Antifungal-resistant dermatophytosis case report form re

Form Approved

OMB No. 0920-1385

Exp. Date: 3/31/26

Antifungal-resistant dermatophytosis case report form

Unique patient ID (DCIPHER): ________________

ARLN specimen ID: ________________ | ARLN isolate ID:________________ | ARLN patient ID:________________

Form completion data
Name of person completing this form: _______________________ Institution: _______________________ Email: ____________________ Telephone: ___________________ Date form completed: _________________
A. 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 country of primary residence (e.g., USA)	_______________________ □ Unknown
6. Patient’s state, jurisdiction, or territory of primary residence	_______________________ □ Unknown
7. Patient's county of primary residence (Please do not write the word “County”; for example, write “Cook” instead of “Cook County”):	_______________________ □ Unknown
8. Patient’s city of primary residence	_______________________ □ 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 □ Unknown □ Other (specify): ____________________________________

B. Patient underlying risk factors & medical conditions present during the 2 years before DISC (unless other timeframe specified)
1. Cancer □ Yes □ No □ Unknown □ Hematologic malignancy specify type: _____________ □ Solid organ malignancy specify type:____________	3. Other immunocompromising conditions □ 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
2. 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 conditions □ Liver disease □ Cirrhosis □ Diabetes □ History of stroke, plegia, paralysis □ Chronic kidney disease □ Chronic respiratory failure □ Cardiac disease □ Other, specify: ______________	5. Other potentially relevant underlying conditions? □ Yes (specify below) □ No □ Unknown ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

C. Incident specimen data
1. Date of incident specimen collection (DISC)*: (mm-dd-yyyy) *This is the earliest date that a patient had a positive test for antifungal-resistant dermatophytosis	___ ___ - ___ ___ - ___ ___ ___ ___
2. Test type	□ Culture □ PCR
3. Body site	□ Tinea capitis (scalp, hair) □ Tinea barbae (beard) or faciei (face) □ Tinea manuum (hands) □ Tinea unguium (toenails) □ Tinea unguium (fingernails) □ Tinea genitalis (genitals) □ Tinea corporis (other parts of body such as arms or legs), specify: _________ □ Tinea cruris (groin, inner thighs, or buttocks) □ Tinea pedis (feet) □ Other body site specify: _________
4. Genus and species	□ Trichophyton mentagrophytes  □ Genotype VIII (T indotineae) □ Other genotype, specify: _______ □ Unknown genotype □ Trichophyton rubrum □ Other Trichophyton species Species: _______□ species unknown □ Microsporum  Species: _______ □ species unknown □ Epidermophyton  Species: _______□ species unknown □ Other genus (specify) __________ Species: _______□ species unknown
5. Antifungal susceptibility testing	Drug, minimum inhibitor concentration (MIC), mg/L (μg/mL) Terbinafine (Lamisil) ____________ Itraconazole (Sporanox) ___________ Amphotericin B ___________ Anidulafungin (Eraxis) ___________ Caspofungin (Cancidas) ___________ Fluconazole (Diflucan) ___________ Flucytosine (5FC) ___________ Ibrexafungerp (Brexafemme) ___________ Isavuconazole (Cresemba) ___________ Micafungin (Mycamine) ___________ Posaconazole (Noxafil) ___________ Voriconazole (Vfend) ___________
Molecular determinant of resistance (e.g., SQLE):	_________________________________________ □ Unknown

D. Patient diagnosis and outcomes

1. Patient location at time of incident specimen collection:   □ Hospital inpatient       □ Intensive care unit             □ Surgery/OR            □ Radiology            □ Other inpatient _______________

□ Outpatient       □ Emergency room            □ Clinic/Provider’s office (specify)        □ Dermatologist □ Infectious Diseases □ Podiatrist □ Primary care (adult) □ Primary care (pediatrics) □ Other provider type, specify _______ □ Unknown provider type      □ Dialysis center            □ Surgery            □ Urgent care                      □ Observational/clinical decision unit           □ Other outpatient ____________________

□ Long-term care facility (LTCF)  □ Long-term acute care hospital (LTACH)    □ Autopsy  □ Unknown  □ Other ____________________

2. Rash onset date (mm/dd/yyyy): ____/_____/_______

3. Indicate body site(s) affected.

□ Tinea capitis (scalp, hair)

□ Tinea barbae (beard)

□ Tinea manuum (hands)

□ Tinea unguium (toenails)

□ Tinea unguium (fingernails)

□ Tinea genitalis (genitals)

□ Tinea corporis (other parts of body such as arms or legs), specify: _________

□ Tinea cruris (groin, inner thighs, or buttocks)

□ Tinea pedis (feet)

□ Other body site, specify: _________

□ Unknown

4. Date of most recent follow-up for rash (within 90 days after DISC) (mm/dd/yyyy): ____/_____/_______

Compared with the patient's rash on DISC, what was the status of the patient's rash at most recent follow-up?

□ Worse

□ Neither better nor worse

□ Improving, but not fully resolved

□ Fully resolved

□ Unknown

E. Antifungal treatment: Did the patient receive antifungal drugs during the 90 days before to 60 days after the DISC? □ Yes □ No □ Unknown (If yes, please complete the table below for each drug received)
Systemic antifungals Amphotericin B lipid complex (ABLC) Liposomal Amphotericin B (L-AmB) Amphotericin B colloidal dispersion (ABCD) Anidulafungin (ANF) Caspofungin (CAS)	Fluconazole (FLC) Flucytosine (5FC) Griseofulvin (GSF) Ibrexafungerp (IBR) Isavuconazole (ISA) Itraconazole (ITC)	Micafungin (MFG) Terbinafine (TRB-S) Posaconazole (PSC) Voriconazole (VRC) Other systemic drug (specify) (OTH-S): _________	Unknown drug (UNK-S)
Topical antifungals
Butenafine (BTF) Ciclopirox (CPX) Clotrimazole (CTZ) Clotrimazole-betamethasone dipropionate (CBM)	Econazole (ECZ) Efinaconazole (EFZ) Ketoconazole (KTC) Luliconazole (LCZ) Miconazole (MCZ)	Naftifine (NFT) Nystatin- triamcinolone (NTC) Oxiconazole (OCZ) Sertaconazole (STC)	Tavaborole (TVB) Terbinafine (TRB-T) Terconazole (TCZ) Other topical antifungal (specify) (OTH-T): _________ Unknown drug (UNK-T)
Drug Abbrev	b. First date given (mm-dd-yyyy)	c. Last date given (mm-dd-yyyy)	e. Therapeutic drug monitoring (TDM)
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Yes Date of earliest TDM: TDM level: Date of second TDM: TDM level: □ No
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Yes Date of earliest TDM: TDM level: Date of second TDM: TDM level: □ No

E. Supplemental patient interview form: Note that “you” in these questions refers to the patient.
1. Have you traveled internationally during the two years before rash onset?	□ Yes  If yes, specify country/city/cities/dates: ______________ □ No  □ Unknown
2. Have you had any known exposures to possible ringworm during the month before rash onset?	□ Yes  If yes, specify country/city/cities/dates: ______________ If yes, select all that apply  □ Other person with possible ringworm  □ Animal with possible ringworm  If yes, what type of animal? □ Cat □ Dog □ Other, specify: ____________ □ Environment (e.g., public showers, gyms, shared equipment), specify: _________  □ Other, specify: ________________  □ No  □ Unknown  Provide any details of exposure that you might be relevant and are not captured above:__________________
3. How many people are in your household (including yourself) and how many developed signs symptoms of ringworm?	Number of people in the household _________ □ Unknown  Number of people in the household who developed possible ringworm _________ □ Unknown
4. Did you use topical steroids before this diagnosis?	□ Yes  If yes, name of drug(s), dose(s), duration(s): __________________________________________________  □ No
5. Did you use topical and/or systemic antibacterial medications before this diagnosis (including those purchased over-the-counter)?*	□ Yes  If yes, name of drug(s), method(s) of administration (e.g., oral, topical), dose, duration: __________________________________________________  □ No
6. Over the last week, how itchy, sore, painful, or stinging has your skin been?*	□ Very much □ A lot □ A little □ Not at all
7. Over the last week, how embarrassed or self-conscious have you been because of your skin?*	□ Very much □ A lot □ A little □ Not at all
8. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
9. Over the last week, how much has your skin influenced the clothes you wear?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
10. Over the last week, how much has your skin affected any social or leisure activities?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
11. Over the last week, how much has your skin made it difficult for your to do any sport?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
12. Over the last week, has your skin prevented you from working or studying?*	□ Yes □ No If no, over the last week, how much has your skin been a problem at work or studying? □ A lot □ A little □ Not at all □ Not relevant □ Not at all □ Not relevant
13. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
14. Over the last week, how much has your skin caused any sexual difficulties?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
15. Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant

*Questions were adapted from the Dermatology Life Quality Index (DLQI); approval obtained from DLQI Administrator.

Additional comments: _____________________________________________________________________________________________

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CDC estimates the average public reporting burden for this collection of information as 30 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).