Candida auris Case Report Form

[NCEZID] Characteristics of Cases of Priority Fungal Diseases

Att 3e-Candida auris Case Report Form

OMB: 0920-1385

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Form Approved

OMB No. 0920-1385

Exp. Date: 3/31/26


Candida auris Case Report Form

Unique Case ID: _____________

Prior Case ID from same patient:

Patient ID:

NNDSS State ID: ________________ | | ARLN specimen ID: ­­­­_______________

Form completion data

Name of person completing this form: _______________________

Institution: _______________________

Email: ____________________

Telephone: ___________________

Date form completed: _________________


Date chart abstraction completed if applicable: ______-______-___________ (mm-dd-yyyy)

CRF status: □ Complete □ Pending, last updated: ______-______-___________ (mm-dd-yyyy)




A. Case Surveillance Information

Reporting state/jurisdiction: ______________

Reporting county: ____________


Why is case of epidemiologic interest? (check all that apply)

Travel-related (traveled to or received healthcare in another country OR part of the United States)

Pediatric case

No history of recent inpatient healthcare □ Echinocandin resistance

Other, specify ___________________


Case classification status* (based on incident specimen of interest, either first specimen or first echinocandin-resistant specimen):

Screening

Reason for screening:

Admission screening because the patient received healthcare in a different state or country from where C. auris was first identified

Admission screening based on local healthcare history because the patient was at risk for C auris because of recent healthcare at a high-risk facility (e.g., Long-term care facility (LTCF) or outbreak facility)

Response screening or point prevalence survey (PPS) (e.g., in response to known cases)

Proactive PPS

Discharge screening

Clinical

Not a case


Date of incident specimen collection (DISC)**: ______-______-___________ (mm-dd-yyyy)

*Based on Council of State and Territorial Epidemiologists position statement

**This is the earliest date that a patient had a positive C. auris specimen collected or, if the epidemiologic interest is ‘echinocandin-resistance’, the echinocandin-resistant specimen collected



B. Patient demographics

1. Age at DISC:

(use months or days if patient was aged <2 years)


________ □ Years □ Months □ Days □ Unknown

2. Sex at birth

Male □ Female □ Unknown

3. Gender identity

Male □ Female □ Transgender, non-binary, or another gender

Prefer not to answer/Decline □ Unknown

3. Ethnic origin

Hispanic or Latino □ Not Hispanic or Latino □ Unknown

4. Race (select all that apply)

American Indian/Alaska Native □ Asian □ Black/African American

Native Hawaiian/Pacific Islander □ White □ Other (specify): ______________________

Unknown


Please specify any additional details noted in the chart about race (e.g., nationality, ethnic group): ____________

5. Patient's county of residence (Please do not write the word “County”; for example, write “Cook” instead of “Cook County”):


_______________________ □ Unknown

6. Patient’s city of primary residence


_______________________ □ Unknown

7. Patient’s state, jurisdiction, or territory of primary residence

_______________________ □ Unknown

8. Patient’s country of residence (e.g., USA)


_______________________ □ Unknown

9. Patient’s ZIP code of primary residence


_______________________ □ Unknown

10. Patient’s type of health insurance at DISC

Private □ Medicare □ Medicaid/state assistance program □ Military □ Indian Health Service □ Incarcerated □ Uninsured □ Other (specify): ______________________________ □ Unknown



C. Patient underlying risk factors & medical conditions present during the 1 year before DISC (unless other timeframe specified)

1. Cancer □ Yes □ No □ Unknown

Hematologic malignancy

specify type: _____________

Solid organ malignancy

specify type:____________


2. Immunocompromised: □ Yes □ No □ Unknown

Transplant in the last 2 years

Hematologic

Solid organ

Chemotherapy

Chronic use of steroids

Medications/therapies that weaken the immune system

TNF-alpha inhibitors (e.g., infliximab, adalimumab, etanercept)

Other (specify): ____________________________________________

Cirrhosis

Liver disease

Cirrhosis

Diabetes

History of stroke, hemiplegia, paraplegia, paralysis

Chronic kidney disease

Chronic respiratory failure

Cardiac disease

Requires care for chronic wounds

Other, specify: ______________

3. HIV infection □ Yes □ No □ Unknown

If yes, choose one of the below

Ever had CD4 < 200 cells/mm3 within past 6 months

Yes □ No □ Unknown


4. Other potentially relevant clinical information?

Yes (specify below) □ No □ Unknown

________________________________

________________________________

________________________________

5. Was mother screened for C. auris? Yes No Unknown

Did mother have a positive C. auris specimen?

