Triazole-resistant Aspergillus fumigatus Case Report For

Form Approved

OMB No. 0920-1385

Exp. Date: 3/31/26

Triazole-resistant Aspergillus fumigatus 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: _________________ Date of incident specimen collection (DISC)*: ______-______-___________ (mm-dd-yyyy) *This is the earliest date that a patient had a positive test for triazole-resistant A. fumigatus
	A. Patient demographics
	1. Age at DISC: (use months or days if patient was aged <2 years)	________ □ Years □ Months □ Days □ Unknown
	2.Assigned sex at birth	□ Male □ Female □ Unknown
3. Gender identity		□ Male □ Female □ Transgender, non-binary, or another gender □ Prefer not to answer/Decline □ Unknown
	4. Ethnic origin	□ Hispanic or Latino □ Not Hispanic or Latino □ Unknown
	5. Race (select all that apply)	□ American Indian/Alaska Native □ Asian □ Black/African American □ Native Hawaiian/Pacific Islander □ White □ Unknown
	6. Patient's county of residence (Please do not write the word “County”; for example, write “Cook” instead of “Cook County”):	_______________________ □ Unknown
	7. Patient’s state, jurisdiction, or territory of residence	_______________________ □ Unknown
	8. Patient’s country of residence (e.g., USA)	_______________________ □ Unknown
	9. Healthcare facility name (Note: ‘healthcare facility’ refers to the facility where the patient’s incident specimen was collected)	_______________________ □ Unknown
	10. Healthcare facility CMS ID #	_______________________ □ Unknown

A. Patient Demographics (continued)
11. Healthcare facility ZIP code	_______________________ □ Unknown
12. Healthcare facility state, jurisdiction, or territory	_______________________ □ Unknown
13. Healthcare facility type	□ Acute care hospital (ACH) □ Long-term acute care hospital (LTACH) □ Skilled nursing facility with ventilated residents (vSNF) □ Skilled nursing facility without ventilated residents (SNF) □ Outpatient □ Unknown □ Other ________________________

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:____________ □ Chemotherapy If yes, specify: ________________	3. Chronic pulmonary diagnosis □ Yes □ No □ Unknown □ Chronic obstructive pulmonary disease (COPD) or emphysema □ Bronchiectasis □ Cystic fibrosis □ Allergic bronchopulmonary aspergillosis (ABPA) □ Pulmonary fibrosis □ Asthma □ Interstitial Lung Disease □ Other chronic pulmonary diagnosis (specify):____________
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. Positive respiratory viral test in 120 days before or after DISC □ Yes □ No □ Unknown If yes, (select all that apply): □ SARS-CoV-2 (PCR or antigen test) □ antigen □ PCR □ unknown test type □ Influenza □ Other respiratory virus (specify) ________________	5. Transplant received within 2 years before DISC □ Yes □ No □ Unknown □ Solid organ transplant: □ Lung □ Heart □ Kidney □ Pancreas □ Liver □ Skin graft □Other:___________________________ □ Hematopoietic stem cell transplant (HSCT)
6. Other selected conditions: □ Yes □ No □ Unknown □ Cardiovascular disease (specify): _________________ □ Diabetes mellitus □ End stage renal disease/dialysis □ Autoimmune disease(s) or inherited immunodeficiency(-ies) (specify): _________________________ □ Medications/therapies that weaken the immune system □ TNF-alpha inhibitors (e.g., infliximab, adalimumab, etanercept) □ Other (specify): ____________________________________________ □ Cirrhosis □ Liver disease without cirrhosis □ Systemic lupus erythematosus □ Active tuberculosis □ Pregnant □ Pregnant on DISC Gestational age (weeks):_______ Unknown □ Post-partum (gave birth within 6 weeks before DISC)	7. Other potentially relevant clinical information? □ Yes (specify below) □ No □ Unknown ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

C. Patient diagnosis and outcomes
1. According to treating clinicians, which clinical syndrome(s) related to Aspergillus did the patient have?	□ Invasive pulmonary aspergillosis (IPA) □ Other disease/syndrome(s) related to A. fumigatus: ___________________ □ Aspergillus was not believed to be causing clinical illness or is not mentioned in medical records □ Unknown
2. Was the patient hospitalized at an acute care hospital in the 30 days before to 30 days after DISC?	□ Yes □ No □ Unknown If yes, dates of admission of hospitalization most proximal to DISC, Admission date: ______-______-___________ (mm-dd-yyyy) Discharge date: ______-______-___________ (mm-dd-yyyy) □ Still hospitalized If yes, Received ICU-level care in the 14 days before DISC?: □ Yes □ No □ Unknown Received ICU-level care in the 14 days after DISC?: □ Yes □ No □ Unknown Discharge ICD-10 diagnosis code(s): _________________________________
3. Died within 30 days after DISC?	□ No □ Yes, date of death _______ - _______- ______________ (mm-dd-yyyy) Cause(s) of death _________________ □ Unknown

	D. Antifungal treatment: Did the patient receive antifungal drugs during the 60 days before to 30 days after the DISC? □ Yes □ No □ Unknown (If yes, please complete the table below for each drug received).
Select one of the following to complete each row of the table
Amphotericin B lipid complex (ABLC) Liposomal Amphotericin B (L-AmB) Amphotericin B colloidal dispersion (ABCD) Anidulafungin (ANF)		Caspofungin (CAS) Fluconazole (Not mold-active) (FLC) Flucytosine (5FC) Ibrexafungerp (IBR)	Isavuconazole (ISA) Itraconazole (ITC) Micafungin (MFG) Posaconazole (PSC) Voriconazole (VRC)	Other drug (specify): ________________________ Unknown drug (UNK)

Drug Abbrev	b. First date given (mm-dd-yyyy)	c. Last date given (mm-dd-yyyy)	d. Indication	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	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection	□ 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	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection	□ 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	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection	□ 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	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection	□ 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	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection	□ Yes Date of earliest TDM: TDM level: Date of second TDM: TDM level: □ No

Supplemental patient interview form:

Note that “you” in these questions refers to the patient.

1. Person interviewed

□ Patient □ Someone other than the patient, (specify relationship to patient): _______________

2. What was your job or occupation before [DISC]?

___________________________ □ Unemployed □ Student □ Retired □ N/A

□ Refused to answer □ Unknown

3. What was your industry before [DISC]?

___________________________ □ Unemployed □ Student □ Retired □ N/A

□ Refused to answer □ Unknown

3. Did you travel outside of

[healthcare facility state] within 3 months before [DISC]?

(note: if healthcare facility is in a different state from patient’s residence, then please count time spent in the patient’s home state as “travel”)

List state(s), territory(-ies), jurisdiction(s), country(-ies)

□ Yes □ No □ Unknown

__________________________________________________________________

__________________________________________________________________

4. Did you perform any of the following activities during the 90 days before [DISC]

Gardening	□ Yes □ No □ Unknown
Handling compost	□ Yes □ No □ Unknown
Handling a fungicide product (agriculture) Handling a fungicide product (home gardening)	□ Yes □ No □ Unknown
Spending time on a farm	□ Yes □ No □ Unknown
If patient spent time on a farm in 90 days before DISC, describe location, type of crop(s) grown (if applicable), and activities performed on farm: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

Additional comments: _____________________________________________________________________________________________

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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).