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pdfState 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
| File Type | application/pdf |
| Author | fxe9 |
| File Modified | 2023-08-09 |
| File Created | 2023-08-09 |