Form HAIC.400.7 CLOSTRIDIOIDES DIFFICILE INFECTION (CDI) SURVEILLANCE EM

1. PATIENT ID:

2. STATE ID:

3. SPECIMEN ID:

4. Date of incident C. diff+ stool collection (DISC):

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

Form Approved
OMB No. 092-0978
Expiration Date: 2/28/26

Patient’s Name:

Phone No.:

Address:
Address type:
5. STATE:

Hospital:

6a. COUNTY:

9. Diagnostic assay for C. diff
Not tested Unknown
9a. EIA Positive Negative
9b. GDH Positive Negative
Not tested Unknown
9c. Cytotoxin Positive Negative
Not tested Unknown
9d. NAAT (C. diff only) Positive Negative
Not tested Unknown
Not tested Unknown
9e. NAAT (GI panel) Positive Negative
9.e.1 If positive, was result suppressed? Yes No Unknown
9f. Other (specify): Positive Negative
Not tested Unknown

6b. PLANNING REGION:
7. LABORATORY ID
WHERE INCIDENT
SPECIMEN IDENTIFIED:
8. FACILITY ID WHERE
PATIENT TREATED:
10. DATE OF BIRTH:

12. SEX AT BIRTH:

14. RACE: (Check all that apply)

Male Female Unknown
Transgender

■ Unknown
11. AGE: (years)

Chart Number:

■ American Indian or
Alaska Native
■ Asian
■ Black or African American

13. ETHNIC ORIGIN:
Hispanic or Latino

Not Hispanic or Latino Unknown

15. Was the patient hospitalized on the day of or in the 6 calendar days after the DISC?
15a. If YES, Date of Admission:

■ Native Hawaiian or
Other Pacific Islander
■ White
■ Unknown

● Yes

● No

● Unknown

Unknown

16. Where was the patient located on the 3rd calendar day before the DISC?
● Private Residence
● LTACH
Facility ID:
●

Homeless
● LTCF
Facility ID:
● Incarcerated
● Hospital Inpatient
Facility ID:
● Other (specify):
16a. Was the patient transferred from this hospital?
● Unknown
● Yes No Unknown
17. Location of incident C. diff+ stool collection
● Outpatient
● Hospital Inpatient
Facility ID:
● Emergency room
● Clinic/doctor’s office
● Dialysis center
● Surgery
● Observation/Clinical decision unit
● Other outpatient

● LTCF

Facility ID:
● ICU
● OR
● Radiology
● Other inpatient

● Autopsy

Facility ID:

● Other (specify):

● LTACH
● Unknown

Facility ID:

18. HCFO classification questions:
18a. Was incident C. diff+ stool collected at least 3 calendar days after the date of hospital admission?
No
Yes (HCFO - go to 18d)
18b. Was incident C. diff+ stool collected in an outpatient setting for a LTCF resident, or in a LTCF or LTACH?
No
Yes (HCFO - go to 18d)
18c. Was the patient admitted from a LTCF or a LTACH?
(HCFO - go to 18d)
Yes–Facility ID:

No (CO - complete CRF)

18d. If HCFO, was this case sampled for full CRF?
Yes (Complete CRF)
No (STOP data abstraction here)
● 1

● 2

● 3

● 4

● 5

● 6

● 7

● 8

● 9

● 10

Public reporting burden of this collection of information is estimated to average 38 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).
CS 342179-A

8/3/2023

19. Patient Outcome:
Unknown
Survived Died
19a. Date of discharge:
Unknown
19c. Date of Death:
Left against medical advice (AMA)
19b. If survived, discharged to:
● LTACH Facility ID:
● Private residence
● LTCF Facility ID:

Unknown

● Other (specify):
● Unknown

20. Exposures to healthcare in the 12 weeks before the DISC
20a. Previous hospitalization Yes No Unknown

Facility ID:

20b. Overnight stay in LTACH Yes No Unknown

Facility ID:

20c. Overnight stay in LTCF Yes No Unknown

Facility ID:

