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pdfState ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Office Initials ________
CANDIDEMIA 2019 CASE REPORT FORM
Patient name: ________________________________________________
Medical Record No.: _______________________________________
(Last, First, MI)
Hospital: ________________________________________________
Address: ____________________________________________________
(Number, Street, Apt. No.)
Acc No. (incident isolate): __________________________________
________________________________ ___________________
(City, State)
Acc No. (subseq isolate): __________________________________
(Zip Code)
Phone no.: (
) _________ - __________________________
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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:
6. CRF status:
___ ___ - ___ ___ - ___ ___ ___ ___
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
4. Isolate available?
IDs:
2. Date review completed:
1
Yes
0
No
___ ___ - ___ ___ - ___ ___ ___ ___
1
Complete
2
Pending
3 Chart
unavailable
7. SO’s
initials:
_________
DEMOGRAPHICS
8. State ID:
9. Patient ID:
10. State: _________________
11. County: ______________________
_____________________
12. Lab ID where positive culture was identified: _________________
13. Date of birth (mm-dd-yyyy):
14. Age:
___ ___ - ___ ___ - ___ ___ ___ ___
_________ 1
16. Weight:
_________ lbs. ________ oz. OR
17. Height:
_________ ft. ________ in. OR
18. BMI: (record only if ht. and/or wt. is not
available)
_________kg
_________cm
__________________
Unknown
15. Sex:
days 2
mos 3
Male
yrs
Unknown
19. Race (check all that apply):
Female
Check if transgender
Unknown
20. Ethnic origin:
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
1
Hispanic/Latino
Asian
White
2
Not Hispanic/Latino
Black/African American
Unknown
9
Unknown
LABORATORY DATA
21. Date of Incident Specimen Collection (DISC) (mm-dd-yyyy): ___ ___ - ___ ___ - ___ ___ ___ ___
22. Location of Specimen Collection:
Hospital Inpatient
Facility ID: _________
Outpatient
LTCF
Facility ID: _________
Facility ID: _________
ICU
Emergency Room
Surgery/OR
Clinic/Doctor’s office
Radiology
Dialysis center
Autopsy
Other inpatient
Surgery
Other (specify): ________________________
Observational/clinical decision unit
Unknown
LTACH
Facility ID: _________
Other outpatient
23. Incident Specimen Collection Site
(check all that apply):
Blood, Central Line
Blood, Peripheral stick
Blood, not specified
Other (specify): ____________
Unknown
Version: Short Form 2019
24. Candida species from initial positive blood culture (check all that apply):
Candida albicans (CA)
Candida krusei (CK)
Candida glabrata (CG)
Candida parapsilosis (CP)
Candida guilliermondii (CGM)
Candida, other (CO) specify: ______________
Candida tropicalis (CT)
Candida dubliniensis (CD)
Candida, germ tube negative/non albicans (CGN)
Candida species (CS)
Candida lusitaniae (CL)
Pending
Last Updated: 08/01/2018
Page 1 of 7
State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Office Initials ________
25. Antifungal susceptibility testing (check here
Date of culture
Species
1
2
3
4
5
6
7
8
9
10
11
12
1
2
3
4
5
6
7
8
9
10
11
12
if no testing done/no test reports available):
Drug
CA
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending
CA
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending
MIC
Interpretation
Amphotericin B
S
SDD
I
R
NS
NI
ND
Anidulafungin (Eraxis)
S
SDD
I
R
NS
NI
ND
Caspofungin (Cancidas)
S
SDD
I
R
NS
NI
ND
Fluconazole (Diflucan)
S
SDD
I
R
NS
NI
ND
Flucytosine (5FC)
S
SDD
I
R
NS
NI
ND
Itraconazole (Sporanox)
S
SDD
I
R
NS
NI
ND
Micafungin (Mycamine)
S
SDD
I
R
NS
NI
ND
Posaconazole (Noxafil)
S
SDD
I
R
NS
NI
ND
Voriconazole (Vfend)
S
SDD
I
R
NS
NI
ND
Amphotericin B
S
SDD
I
R
NS
NI
ND
Anidulafungin (Eraxis)
S
SDD
I
R
NS
NI
ND
Caspofungin (Cancidas)
S
SDD
I
R
NS
NI
ND
Fluconazole (Diflucan)
S
SDD
I
R
NS
NI
ND
Flucytosine (5FC)
S
SDD
I
R
NS
NI
ND
Itraconazole (Sporanox)
S
SDD
I
R
NS
NI
ND
Micafungin (Mycamine)
S
SDD
I
R
NS
NI
ND
Posaconazole (Noxafil)
S
SDD
I
R
NS
NI
ND
Voriconazole (Vfend)
S
SDD
I
R
NS
NI
ND
26. Additional non-Candida organisms isolated from blood cultures on the day of or in the 7 days before the DISC:
1
Yes 0
No 9
Unknown
26a. If yes, additional organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________
27. At the time of DISC, was the patient known to be colonized with or being managed as if they were colonized with multi-drug
resistant organism (MDRO) infection control (e.g.: on contact precautions)? MDROs include CRE, CRPA, CRAB, MRSA, and VRE.
