Form Short Form 2024 Short Form 2024 CANDIDEMIA 2024 CASE REPORT FORM

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________
Form Approved

CANDIDEMIA 2024 CASE REPORT FORM

OMB No. 0920-0978

Patient name: ________________________________________________

Medical Record No.: _______________________________________

(Last, First, MI)

Hospital: ________________________________________________

Address: ____________________________________________________
(Number, Street, Apt. No.)

Acc No. (incident isolate): __________________________________

________________________________ ___________________
(City, State)

Address type:
1 Residential 2
Phone no.: (

Acc No. (subseq isolate): __________________________________

(Zip Code)

Post office 3

Long-term care facility 4

Corrections 5

Military 6

Homeless 7

Other 8

Insufficient 9

Missing

) _________ - __________________________

…………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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
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
___ ___ - ___ ___ - ___ ___ ___ ___

6. CRF status: 7. SO’s
initials:
1 Complete

1. Date reported to EIP site:

___ ___ - ___ ___ - ___ ___ ___ ___

2

Pending

3 Chart
unavailable

_________

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
_________kg
Unknown

17. Height:
_________ ft. ________ in. OR
_________cm
Unknown

15. Sex:
days 2

mos 3

Male

yrs

19. Race (check all that apply):

Female

Check if transgender

18. BMI: (record only if ht. and/or wt. is not
available) __________________

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: _________
ICU
Surgery/OR
Radiology
Other inpatient

Outpatient
Facility ID: _________
Emergency Room
Clinic/Doctor’s office
Dialysis center
Surgery
Observational/clinical decision unit
Other outpatient

LTCF
Facility ID: _________
LTACH
Facility ID: _________
Autopsy
Other (specify): ________________________
Unknown

23. Candida species from initial positive blood culture (check all that apply):

Candida albicans (CA)
Candida auris (CAU)
Candida glabrata (CG)
Candida parapsilosis (CP)
Candida tropicalis (CT)

Candida dubliniensis (CD)
Candida lusitaniae (CL)
Candida krusei (CK)
Candida guilliermondii (CGM)

Candida, other (CO) specify: ______________
Candida, germ tube negative/non albicans (CGN)
Candida species (CS)
Pending

Public reporting burden of this collection of information is estimated to average 40 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 D74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).

Version: Short Form 2024

Last Updated: 07/29/2023

Page 1 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________
24. Antifungal susceptibility testing (check here
Date of culture

Species

1
13
2
3
4
5
6
7
8
9
10
11
12

1
13
2
3
4
5
6
7
8
9
10
11
12

if no testing done/no test reports available):
Drug

CA
CAU
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending

CA
CAU
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending

MIC

Interpretation

Amphotericin B

S

SDD

I

R

NI

ND

Anidulafungin (Eraxis)

S

SDD

I

R

NI

ND

Caspofungin (Cancidas)

S

SDD

I

R

NI

ND

Fluconazole (Diflucan)

S

SDD

I

R

NI

ND

Flucytosine (5FC)

S

SDD

I

R

NI

ND

Itraconazole (Sporanox)

S

SDD

I

R

NI

ND

Micafungin (Mycamine)

S

SDD

I

R

NI

ND

Posaconazole (Noxafil)

S

SDD

I

R

NI

ND

Voriconazole (Vfend)

S

SDD

I

R

NI

ND

Amphotericin B

S

SDD

I

R

NI

ND

Anidulafungin (Eraxis)

S

SDD

I

R

NI

ND

Caspofungin (Cancidas)

S

SDD

I

R

NI

ND

Fluconazole (Diflucan)

S

SDD

I

R

NI

ND

Flucytosine (5FC)

S

SDD

I

R

NI

ND

Itraconazole (Sporanox)

S

SDD

I

R

NI

ND

Micafungin (Mycamine)

S

SDD

I

R

NI

ND

Posaconazole (Noxafil)

S

SDD

I

R

NI

ND

Voriconazole (Vfend)

S

SDD

I

R

NI

ND

25. Did the patient have a PCR molecular test for Candida (e.g., T2), in the 6 days before or two days after the DISC?
1

Yes 0

No 9

Unknown

25a. If yes, test type: ______________________
25b. Result: ______________________________
26. Any subsequent positive Candida blood cultures in the 29 days after, not including the DISC?

1

Yes 0

No 9

Unknown

26a. If yes, provide dates of all subsequent positive Candida blood cultures and select the species:
Date Drawn (mm-dd-yyyy)

Species identified*

___ ___ - ___ ___ - ___ ___ ___ ___

CA

CAU

CG

CP

CT

CD

CL

CK

CGM

CO:_________

CGN

CS

Pending

___ ___ - ___ ___ - ___ ___ ___ ___

CA

CAU

CG

CP

CT

CD

CL

CK

CGM

CO:_________

CGN

CS

Pending

___ ___ - ___ ___ - ___ ___ ___ ___

CA

CAU

CG

CP

CT

CD

CL

CK

CGM

CO:_________

CGN

CS

Pending

___ ___ - ___ ___ - ___ ___ ___ ___

CA

CAU

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)

Version: Short Form 2024

Last Updated: 07/29/2023

Page 2 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________
27. Documented negative Candida blood culture on the day of or in the 29 days after the DISC (in which no blood cultures after this
negative culture were positive in the 29 days after the DISC)? 1 Yes 0
No 9 Unknown
27a. If yes, date of negative blood culture: ___ ___ - ___ ___ - ___ ___ ___ ___
28. On the day of or in the 6 days before the DISC, was the patient known to be colonized with or being managed as if they were
colonized with a multi-drug resistant organism (MDRO) (e.g., on contact precautions)? MDROs include CRE, CRPA, CRAB, MRSA, and VRE.
1

Yes 0

No 9

Unknown

28a. If yes, specify organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________
29. Additional non-Candida organisms isolated from blood cultures on the day of or in the 6 days before the DISC:
1

Yes 0

No 9

Unknown

29a. If yes, additional organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________
30. Did the patient have any of the following types of infection related to their Candida infection? (check all that apply):
None

Unknown

Abdominal infection

Urinary tract infection

Pulmonary infection

Endocarditis

Hepatobiliary or pancreatic

Esophagitis

Abscess (specify): _________

Oral/thrush

CNS infection (meningitis, brain abscess)

Abscess

Septic emboli (specify location): ________

Peritonitis/peritoneal fluid

Osteomyelitis

Eyes

Splenic

Skin /wound infection

Other (specify): __________

Endophthalmitis
Chorioretinitis

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: _________________

Unknown

Date of second transfer: ___ ___ - ___ ___ - ___ ___ ___ ___
Hospital ID: _________________

Unknown

Unknown

Unknown

31c. Where was the patient located prior to admission or, if not currently hospitalized, where was the patient located on the 3rd calendar day before
the DISC? (Check one)
1

Private residence

2

Hospital inpatient

4

Facility ID: ____________
3

5

LTCF

LTACH

6

Incarcerated

Facility ID: _____________

7

Other (specify): ______________________

Homeless

9

Unknown

Facility ID: ____________
32. Was the patient in an ICU in the 14 days before, not including the DISC?
1

Yes

0

No

9

Unknown

33. Was the patient in an ICU on the day of incident specimen collection or in the 13 days after the DISC?
1

Yes

0

No

9

Unknown

34. Did the patient receive dialysis or renal replacement therapy (RRT) in the 30 days before the DISC, not including the DISC?
1

Yes

0

No

9

35. Patient outcome: 1

Unknown
Survived

9

Unknown

Date of discharge:
___ ___ - ___ ___ - ___ ___ ___ ___

2

Died
Date of death:

Unknown

___ ___ - ___ ___ - ___ ___ ___ ___

Unknown

Left against medical advice (AMA)

Version: Short Form 2024

Last Updated: 07/29/2023

Page 3 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________
35a. 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

36. 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
Not applicable (i.e., patient not hospitalized)
B48 (other mycoses, not classified elsewhere)

A41.9 (sepsis, unspecified organism)

Specify sub-code: ___________________

B49 (unspecified mycoses)

R65.2 (severe sepsis)

Specify sub-code: ___________________

T80.211 (BSI due to central venous catheter)

Other Candida-related code

B37 (candidiasis)

Specify code: ___________________

P37.5 (neonatal candidiasis)
37. Previous Hospitalization in the 90 days before, not including the DISC: 1
37a. If yes, date of discharge: ___ ___ - ___ ___ - ___ ___ ___ ___

Yes

0

No

9

Unknown

Unknown

Facility ID: ____________
38. Overnight stay in LTACH in the 90 days before, not including the DISC: 1

Yes

0

No

9

Unknown

Facility ID: ____________
39. Overnight stay in LTCF in the 90 days before, not including the DISC: 1

Yes

0

No

9

Unknown

Facility ID: ____________

UNDERLYING CONDITIONS
40. 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 (specify): ________

Version: Short Form 2024

None

Unknown

Liver Disease
Chronic Liver Disease
Ascites
Cirrhosis
Hepatic Encephalopathy
Variceal Bleeding
Hepatitis B, chronic
Hepatitis C
Treated, in SVR
Current, chronic
Hepatitis B, acute
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): _________________

Last Updated: 07/29/2023

Plegias/Paralysis
Hemiplegia
Paraplegia
Quadriplegia
Renal Disease
Chronic Kidney Disease
Lowest serum creatinine: ______________mg/DL
Unknown or not done
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

