Form 0920-0978 CDI Case Report Form

1. PATIENT ID:

2. STATE ID:

3. SPECIMEN ID:

4. DATE OF INCIDENT C. diff+ STOOL COLLECTION:

Patient’s Name:

(State)

6. COUNTY:

10. DATE OF BIRTH:

11. AGE:
(Years)

12. SEX AT
BIRTH:

Unknown

8. FACILITY ID WHERE
PATIENT TREATED

9. POSITIVE DIAGNOSTIC ASSAY FOR C. diff
(Check all that apply)

EIA

13. ETHNIC ORIGIN:

Cytotoxin

Unknown

Culture

NAAT

GDH

Other (specify):

14. RACE: (Check all that apply)

Hispanic or Latino
Not Hispanic or Latino
Unknown

Male
Female
Unknown

/

-

Hospital:

(Zip Code)

7. LABORATORY ID WHERE
INCIDENT SPECIMEN
IDENTIFIED

(Residence of Patient)

)

Chart Number:

(Number, Street, Apt. No.)
(City)

/

Phone No.: (

(Last, First, M.I.)

Address:

(Residence of
Patient)

/

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

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

5. STATE:

/

American Indian or
Alaska Native

Native Hawaiian or
Other Pacific Islander

Asian

White

Black or African American

Unknown

Transgender

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

Yes

No

Unknown

15a. If YES, Date of Admission:
/
/
Unknown
16. Where was the patient located on the 3rd calendar day before the date of incident C. diff+ stool collection?
Private Residence
LTCF
Facility ID:
Hospital Inpatient Facility ID:
16a. Was patient transferred from this hospital?
LTACH
Facility ID:

Homeless
Incarcerated
Yes

No

18. HCFO classification questions:

17. Location of incident C. diff+ stool collection
Outpatient
Facility ID:

Hospital Inpatient
Facility ID:

LTCF
Facility ID:

Emergency room

ICU

Clinic/doctor’s office

OR

LTACH
Facility ID:

Dialysis center

Radiology
Other inpatient

Autopsy

Surgery
Observation/

Other (specify):
Unknown

Unknown

18a. Was incident C. diff+ stool collected at least 3 calendar
days after the date of hospital admission?
Yes (HCFO - go to 18d)

18b. Was incident C. diff+ stool collected in an outpatient
setting for a LTCF resident, or in a LTCF or LTACH?
Yes (HCFO - go to 18d)
Yes (HCFO - go to 18d)

Clinical decision unit

No (CO - complete CRF)

Facility ID:

Unknown

18d. If HCFO, was this case sampled for full CRF?
Yes (Complete CRF)
1

19. Patient Outcome

No

18c. Was the patient admitted from a LTCF or a LTACH?

Other (specify):

Other outpatient

No

2

3

4

No (STOP data abstraction here!)
5

6

7

8

9

10

Unknown
Died

Survived

19a. Date of discharge:

/

/

Unknown

19c. Date of death:

/

/

Unknown

Left against medical advice (AMA)

19b. If survived, discharged to:
Private residence
LTCF

Facility ID:

LTACH

Facility ID:

Other (specify):
Unknown
Public reporting burden of this collection of information is estimated to average 35 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. 07-2018

CS294615

Page 1 of 4

20. Exposures to healthcare in the 12 weeks before the date of incident C. diff+ stool collection
20a. Previous hospitalization
Yes
20a.1 If yes, date of discharge closest to date of incident C. diff+ stool collection:
Unknown
/
/
20b. Overnight stay in LTACH
Yes
20c. Overnight stay in LTCF
Yes
20d. Chronic dialysis
Yes
Hemodialysis
Unknown
Peritoneal
20d.1 Type
20e. Surgery
Yes
20f. ER visit
Yes
20g. Observation/CDU stay
Yes
21. UNDERLYING CONDITIONS: (Check all that apply)

Chronic lung disease

None

Unknown

Facility ID:

No
No
No

Unknown
Unknown
Unknown

Facility ID:
Facility ID:

