Haic 400.7 Clostridioides Difficile Infection (cdi) Surveillance Em

1. PATIENT ID:

2. STATE ID:

3. Date of incident C. diff+ stool collection (DISC):

CLOSTRIDIOIDES DIFFICILE INFECTION (CDI) SURVEILLANCE
EMERGING INFECTIONS PROGRAM CASE REPORT

Form Approved
OMB No. 092-0978
Expiration Date: 2/28/26

Specimen ID:

Patient’s Name:

Address:
Address type:
4. STATE:

Hospital:

5. COUNTY:

9. Diagnostic assay for C. diff
9a. EIA Positive Negative
Not tested Unknown
9b. GDH Positive Negative
Not tested Unknown
9c. Cytotoxin Positive Negative
Not tested Unknown
9d. NAAT (C. diff only) Positive Negative
Not tested Unknown
9e. NAAT (GI panel) Positive Negative
Not tested Unknown
9e.1 If positive, was result suppressed? Yes No Unknown
9f. Other (specify):
Positive Negative
Not tested Unknown

6. PLANNING REGION:
7. LABORATORY ID
WHERE INCIDENT
SPECIMEN IDENTIFIED:
8. FACILITY ID WHERE
PATIENT TREATED:
10. DATE OF BIRTH:

12. SEX AT BIRTH:

■ Unknown
11. AGE: (years)

Chart Number:

■ Male
■ Female
■ Unknown
■ Transgender

13. RACE AND/OR ETHNICITY: (Select all that apply)
■ American Indian or Alaska Native
■ Asian
■ Black or African American
■ Hispanic or Latino

14. Was the patient hospitalized on the day of or in the 6 calendar days after the DISC?
14a. If YES, Date of Admission:

■ Middle Eastern or North African
■ Native Hawaiian or Pacific Islander
■ White
■ Unknown
Yes No Unknown

Unknown

15. Where was the patient located on the 3 calendar day before the DISC?
● Private Residence
● LTACH
Facility ID:
●

Homeless
● LTCF
Facility ID:
● Correctional or detention facility
● Hospital Inpatient
Facility ID:
● Drug/alcohol rehabilitation
15a. Was the patient transferred from this hospital?
● Other
● Yes No Unknown
● Unknown
rd

16. Location of incident C. diff+ stool collection
● Outpatient
● Hospital Inpatient
Facility ID:
● Emergency room
● Clinic/doctor’s office
● Dialysis center
● Surgery
● Observation/Clinical decision unit
● Other outpatient

Facility ID:
● ICU
● OR
● Radiology
● Other inpatient

● LTCF

● Autopsy

Facility ID:

● Other
● Unknown

● LTACH
Facility ID:

17a. Previous hospitalization in the 12 weeks before the DISC: Yes No Unknown

Facility ID:

17a.1 If yes, date of discharge closest to DISC: Unknown
17b. Overnight stay in LTACH in the 12 weeks before the DISC: Yes No Unknown

Facility ID:

17c. Overnight stay in LTCF in the 12 weeks before the DISC Yes No Unknown

Facility ID:

18. Epiclass questions:
18a. Was incident C. diff+ stool collected at least 3 calendar days after the date of hospital admission?
Yes (HO - go to 18e)
No
18b. Was incident C. diff+ stool collected in an outpatient setting for a LTCF resident, or in a LTCF or LTACH?
Yes, LTCF (LTCFO - go to 18e)
Yes, LTACH (HO - go to 18e)
No
Public reporting burden of this collection of information is estimated to average 38 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 D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0978).
CS351613-A

8/14/2024

18c. Was the patient admitted from a LTCF or a LTACH?
Yes, LTCF (LTCFO - go to 18e) / Facility ID:

Yes, LTACH (HO - go to 18e) / Facility ID:

No

18d. Did patient have a previous hospitalization or overnight stay in a LTCF or LTACH in the 12 weeks before the DISC?
Yes (COHCFA – go to 18e)
No (CA – go to 18e)
18e. Was this case sampled for full CRF?
Yes (Complete CRF)
No (STOP data abstraction here)
19. Patient Outcome:

Survived Died

19a. If survived, date of discharge:

Hospitalized > 1 year
Unknown

19b. If survived, discharged to:
● Private residence

Unknown
19c. Date of Death:

Left against medical advice (AMA)

● Homeless

● Other
● Unknown

● LTCF

Facility ID:

● Correctional or detention facility

● LTACH

Facility ID:

● Drug/alcohol rehabilitation

Unknown

20a. Chronic dialysis in the 12 weeks before the DISC Yes No Unknown
20a.1 Type: Hemodialysis Peritoneal Unknown
20b. Surgery in the 12 weeks before the DISC

Yes No Unknown

20c. ER visit in the 12 weeks before the DISC

Yes No Unknown

20d. Observation/CDU stay in the 12 weeks before the DISC

Yes No Unknown

21. 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
■ AIDS/CD4 count < 200
■ Primary immunodeficiency
■ Transplant, hematopoietic stem cell
■ Transplant, solid organ (specify):

22a. Weight
lbs oz OR

None Unknown
Liver disease
■ Chronic liver disease
■ Ascites
■ Cirrhosis
■ Hepatic encephalopathy
■ Variceal bleeding
■ Hepatitis C
■ Treated, in SVR
■ Current, chronic
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
■ Paresis
■ Parkinson’s disease
■ Spinal cord injury

kg Unknown

22b. Height
ft in OR

cm

23. S ubstance Use
23a. Smoking: ■ None documented Unknown
■ Tobacco
E-Nicotine Delivery System Marijuana
23c. Other substances: (Check all that apply)
24. Was CDI a primary or contributing
reason for patient’s admission?
● Yes
● No
● Not admitted
● Unknown

Opioid use disorder

Injection drug use

25. Was ICD-9 008.45 or ICD-10 A04.7 listed
on the discharge form?
● Yes
● Not admitted
● No
● Unknown
25a. If YES, what was the POA code assigned to it?
● Y, Yes
● W, Clinically Undetermined
● N, No
● Missing
● U, Unknown
● Not Applicable
2

Plegias/Paralysis
■ Hemiplegia
■ Paraplegia
■ Quadriplegia
Renal disease
■ Chronic kidney disease
Lowest serum creatinine:
mg/DL
■ Unknown or not done
Skin condition
■ Blistering disease
■ Burn
■ Decubitus/pressure ulcer
■ Eczema
■ Psoriasis
■ Surgical wound
■ Other chronic ulcer or chronic wound
Other
■ Connective tissue disease
■ Obesity or morbid obesity
■ Pregnancy

Unknown

22c. BMI

Unknown

23b. Alcohol abuse:
● Yes
None documented Unknown
None documented Unknown
26. Was the patient in an ICU on the day of or
in the 6 days after the DISC?
Yes
No
Unknown
26a. If YES, date of ICU admission:
■ Unknown

28. Fever (in the 2 calendar days before or calendar day
of the DISC)

27. Symptoms (in the 6 calendar days before, the day of, or 1 calendar day after the DISC)
(Check all that apply)

■ “Asymptomatic” documented in medical record
■ Diarrhea by definition (unformed or watery stool,
≥ 3/day for ≥ 1 day)
■ Diarrhea documented, but unable to determine
if it is by definition

■ Nausea
■ Vomiting
■ No diarrhea, nausea, or
vomiting documented
■ Information not available

29. Did provider indicate that patient may be colonized by C. difficile?

■ Fever ≥38°C or ≥100.4°F documented
Highest fever documented:
■ Self-reported fever
■ No fever documented
■ Information not available

Yes No

33. Were other enteric pathogens isolated from stool collected
on the DISC?
■ Astrovirus
■ None
■ No other
■ Campylobacter
pathogens tested
■ Enteroaggregative E. coli (EAEC)
■

Unknown
■ Enteropathogenic E. coli (EPEC)
■ Enterotoxigenic E. coli (ETEC)
■ Norovirus
■ Rotavirus
■ Salmonella
■ Sapovirus
■ Shiga Toxin-Producing E.coli
■ Shigella
■ Yersinia enterocolitica
■ Other (specify):

■ Unknown

34b. White blood cell count ≤ 1,000/µl:
● Yes
● No
● Not Done
● Information not available

■ Yes, name unknown

■ Cefpodoxime
■ Ceftaroline
■ Ceftazidime
■ Ceftazidime/avibactam
■ Ceftolozane/tazobactam
■ Ceftriaxone
■ Cefuroxime
■ Cephalexin
■ Ciprofloxacin
■ Clarithromycin
■ Clindamycin
■ Dalbavancin
■ Daptomycin
■ Delafloxacin
■ Doxycycline

● Yes
● No
● Unknown

32a. If YES, Date of Procedure:

34. LABORATORY FINDINGS (in the 6 calendar days before, the day of,
or the 6 calendar days after the DISC)
34a. Albumin ≤ 2.5g/dl:
34c. White blood cell count ≥ 15,000/µl:
● Yes
● Yes
● No
● No
● Not Done
● Not Done
● Information not available
● Information not available

36. MEDICATIONS taken in the 12 weeks before the DISC:
36a. Proton pump inhibitor (e.g. Omeprazole,
36b. H2 Blockers (e.g. Famotidine,
Lansoprazole, Pantoprazole, Rabeprazole)
Ranitidine, Cimetidine)
● Yes
● Yes
● No
● No
● Unknown
● Unknown

■ Amikacin
■ Amoxicillin
■ Amoxicillin/clavulanic acid
■ Ampicillin
■ Ampicillin/sulbactam
■ Azithromycin
■ Aztreonam
■ Cefadroxil
■ Cefazolin
■ Cefdinir
■ Cefepime
■ Cefiderocol
■ Cefixime
■ Cefotaxime
■ Cefoxitin

■ Neither toxic megacolon
nor ileus
■ Information not available

32. Colectomy (related to CDI):

35. Antimotility agents in the 6 calendar days before, day of, or 6 days after DISC:

36d. Antimicrobial therapy (Check all that apply)

°F

Unknown

30. Toxic megacolon and ileus (in the 6 calendar days before, the day of, or the 6 calendar days after the DISC)
30a. Radiographic findings
30b. Clinical findings
■ Toxic megacolon
■ Neither toxic megacolon
■ Toxic megacolon
nor ileus
■ Ileus
■ Ileus
■ Radiology not performed
■ Both toxic megacolon
■ Both toxic megacolon
and ilieus
and ilieus
■ Information not available
31. Was pseudomembranous colitis listed in the surgical pathology, endoscopy,
or autopsy report in the 6 calendar days before, the day of, or the 6
calendar days after the DISC?
● Yes
● Not Done
● No
● Information not available

°C or

■ None

Yes No Unknown
36c. Immunosuppressive therapy (Check all that apply)
■ Steroids
■ None
■ Chemotherapy
■ Unknown
■ Other agents (specify):

■ Unknown

■ Eravacycline
■ Ertapenem
■ Fosfomycin
■ Gentamicin
■ Imipenem/cilastatin
■ Levofloxacin
■ Linezolid
■ Meropenem
■ Meropenem/vaborbactam
■ Metronidazole
■ Moxifloxacin
■ Nitrofurantoin
■ Omadacycline
■ Oritavancin
■ Penicillin

3

34d. S erum creatinine > 1.5 mg/dl
● Yes
● No
● Not Done
● Information not available

■ Piperacillin/tazobactam
■ Polymyxin B
■ Polymyxin E (colistin)
■ Rifaximin
■ Tedizolid
■ Telavancin
■ Tigecycline
■ Tobramycin
■ Trimethoprim
■ Trimethoprim/sulfamethoxazole
■ Vancomycin (IV)
■ Vancomycin (PO for prophylaxis)
■ Other (specify):

36e. Was patient treated for suspected or confirmed CDI in the 12 weeks before the DISC?
36e.1 If YES, which medication was taken (Check all that apply):

37. Treatment for incident CDI
37a.1 Course 1
Start Date:

■ No treatment

Unknown

■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)

■ Metronidazole
■ Vancomycin
■ Fidaxomicin

● Yes

● No

● Unknown

■ Other, (specify):
■ Unknown

■ Unknown treatment

Stop Date:

Unknown OR Duration (days):

■ Metronidazole (PO)
■ Metronidazole (IV)
■ Metronidazole (Unknown route)
■ Fidaxomicin

Unknown

■ Rifaximin
■ Nitazoxanide
■ Other (specify):

37a.2 Course 2
Start Date:
Unknown
■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)

Stop Date:
Unknown OR Duration (days):
■ Metronidazole (PO)
■ Rifaximin
■ Metronidazole (IV)
■ Nitazoxanide
■ Metronidazole (Unknown route)
■ Other (specify):
■ Fidaxomicin

Unknown

Stop Date:
Unknown OR Duration (days):
■ Metronidazole (PO)
■ Rifaximin
■ Metronidazole (IV)
■ Nitazoxanide
■ Metronidazole (Unknown route)
■ Other (specify):
■ Fidaxomicin

Unknown

Stop Date:
Unknown OR Duration (days):
■ Metronidazole (PO)
■ Rifaximin
■ Metronidazole (IV)
■ Nitazoxanide
■ Metronidazole (Unknown route)
■ Other (specify):
■ Fidaxomicin

Unknown

37a.3 Course 3
Start Date:
Unknown
■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)
37a.4 Course 4
Start Date:
Unknown
■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)
37b. Probiotics (specify):
37c. Adjunctive therapy
● Conventional FMT

Date: Unknown

● Rebyota Date:

Unknown

● Bezlotoxumab

Date: Unknown

● Other (specify):

Date: Unknown

● Vowst Date: Unknown
38. Previous unique CDI episode

(>8 weeks before the DISC):

● Yes
● No
38a. If YES, previous STATEID:

39. Any recurrent C. diff+
episodes following this
incident C. diff+ episode?
● Yes
● No

40. CRF status:
● Complete
● Incomplete
● Chart unavailable
after 3 requests

39a. If YES, Date of first
recurrent specimen:

Comments:

4

41. Initials of S.O.:

42. Date of abstraction: