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pdf1. PATIENT ID:
2. STATE ID:
3. SPECIMEN ID:
4. Date of incident C. diff+ stool collection (DISC):
Form Approved
OMB No. 092-0978
/
/
CLOSTRIDIOIDES DIFFICILE INFECTION (CDI) SURVEILLANCE
EMERGING INFECTIONS PROGRAM CASE REPORT
Phone No.:
Patient’s Name:
Address:
Hospital:
Address type:
5. STATE:
6. COUNTY:
(Residence of Patient)
(Residence of Patient)
7. LABORATORY ID WHERE
INCIDENT SPECIMEN
IDENTIFIED
Chart Number:
9. 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)
9.e.1 If positive, was result suppressed?
9f. Other (specify):
10. DATE OF BIRTH:
/
12. SEX AT BIRTH:
Male
Female
/
Unknown
13. ETHNIC ORIGIN:
Hispanic or Latino
11. AGE: (years)
Negative
Not tested
No
Unknown
Positive
Negative
Not tested
14. RACE: (Check all that apply)
Transgender
Unknown
Positive
Yes
Not Hispanic or Latino
Unknown
15. Was the patient hospitalized on the day of or in the 6 calendar days after the DISC?
American Indian or
Alaska Native
Native Hawaiian or
Other Pacific Islander
Asian
White
Black or African American
Unknown
Yes
No
Unknown
/
/
Unknown
15a. If YES, Date of Admission:
rd
16. Where was the patient located on the 3 calendar day before the DISC?
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
Emergency room
ICU
LTACH
Clinic/doctor’s office
OR
Facility ID:
Dialysis center
Radiology
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
Surgery
Other inpatient
Autopsy
18c. Was the patient admitted from a LTCF or a LTACH?
Yes (HCFO - go to 18d)
No (CO - complete CRF)
Observation/
Other (specify):
Clinical decision unit
Other outpatient
19. Patient Outcome
Unknown
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
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:
Other (specify):
LTACH
Facility ID:
Unknown
Public reporting burden of this collection of information is estimated to average 38 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).
CS325367
7/19/2021
Page 1 of 4
20. Exposures to healthcare in the 12 weeks before the DISC
20a. Previous hospitalization
20a.1 If yes, date of discharge closest to DISC:
/
/
Unknown
20b. Overnight stay in LTACH
20c. Overnight stay in LTCF
20d. Chronic dialysis
Hemodialysis
Peritoneal
Unknown
20d.1 Type
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
Yes
Marijuana
Unknown
Documented Use Disorder (DUD)/Abuse?
Marijuana/cannabinoid (other than smoking)
Opioid, DEA schedule I (e.g., heroin)
Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)
Opioid, NOS
Cocaine
Methamphetamine
DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse
DUD or Abuse
Other (specify):
DUD or Abuse
Unknown substance
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
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 DISC?
Yes
No
Y, Yes
N, No
U, Unknown
7/19/2021
Unknown
Mode of delivery: (Check all that apply)
Not Admitted
Unknown
25a. If YES, what was the POA code
assigned to it?
CS325367
No
W, Clinically Undetermined
Missing
Not Applicable
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 DISC) (Check all that apply)
28. Fever (in the 2 calendar days before or calendar day of the DISC)
“Asymptomatic” documented in medical record
Diarrhea by definition (unformed or watery stool, ≥ 3/day for ≥ 1 day)
Diarrhea documented, but unable to determine if it is by definition
Nausea
Vomiting
No diarrhea, nausea, or vomiting documented
Information not available
Fever ≥38°C or ≥100.4°F documented
Highest fever documented:
°C or
°F
Self-reported fever
No fever documented
Information not available
29. Toxic megacolon and ileus (in the 6 calendar days before, the day of, or the 6 calendar days after the DISC)
29a. Radiographic findings
29b. Clinical findings
Toxic megacolon
Neither toxic megacolon nor ileus
Toxic megacolon
Neither toxic megacolon nor ileus
Ileus
Radiology not performed
Ileus
Information not available
Both toxic megacolon and ileus
Information not available
Both toxic megacolon and ileus
30. 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 DISC?
Yes
No
Not Done
Information not available
32. Were other enteric pathogens isolated from stool collected on
the DISC?
