CDC Rev 09-2016 CLOSTRIDIUM DIFFICILE INFECTION (CDI) SURVEILLANCE EMERG

Form approved OMB No. 0920-0978
Patient ID: ______________________________________________________

Specimen ID: ____________________________________________________

– CLOSTRIDIUM DIFFICILE INFECTION (CDI) SURVEILLANCE EMERGING INFECTIONS PROGRAM CASE REPORT FORM –
Patient’s Name: ___________________________________________________________________________________	

Phone No.: (

) ___________-___________________

(Last, First, M.I.)

Address: _______________________________________________________________________________	

Chart Number: ____________________________________

(Number, Street, Apt. No.)

	

________________________________________________ ________________ ___________________ 	
(City) 	

(State) 	

– Patient identifier information is NOT transmitted to CDC –

U.S. DEPARTMENT OF
HEALTH and HUMAN SERVICES CENTERS
FOR DISEASE CONTROL AND PREVENTION
ATLANTA, GA 30333

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

1. STATE:

2. COUNTY:

(Residence of Patient)

(Residence of Patient)

££

3. STATE ID:

_________________________________________

5. DATE OF BIRTH:
	Mo.	 Day	

6. AGE:

Year

8a. DATE OF INCIDENT STOOL
COLLECTION POSITIVE FOR C. diff:
Day	

Year

££	££ 	
££££

1 £ Male
2 £ Female

7b. ETHNIC ORIGIN:
1 £ Hispanic or Latino
2 £ Not Hispanic or Latino
7 £ Unknown

8b. Positive diagnostic assay for C. diff:
(Check all that apply)
1 £ EIA	

1 £ GDH	

1 £ NAAT

1 £ Culture	 1 £ Cytotoxin	
1 £ Unknown
1 £ Other (specify):
________________________

9. Was patient hospitalized at the time of, or within 7 days after,
stool collection?
1 £ Yes	 2 £ No	 7 £ Unknown
If YES, Date of Admission:	
Mo.	
Day	
Year

	

£££££££££

7a. SEX:

££	££	££££ £££
	Mo.	

Hospital: ______________________________________________

(Zip Code)

4a. LAB/HOSPITAL WHERE
TOXIN ASSAY PERFORMED:
_______________________

7c. RACE: (Check all that apply)
1 £ American Indian or Alaska Native	
1 £ Asian
1 £ Black or African American

4b. PROVIDER ID WHERE
PATIENT TREATED:
___________________
1 £ Native Hawaiian or
Other Pacific Islander
1 £ White
1 £ Unknown

8c. Location of stool collection: (Check one)
1 £ Hospital Inpatient
4 £ Long Term Care/
Facility ID _________
Skilled Nursing
Facility
2 £ Long Term Acute Care
Facility ID _______
Hospital
Facility ID _________ 5 £ Outpatient
3 £ Emergency Room

7 £ Unknown
8 £ Observation
Unit/CDU

6 £ Other (specify): ___________________

10. Where was the patient a resident 4 days prior to stool collection? (Check one)

££	££	
££££

1 £ Hospital Inpatient
Facility ID ______________
2 £ Long Term Acute Care Hospital
Facility ID ______________

4 £ Long Term Care/ Skilled
Nursing Facility
Facility ID _____________

6 £ Incarcerated
7 £ Unknown

5 £ Homeless

_______________

8 £ Other (specify):

3 £ Home
11.	 HCFO classification questions:
a. Was stool collected ≥ 4 days after hospital admission?
1 £ Yes (HCFO)	
2 £ No (go to 11b.)

12. Was CDI a primary or contributing reason for patient’s admission?
1 £ Yes	

b. If no, was stool collected at LTCF/SNF/LTACH?
1 £ Yes (HCFO)	
2 £ No (go to 11c.)
c. If no, was the patient admitted from LTCF/SNF or another acute care setting?
1 £ Yes (HCFO)	
2 £ No (CO – complete CRF)
Facility ID ______________
d. If HCFO, was this case selected for full CRF based on sampling frame (1:10)?
1 £ Yes (Complete CRF)	2 £ No (STOP data abstraction here!)
14. Exclusion criteria for CA-CDI: (Check all that apply) £ None
£ Unknown
1 £ Hospitalized (overnight) at any time in the 12 weeks prior to stool collection date.
If yes, Date of most recent discharge:
	Mo.	
Day	
Year

