Form 2046 R3.0: Fungal Infection Pre-HSCT Date

Transcription

1 Key Fields Sequence Number: Date Received: - - CIBMTR Center Number: CIBMTR Recipient ID: Today's Date: - - Date of HSCT for which this form is being completed: - - HSCT type: (check all that apply) Autologous Allogeneic, unrelated Allogeneic, related Syngeneic (identical twin) Product type: (check all that apply) Marrow PBSC Cord blood Other product Specify: History of Clinically Significant Fungal Infection Questions: Aspergillus yes no Specify the following for the first incidence of Aspergillus infection: 2 Specify the Aspergillus species: 3 If Other Aspergillus, please specify: 4 Specify the site of infection: 5 Specify the date of onset: First diagnostic test: 7 Second diagnostic test: 8 Third diagnostic test: Specify the following for the second incidence of Aspergillus infection: 9 Specify the Aspergillus species: 10 If Other Aspergillus, please specify: 11 Specify the site of infection: 12 Specify the date of onset: First diagnostic test: 14 Second diagnostic test: 15 Third diagnostic test: 16 Fusarium yes no Specify the following for the first incidence of Fusarium infection: 17 Specify the site of infection: 18 Specify the date of onset: - - The Medical College of Wisconsin, Inc. All rights reserved. Page 1 / 7

2 19 First diagnostic test: 20 Second diagnostic test: 21 Third diagnostic test: Specify the following for the second incidence of Fusarium infection: 22 Specify the site of infection: 23 Specify the date of onset: First diagnostic test: 25 Second diagnostic test: 26 Third diagnostic test: Mucormycosis yes no Specify the following for the first incidence of Mucormycosis infection: 28 Specify the site of infection: 29 Specify the date of onset: First diagnostic test: 31 Second diagnostic test: 32 Third diagnostic test: 33 Specify the site of infection: 34 Specify the date of onset: First diagnostic test: 36 Second diagnostic test: 37 Third diagnostic test: Rhizopus yes no Specify the following for the first incidence of Rhizopus infection: 39 Specify the site of infection: 40 Specify the date of onset: First diagnostic test: 42 Second diagnostic test: 43 Third diagnostic test: Specify the following for the second incidence of Rhizopus infection: 44 Specify the site of infection: 45 Specify the date of onset: First diagnostic test: 47 Second diagnostic test: 48 Third diagnostic test: 49 Zygomycetes yes no Specify the following for the first incidence of Zygomycetes infection: 50 Specify the site of infection: The Medical College of Wisconsin, Inc. All rights reserved. Page 2 / 7

3 51 Specify the date of onset: First diagnostic test: 53 Second diagnostic test: 54 Third diagnostic test: Specify the following for the second incidence of Zygomycetes infection: 55 Specify the site of infection: 56 Specify the date of onset: First diagnostic test: 58 Second diagnostic test: 59 Third diagnostic test: History of Antifungal Therapy Questions: IV amphotericin (Fungizone) (1) Questions: Course given? yes no 61 Date Started Daily Dose: mg 63 Reason for antifungal therapy started: Prophylaxis 64 Therapy Stopped? yes no 65 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity IV amphotericin lipid formulation (e.g., Abelcet, AmBisome, Amphotec) (1) Questions: Course given? yes no 68 Specify therapy given: 69 Date Started Daily Dose: mg 71 Reason for antifungal therapy started: Prophylaxis The Medical College of Wisconsin, Inc. All rights reserved. Page 3 / 7

4 72 Therapy Stopped? yes no 73 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity Caspofungin (Cancidas) (1) Questions: Course given? yes no 76 Date Started Daily Dose: mg 78 Reason for antifungal therapy started: Prophylaxis 79 Therapy Stopped? yes no 80 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity Fluconazole (Diflucan) (1) Questions: Course given? yes no 83 Date Started Daily Dose: mg 85 Reason for antifungal therapy started: Prophylaxis 86 Therapy Stopped? yes no 87 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity Itraconazole (Sporanox) (1) Questions: The Medical College of Wisconsin, Inc. All rights reserved. Page 4 / 7

5 89 Course given? yes no 90 Date Started Daily Dose: mg 92 Reason for antifungal therapy started: Prophylaxis 93 Therapy Stopped? yes no 94 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity Micafungin (Mycamine) (1) Questions: Course given? yes no 97 Date Started Daily Dose: mg 99 Reason for antifungal therapy started: Prophylaxis 100 Therapy Stopped? yes no 101 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity Posaconazole (Noxafil) (1) Questions: Course given? yes no 104 Date Started Daily Dose: mg The Medical College of Wisconsin, Inc. All rights reserved. Page 5 / 7

6 106 Reason for antifungal therapy started: Prophylaxis 107 Therapy Stopped? yes no 108 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity Voriconazole (Vfend) (1) Questions: Course given? yes no 111 Date Started Daily Dose: mg 113 Reason for antifungal therapy started: Prophylaxis 114 Therapy Stopped? yes no 115 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity 117 Specify drug level: µg/ml 118 Date: - - not tested / unknown 119 Specify drug level: µg/ml 120 Date: - - not tested / unknown 121 Specify drug level: µg/ml 122 Date: - - not tested / unknown 123 Course given? Other Systemic Antifungal Agent (1) Questions: yes no 124 Specify antifungal agent: 125 Date Started Daily Dose: mg The Medical College of Wisconsin, Inc. All rights reserved. Page 6 / 7

7 127 Reason for antifungal therapy started: Prophylaxis 128 Therapy Stopped? yes no 129 Date Stopped Reason antifungal therapy stopped: Therapy complete Toxicity First Name: Phone number: Last Name: Fax number: address: The Medical College of Wisconsin, Inc. All rights reserved. Page 7 / 7