Fungal Infection Post-Infusion Data
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1 Fungal Infection Post-Infusion Data Registry Use Only Sequence Number: Date Received: CIBMTR Center Number: Event date: / / Visit: 100 day 6 months 1 year 2 years >2 years. Specify: CIBMTR Form 2146 revision 4 (page 1 of 6). 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 post-hct / post-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 Bone Brain Chest Sinus Other imaging site 5. Specify other imaging site: CIBMTR Form 2146 revision 4 (page 2 of 6). 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) Eye Lung (includes sputum) Spleen 8. Specify other sample source: 9. Culture 10. Specify sample source that supported the diagnosis of fungal infection: (check all that Bone Brain / central nervous system (CNS) Eye Lung (includes sputum) Spleen 11. Specify other sample source: 12. KOH / Calcofluor / Giemsa stain 13. Specify sample source that supported the diagnosis of fungal infection: (check all that Bone Central nervous system (CNS) Lung (includes sputum) Spleen 14. Specify other sample source: CIBMTR Form 2146 revision 4 (page 3 of 6). Last Updated May, 2018.
4 15. Galactomannan assay 16. Specify sample source that supported the diagnosis of fungal infection: (check all that Bronchial fluid (BAL) Cerebrospinal fluid (CSF) 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 Bronchial fluid (BAL) Cerebrospinal fluid (CSF) 20. Specify other sample source: 21. PCR assay 22. Specify sample source that supported the diagnosis of fungal infection: (check all that Bronchial fluid (BAL) Cerebrospinal fluid (CSF) Tissue - Also answer question 24 - Also answer question Specify other sample source: - Go to question Specify tissue: (check all that Brain Eye Lung Other tissue 25. Specify other tissue: CIBMTR Form 2146 revision 4 (page 4 of 6). Last Updated May, 2018.
5 Hematologic Findings at Diagnosis of Infection Provide values closest to the date of diagnosis of the infection (+/- 7 days) 26. Date of complete blood count: / / 27. WBC: 29. Neutrophils 31. Monoctyes 33. Lymphoctyes 35. Platelets 28. x 10 9 /L (x 10 3 /mm 3 ) x 10 6 /L 30. % 32. % 34. % 36. x 10 9 /L (x 10 3 /mm 3 ) x 10 6 /L 37. Serum creatinine 38. mg/dl mmol/l µmol/l 39. Upper limit of normal for your institution: mg/dl mmol/l µmol/l 40. ALT (SGPT) 41. U/L µkat/l 42. Upper limit of normal for your institution: U/L µkat/l CIBMTR Form 2146 revision 4 (page 5 of 6). Last Updated May, 2018.
6 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. 43. Did the recipient receive any therapy between 7 days prior to the date of infection diagnosis and the date of contact for this reporting period? 44. 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 45. Specify other antifungal drug: 46. Date therapy started 47. Date started: / / Date estimated 48. Was this therapy still being given at 30 days (± 3 days) after the date of diagnosis of infection? (for cases where 30 days (± 3 days) falls in the next reporting period, indicate if the recipient was still receiving this therapy at the date of last contact) Copy and complete questions to report multiple antifungal drugs 49. What was the status of the infection? (at the end of the reporting period) Ongoing Improved Resolved First Name: Last Name: address: Date: / / CIBMTR Form 2146 revision 4 (page 6 of 6). Last Updated May, 2018.
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