Yes No Unknown


D. Specimen information for incident specimen of interest and all specimens within 30 days of DISC

Specimen collection date (mm/dd/yyyy))

Specimen type

ARLN specimen ID

Drug

MIC




Screening

Axilla/Groin

Axilla/Groin/Nares

Axilla

Groin

Other, specify: _______

Unknown


Clinical; Clinical specimen ID: __________

Blood

Urine

Respiratory

Wound

Other, specify: ________

Unknown




Amphotericin B



Anidulafungin (Eraxis)



Caspofungin (Cancidas)



Fluconazole (Diflucan)



Flucytosine (5FC)



Ibrexafungerp (Brexafemme)


Isavuconazole (Cresemba)



Itraconazole (Sporanox)


Micafungin (Mycamine)


Posaconazole (Noxafil)


Voriconazole (Vfend)


Did the patient have a prior C. auris specimen? □ Yes □ No □ Unknown

If yes, what was the date of the first C. auris positive specimen (i.e., when the patient was first known to be positive)? ______-______-___________ (mm-dd-yyyy)

If yes, list the most recent C. auris specimen with AFST results prior to the ech-R isolate:

Specimen collection date (mm/dd/yyyy))

Specimen type

ARLN specimen ID

Drug

MIC




Screening

Axilla/Groin

Axilla/Groin/Nares

Axilla

Groin

Other, specify: ________

Unknown


Clinical; Clinical specimen ID: __________

Blood

Urine

Respiratory

Wound

Other, specify: ________

Unknown




Amphotericin B




Anidulafungin (Eraxis)



Caspofungin (Cancidas)




Fluconazole (Diflucan)




Flucytosine (5FC)




Ibrexafungerp (Brexafemme)



Isavuconazole (Cresemba)




Itraconazole (Sporanox)



Micafungin (Mycamine)



Posaconazole (Noxafil)



Voriconazole (Vfend)




Complete questions 1 – 3 for the incident specimen of interest (first specimen or first echinocandin-resistant specimen). If patient had multiple positive specimens on the same day meeting the same criteria (first positive specimens or first echinocandin resistant specimens), please complete for each of those specimens.


1. Specimen Clade:

Clade I □ Clade II □ Clade III □ Clade IV □ Clade V □ Other, specify: _________


Interpretation of relatedness: __________________________

2. Location of patient at time of specimen collection:

Hospital inpatient

Was the patient in the ICU Y/N

Was the patient in a unit providing specialized care to a specific population

Pediatric

Oncology

Burn

Other, specify____________________

Outpatient, specify: ___________________

____________

Long-term acute care hospital (LTACH)

Was the patient in an ICU Y/N

Ventilator-capable skilled nursing facility (vSNF)

Was the patient in a dedicated vent unit

Skilled nursing facility (SNF)

Autopsy

Unknown

Other (specify) ________________

3. Name and location of facility at time of specimen collection

Facility name:

Facility CMS ID:

Facility state, jurisdiction, or territory:

Facility zip code:



F. Patient medical history, symptoms, diagnosis, and outcomes

1. Specify from where the patient was directly admitted:

Private Residence

Hospital inpatient

Was the patient in the ICU Y/N

Was the patient in a unit providing specialized care to a specific population

Pediatric

Oncology

Burn

Other, specify____________________

Outpatient, specify: ___________________

Long-term acute care hospital (LTACH)

Was the patient in the ICU Y/N

Ventilator-capable skilled nursing facility (vSNF)

Was the patient in a dedicated vent unit

Skilled nursing facilities facility (SNF)

Unknown

Other (specify)

2. Does the patient have a history of additional prior healthcare encounters in the 90 days before DISC

No

Yes

If yes, please indicate the type of healthcare encounters in the past 90 days (check all that apply)

Hospital inpatient

Intensive care unit

Outpatient

(specify): ____________

Long-term acute care hospital (LTACH)

Ventilator-capable skilled nursing facility (vSNF)

Skilled nursing facility (SNF)

Unknown

Other (specify)