££	££ £
	£££  

£ Unknown

Facility ID ______________
1 £ Overnight stay in LTACH at any time in the 12 weeks prior to stool collection date
Facility ID ______________
1 £ Residence in LTCF/SNF at any time in the 12 weeks prior to stool collection date
Facility ID ______________
16.	Patient outcome:	7 £ Unknown
1 £ Survived		
Date of Discharge:	
Mo.	
Day	

	

	

3 £ Not Admitted	

7 £ Unknown

15.	Exposures to healthcare:
a.	Chronic Hemodialysis prior to incident C. diff + stool:
	1 £ Yes	 2 £ No	 7 £ Unknown
b.	Surgical procedure in the 12 weeks prior to incident C. diff + stool:
	1 £ Yes	 2 £ No	 7 £ Unknown
c.	ER visits in the 12 weeks prior to incident C. diff + stool:
	1 £ Yes	 2 £ No	 7 £ Unknown
d.	Observation/CDU stay in the 12 weeks prior to incident C.diff + stool:
	1 £ Yes	 2 £ No	 7 £ Unknown

Year	

££	££	££££	

If survived, patient was discharged to:
2 £ Long Term Acute Care Hospital	
Facility ID ______________	
3 £ Home	

2 £ No	

13. Were other enteric pathogens detected from stool at the same date
incident C. diff + stool was collected?
1 £ Campylobacter	5 £ None	
8 £ Other (specify):
2 £ Salmonella	6 £ No other pathogens tested	 ______________
3 £ Shiga Toxin-Producing E. coli	9 £ Norovirus
4 £ Shigella 	
7 £ Unknown 	
10 £ Rotavirus	
			

4 £ Long Term Care/ Skilled Nursing Facility	
Facility ID ______________
5 £ Other 	

2 £ Died	
Date of Death:	

Mo.	

Day	

Year

££	££	££££

7 £ Unknown

Public reporting burden of this collection of information is estimated to average 20 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).

Page 1 of 2

17a. Colectomy (related to CDI):
1 £ Yes 2 £ No 7 £ Unknown
If YES, Date of Procedure
	Mo.	
Day	

Year

££	££ £
	£££

17b. ICU Admission ( on the day of or within 7 days after incident
stool collection):
1 £ Yes 2 £ No 7 £ Unknown

17c. Any additional positive stool test for C. diff ≥ 2 and ≤ 8
weeks after the last C. diff + stool specimen?
	1 £ Yes 2 £ No
If YES, Date of first recurrent specimen
	Mo.	
Day	
Year

If YES, Date of ICU Admission
	Mo.	
Day	
Year

££	££ 	
££££

18.	 RADIOGRAPHIC FINDINGS (within 7 days before or after
incident C. diff + stool):
1 £ Toxic megacolon	
4 £ Both
2 £ lleus	
5 £ Not Done
3 £ Neither	
7 £ Information not available

££	££ 	
££££

£ Unknown

19. Was pseudomembranous colitis listed in the
surgical pathology, endoscopy, or autopsy report
(within 7 days before or after incident C. diff + stool)?
1 £ Yes	
3 £ Not Done
2 £ No	
7 £ Information not available

20.2 CLINICAL FINDINGS (within 7 days before and up to 1 day after incident C. diff + stool):
d. Diarrhea:	

e. Upper GI Symptoms:

1 £ Diarrhea by definition (unformed or watery stool, ≥ 3/day for ≥ 1 day)	
2 £ Diarrhea documented, but unable to determine if it is by definition	
3 £ No Diarrhea documented	
4 £ “Asymptomatic” documented in medical record	
7 £ Information not available	

1 £ Nausea
2 £ Vomiting
3 £ Neither
4 £ Both
7 £ Information not available

20.1 LABORATORY FINDINGS (within 7 days
before or after incident C. diff + stool):
a. Albumin ≤ 2.5g/dl:
1 £ Yes 2 £ No 3 £ Not Done
7 £ Information not available
b. White blood cell count ≤ 1,000/µl:
1 £ Yes 2 £ No 3 £ Not Done
7 £ Information not available
c. White blood cell count ≥ 15,000/µl:
1 £ Yes 2 £ No 3 £ Not Done
7 £ Information not available

