Candida auris Case Report Form rev

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
4. What is your race and/or ethnicity? (select all that apply and enter additional details in the spaces provided)	□ American Indian or Alaska Native Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc. ____________________________________________ □ Asian – provide details below □ Chinese □ Asian Indian □ Filipino □ Vietnamese □ Korean □ Japanese Enter, for example, Pakistani, Hmong, Afghan, etc. ____________________________________________ □ Black or African American – provide details below □ African American □ Jamaican □ Haitian □ Nigerian □ Ethiopian □ Somali Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. ____________________________________________ □ Hispanic or Latino – provide details below □ Mexican □ Puerto Rican □ Salvadoran □ Cuban □ Dominican □ Guatemalan Enter, for example, Colombian, Honduran, Spaniard, etc. ____________________________________________ □ Middle Eastern or North African – provide details below □ Lebanese □ Iranian □ Egyptian □ Syrian □ Iraqi □ Israeli Enter, for example, Moroccan, Yemeni, Kurdish, etc. ____________________________________________ □ Native Hawaiian or Pacific Islander – provide details below □ Native Hawaiian □ Samoan □ Chamorro □ Tongan □ Fijian □ Marshallese Enter, for example, Chuukese, Palauan, Tahitian, etc. ____________________________________________ □ White – provide details below □ English □ German □ Irish □ Italian □ Polish □ Scottish Enter, for example, French, Swedish, Norwegian, etc. ____________________________________________
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).