No
No
No

Unknown
Unknown
Unknown

Unknown

Liver disease

Cystic fibrosis
Chronic pulmonary disease

Plegias/Paralysis

Chronic liver disease
Ascites
Cirrhosis
Hepatic encephalopathy
Variceal bleeding
Hepatitis C
Treated, in SVR
Current, chronic

Chronic metabolic disease
Diabetes mellitus
With chronic complications

Cardiovascular disease
CVA/Stroke/TIA
Congenital heart disease
Congestive heart failure
Myocardial infarction
Peripheral vascular disease (PVD)

Hemiplegia
Paraplegia
Quadriplegia

Renal disease
Chronic kidney disease
Lowest serum creatinine:
Burn
Decubitus/pressure ulcer
Surgical wound
Other chronic ulcer or chronic wound
Other (specify):

Malignancy, hematologic
Malignancy, solid organ (non-metastatic)
Malignancy, solid organ (metastatic)

Neurologic condition

Diverticular disease
Inflammatory bowel disease
Peptic ulcer disease
Short gut syndrome

Other

Cerebral palsy
Chronic cognitive deficit
Dementia
Epilepsy/seizure/seizure disorder
Multiple sclerosis
Neuropathy
Parkinson’s disease
Other (specify):

Immunocompromised condition
HIV
AIDS/CD4 count < 200
Primary immunodeficiency
Transplant, hematopoietic stem cell
Transplant, solid organ

22a. Weight

Connective tissue disease
Obesity or morbid obesity
Pregnancy

22b. Height
oz OR

mg/dl

Skin condition

Malignancy

Gastrointestinal disease

lbs

No

kg

Unknown

ft

22c. BMI
in OR

cm

Unknown

Unknown

23. Substance Use
23a. Smoking:
Tobacco

None
E-Nicotine Delivery System

23c. Other substances: (Check all that apply)

None

23b. Alcohol abuse:

Unknown
Marijuana
Unknown

Documented Use Disorder (DUD)/Abuse?

DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse

Marijuana/cannabinoid (other than smoking)
Opioid, DEA schedule I (e.g., heroin)
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
Cocaine or methamphetamine
Other (specify):
Unknown substance

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

No

Not Admitted

Unknown

Mode of delivery: (Check all that apply)

IDU
IDU
IDU
IDU
IDU
IDU

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

No

Not Admitted

Unknown

25a. If YES, what was the POA code
assigned to it?
Y, Yes
N, No
U, Unknown

CDC Rev. 07-2018

Yes
No
Unknown

W, Clinically
Undetermined
Missing
Not Applicable
CS294615

Skin popping
Skin popping
Skin popping
Skin popping
Skin popping
Skin popping

non-IDU
non-IDU
non-IDU
non-IDU
non-IDU
non-IDU

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

26. Was the patient in an ICU on the day of
or in the 6 days after the date of
incident C. diff+ stool collection?
Yes

No

Unknown

26a. If YES, date of ICU admission:

/

/

Unknown

Page 2 of 4

28. Toxic megacolon and ileus (in the 6 calendar days before, the day of,
or the 6 calendar days after the date of incident C. diff+ stool collection)

27. 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)

28b. Clinical findings

28a. Radiographic findings

“Asymptomatic” documented in medical record
Diarrhea by definition (unformed or watery stool, ≥ 3/day for ≥ 1 day)

Toxic megacolon

Toxic megacolon

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

Ileus

Ileus

Nausea

Both toxic megacolon and ileus

Both toxic megacolon and ileus

Vomiting

Neither toxic megacolon nor ileus

Neither toxic megacolon nor ileus

No diarrhea, nausea, or vomiting documented

Radiology not performed

Information not available

Information not available

Information not available

30. Colectomy
(related to CDI):

29. 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?
Yes
No

/

Yes
No
Unknown

Not Done
Information not available

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

/

Unknown

32. 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:
32a. Albumin ≤2.5g/dl:

Campylobacter
Norovirus
Rotavirus
Salmonella
Shiga Toxin-Producing E.coli
Shigella
Other (specify):
None
No other pathogens tested
Unknown