20d. Chronic dialysis Yes No Unknown

20d.1 Type:

20e. Surgery

Yes No Unknown

20f. ER visit

Yes No Unknown

20g. Observation/CDU stay

Yes No Unknown

21. UNDERLYING CONDITIONS: (Check all that apply)
Chronic lung disease
■ Cystic fibrosis
■ Chronic pulmonary disease
Chronic metabolic disease
■ Diabetes mellitus
■ With chronic complications
Cardiovascular disease
■ CVA/Stroke/TIA
■ Congenital heart disease
■ Congestive heart failure
■ Myocardial infarction
■ Peripheral vascular disease (PVD)
Gastrointestinal disease
■ Diverticular disease
■ Inflammatory bowel disease
■ Peptic ulcer disease
■ Short gut syndrome
Immunocompromised condition
■ HIV
■ AIDS/CD4 count < 200
■ Primary immunodeficiency
■ Transplant, hematopoietic stem cell
■ Transplant, solid organ (specify):
22a. Weight
lbs oz OR
23. Substance Use

22b. Height
ft in OR

cm

Plegias/Paralysis
■ Hemiplegia
■ Paraplegia
■ Quadriplegia
Renal disease
■ Chronic kidney disease
Lowest serum creatinine:
mg/DL
■ Unknown or not done
Skin condition
■ Burn
■ Decubitus/pressure ulcer
■ Surgical wound
■ Other chronic ulcer or chronic wound
■ Other (specify):
Other
■ Connective tissue disease
■ Obesity or morbid obesity
■ Pregnancy

None

Substance

22c. BMI

Unknown

23b. Alcohol abuse:
● Yes
● No

● Unknown

Unknown

■ None Unknown
■ Tobacco
E-Nicotine Delivery System Marijuana

23c. Other substances: (Check all that apply)

Unknown

Hemodialysis Peritoneal Unknown

None Unknown
Liver disease
■ Chronic liver disease
■ Ascites
■ Cirrhosis
■ Hepatic encephalopathy
■ Variceal bleeding
■ Hepatitis C
■ Treated, in SVR
■ Current, chronic
Malignancy
■ Malignancy, hematologic
■ Malignancy, solid organ (non-metastatic)
■ Malignancy, solid organ (metastatic)
Neurologic condition
■ Cerebral palsy
■ Chronic cognitive deficit
■ Dementia
■ Epilepsy/seizure/seizure disorder
■ Multiple sclerosis
■ Neuropathy
■ Parkinson’s disease
■ Other (specify):

kg Unknown

23a. Smoking:

20a.1 If yes, date of discharge
closest to DISC:

Unknown
Mode of delivery: (Check all that apply)

Documented Use Disorder (DUD)/Abuse?

Marijuana/cannabinoid (other than smoking)

DUD or Abuse

IDU

skin popping non-IDU Unknown

Opioid, DEA schedule I (e.g., heroin)

DUD or Abuse

IDU

skin popping non-IDU Unknown

Opioid, DEA schedule II-IV (e.g., methadone, oxycodone)

DUD or Abuse

IDU

skin popping non-IDU Unknown

Opioid, NOS

DUD or Abuse

IDU

skin popping non-IDU Unknown

Cocaine

DUD or Abuse

IDU

skin popping non-IDU Unknown

Methamphetamine

DUD or Abuse

IDU

skin popping non-IDU Unknown

Other (specify):

DUD or Abuse

IDU

skin popping non-IDU Unknown

Unknown substance

DUD or Abuse

IDU

skin popping non-IDU Unknown

During the current hospitalization, did the patient receive medication assisted treatment (MAT) for opioid use disorder?
Yes No
N/A (patient not hospitalized or did not have DUD)
2

24. Was CDI a primary or contributing
reason for patient’s admission?
● Yes
● No
● Not admitted
● Unknown

25. Was ICD-9 008.45 or ICD-10 A04.7 listed
on the discharge form?
● Yes
● Not admitted
● No
● Unknown

26. Was the patient in an ICU on the day of or
in the 6 days after the DISC?
● Yes
● No
● Unknown

25a. If YES, what was the POA code assigned to it?
● Y, Yes
● W, Clinically Undetermined
● N, No
● Missing
● U, Unknown
● Not Applicable