Page 4 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________

SOCIAL HISTORY
41. Smoking (Check all that apply):

42. Alcohol Abuse:

None

Tobacco

1

Yes

Unknown

E-nicotine delivery system

0

No

Marijuana

9

Unknown

43. 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

Non-IDU

Unknown

Opioid, DEA schedule I (e.g., Heroin)

DUD or abuse

IDU

Non-IDU

Unknown

Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)

DUD or abuse

IDU

Non-IDU

Unknown

Opioid, NOS

DUD or abuse

IDU

Non-IDU

Unknown

Cocaine

DUD or abuse

IDU

Non-IDU

Unknown

Methamphetamine

DUD or abuse

IDU

Non-IDU

Unknown

Other (specify): _________________

DUD or abuse

IDU

Non-IDU

Unknown

Unknown substance

DUD or abuse

IDU

Non-IDU

Unknown

44. During the current hospitalization, did the patient receive medication-assisted treatment (MAT) for opioid use disorder?
1

Yes

0

No

8

N/A (patient not hospitalized or did not have DUD)

9

Unknown

OTHER CONDITIONS
45. For cases ≤ 1 year of age:
46. Chronic Dialysis:
Type:

Gestational age at birth: _______ wks 9

Not on chronic dialysis

Hemodialysis

Unknown

AV fistula/graft

Abdominal surgery (specify): _________________
Open abdomen

0

AND

Laparoscopic

9

Unknown

Non-abdominal surgery (specify): __________________

Birth weight: __________ gms

9

Unknown

46a. If Hemodialysis, type of vascular access:

Peritoneal

47. Surgeries in the 90 days before, not including the DISC:
If yes: 1

Unknown

Hemodialysis central line

Unknown

48. Pancreatitis in the 90 days before, not including the DISC:
1

Yes

0

No

9

Unknown

No surgery
49. Did the patient have any ostomies of the gastrointestinal tract including ileostomy, colostomy, etc. in the 30 calendar days before, not
including the DISC?
1

Yes

0

No

9

Unknown
50a. If yes, did the patient have any urinary tract procedures in the 90 days
before, not including the DISC?

50. Chronic Urinary Tract Problems/Abnormalities:
1

Yes

0

No

9

Unknown

1

Yes

0

No

9

Unknown

51. Was the patient neutropenic in the 2 calendar days before, not including the DISC?
1

Yes

0

No

9

Unknown (no WBC days -2 or 0, or no differential)

52. Did the patient have a CVC in the 2 calendar days before, not including the DISC?
1

Yes

2

No

3

Had CVC but can’t find dates

9

If yes, was the central line in place for > 2 calendar days: 1

Unknown
Yes

0

No

9

Unknown

52a. If yes, CVC type: (Check all that apply)
Non-tunneled CVCs

Implantable ports

Other (specify): ________________________

Tunneled CVCs

Peripherally inserted central catheter (PICC)

Unknown

52b. Were all CVCs removed or changed in the 2 days before 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

53. Did the patient have a midline catheter in the 2 calendar days before, not including the DISC?
1 Yes
0 No
9 Unknown

Version: Short Form 2024

Last Updated: 07/29/2023

Page 5 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________
54. Did the patient have any of the following indwelling devices or other devices present in the 2 calendar days before, not including the
DISC?
None
Unknown
Urinary Catheter/Device
Indwelling urethral
Suprapubic

Respiratory
ET/NT
Tracheostomy
Invasive mechanical ventilation

Gastrointestinal
Abdominal drain (specify): _________________
Gastrostomy

55. Did the patient have a positive SARS-CoV-2 test result (molecular assay, antigen, or other confirmatory test, excluding serology) from
a specimen collected in the 90 days before the DISC or on the DISC?
1

Yes

0

No

9

Unknown

55a. If yes, date of specimen collection for initial positive SARS-CoV-2 test:
Date: ________

9

Date Unknown

55b. If yes, EIP COVID-NET Case ID: ____________
None or N/A
56. Did the patient receive systemic antibacterial medication in the 14 days before, not including the DISC?
1

Yes

0

No

9

Unknown

57. Did the patient receive any systemic steroids in the 30 days before, not including the DISC?
1

Yes

0

No

9

Unknown

57a. If yes, what was the reason steroids were administered? (check all that apply)
Steroid(s) given as an outpatient medication
Steroid(s) given, prior to Candida DISC, during hospitalization associated with candidemia episode
Steroid(s) given as part of treatment/management for COVID-19
None of the above
58. Did the patient receive total parenteral nutrition (TPN) in the 14 days before, not including the DISC?
1

Yes

0

No

9

Unknown

59. Did the patient receive systemic antifungal medication on the day of or in the 13 days before the DISC?
1

Yes (if Yes, fill out question 66)

0

No

9

Unknown

60. Was the patient administered systemic antifungal medication after, not including the DISC?
1

Yes (if Yes, fill out question 66)

0

No

9

Unknown

61. 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 or
contaminated
------------IF ANY ANTIFUNGAL MEDICATION WAS GIVEN, COMPLETE NEXT PAGE. ------------

OTHER
62. Does the chart indicate that the incident specimen was considered a contaminant or was considered to not be indicative of true
infection?
1

Yes

0

No

9

Unknown

63. Was the patient under the care of an infectious disease physician on the day of the DISC or within the 6 days after the DISC?
1

Yes

0

No

9

Unknown

64. Did the patient have an echocardiogram (ECHO), including transthoracic (TTE) or transesophogeal (TEE), on the day of or 13 days
after the DISC?
1

Yes

0

No

9

Unknown

65. Did the patient have a dilated fundoscopic eye exam on the day of or 13 days after the DISC?
1

Yes

0

No

9

Unknown

Version: Short Form 2024

Last Updated: 07/29/2023

Page 6 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer 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

66. 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 care 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 2024

Last Updated: 07/29/2023

Page 7 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________

AFST results for additional Candida isolates
Antifungal susceptibility testing (check here
Date of culture

Species
1
13
2
3
4
5
6
7
8
9
10
11
12

CA
CAU
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending

1
13
2
3
4
5
6
7
8
9
10
11
12

CA
CAU
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending

Drug

Species
1
13
2
3
4
5
6
7
8
9
10
11
12

CA
CAU
CG
CP
CT
CD
CL
CK
CGM
CO
CGN
CS
Pending

1
13
2
3
4
5
6
7
8
9

CA
CAU
CG
CP
CT
CD
CL
CK
CGM
CO

Version: Short Form 2024

MIC

Interpretation

Amphotericin B

S

SDD

I

R

NI

ND

Anidulafungin (Eraxis)

S

SDD

I

R

NI

ND

Caspofungin (Cancidas)

S

SDD

I

R

NI

ND

Fluconazole (Diflucan)

S

SDD

I

R

NI

ND

Flucytosine (5FC)

S

SDD

I

R

NI

ND

Itraconazole (Sporanox)

S

SDD

I

R

NI

ND

Micafungin (Mycamine)

S

SDD

I

R

NI

ND

Posaconazole (Noxafil)

S

SDD

I

R

NI

ND

Voriconazole (Vfend)

S

SDD

I

R

NI

ND

Amphotericin B

S

SDD

I

R

NI

ND

Anidulafungin (Eraxis)

S

SDD

I

R

NI

ND

Caspofungin (Cancidas)

S

SDD

I

R

NI

ND

Fluconazole (Diflucan)

S

SDD

I

R

NI

ND

Flucytosine (5FC)

S

SDD

I

R

NI

ND

Itraconazole (Sporanox)

S

SDD

I

R

NI

ND

Micafungin (Mycamine)

S

SDD

I

R

NI

ND

Posaconazole (Noxafil)

S

SDD

I

R

NI

ND

Voriconazole (Vfend)

S

SDD

I

R

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

NI

ND

Anidulafungin (Eraxis)

S

SDD

I

R

NI

ND

Caspofungin (Cancidas)

S

SDD

I

R

NI

ND

Fluconazole (Diflucan)

S

SDD

I

R

NI

ND

Flucytosine (5FC)

S

SDD

I

R

NI

ND

Itraconazole (Sporanox)

S

SDD

I

R

NI

ND

Micafungin (Mycamine)

S

SDD

I

R

NI

ND

Posaconazole (Noxafil)

S

SDD

I

R

NI

ND

Voriconazole (Vfend)

S

SDD

I

R

NI

ND

Amphotericin B

S

SDD

I

R

NI

ND

Anidulafungin (Eraxis)

S

SDD

I

R

NI

ND

Caspofungin (Cancidas)

S

SDD

I

R

NI

ND

Fluconazole (Diflucan)

S

SDD

I

R

NI

ND

Flucytosine (5FC)

S

SDD

I

R

NI

ND

Itraconazole (Sporanox)

S

SDD

I

R

NI

ND

Micafungin (Mycamine)

S

SDD

I

R

NI

ND

Posaconazole (Noxafil)

S

SDD

I

R

NI

ND

Last Updated: 07/29/2023

Page 8 of 9

State ID: _____________ Date of Incident Specimen Collection (mm-dd-yyyy): ___-___-_______ Surveillance Officer Initials ________
10
11
12

CGN
CS
Pending

Version: Short Form 2024

Voriconazole (Vfend)

Last Updated: 07/29/2023

S

SDD

I

R

NI

ND

Page 9 of 9