Yes
No
Not Done
Information not available
32b. White blood cell count ≤ 1,000/µl:
Yes
No
Not Done
Information not available
32c. White blood cell count ≥ 15,000/µl:
Yes
No
Not Done
Information not available

33. Medications taken in the 12 weeks before the date of incidentC. diff+ stool collection:
33a. Proton pump inhibitor
33b. H2 Blockers
(e.g. Famotidine, Ranitidine, Cimetidine)
(e.g. Omeprazole, Lansoprazole,
Pantoprazole, Rabeprazole)
Yes
No
Unknown

Yes
No
Unknown

33d. Antimicrobial therapy (Check all that apply)
Amikacin
Amoxicillin
Amoxicillin/clavulanic acid
Ampicillin
Ampicillin/sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefdinir
Cefepime
Cefixime
Cefotaxime

30a. If YES, date of procedure:

None

Cefoxitin
Cefpodoxime
Ceftaroline
Ceftazidime
Ceftazidime/avibactam
Ceftizoxime
Ceftolozane/tazobactam
Ceftriaxone
Cefuroxime
Cephalexin
Ciprofloxacin
Clarithromycin

33c. Immunosuppressive therapy
(Check all that apply)
Steroids
Chemotherapy
Other agents (specify):
None
Unknown

Unknown
Clindamycin
Dalbavancin
Daptomycin
Delafloxacin
Doripenem
Doxycycline
Ertapenem
Fosfomycin
Gentamicin
Imipenem/cilastatin
Levofloxacin
Linezolid

Meropenem
Meropenem/vaborbactam
Metronidazole
Moxifloxacin
Nitrofurantoin
Oritavancin
Penicillin
Piperacillin/tazobactam
Polymyxin B
Polymyxin E (colistin)
Rifaximin
Tedizolid

Telavancin
Tigecycline
Tobramycin
Trimethoprim
Trimethoprim/sulfamethoxazole
Vancomycin (IV)
Other (specify):

33e. 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

33e.1 If YES, which medication was taken (Check all that apply):
Metronidazole
CDC Rev. 07-2018

Vancomycin

Fidaxomicin

Other, (specify)
CS294615

Unknown
Page 3 of 4

34. Treatment for incident CDI

No treatment

Unknown treatment

34a.1 Course 1
Start Date:
/
/
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)

Unknown Stop Date:
/
/
Metronidazole (PO)
Metronidazole (IV)
Metronidazole (Unknown route)
Fidaxomicin

Unknown OR Duration (days)
Rifaximin
Nitazoxanide
Other (specify):

Unknown

Unknown Stop Date:
/
/
Metronidazole (PO)
Metronidazole (IV)
Metronidazole (Unknown route)
Fidaxomicin

Unknown OR Duration (days)
Rifaximin
Nitazoxanide
Other (specify):

Unknown

Unknown Stop Date:
/
/
Metronidazole (PO)
Metronidazole (IV)
Metronidazole (Unknown route)
Fidaxomicin

Unknown OR Duration (days)
Rifaximin
Nitazoxanide
Other (specify):

Unknown

Unknown Stop Date:
/
/
Metronidazole (PO)
Metronidazole (IV)
Metronidazole (Unknown route)
Fidaxomicin

Unknown OR Duration (days)
Rifaximin
Nitazoxanide
Other (specify):

Unknown

34a.2 Course 2
Start Date:
/
/
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)

34a.3 Course 3
/
/
Start Date:
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)

34a.4 Course 4
/
/
Start Date:
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)

34b.

Probiotics (specify):

34c.

Stool transplant Date:

/

/

35. Previous unique CDI episode
(>8 weeks before the date of incident C. diff+
stool collection):
Yes
No

35a. If YES, previous STATEID:

Unknown
36. Any recurrent C. diff+ episodes
following this incident C. diff+
episode?
Yes
No

36a. If YES, date of first recurrent
specimen:

/

37. CRF status:

38. Initials of S.O:

Complete
Incomplete
Chart unavailable after
3 requests

/

39. COMMENTS:

CDC Rev. 07-2018

CS294615

Page 4 of 4