Form 0920-0978 Candidemia Case Report

State 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