■ Unknown

28. Fever (in the 2 calendar days before or calendar day
of the DISC)

27. Symptoms (in the 6 calendar days before, the day of, or 1 calendar day after the DISC)
(Check all that apply)

■ “Asymptomatic” documented in medical record
■ Diarrhea by definition (unformed or watery stool,
≥ 3/day for ≥ 1 day)
■ Diarrhea documented, but unable to determine
if it is by definition

26a. If YES, date of ICU admission:

■ Nausea
■ Vomiting
■ No diarrhea, nausea, or
vomiting documented
■ Information not available

■ Fever ≥38°C or ≥100.4°F documented
Highest fever documented:
■ Self-reported fever
■ No fever documented
■ Information not available

29. Toxic megacolon and ileus (in the 6 calendar days before, the day of, or the 6 calendar days after the DISC)
29b. Clinical findings
29a. Radiographic findings
■ Toxic megacolon
■ Neither toxic megacolon
■ Toxic megacolon
nor ileus
■ Ileus
■ Ileus
■ Radiology not performed
■ Both toxic megacolon and ilieus
■ Both toxic megacolon and ilieus
■ Information not available

°C or

■ Neither toxic megacolon
nor ileus
■ Information not available

30. Was pseudomembranous colitis listed in the surgical pathology,
endoscopy, or autopsy report in the 6 calendar days before,
the day of, or the 6 calendar days after the DISC?
● Yes
● Not Done
● No
● Information not available

31. Colectomy (related to CDI):

32. Were other enteric pathogens isolated from stool collected
on the DISC?
■ Astrovirus
■ Shigella
■ Campylobacter
■ Yersinia enterocolitica
■ Enteroaggregative E. coli (EAEC) ■ Other (specify):
■ Enteropathogenic E. coli (EPEC)
■ Enterotoxigenic E. coli (ETEC)
■ Norovirus
■ Rotavirus
■ Salmonella
■ None
■ No other
■ Sapovirus
pathogens tested
■ Shiga Toxin-Producing E.coli
■ Unknown

33. LABORATORY FINDINGS (in the 6 calendar days before, the day of,
or the 6 calendar days after the DISC)
33a. Albumin ≤ 2.5g/dl:
33c. White blood cell count
≥ 15,000/µl:
● Yes
● Yes
● No
● No
● Not Done
● Not Done
● Information not available
● Information not available
33b. White blood cell count
33d. S erum creatinine
≤ 1,000/µl:
> 1.5 mg/dl
● Yes
● Yes
● No
● No
● Not Done
● Not Done
● Information not available
● Information not available

34. MEDICATIONS taken in the 12 weeks before the DISC:
34a. Proton pump inhibitor (e.g. Omeprazole,
34b. H2 Blockers (e.g. Famotidine,
Lansoprazole, Pantoprazole, Rabeprazole)
Ranitidine, Cimetidine)
● Yes
● Yes
● No
● No
● Unknown
● Unknown
34d. Antimicrobial therapy (Check all that apply)
■ Amikacin
■ Amoxicillin
■ Amoxicillin/clavulanic acid
■ Ampicillin
■ Ampicillin/sulbactam
■ Azithromycin
■ Aztreonam
■ Cefadroxil
■ Cefazolin
■ Cefdinir
■ Cefepime
■ Cefiderocol
■ Cefixime
■ Cefotaxime
■ Cefoxitin

■ Yes, name unknown

■ Cefpodoxime
■ Ceftaroline
■ Ceftazidime
■ Ceftazidime/avibactam
■ Ceftizoxime
■ Ceftolozane/tazobactam
■ Ceftriaxone
■ Cefuroxime
■ Cephalexin
■ Ciprofloxacin
■ Clarithromycin
■ Clindamycin
■ Dalbavancin
■ Daptomycin
■ Delafloxacin

