Antifungal-resistant dermatophytosis case report form re

[NCEZID] Characteristics of Cases of Priority Fungal Diseases

Att 3f- Antifungal-resistant dermatophytosis case report form

OMB: 0920-1385

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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. What is your race and/or ethnicity? (select all that apply and enter additional details in the spaces provided)

American Indian or Alaska Native

Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

____________________________________________


Asian – provide details below

Chinese □ Asian Indian □ Filipino □ Vietnamese □ Korean □ Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

____________________________________________


Black or African American – provide details below

African American □ Jamaican □ Haitian □ Nigerian □ Ethiopian □ Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc. ____________________________________________



Hispanic or Latino – provide details below

Mexican □ Puerto Rican □ Salvadoran □ Cuban □ Dominican □ Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc. ____________________________________________


Middle Eastern or North African – provide details below

Lebanese □ Iranian □ Egyptian □ Syrian □ Iraqi □ Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc. ____________________________________________


Native Hawaiian or Pacific Islander – provide details below

Native Hawaiian □ Samoan □ Chamorro □ Tongan □ Fijian □ Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc. ____________________________________________


White – provide details below

English □ German □ Irish □ Italian □ Polish □ Scottish

Enter, for example, French, Swedish, Norwegian, etc. ____________________________________________


5. Patient’s country of primary residence (e.g., USA)


_______________________ □ Unknown

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

_______________________ □ Unknown

7. Patient's county of primary residence (Please do not write the word “County”; for example, write “Cook” instead of “Cook County”):



_______________________ □ Unknown

8. Patient’s city of primary residence


_______________________ □ Unknown

9. Patient’s ZIP code of primary residence


_______________________ □ Unknown

10. 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: _____________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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).


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