Antifungal-resistant dermatophytosis case report form

Form Approved

OMB No. 0920-1385

Exp. Date: 3/31/26

Antifungal-resistant dermatophytosis case report form

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: _________________
A. Patient demographics
1. Age at DISC: (use months or days if patient was aged <2 years)	________ □ Years □ Months □ Days □ Unknown
2. Sex at birth	□ Male □ Female □ Unknown
3. Gender identity	□ Male □ Female □ Transgender, non-binary, or another gender □ Prefer not to answer/Decline □ Unknown
4. Ethnic origin	□ Hispanic or Latino □ Not Hispanic or Latino □ Unknown
5. Race (select all that apply)	□ American Indian/Alaska Native □ Asian □ Black/African American □ Native Hawaiian/Pacific Islander □ White □ Other (specify): _________________ □ Unknown Please specify any additional details noted in the chart about race/ethnic background (e.g., nationality, ethnic group): ____________
6. Patient’s country of primary residence (e.g., USA)	_______________________ □ Unknown
7. Patient’s state, jurisdiction, or territory of primary residence	_______________________ □ Unknown
8. Patient's county of primary residence (Please do not write the word “County”; for example, write “Cook” instead of “Cook County”):	_______________________ □ Unknown
9. Patient’s city of primary residence	_______________________ □ Unknown
10. Patient’s ZIP code of primary residence	_______________________ □ Unknown
11. Patient’s type of health insurance at DISC	□ Private □ Medicare □ Medicaid/state assistance program □ Military □ Indian Health Service □ Incarcerated □ Uninsured □ Unknown □ Other (specify): ____________________________________

B. Patient underlying risk factors & medical conditions present during the 2 years before DISC (unless other timeframe specified)
1. Cancer □ Yes □ No □ Unknown □ Hematologic malignancy specify type: _____________ □ Solid organ malignancy specify type:____________	3. Other immunocompromising conditions □ Yes □ No □ Unknown □ Transplant in the last 2 years □ Hematologic □ Solid organ □ Chemotherapy □ Chronic use of steroids □ Medications/therapies that weaken the immune system □ TNF-alpha inhibitors (e.g., infliximab, adalimumab, etanercept) □ Other (specify): ____________________________________________ □ Cirrhosis
2. HIV infection □ Yes □ No □ Unknown If yes, choose one of the below Ever had CD4 < 200 cells/mm3 within past 6 months □ Yes □ No □ Unknown
4. Other conditions □ Liver disease □ Cirrhosis □ Diabetes □ History of stroke, plegia, paralysis □ Chronic kidney disease □ Chronic respiratory failure □ Cardiac disease □ Other, specify: ______________	5. Other potentially relevant underlying conditions? □ Yes (specify below) □ No □ Unknown ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

C. Incident specimen data
1. Date of incident specimen collection (DISC)*: (mm-dd-yyyy) *This is the earliest date that a patient had a positive test for antifungal-resistant dermatophytosis	___ ___ - ___ ___ - ___ ___ ___ ___
2. Test type	□ Culture □ PCR
3. Body site	□ Tinea capitis (scalp, hair) □ Tinea barbae (beard) or faciei (face) □ Tinea manuum (hands) □ Tinea unguium (toenails) □ Tinea unguium (fingernails) □ Tinea genitalis (genitals) □ Tinea corporis (other parts of body such as arms or legs), specify: _________ □ Tinea cruris (groin, inner thighs, or buttocks) □ Tinea pedis (feet) □ Other body site specify: _________
4. Genus and species	□ Trichophyton mentagrophytes  □ Genotype VIII (T indotineae) □ Other genotype, specify: _______ □ Unknown genotype □ Trichophyton rubrum □ Other Trichophyton species Species: _______□ species unknown □ Microsporum  Species: _______ □ species unknown □ Epidermophyton  Species: _______□ species unknown □ Other genus (specify) __________ Species: _______□ species unknown
5. Antifungal susceptibility testing	Drug, minimum inhibitor concentration (MIC), mg/L (μg/mL) Terbinafine (Lamisil) ____________ Itraconazole (Sporanox) ___________ Amphotericin B ___________ Anidulafungin (Eraxis) ___________ Caspofungin (Cancidas) ___________ Fluconazole (Diflucan) ___________ Flucytosine (5FC) ___________ Ibrexafungerp (Brexafemme) ___________ Isavuconazole (Cresemba) ___________ Micafungin (Mycamine) ___________ Posaconazole (Noxafil) ___________ Voriconazole (Vfend) ___________
Molecular determinant of resistance (e.g., SQLE):	_________________________________________ □ Unknown

D. Patient diagnosis and outcomes

1. Patient location at time of incident specimen collection:   □ Hospital inpatient       □ Intensive care unit             □ Surgery/OR            □ Radiology            □ Other inpatient _______________

□ Outpatient       □ Emergency room            □ Clinic/Provider’s office (specify)        □ Dermatologist □ Infectious Diseases □ Podiatrist □ Primary care (adult) □ Primary care (pediatrics) □ Other provider type, specify _______ □ Unknown provider type      □ Dialysis center            □ Surgery            □ Urgent care                      □ Observational/clinical decision unit           □ Other outpatient ____________________

□ Long-term care facility (LTCF)  □ Long-term acute care hospital (LTACH)    □ Autopsy  □ Unknown  □ Other ____________________

2. Rash onset date (mm/dd/yyyy): ____/_____/_______

3. Indicate body site(s) affected.

□ Tinea capitis (scalp, hair)

□ Tinea barbae (beard)

□ Tinea manuum (hands)

□ Tinea unguium (toenails)

□ Tinea unguium (fingernails)

□ Tinea genitalis (genitals)

□ Tinea corporis (other parts of body such as arms or legs), specify: _________

□ Tinea cruris (groin, inner thighs, or buttocks)

□ Tinea pedis (feet)

□ Other body site, specify: _________

□ Unknown

4. Date of most recent follow-up for rash (within 90 days after DISC) (mm/dd/yyyy): ____/_____/_______

Compared with the patient's rash on DISC, what was the status of the patient's rash at most recent follow-up?

□ Worse

□ Neither better nor worse

□ Improving, but not fully resolved

□ Fully resolved

□ Unknown

E. Antifungal treatment: Did the patient receive antifungal drugs during the 90 days before to 60 days after the DISC? □ Yes □ No □ Unknown (If yes, please complete the table below for each drug received)
Systemic antifungals Amphotericin B lipid complex (ABLC) Liposomal Amphotericin B (L-AmB) Amphotericin B colloidal dispersion (ABCD) Anidulafungin (ANF) Caspofungin (CAS)	Fluconazole (FLC) Flucytosine (5FC) Griseofulvin (GSF) Ibrexafungerp (IBR) Isavuconazole (ISA) Itraconazole (ITC)	Micafungin (MFG) Terbinafine (TRB-S) Posaconazole (PSC) Voriconazole (VRC) Other systemic drug (specify) (OTH-S): _________	Unknown drug (UNK-S)
Topical antifungals
Butenafine (BTF) Ciclopirox (CPX) Clotrimazole (CTZ) Clotrimazole-betamethasone dipropionate (CBM)	Econazole (ECZ) Efinaconazole (EFZ) Ketoconazole (KTC) Luliconazole (LCZ) Miconazole (MCZ)	Naftifine (NFT) Nystatin- triamcinolone (NTC) Oxiconazole (OCZ) Sertaconazole (STC)	Tavaborole (TVB) Terbinafine (TRB-T) Terconazole (TCZ) Other topical antifungal (specify) (OTH-T): _________ Unknown drug (UNK-T)
Drug Abbrev	b. First date given (mm-dd-yyyy)	c. Last date given (mm-dd-yyyy)	e. Therapeutic drug monitoring (TDM)
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Yes Date of earliest TDM: TDM level: Date of second TDM: TDM level: □ No
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Yes Date of earliest TDM: TDM level: Date of second TDM: TDM level: □ No

E. Supplemental patient interview form: Note that “you” in these questions refers to the patient.
1. Have you traveled internationally during the two years before rash onset?	□ Yes  If yes, specify country/city/cities/dates: ______________ □ No  □ Unknown
2. Have you had any known exposures to possible ringworm during the month before rash onset?	□ Yes  If yes, specify country/city/cities/dates: ______________ If yes, select all that apply  □ Other person with possible ringworm  □ Animal with possible ringworm  If yes, what type of animal? □ Cat □ Dog □ Other, specify: ____________ □ Environment (e.g., public showers, gyms, shared equipment), specify: _________  □ Other, specify: ________________  □ No  □ Unknown  Provide any details of exposure that you might be relevant and are not captured above:__________________
3. How many people are in your household (including yourself) and how many developed signs symptoms of ringworm?	Number of people in the household _________ □ Unknown  Number of people in the household who developed possible ringworm _________ □ Unknown
4. Did you use topical steroids before this diagnosis?	□ Yes  If yes, name of drug(s), dose(s), duration(s): __________________________________________________  □ No
5. Did you use topical and/or systemic antibacterial medications before this diagnosis (including those purchased over-the-counter)?*	□ Yes  If yes, name of drug(s), method(s) of administration (e.g., oral, topical), dose, duration: __________________________________________________  □ No
6. Over the last week, how itchy, sore, painful, or stinging has your skin been?*	□ Very much □ A lot □ A little □ Not at all
7. Over the last week, how embarrassed or self-conscious have you been because of your skin?*	□ Very much □ A lot □ A little □ Not at all
8. Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
9. Over the last week, how much has your skin influenced the clothes you wear?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
10. Over the last week, how much has your skin affected any social or leisure activities?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
11. Over the last week, how much has your skin made it difficult for your to do any sport?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
12. Over the last week, has your skin prevented you from working or studying?*	□ Yes □ No If no, over the last week, how much has your skin been a problem at work or studying? □ A lot □ A little □ Not at all □ Not relevant □ Not at all □ Not relevant
13. Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
14. Over the last week, how much has your skin caused any sexual difficulties?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant
15. Over the last week, how much of a problem has the treatment for your skin been, for example by making your home messy, or by taking up time?*	□ Very much □ A lot □ A little □ Not at all □ Not relevant

*Questions were adapted from the Dermatology Life Quality Index (DLQI); approval obtained from DLQI Administrator.

Additional comments: _____________________________________________________________________________________________

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CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1385).