Form 0920-0978 Clostridioides Difficile Infection (CDI Surveillance Eme

1. PATIENT ID:

2. STATE ID:

3. SPECIMEN ID:

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

Form Approved
OMB No. 092-0978

/

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

Patient’s Name:

Phone No.: (

(Last, First, M.I.)

Address:

(State)

5. STATE:

6. COUNTY:

(Residence of Patient)

(Residence of Patient)

7. LABORATORY ID WHERE
INCIDENT SPECIMEN
IDENTIFIED

)

-

Chart Number:

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

Hospital:

(Zip Code)

9. POSITIVE DIAGNOSTIC ASSAY FOR C. diff+

8. FACILITY ID WHERE
PATIENT TREATED

9a. EIA

Positive

Negative

Not tested

9b. GDH

Positive

Negative

Not tested

9c. Cytotoxin

Positive

Negative

Not tested

9d. NAAT (C. diff only)

Positive

Negative

Not tested

9e. NAAT (GI panel)

Positive

Negative

Not tested

9.e.1 If positive, was result suppressed?
9f. Other (specify):

10. DATE OF BIRTH:

/

/

12. SEX AT BIRTH:
Male
Female

/

13. ETHNIC ORIGIN:
Hispanic or Latino

11. AGE: (years):

No

Unknown

Positive

Negative

Not tested

14. RACE: (Check all that apply)
Unknown

Transgender

Unknown

Yes

Not Hispanic or Latino

Unknown

American Indian or
Alaska Native

Native Hawaiian or
Other Pacific Islander

Asian

White

Black or African American

Unknown

15. Was the patient hospitalized on the day 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:

Homeless
Incarcerated

16a. Was the patient transferred from this hospital?
LTACH

Yes

No

Unknown

Other (specify):
Unknown

Facility ID:
18. HCFO classification questions:

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

Hospital Inpatient
Facility ID:

LTCF
Facility ID:

18a. Was incident C. diff+ stool collected at least 3 calendar
days after the date of hospital admission?
Yes (HCFO - go to 18d)
No
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)
No

Emergency room

ICU

LTACH

Clinic/doctor’s office

OR

Facility ID:

Dialysis center

Radiology

Surgery

Other inpatient

Observation/

Autopsy
Other (specify):

Clinical decision unit
Other outpatient

19. Patient Outcome

18c. Was the patient admitted from a LTCF or a LTACH?
Yes (HCFO - go to 18d)
No (CO - complete CRF)
Facility ID:
18d. If HCFO, was this case sampled for full CRF?
Yes (Complete CRF)
No (STOP data abstraction here!)
1
2
3
4
5
6
7
8
9

Unknown

10

Unknown

Survived

Died

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 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).

CDC Rev. 08-2019

CS308111

Page 1 of 4

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

Chronic lung disease

None

No

Unknown

Facility ID:

Yes
Yes
Yes

No
No
No

Unknown
Unknown
Unknown

Facility ID:
Facility ID:

Yes
Yes
Yes

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:
Unknown or not done
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

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

Other
Connective tissue disease
Obesity or morbid obesity
Pregnancy

22b. Height
oz OR

kg

Unknown

mg/DL

Skin condition

Malignancy

Gastrointestinal disease

lbs

Yes

22c. BMI

ft

in OR

cm

Unknown

Unknown

23. Substance Use
23a. Smoking:

23b. Alcohol abuse:

None

Unknown

Tobacco

E-Nicotine Delivery System

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

None

Marijuana

Unknown

Documented Use Disorder (DUD)/Abuse?

Marijuana/cannabinoid (other than smoking)
DUD or Abuse
Opioid, DEA schedule I (e.g., heroin)
DUD or Abuse
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
DUD or Abuse
Opioid, NOS
DUD or Abuse
Cocaine
DUD or Abuse
Methamphetamine
DUD or Abuse
Other (specify):
DUD or Abuse
Unknown substance
DUD or Abuse
During the current hospitalization, did the patient receive medication assisted treatment
(MAT) for opioid use disorder?

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
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
IDU
Skin popping
non-IDU
Unknown
Yes
No
N/A (patient not hospitalized or did not have DUD)

25. Was ICD-9 008.45 or ICD-10 A04.7 listed on 26. Was the patient in an ICU on the day of or in
the discharge form?
the 6 days after the date of incident C. diff+
stool collection?
Yes

No

Not Admitted

Unknown

25a. If YES, what was the POA code
assigned to it?
Y, Yes
N, No
U, Unknown
CDC Rev. 08-2019

Yes
No
Unknown

W, Clinically Undetermined
Missing
Not Applicable
CS308111

Yes

No

Unknown

26a. If YES, date of ICU admission:

/

/

Unknown
Page 2 of 4

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)

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)

“Asymptomatic” documented in medical record

28a. Radiographic findings

28b. Clinical findings

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

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

Not Done
Information not available

31. Were other enteric pathogens isolated from stool collected on the
date of incident C. diff+ stool collection?
Campylobacter
Norovirus
Rotavirus
Salmonella
Shiga Toxin-Producing E.coli
Shigella
Other (specify):
None
No other pathogens tested
Unknown

30. Colectomy
(related to CDI):
Yes
No
Unknown

30a. If YES, Date of Procedure:

/

/

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:
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 incident C. diff+ stool collection:
33a. Proton pump inhibitor
(e.g. Omeprazole, Lansoprazole,
Pantoprazole, Rabeprazole)

33b. H2 Blockers
(e.g. Famotidine, Ranitidine, Cimetidine)

Yes
No
Unknown

Steroids
Chemotherapy
Other agents (specify):
None
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

None

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

33c. Immunosuppressive therapy
(Check all that apply)

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. 08-2019

Vancomycin

Fidaxomicin

Other, (specify)
CS308111

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:

/

/

Unknown

35. Previous unique CDI episode
36. Any recurrent C. diff+
(>8 weeks before the date of
episodes following this
incident C. diff+ stool collection):
incident C. diff+ episode?
Yes
No

Yes
No

35a. If YES, previous STATEID:

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

/

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

38. Initials of
S.O:

39. Date of abstraction:

/

/

/

40. Comments:

CDC Rev. 08-2019

CS308111

Page 4 of 4