1
Yes 0
No 9
Unknown
27a. If yes, specify organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________
28. Any subsequent positive Candida blood cultures in the 30 days after the DISC?
1
Yes 0
No 9
Unknown
28a. If yes, provide dates of all subsequent positive Candida blood cultures and select the species:
Date Drawn (mm-dd-yyyy)
Species identified*
___ ___ - ___ ___ - ___ ___ ___ ___
CA
CG
CP
CT
CD
CL
CK
CGM
CO:_________
CGN
CS
Pending
___ ___ - ___ ___ - ___ ___ ___ ___
CA
CG
CP
CT
CD
CL
CK
CGM
CO:_________
CGN
CS
Pending
___ ___ - ___ ___ - ___ ___ ___ ___
CA
CG
CP
CT
CD
CL
CK
CGM
CO:_________
CGN
CS
Pending
___ ___ - ___ ___ - ___ ___ ___ ___
CA
CG
CP
CT
CD
CL
CK
CGM
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)
29. Documented negative Candida blood culture in the 30 days after the DISC? 1
Yes 0
No 9
Unknown
29a. If yes, date of negative blood culture: ___ ___ - ___ ___ - ___ ___ ___ ___
Version: Short Form 2019
Last Updated: 08/01/2018
Page 2 of 7
State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Office Initials ________
30. Did the patient have any of the following types of infection/colonization related to their Candida infection?
(check all that apply):
Abscess
None
Unknown
Candiduria
Peritonitis
Osteomyelitis
Splenic
CNS involvement (meningitis, brain abscess)
Respiratory specimen with Candida
Skin lesions
Liver
Eyes (endophthalmitis or chorioretinitis)
Septic emboli
Other (specify): ______________________
Pulmonary
Endocarditis
Lungs
Brain
MEDICAL ENCOUNTERS
31. Was the patient hospitalized on the day of or in the 6 days after the DISC?
31a. If yes,
Date of first admission: ___ ___ - ___ ___ - ___ ___ ___ ___
Hospital ID: _________________
1
Yes 0
No 9
Unknown
Unknown
Unknown
31b. Was the patient transferred during this hospitalization?
1
Yes 0
No 9
Unknown
If yes, enter up to two transfers:
Date of transfer: ___ ___ - ___ ___ - ___ ___ ___ ___
Hospital ID: _________________
Date of second transfer: ___ ___ - ___ ___ - ___ ___ ___ ___
Unknown
Hospital ID: _________________
Unknown
Unknown
Unknown
32. Where was the patient located prior to admission? (Check one)
1
Private residence
3
LTCF
4
Facility ID: ____________
33. Patient outcome: 1
5
Survived
LTACH
6
Incarcerated
Facility ID: _____________
7
Other (specify): ______________________
Homeless
9
Unknown
9
2
Unknown
Date of discharge:
___ ___ - ___ ___ - ___ ___ ___ ___
Died
Date of death:
Unknown
___ ___ - ___ ___ - ___ ___ ___ ___
Unknown
Left against medical advice (AMA)
33a. Discharged to:
0
Not applicable (i.e. patient died, or not hospitalized)
1
Private residence
2
LTCF
3
LTACH Facility ID: _________________
Facility ID: _________________
5
Other (specify): _____________________
6
Homeless
7
Incarcerated
9
Unknown
34. Did the patient have any of the following classes or specific ICD-10 codes, including any sub-codes for this hospitalization?
(Check all that apply):
None
Unknown
B37 (candidiasis)
B48 (other mycoses, not classified elsewhere)
Specify sub-code: ___________________
B49 (unspecified mycoses)
Specify sub-code: ___________________
T80.211 (BSI due to central venous catheter)
A41.9 (sepsis, unspecified organism)
P37.5 (neonatal candidiasis)
R65.2 (severe sepsis)
35. Previous Hospitalization in the 90 days before the DISC: 1
35a. If yes, date of discharge: ___ ___ - ___ ___ - ___ ___ ___ ___
Yes
0
No
9
Unknown
Unknown
Facility ID: ____________
36. Overnight stay in LTACH in the 90 days before the DISC: 1
Yes
0
No
9
Unknown
Facility ID: ____________
37. Overnight stay in LTCF in the 90 days before the DISC: 1
Yes
0
No
9
Unknown
Facility ID: ____________
Version: Short Form 2019
Last Updated: 08/01/2018
Page 3 of 7
State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Office Initials ________
UNDERLYING CONDITIONS
38. Underlying conditions (Check all that apply):
Chronic Lung Disease
Cystic Fibrosis
Chronic Pulmonary disease
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)
Gastrointestinal Disease
Diverticular disease
Inflammatory Bowel Disease
Peptic Ulcer Disease
Short gut syndrome
Immunocompromised Condition
HIV infection
AIDS/CD4 count <200
Primary Immunodeficiency
Transplant, Hematopoietic Stem Cell
Transplant, Solid Organ
None
Unknown
Liver Disease
Chronic Liver Disease
Ascites
Cirrhosis
Hepatic Encephalopathy
Variceal Bleeding
Hepatitis C
Treated, in SVR
Current, chronic
Malignancy
Malignancy, Hematologic
Malignancy, Solid Organ (non-metastatic)
Malignancy, Solid Organ (metastatic)
Neurologic Condition
Cerebral palsy
Chronic Cognitive Deficit
Dementia
Epilepsy/seizure/seizure disorder
Multiple sclerosis
Neuropathy
Parkinson’s disease
Other (specify): _________________
Plegias/Paralysis
Hemiplegia
Paraplegia
Quadriplegia
Renal Disease
Chronic Kidney Disease
Lowest serum creatinine: ______________mg/DL
Skin Condition
Burn
Decubitus/Pressure Ulcer
Surgical Wound
Other chronic ulcer or chronic wound
Other (specify): _________________
Other
Connective tissue disease
Obesity or morbid obesity
Pregnant
SOCIAL HISTORY
39. Smoking (Check all that apply):
40. Alcohol Abuse:
None
Tobacco
1
Yes
Unknown
E-nicotine delivery system
0
No
Marijuana
9
Unknown
41. Other Substances (Check all that apply):
None
Unknown
Documented Use Disorder (DUD/Abuse):
Mode of Delivery (Check all that apply):
Marijuana (other than smoking)
DUD or abuse
IDU
Skin popping
Non-IDU
Unknown
Opioid, DEA schedule I (e.g., Heroin)
DUD or abuse
IDU
Skin popping
Non-IDU
Unknown
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
DUD or abuse
IDU
Skin popping
Non-IDU
Unknown
Cocaine or methamphetamine
DUD or abuse
IDU
Skin popping
Non-IDU
Unknown
Other* (specify): _________________
DUD or abuse
IDU
Skin popping
Non-IDU
Unknown
Unknown substance
DUD or abuse
IDU
Skin popping
Non-IDU
Unknown
*Includes hallucinogens (LSD, mushrooms, etc.), club drugs, (MDMA, GHB, etc.), dissociative drugs
(ketamine, etc.), inhalants.