31a. If YES, Date of Procedure:

● Yes
● No
● Unknown

■ None

■ Unknown

34c. Immunosuppressive therapy (Check all that apply)
■ Steroids
■ None
■ Chemotherapy
■ Unknown
■ Other agents (specify):
■ Unknown

■ Doripenem
■ Doxycycline
■ Eravacycline
■ Ertapenem
■ Fosfomycin
■ Gentamicin
■ Imipenem/cilastatin
■ Levofloxacin
■ Linezolid
■ Meropenem
■ Meropenem/vaborbactam
■ Metronidazole
■ Moxifloxacin
■ Nitrofurantoin
■ Omadacycline

3

°F

■ Oritavancin
■ Penicillin
■ Piperacillin/tazobactam
■ Polymyxin B
■ Polymyxin E (colistin)
■ Rifaximin
■ Tedizolid
■ Telavancin
■ Tigecycline
■ Tobramycin
■ Trimethoprim
■ Trimethoprim/sulfamethoxazole
■ Vancomycin (IV)
■ Vancomycin (PO for prophylaxis)
■ Other (specify):

34e. Was patient treated for suspected or confirmed CDI in the 12 weeks before the DISC?
34f.1 If YES, which treatment was taken? (Check all that apply)

35. Treatment for incident CDI
35a.1 Course 1
Start Date:

■ No treatment

● No

● Unknown

■ Other, (specify):
■ Unknown

■ Unknown treatment

Stop Date:

Unknown

■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)

■ Metronidazole
■ Vancomycin
■ Fidaxomicin

● Yes

Unknown OR Duration (days):

■ Metronidazole (PO)
■ Metronidazole (IV)
■ Metronidazole (Unknown route)
■ Fidaxomicin

Unknown

■ Rifaximin
■ Nitazoxanide
■ Other (specify):

35a.2 Course 2
Start Date:
Unknown
■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)

Stop Date:
Unknown OR Duration (days):
■ Metronidazole (PO)
■ Rifaximin
■ Metronidazole (IV)
■ Nitazoxanide
■ Metronidazole (Unknown route)
■ Other (specify):
■ Fidaxomicin

Unknown

Stop Date:
Unknown OR Duration (days):
■ Metronidazole (PO)
■ Rifaximin
■ Metronidazole (IV)
■ Nitazoxanide
■ Metronidazole (Unknown route)
■ Other (specify):
■ Fidaxomicin

Unknown

Stop Date:
Unknown OR Duration (days):
■ Metronidazole (PO)
■ Rifaximin
■ Metronidazole (IV)
■ Nitazoxanide
■ Metronidazole (Unknown route)
■ Other (specify):
■ Fidaxomicin

Unknown

35a.3 Course 3
Start Date:
Unknown
■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)
35a.4 Course 4
Start Date:
Unknown
■ Vancomycin (PO)
■ Vancomycin (Rectal)
■ Vancomycin (Unknown route)
■ Vancomycin taper (any route)
35b. Probiotics (specify):
35c.

Stool transplant Date:

Unknown

36. Did the patient have a positive test(s) for SARS-CoV-2 (molecular
assay, antigen, or other viral test; excluding serology) in the 90 days
before or day of the DISC?
● Yes

● No

36a. Specimen collection dates for positive tests in the 90 days
before or day of DISC
36a.1. First positive test:

● Unknown

36a.2 Most recent positive test:

■ Date Unknown
37. COVID-NET Case IDs in the year before or day of DISC:
38. Previous unique CDI episode

(>8 weeks before the DISC):

● Yes
● No
38a. If YES, previous STATEID:

39. Any recurrent C. diff+
episodes following this
incident C. diff+ episode?
● Yes
● No

■ Date Unknown

None or N/A
40. CRF status:
● Complete
● Incomplete
● Chart unavailable after
3 requests

39a. If YES, Date of first
recurrent specimen:

Comments:

4

41. Initials of S.O.:

42. Date of abstraction: