Form 0920-22BG Case Report Form

Form Approved
OMB Control No.: 0920-XXXX
Exp. date: XX/XX/XXXX

Triazole-resistant Aspergillus fumigatus
Case Report Form

THIS SECTION IS COMPLETED BY CDC

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 (mm-dd-yyyy):

Date of incident specimen collection (DISC)* (mm-dd-yyyy):

*This is the earliest date that a patient had a positive test for triazole-resistant A. fumigatus

A. Patient demographics
1. Age at DISC (use months or days
if patient was aged <2 years):
● Years
● Months
● Days
● Unknown
4. Race (select all that apply):
■ American Indian/
Alaska Native
■ Asian
■ Black/African American

2. Sex:

3. Ethnic origin:

● Male
● Female
● Other (specify):

● Hispanic or Latino
● Not Hispanic or Latino
● Unknown

● Unknown

■ Native Hawaiian/
Pacific Islander
■ White
■ Unknown

6. Patient’s state, jurisdiction, or territory of residence:

5. Patient’s county of residence (Please do not write the word
“County”; for example, write “Cook” instead of “Cook County”):
■ Unknown
7. Patient’s country of residence (e.g., USA):
■ Unknown

■ Unknown

8. Healthcare facility name (Note: ‘healthcare facility’ refers to
the facility where the patient’s incident specimen was collected):

9. Healthcare facility CMS ID#:
■ Unknown

■ Unknown
10. Healthcare facility ZIP code:
■ Unknown

11. Healthcare facility state, jurisdiction, or territory:
■ Unknown

12. Healthcare facility type:
● Acute care hospital
● Long-term acute care hospital (LTACH)
● Skilled nursing facility with ventilated residents (vSNF)
● Skilled nursing facility without ventilated residents (SNF)

● Outpatient
● Unknown
● Other:

Public reporting burden of this collection of information is estimated to average 30 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 30333; ATTN: PRA 0920-XXXX.
CS 328137-A

3/29/2022

B. Patient underlying risk factors & medical conditions present during the 2 years before DISC
(unless other timeframe specified)
1. Cancer
● Yes
● No
● Unknown
2. HIV-infection
● Yes
● No
● Unknown

3. Chronic pulmonary diagnosis:

If yes (select all that apply):
■ Hematologic malignancy, specify type:
■ Solid organ malignancy, specify type:

If yes, choose one of the below:
Ever had CD4 < 200 cells/mm3 within past 6 months?
● Yes
● No
● Unknown
● Yes

● No

■ Chronic obstructive pulmonary disease (COPD)
or emphysema
■ Bronchiectasis
■ Cystic fibrosis
■ Allergic bronchopulmonary aspergillosis (ABPA)

4. Positive respiratory viral test
in 30 days before DISC?
● Yes
● No
● Unknown

5. Transplant received within
2 years before DISC?
● Yes
● No
● Unknown

● Unknown

■ Pulmonary fibrosis
■ Asthma
■ Interstitial lung disease
■ Other chronic pulmonary diagnosis (specify):

If yes, (select all that apply):
■ SARS-CoV-2 (PCR or antigen test), (if yes, select one):
or
Unknown test type
● Antigen
● PCR
■ Influenza
■ Other respiratory virus (specify):
If yes, specify:
■ Solid organ transplant (specify):
● Lung
● Heart
● Kidney
● Pancreas

● Liver
● Skin graft
● Other:

■ Hematopoietic stem cell transplant (HSCT)
6. Other selected conditions:
● Yes
● No
● Unknown

7. Other potentially relevant
clinical information?
● Yes
● No
● Unknown

If yes, specify:
■ Diabetes mellitus
■ End stage renal disease/dialysis
■ Autoimmune disease(s) or inherited
immunodeficiency(-ies), (specify):

If yes, specify:

■ Cirrhosis
■ Medications/therapies that weaken
the immune system (specify):

C. Patient diagnosis and outcomes
1. According to treating clinicians, which clinical syndrome(s) related to Aspergillus did the patient have?
■ Invasive pulmonary aspergillosis (IPA)
■ Other disease/syndrome(s) related to A. fumigatus:
OR
● Aspergillus was not believed to be causing clinical illness or is not mentioned in medical records
● Unknown
2. Was the patient
hospitalized at an acute
care hospital in the 30
days before to 30 days
after DISC?
● Yes
● No
● Unknown

3. Died within 30 days
after DISC?
● No
● Yes, date of death:

If yes, dates of admission of hospitalization most proximal to DISC:
Admission date (mm-dd-yyyy):

Discharge date: (mm-dd-yyyy):

■

Still hospitalized

If yes, received ICU-level care
in the 14 days before DISC?

Received ICU-level care
in the 14 days after DISC?

● Yes
● No
● Unknown

● Yes
● No
● Unknown

Discharge ICD-10
diagnosis code(s):

Cause(s) of death:
● Unknown

D. Antifungal treatment
Please use the table below to indicate antifungal drugs that the patient received during the 60 days before to 30 days after
the DISC. Indicate one of the following to complete each row of the table.
Amphotericin B lipid complex (ABLC)
Liposomal Amphotericin B (L-AmB)
Amphotericin B coloidal dispersion (ABCD)
Anidulafungin (ANF)
Caspofungin (CAS)
Fluconazole (not mold-active) (FLC)
a. Drug
Abbrev

Flucytosine (5FC)
Isavuconazole (ISA)
Itraconazole (ITC)
Micafungin (MFG)
Posaconazole (PSC)
Voriconazole (VRC)

Other drug (OTH) (specify):

Unknown drug (UNK)

b. First date given (mm-dd-yyyy)

c. Last date given (mm-dd-yyyy)

d. Indication

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

a. Drug
Abbrev

b. First date given (mm-dd-yyyy)

c. Last date given (mm-dd-yyyy)

d. Indication

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

● Start date unknown
● Start date was >60 days
before DISC

● Still on treatment at
time CRF completed
● Stop date unknown

● Prophylaxis
● Treatment for Aspergillus
● Treatment for non-Aspergillus infection

F. Supplemental patient interview form (Note that “you” in these questions refers to the patient.)
1. Person interviewed
● Patient
● Someone other than the patient,
(specify relationship to patient):

2. What was your job or occupation before [DISC]?
● Unemployed
● Retired
● N/A

● Refused to answer
● Unknown

3. Did you travel outside of [healthcare facility state] within 3 months before [DISC]? (note: if healthcare facility is in a
different state from patient’s residence, then please count time spent in the patient’s home state as “travel”)
● Yes
● No
● Unknown
If yes, list state(s), territory(-ies), jurisdiction(s), country(-ies):

4. Did you perform any of the following activities during the 90 days before [DISC]
Gardening

Yes No Unknown

Handling compost

Yes No Unknown

Handling a fungicide product

Yes No Unknown

Spending time on a farm

Yes No Unknown

If you spent time on a farm in the 90 days before [DISC], describe location, type of crop(s) grown (if applicable),
and activities performed on farm:

Additional comments: