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EIP CDI Surveillance: CDI Case Treatment Questionnaire
ICR 201801-0920-004 · OMB 0920-0978 · Object 80159501.
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Form approved OMB No. 0920-0978 EIP CDI Surveillance: CDI Case Treatment Questionnaire DEPARTMENT OF HEALTH & HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION ATLANTA, GA 30333 Patient ID: State ID: Incident C.difficile Specimen Collection Date: No Treatment ______/______/______ Unknown Treatment The objective of this form is to capture the use of the antimicrobial agents listed below for the treatment of an incident C.difficile episode (CDI case). For each therapy used, please select the route (when appropriate), enter the start and stop dates (select N/A if date is not available), and select the dosage. If patient is on taper, please select the initial dose of the taper and check taper=YES. Please note: The treatment of C.difficile usually lasts 10-14 days and it may start +/- 7 days of incident stool collection date. If >7 days have elapsed between the last dose and the subsequent dose of an antimicrobial therapy, only the first antimicrobial therapy course should be documented. Vancomycin (Vancocin) (Do NOT Record Vancomycin IV) PO Route: Rectal PO Route: Unknown Rectal PO Route: Unknown Rectal PO Route: Unknown Rectal Unknown Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Dosage: 500mg Dosage: 500mg Dosage: 500mg Dosage: 500mg 125mg 250mg Other ______________ Frequency: Once a Day Taper: TID BID Other ______________ QID YES 125mg Unknown NO 250mg Other ______________ Unknown Frequency: Once a Day BID Taper: YES NO Route: PO IV 250mg Other ______________ Frequency: TID Other ______________ QID 125mg Unknown Once a Day QID Unknown TID BID Other ______________ Taper: YES NO Route: PO IV 125mg Unknown 250mg Other ______________ Unknown Frequency: Once a Day Unknown BID TID Other ______________ QID Taper: YES NO Route: PO IV Unknown Metronidazole (Flagyl) PO Route: IV Unknown Start Date: ______/______/______ N/A Stop Date: ______/______/______ Dosage: 125mg 250mg Other ______________ Frequency: Once a Day Taper: BID Other ______________ QID YES Unknown Unknown Unknown Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A 500mg Dosage: 500mg Dosage: 500mg Dosage: 500mg 125mg Other ______________ Unknown TID Unknown Frequency: Once a Day BID Other ______________ QID Taper: NO 250mg YES 125mg Other ______________ Unknown Frequency: TID Once a Day QID Unknown Taper: NO 250mg BID Other ______________ YES 125mg Other ______________ Unknown TID Unknown Frequency: Once a Day BID Other ______________ QID Taper: NO 250mg YES Unknown TID Unknown NO Fidaxomicin (Dificid) - PO Start Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Dosage: QID Once a Day N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Dosage: 200mg Other ______________ Frequency: Start Date: ______/______/______ BID Other ______________ Other ______________ Unknown TID Unknown Dosage: 200mg Frequency: QID Once a Day BID Other ______________ Other ______________ Unknown Frequency: TID Dosage: 200mg Unknown QID Once a Day BID Other ______________ Other ______________ Unknown TID Unknown 200mg Frequency: QID Once a Day BID Other ______________ Unknown TID Unknown Public reporting burden of this collection of information is estimated to average 10 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0978). Page 1 of 2 State ID: Patient ID: Probiotics YES / Specimen Collection Date: / Stool Transplant NO YES If yes, specify: ____________________________________________________________ NO Start Date: N/A ______/______/______ Stop Date: ______/______/______ N/A Rifaximin (Xifaxan) – PO Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Dosage: Dosage: 400mg Other ______________ Frequency: Once a Day QID Other ______________ Unknown Frequency: TID BID Other ______________ Dosage: 400mg QID Unknown Once a Day BID Other ______________ Other ______________ Unknown Frequency: TID Dosage: 400mg Once a Day QID Unknown Other ______________ Unknown Frequency: TID BID Other ______________ 400mg QID Unknown Once a Day BID Other ______________ Unknown TID Unknown Nitazoxanide (Alinia, Annita) – PO Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Start Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Stop Date: ______/______/______ N/A Dosage: Dosage: 500mg Other ______________ Frequency: Once a Day QID Frequency: TID BID Other ______________ Dosage: 500mg Other ______________ Unknown QID Unknown Once a Day BID Other ______________ Other ______________ Frequency: TID Dosage: 500mg Unknown Once a Day QID Unknown Frequency: TID BID Other ______________ 500mg Other ______________ Unknown QID Unknown Once a Day BID Other ______________ Unknown TID Unknown Other Specify: ________________________________ Route: Start Date: Dosage: PO Rectal IV IM Route: Unknown N/A ______/______/______ _________________ Specify: ________________________________ Unknown Stop Date: ______/______/______ Frequency: _________________ N/A Unknown Start Date: Dosage: PO Rectal IV IM _________________ Route: Unknown N/A ______/______/______ Unknown Stop Date: ______/______/______ Frequency: _________________ N/A Unknown Start Date: Dosage: PO Rectal IV ______/______/______ _________________ IM IV IM Unknown N/A ______/______/______ _________________ Unknown Stop Date: ______/______/______ Frequency: _________________ N/A Unknown Start Date: Dosage: PO Rectal IV IM Unknown N/A ______/______/______ _________________ Unknown Stop Date: ______/______/______ Frequency: _________________ N/A Unknown Specify: ________________________________ Specify: ________________________________ Route: Dosage: Rectal Specify: ________________________________ Specify: ________________________________ Route: Start Date: PO Route: Unknown N/A Unknown Stop Date: ______/______/______ Frequency: _________________ N/A Unknown Start Date: Dosage: PO Rectal IV IM ______/______/______ _________________ Unknown N/A Unknown Stop Date: ______/______/______ Frequency: _________________ N/A Unknown comments Page 2 of 2 CS253103
| File Type | application/pdf |
| File Title | EIP CDI Surveillance: CDI Case Treatment Questionnaire |
| File Modified | 2014-11-19 |
| File Created | 2014-11-19 |