have a midline catheter 2 days before, the day before, or on the day of initial culture date?
1

Yes

0

No

9

Unknown

MEDICATIONS
40. Did the patient receive systemic antibacterial medication in the 14 days before initial culture date?
1 Yes 0
No 9 Unknown
41. Did the patient receive total parenteral nutrition (TPN) in the 14 days before initial culture date?
1

Yes

0

No

9

Unknown

42. Did the patient receive systemic antifungal medication during hospitalization, including the 14 days before initial culture date (even
if a different hospitalization)?
1

Yes (if Yes, fill out question 45)

0

No

9

Unknown

43. Was the patient prescribed systemic antifungal medication to treat candidemia, or was medication ongoing, at hospital discharge?
1

Yes (if Yes, fill out question 46)

0

No

9

Unknown

44. If antifungal medication was not given to treat current candidemia infection, what was the reason?
1 Patient died before culture result available to clinicians
4 Medical records indicated culture result not clinically significant
2

Comfort care only measures were instituted

5

Other reason documented in medical records, specify: ______________

3

Patient discharged before culture result available to clinician

6

Unknown

------------IF ANY ANTIFUNGAL MEDICATION WAS GIVEN, COMPLETE NEXT PAGE. OTHERWISE END OF CHART REVIEW FORM------------

Version: Short Form 2017

Last Updated: 11/15/2017

Page 3 of 5

State ID: ______________________ Date of Initial Culture (mm/dd/yyyy): ___/___/________ Surveillance Office Initials ________

ANTIFUNGAL MEDICATION TABLES
Drug abbreviations (NOTE: Please use abbreviation when entering data):
Amphotericin – any IV formulation (Amphotec, Amphocil,
Fungizone, Abelcet, AmBiosome, etc.)=AMBIV
Amphotericin – any inhaled formulation ()=AMBINH
Anidulafungin (Eraxis)=ANF
Caspofungin (Cancidas)=CAS

Fluconazole (Diflucan)=FLC
Flucytosine (5FC)=5FC
Isuvaconazole (cresemba)=ISU
Itraconazole (Sporanox)=ITC
Micafungin (Mycamine)=MFG

Other=OTH
Posaconazole (Noxafil)=PSC
UNKNOWN DRUG=UNK
Voriconazole (Vfend)=VRC

45. ANTIFUNGAL MEDICATION DURING HOSPITALIZATION, INCLUDING THE 14 DAYS BEFORE INITIAL CULTURE DATE (EVEN IF A DIFFERENT HOSPITALIZATION)
a. Drug
c. Date start
e. Date stop
f. Indication
g. Reason for stopping*
b. First date given (mm/dd/yyyy)
d. Last date given (mm/dd/yyyy)
Abbrev
unknown
unknown
(Check if for prophylaxis)

/
/
/

/
/
/

/
/
/

/
/
/

Prophylaxis
Prophylaxis
Prophylaxis

*Reasons for stopping antifungal treatment include: (1) completion of treatment; (2) started on different antifungal; (3) hospital discharge; (4) withdrawal of care/transition to comfort care only; (5) death; (6) other; (7) no additional records/lost to
follow-up; (8) not applicable, no therapy given; and (9) unknown.
**If a medication is given before initial culture date and the patient continues taking that medication after initial culture date, then put initial culture date as last date given for Q46 and as first date given for Q47.

46. ANTIFUNGAL MEDICATION ONGOING OR PRESCRIBED AT DISCHARGE
c. Date start
a. Drug Abbrev
b. Prescription start date*(mm/dd/yyyy)
unknown

/
/
/

/
/
/

d. Prescription end date (mm/dd/yyyy)

/
/
/

e. Date stop
unknown

f. Total duration of postdischarge treatment (days)

/
/
/

*Put discharge date as prescription start date if only given, for example, the prescription name x14.

-------------------------------------END OF CHART REVIEW FORM-------------------------------------

Version: Short Form 2017

Last Updated: 11/15/2017

Page 4 of 5

State ID: ______________________ Date of Initial Culture (mm/dd/yyyy): ___/___/________ Surveillance Office Initials ________

AFST results for additional Candida isolates
Antifungal susceptibility testing (check here
Date of culture

Species

Drug

MIC

Interpretation

Amphotericin B

S

SDD

I

R

NS

1

CA

2

CG

Anidulafungin (Eraxis)

S

SDD

I

R

NS

3

CK

Caspofungin (Cancidas)

S

SDD

I

R

NS

4

CL

5

CP

Fluconazole (Diflucan)

S

SDD

I

R

NS

6

CT

7

CO

8

Flucytosine (5FC)

S

SDD

I

R

NS

Itraconazole (Sporanox)

S

SDD

I

R

NS

CGN

Micafungin (Mycamine)

S

SDD

I

R

NS

9

CS

Posaconazole (Noxafil)

S

SDD

I

R

NS

10

Pending

Voriconazole (Vfend)

S

SDD

I

R

NS

1

CA

Amphotericin B

S

SDD

I

R

NS

2

CG

Anidulafungin (Eraxis)

S

SDD

I

R

NS

3

CK

Caspofungin (Cancidas)

S

SDD

I

R

NS

4

CL

5

CP

Fluconazole (Diflucan)

S

SDD

I

R

NS

6

CT

Flucytosine (5FC)

S

SDD

I

R

NS

7

CO

Itraconazole (Sporanox)

S

SDD

I

R

NS

8

CGN

Micafungin (Mycamine)

S

SDD

I

R

NS

9

CS

Posaconazole (Noxafil)

S

SDD

I

R

NS

10

Pending

Voriconazole (Vfend)

S

SDD

I

R

NS

Antifungal susceptibility testing (check here
Date of culture

Version: Short Form 2017

if no testing done/no test reports available):

Species

if no testing done/no test reports available):
Drug

MIC

Interpretation

Amphotericin B

S

SDD

I

R

NS

CG

Anidulafungin (Eraxis)

S

SDD

I

R

NS

CK

Caspofungin (Cancidas)

S

SDD

I

R

NS

4

CL

5

CP

Fluconazole (Diflucan)

S

SDD

I

R

NS

6

CT

Flucytosine (5FC)

S

SDD

I

R

NS

7

CO

Itraconazole (Sporanox)

S

SDD

I

R

NS

8

CGN

Micafungin (Mycamine)

S

SDD

I

R

NS

9

CS

Posaconazole (Noxafil)

S

SDD

I

R

NS

10

Pending

Voriconazole (Vfend)

S

SDD

I

R

NS

S

SDD

I

R

NS

1

CA

2
3

1

CA

Amphotericin B

2

CG

Anidulafungin (Eraxis)

S

SDD

I

R

NS

3

CK

Caspofungin (Cancidas)

S

SDD

I

R

NS

4

CL

5

CP

Fluconazole (Diflucan)

S

SDD

I

R

NS

6

CT

Flucytosine (5FC)

S

SDD

I

R

NS

7

CO

Itraconazole (Sporanox)

S

SDD

I

R

NS

8

CGN

Micafungin (Mycamine)

S

SDD

I

R

NS

9

CS

Posaconazole (Noxafil)

S

SDD

I

R

NS

10

Pending

Voriconazole (Vfend)

S

SDD

I

R

NS

Last Updated: 11/15/2017

Page 5 of 5