Fungal Infection Pre-Infusion Data

Transcription

1 Fungal Infection Pre-Infusion Data Registry Use Only Sequence Number: Date Received: CIBMTR Center Number: Event date: / / CIBMTR Form 2046 revision 5 (page 1 of 5). Last Updated May, 2018.

2 Infection Episode Information for this report should come from an actual examination by the Transplant Center physician, or the physician who is following the recipient pre-hct / pre-infusion, or abstraction of the recipient s medical records. 1. Organism: 211 Aspergillus flavus 212 Aspergillus fumigatus 213 Aspergillus niger 215 Aspergillus terreus 214 Aspergillus ustus 210 Aspergillus, NOS 270 Blastomyces (dermatitidis) 201 Candida albicans 208 Candida non-albicans 222 Cryptococcus gattii 221 Crytococcus neoformans 230 Fusarium (all species) 261 Histoplasma (capsulatum) 241 Mucorales (all species) 242 Rhizopus (all species) 272 Scedosporium (all species) 240 Zygomycetes, NOS 503 Suspected fungal infection 2. Date of infection diagnosis: / / Specify all diagnostic tests performed, which had a positive result, to determine the diagnosis of the fungal infection. 3. Radiographic findings (e.g. x-ray, CT, or MRI) 4. Specify imaging sites that supported the diagnosis of fungal infection: (check all that Abdomen / pelvis Brain Chest Sinus Other imaging site 5. Specify other imaging site: CIBMTR Form 2046 revision 5 (page 2 of 5). Last Updated May, 2018.

3 6. Pathology (e.g. biopsy, cytology) 7. Specify sample source that supported the diagnosis of fungal infection: (check all that Brain / central nervous system (CNS) 8. Specify other sample source: 9. Culture 10. Specify sample source that supported the diagnosis of fungal infection: (check all that Brain / central nervous system (CNS) 11. Specify other sample source: 12. KOH / Calcofluor / Giemsa stain 13. Specify sample source that supported the diagnosis of fungal infection: (check all that Central nervous system (CNS) 14. Specify other sample source: CIBMTR Form 2046 revision 5 (page 3 of 5). Last Updated May, 2018.

4 15. Galactomannan assay 16. Specify sample source that supported the diagnosis of fungal infection: (check all that 17. Specify other sample source: 18. 1,3-Beta-D-glucan (Fungitell) assay 19. Specify sample source that supported the diagnosis of fungal infection: (check all that 20. Specify other sample source: 21. PCR assay 22. Specify sample source that supported the diagnosis of fungal infection: (check all that Tissue 23. Specify other sample source: - Go to question Specify tissue: (check all that Brain Lung Other tissue 25. Specify other tissue: CIBMTR Form 2046 revision 5 (page 4 of 5). Last Updated May, 2018.

5 Treatment of Infection Specify all medications received by the recipient from 7 days prior to the date of infection diagnosis until the end of the reporting period for this form. If the recipient received the medication, please record the date that the medication started. 26. Did the recipient receive any therapy between 7 days prior to the date of infection diagnosis and the date of infusion? 27. Antifungal drugs Amphotericin products (Amphocin, Fungizone, Ambisome, Abelcet, Amphotec) Anidulafungin (Eraxis) Caspofungin (Cancidas) Fluconazole (Diflucan) Isavuconazole (Cresemba) Itraconazole (Sporanox) Micafungin (Mycamine) Posaconazole (Noxafil) Voriconazole (Vfend) Other antifungal drug 28. Specify other antifungal drug: 29. Date therapy started Known 30. Date started: / / Date estimated Copy and complete questions to report multiple antifungal drugs 31. What was the status of the infection? (at the last evaluation prior to the start of the preparative regimen) Ongoing Improved Resolved First Name: Last Name: address: Date: / / CIBMTR Form 2046 revision 5 (page 5 of 5). Last Updated May, 2018.