21. UNDERLYING CONDITIONS: (Check all that apply) If none or no chart available, check appropriate box
1 £ None 1 £ Unknown
1 £ AIDS	
1 £ Connective Tissue Disease	
1 £ Inflammatory Bowel Disease	
1 £ Chronic Cognitive Deficit	
1 £ CVA/Stroke	
1 £ Myocardial Infarct	
1 £ Chronic Kidney Disease	
1 £ Dementia	
1 £ Peptic Ulcer Disease	
1 £ Chronic Liver Disease	
1 £ Diabetes	
1 £ Peripheral Vascular Disease	
1 £ Chronic Pulmonary Disease	
1 £ Diverticular Disease	
1 £ Primary Immunodeficiency
1 £ Congenital Heart Disease	
1 £ Hemiplegia/Paraplegia	
1 £ Short Gut Syndrome
1 £ Congestive Heart Failure	
1 £ HIV	
1 £ Solid Organ Transplant
22. Was ICD-9 008.45 or ICD-10 A04.7 listed on the discharge form?
1 £ Yes 2 £ No 3 £ Not Admitted 7 £ Unknown
If YES, what was the POA code assigned to it?
1 £ Y,Yes
3 £ U, Unknown	
2 £ N, No 4 £ W, Clinically Undetermined

1 £ Stem Cell Transplant
1 £ Solid Tumor (non metastatic)
1 £ Hematologic Malignancy
1 £ Metastatic Solid Tumor

23. At time of incident C. diff + stool, patient was:
1 £ Pregnant 2 £ Post-partum 3 £ Neither
Delivery Date:	

	

5 £ Missing
6 £ Not Applicable

Mo.	

Day	

7 £ Unknown

Year

££	££	££££

24. MEDICATIONS TAKEN 12 WEEKS PRIOR TO INCIDENT STOOL COLLECTION DATE (including current hospital stay if collection date > admission date):
(If none or no chart available, check appropriate box)
a. Proton pump inhibitor	1 £ Yes	
(e.g. Esomeprazole, Omeprazole, Lansoprazole, Pantoprazole, Rabeprazole)

2 £ No	

7 £ Unknown

b. 	H2 Blockers (e.g. Famotidine, Ranitidine, Cimetidine)	

2 £ No	

7 £ Unknown

1 £ Yes	

c. 	Immunosuppressive therapy (Check all that apply)		
1 £ None	
1 £ Steroids	
1 £ Chemotherapy	
1 £ Other agents (specify): ____________________________

1 £ Unknown

d. Antimicrobial therapy (Check all that apply)	1 £ Yes, name unknown	
1 £ Amikacin
1 £ Cefazolin
1 £ Ceftriaxone
1 £ Doxycycline
1 £ Amoxicillin
1 £ Cefdinir
1 £ Cefuroxime
1 £ Ertapenem
1 £ Amoxicillin/Clavulanic Acid 1 £ Cefepime
1 £ Cephalexin
1 £ Gentamicin
1 £ Ampicillin
1 £ Cefotaxime
1 £ Ciprofloxacin
1 £ Imipenem
1 £ Amp/sulb
1 £ Cefoxitin
1 £ Clarithromycin 1 £ Levofloxacin
1 £ Azithromycin
1 £ Cefpodoxime 1 £ Clindamycin
1 £ Linezolid
1 £ Aztreonam
1 £ Ceftazidime
1 £ Daptomycin
1 £ Meropenem

1 £ Unknown
1 £ Tetracycline
1 £ Tigecycline
1 £ Tobramycin
1 £ Trimethoprim -Sulfamethoxazole
1 £ Vancomycin (IV)
1 £ Other (specify):
____________________

1 £ None	
1 £ Metronidazole
1 £ Moxifloxacin
1 £ Nitrofurantoin
1 £ Penicillin
1 £ Piperacillin-Tazobactam
1 £ Rifampin
1 £ Rifaximin

e. Was patient treated for previous suspected or confirmed CDI in the prior 12 weeks?
1 £ Yes	2 £ No	7 £ Unknown
If YES, which medication was taken (check all that apply, or unknown if applicable):
1 £ Metronidazole	1 £ Vancomycin	1 £ Fidaxomicin	
1 £ Other, specify:______________	

1 £ Unknown

– SURVEILLANCE OFFICE USE ONLY –
25. CRF status:
1 £ Complete	 3 £ Edited & Correct
2 £ Incomplete	 4 £ Chart unavailable 	
		after 3 requests

26. Previous unique CDI episode ( >8 weeks prior to this episode):

27. Initials of S.O:

1 £ Yes

_______________

2 £ No

If yes, Previous STATEID:

£££££££££

29. Identified through
audit
1 £ Yes

2 £ No

28. COMMENTS: _______________________________________________________________________________________________________________________

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
CDC Rev. 09-2016	

CS259114	

Page 2 of 2