3. Any history of travel or healthcare outside of the current jurisdiction within one year prior to DISC?

Yes

If yes,

Jurisdiction/Country: ___________________

Healthcare: □ Yes □ No □ Unknown

Notes about care provided: ____________________


Jurisdiction/Country: ___________________

Healthcare: □ Yes □ No □ Unknown

Notes about care provided: ____________________


Jurisdiction/Country: ___________________

Healthcare: □ Yes □ No □ Unknown

Notes about care provided: ____________________


No


4. Has patient ever had multidrug-resistant organisms (MDROs) or C. difficile? (check all that apply)

None

CRAB

CRE

CRPA

C. difficile

MRSA

VRE

Other, specify _____________

Unknown

5. Did patient have any of the following invasive device or procedure in the 7 days prior to DISC? (check all that apply)

Endotracheal tube

Tracheostomy

Ventilator

Central line

Urinary catheter (not condom catheter)

Feeding tube

Require hemodialysis

Wound care

None

6. Did patient receive chlorohexidine gluconate (CHG) bathing during admission where incident specimen of interest was collected?

y=Yes □ No □ N/A (i.e., outpatient) □ Unknown

7. Ambulatory status (choose most appropriate status at DISC)


Ambulatory □ Wheelchair-dependent □ Bedbound □ Unknown

8. Signs of C. auris clinical infection (based on clinician diagnosis with signs/symptoms of clinical infection)?

No

Yes

If yes, please provide details about type or severity of clinical infections: _______________

9. Date and location of discharge from facility of initial positive specimen of interest collection:

______-______-___________ (mm-dd-yyyy)

Location

Acute care hospital

Private residence

Long-term acute care hospital (LTACH)

Ventilator-capable skilled nursing facility (vSNF)

Skilled nursing facility (SNF)

Death

Unknown

Other (specify)

Still admitted

N/A (i.e., outpatient)

Unknown

10. ICD-10 Discharge Code:


11. Died within 30 days after DISC?


No


Yes, date of death _______ - _______- ______________ (mm-dd-yyyy)

Cause(s) of death _________________


Unknown



G. Antifungal treatment: Please use the table below to indicate antifungal drugs that the patient received during the 90 days before to 60 days after the DISC for the specimen of interest, the first specimen or first echinocandin resistant specimen. For all other cases (not echinocandin resistant), please use the table to indicate antifungal drugs that the patient received during the 60 days after DISC.

Select one of the following to complete each row of the table

Amphotericin B lipid complex (ABLC)

Liposomal Amphotericin B (L-AmB)

Amphotericin B colloidal dispersion (ABCD)

Anidulafungin (ANF)

Caspofungin (CAS)

Fluconazole (FLC)

Flucytosine (5FC)

Ibrexafungerp (IBR)


Isavuconazole (ISA)

Itraconazole (ITC)

Micafungin (MFG)

Posaconazole (PSC)


Voriconazole (VRC)

Other drug (specify):

___________________

Unknown drug (UNK)

Drug Abbrev

b. First date given (mm-dd-yyyy)

c. Last date given (mm-dd-yyyy)

d. Indication



___ ___ - ___ ___ - ___ ___ ___ ___


Start date unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Still on treatment at time CRF completed

Stop date unknown

Prophylaxis

Treatment

Unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Start date unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Still on treatment at time CRF completed

Stop date unknown

Prophylaxis

Treatment

Unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Start date unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Still on treatment at time CRF completed

Stop date unknown

Prophylaxis

Treatment

Unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Start date unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Still on treatment at time CRF completed

Stop date unknown

Prophylaxis

Treatment

Unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Start date unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Still on treatment at time CRF completed

Stop date unknown

Prophylaxis

Treatment

Unknown



___ ___ - ___ ___ - ___ ___ ___ ___


Start date unknown


___ ___ - ___ ___ - ___ ___ ___ ___


Still on treatment at time CRF completed

Stop date unknown

Prophylaxis

Treatment

Unknown






H. Regional response information:


1. The region with this facility is considered which epidemiological tier?

Tier 2

Tier 3

Tier 4


2. What is the burden of C. auris in the facility where this case was identified in the last year?

No prior cases in this facility (i.e., this was the first case)

No prior cases in this facility but associated or affiliated facilities (e.g., facilities on the same campus or part of the same medical complex, facilities with frequent transfers) have had cases

Very few cases previously identified (<5 cases)

5-20 cases previously identified

>20 cases or a previous outbreak have occurred at this facility


Please provide more details: __________________________

3. Was transmission suspected?

Yes, this case resulted in transmission to other patients; provide details: _____________________

Yes, this case was part of a larger identified facility outbreak; provide details: _________________

No

Unknown


4. Please provide more details about the investigation and response (e.g., screening? transmission? environmental sampling? Lesson learned or success story?):




CDC estimates the average public reporting burden for this collection of information as 45 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1385).


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