Astrovirus
Campylobacter
Enteroaggregative E. coli (EAEC)
Enteropathogenic E. coli (EPEC)
Enterotoxigenic E. coli (ETEC)
Norovirus
Rotavirus
Salmonella
Sapovirus
Shiga Toxin-Producing E.coli
Shigella
Yersinia enterocolitica
Other (specify):
None
No other pathogens tested
Unknown
31. Colectomy (related to CDI):
31a. If YES, Date of Procedure:
/
Yes
No
Unknown
/
Unknown
33. LABORATORY FINDINGS (in the 6 calendar days before, the day of,
or the 6 calendar days after the DISC)
33a. Albumin ≤ 2.5g/dl:
Yes
No
Not Done
Information not available
33b. White blood cell count
≤ 1,000/µl:
Yes
No
Not Done
Information not available
33c. White blood cell count
≥ 15,000/µl:
Yes
No
Not Done
Information not available
33d. Serum creatinine
> 1.5 mg/dl
Yes
No
Not Done
Information not available
34. MEDICATIONS taken in the 12 weeks before the DISC:
34a. Proton pump inhibitor
(e.g. Omeprazole, Lansoprazole,
Pantoprazole, Rabeprazole)
Yes
No
Unknown
CS325367
7/19/2021
Yes, name unknown
Cefotaxime
Cefoxitin
Cefpodoxime
Ceftaroline
Ceftazidime
Ceftazidime/avibactam
Ceftizoxime
Ceftolozane/tazobactam
Ceftriaxone
Cefuroxime
Cephalexin
Ciprofloxacin
Clarithromycin
34c. Immunosuppressive therapy
(Check all that apply)
Steroids
Chemotherapy
Other agents (specify):
None
Unknown
Yes
No
Unknown
34d. Antimicrobial therapy (Check all that apply)
Amikacin
Amoxicillin
Amoxicillin/clavulanic acid
Ampicillin
Ampicillin/sulbactam
Azithromycin
Aztreonam
Cefadroxil
Cefazolin
Cefdinir
Cefepime
Cefiderocol
Cefixime
34b. H2 Blockers
(e.g. Famotidine, Ranitidine, Cimetidine)
None
Clindamycin
Dalbavancin
Daptomycin
Delafloxacin
Doripenem
Doxycycline
Eravacycline
Ertapenem
Fosfomycin
Gentamicin
Imipenem/cilastatin
Levofloxacin
Linezolid
Unknown
Meropenem
Meropenem/vaborbactam
Metronidazole
Moxifloxacin
Nitrofurantoin
Omadacycline
Oritavancin
Penicillin
Piperacillin/tazobactam
Polymyxin B
Polymyxin E (colistin)
Rifaximin
Tedizolid
Telavancin
Tigecycline
Tobramycin
Trimethoprim
Trimethoprim/sulfamethoxazole
Vancomycin (IV)
Vancomycin (PO for prophylaxis)
Other (specify):
Page 3 of 4
34e. Was patient treated for suspected or confirmed CDI in the 12 weeks before the DISC?
Yes
No
Unknown
34f.1 If YES, which medication was taken (Check all that apply):
Metronidazole
Vancomycin
35. Treatment for incident CDI
Fidaxomicin
Other, (specify)
No treatment
Unknown
Unknown treatment
35a.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
35a.2 Course 2
Start Date:
/
/
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)
35a.3 Course 3
Start Date:
/
/
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)
35a.4 Course 4
Start Date:
/
/
Vancomycin (PO)
Vancomycin (Rectal)
Vancomycin (Unknown route)
Vancomycin taper (any route)
35b.
Probiotics (specify):
35c.
Stool transplant Date:
36. Previous unique CDI episode
(>8 weeks before the DISC):
Yes
No
/
/
Unknown
37. Any recurrent C. diff+
episodes following this
incident C. diff+ episode?
38. CRF status:
Yes
No
36a. If YES, previous STATEID:
37a. If YES, Date of first
recurrent specimen:
/
41. Did the patient have a POSITIVE
test(s) for SARS-CoV-2 (molecular
assay, serology, or other confirmatory
test) in the year before or day of the
DISC?
Yes
No
Unknown
Complete
Incomplete
Chart unavailable
after 3 requests
39. Initials of
S.O:
40. Date of abstraction:
/
/
/
41a. If YES, complete below for MOST RECENT positive test for SARS-CoV-2 in the year before or date of
the DISC:
41a.1. Specimen collection date:
/
/
Unknown
41a.2: Test type:
Antigen
Molecular assay
Serology
Unknown
Other (specify):
42a. COVID-NET Case ID:
42b. NNDSS IDs (please provide at least one of the following when applicable):
Local Case ID:
State case identifier:
Local Record ID:
Legacy case identifier:
CDC 2019-nCOV ID:
Comments:
CS325367
7/19/2021
Page 4 of 4
File Type | application/pdf |
File Title | 2022 CDI Case Report Form |
Subject | CS325367, CDI, Case Report Form, Clostridioides difficile, Clostridioides difficile infections |
Author | Centers for Disease Control and Prevention |
File Modified | 2021-07-30 |
File Created | 2021-07-19 |