OTHER CONDITIONS
42. For cases ≤ 1 year of age:
Gestational age at birth: _______ wks 9
Unknown
AND
Birth weight: __________ gms
9
Unknown
43. Infection with Clostridium difficile in the 90 days before or 30 days after the DISC:
1
Yes
0
No
9
Unknown
43a. If yes, date of first C. diff diagnosis: ___ ___ - ___ ___ - ___ ___ ___ ___
44. Chronic Dialysis:
Type:
Hemodialysis
Not on chronic dialysis
Unknown
Unknown
44a. If Hemodialysis, type of vascular access:
Peritoneal
45. Surgeries in the 90 days before the DISC:
AV fistula/graft
Hemodialysis central line
Unknown
46. Pancreatitis in the 90 days before the DISC:
Abdominal surgery
1
Yes
Non-abdominal surgery (specify): __________________
0
No
No surgery
Version: Short Form 2019
Last Updated: 08/01/2018
Page 4 of 7
State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Office Initials ________
47. Chronic Urinary Tract Problems/Abnormalities:
1
Yes
0
No
9
47a. If yes, did the patient have any urinary tract procedures in the 90 days
before the DISC?
1 Yes
0 No
9 Unknown
Unknown
48. Was the patient neutropenic* on the day of incident specimen collection or at any time in the 2 calendar days before the DISC?
1
Yes
0
No
9
Unknown (no WBC days -2 or 0, or no differential)
49. Was the patient in an ICU in the 14 days before the DISC?
50. Was the patient in an ICU on the day of incident specimen
collection or in the 13 days after the DISC?
1
1
Yes
0
No
9
Unknown
Yes
0
No
9
Unknown
51. Did the patient have a CVC in the 2 calendar days before DISC?
1
Yes
2
No
3
Had CVC but can’t find dates
9
Unknown
If yes, check here if central line in place for > 2 calendar days:
51a. If yes, CVC type: (Check all that apply)
Non-tunneled CVCs
Implantable ports
Other (specify): ________________________
Tunneled CVCs
Peripherally inserted central catheter (PICC)
Unknown
51b. Were all CVCs removed or changed on the day of or in the 6 days after the DISC?
1
2
Yes
No
3
5
CVC removed, but can’t find dates
Died or discharged before indwelling catheter replaced
9
Unknown
52. Did the patient have a midline catheter in the 2 calendar days before DISC?
1 Yes
0 No
9 Unknown
53. Did the patient have any of the following indwelling devices present in the 3 calendar days before DISC?
Urinary Catheter
Indwelling urethral
Suprapubic
Respiratory
ET/NT
Tracheostomy
Gastrointestinal
Gastrostomy
MEDICATIONS
54. Did the patient receive systemic antibacterial medication in the 14 days before the DISC?
1 Yes 0
No 9 Unknown
55. Did the patient receive total parenteral nutrition (TPN) in the 14 days before the DISC?
1
Yes
0
No
9
Unknown
56. Did the patient receive systemic antifungal medication in the 14 days before the DISC?
1
Yes (if Yes, fill out question 59)
0
No
9
Unknown
57. Was the patient prescribed systemic antifungal medication after the DISC?
1
Yes (if Yes, fill out question 59)
0
No
9
Unknown
58. If antifungal medication was not given to treat current candidemia infection, what was the reason?
1
Patient died before culture result available to clinicians
5
Other reason documented in medical records, specify: ______________
2
Comfort care only measures were instituted
6
Patient refused treatment against medical advice
3
Patient discharged before culture result available to clinician
9
Unknown
4
Medical records indicated culture result not clinically significant
------------IF ANY ANTIFUNGAL MEDICATION WAS GIVEN, COMPLETE NEXT PAGE. OTHERWISE END OF CHART REVIEW FORM------------
Version: Short Form 2019
Last Updated: 08/01/2018
Page 5 of 7
State ID: _____________ Date of Incident Specimen Collection (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
Anidulafungin (Eraxis)=ANF
Caspofungin (Cancidas)=CAS
59. ANTIFUNGAL MEDICATION
a. Drug
b. First date given (mm-dd-yyyy)
Abbrev
Fluconazole (Diflucan)=FLC
Flucytosine (5FC)=5FC
Isavuconazole (cresemba)=ISU
Itraconazole (Sporanox)=ITC
Micafungin (Mycamine)=MFG
c. Date start
unknown
d. Last date given (mm-dd-yyyy)
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ - ___ ___ - ___ ___ ___ ___
Other=OTH
Posaconazole (Noxafil)=PSC
UNKNOWN DRUG=UNK
Voriconazole (Vfend)=VRC
e. Date stop
unknown
f. Indication
g. Reason for stopping
(if applicable)*
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
Prophylaxis
Treatment
*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 case only; (5)
death; (6) other; (7) no additional records/lost to follow-up; (8) not applicable, no therapy given; and (9) unknown.
-------------------------------------END OF CHART REVIEW FORM-------------------------------------
Version: Short Form 2019
Last Updated: 08/01/2018
Page 6 of 7
State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Office Initials ________
AFST results for additional Candida isolates
Antifungal susceptibility testing (check here
Date of culture
Species
1
2
3
4
5
6
7
8
9
10
11
12
CA
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending
1
2
3
4
5
6
7
8
9
10
11
12
CA
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending
Drug
Species
1
2
3
4
5
6
7
8
9
10
11
12
CA
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending
1
2
3
4
5
6
7
8
9
10
11
12
CA
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending
Version: Short Form 2019
MIC
Interpretation
Amphotericin B
S
SDD
I
R
NS
NI
ND
Anidulafungin (Eraxis)
S
SDD
I
R
NS
NI
ND
Caspofungin (Cancidas)
S
SDD
I
R
NS
NI
ND
Fluconazole (Diflucan)
S
SDD
I
R
NS
NI
ND
Flucytosine (5FC)
S
SDD
I
R
NS
NI
ND
Itraconazole (Sporanox)
S
SDD
I
R
NS
NI
ND
Micafungin (Mycamine)
S
SDD
I
R
NS
NI
ND
Posaconazole (Noxafil)
S
SDD
I
R
NS
NI
ND
Voriconazole (Vfend)
S
SDD
I
R
NS
NI
ND
Amphotericin B
S
SDD
I
R
NS
NI
ND
Anidulafungin (Eraxis)
S
SDD
I
R
NS
NI
ND
Caspofungin (Cancidas)
S
SDD
I
R
NS
NI
ND
Fluconazole (Diflucan)
S
SDD
I
R
NS
NI
ND
Flucytosine (5FC)
S
SDD
I
R
NS
NI
ND
Itraconazole (Sporanox)
S
SDD
I
R
NS
NI
ND
Micafungin (Mycamine)
S
SDD
I
R
NS
NI
ND
Posaconazole (Noxafil)
S
SDD
I
R
NS
NI
ND
Voriconazole (Vfend)
S
SDD
I
R
NS
NI
ND
Antifungal susceptibility testing (check here
Date of culture
if no testing done/no test reports available):
if no testing done/no test reports available):
Drug
MIC
Interpretation
Amphotericin B
S
SDD
I
R
NS
NI
ND
Anidulafungin (Eraxis)
S
SDD
I
R
NS
NI
ND
Caspofungin (Cancidas)
S
SDD
I
R
NS
NI
ND
Fluconazole (Diflucan)
S
SDD
I
R
NS
NI
ND
Flucytosine (5FC)
S
SDD
I
R
NS
NI
ND
Itraconazole (Sporanox)
S
SDD
I
R
NS
NI
ND
Micafungin (Mycamine)
S
SDD
I
R
NS
NI
ND
Posaconazole (Noxafil)
S
SDD
I
R
NS
NI
ND
Voriconazole (Vfend)
S
SDD
I
R
NS
NI
ND
Amphotericin B
S
SDD
I
R
NS
NI
ND
Anidulafungin (Eraxis)
S
SDD
I
R
NS
NI
ND
Caspofungin (Cancidas)
S
SDD
I
R
NS
NI
ND
Fluconazole (Diflucan)
S
SDD
I
R
NS
NI
ND
Flucytosine (5FC)
S
SDD
I
R
NS
NI
ND
Itraconazole (Sporanox)
S
SDD
I
R
NS
NI
ND
Micafungin (Mycamine)
S
SDD
I
R
NS
NI
ND
Posaconazole (Noxafil)
S
SDD
I
R
NS
NI
ND
Voriconazole (Vfend)
S
SDD
I
R
NS
NI
ND
Last Updated: 08/01/2018
Page 7 of 7
| File Type | application/pdf |
| File Title | CANDIDEMIA 2008-2009 CASE REPORT FORM |
| Author | fxe9 |
| File Modified | 2018-08-09 |
| File Created | 2018-08-09 |