## Form C - entering CDI patient and infection data

Form C is applicable only to the Light and Enhanced surveillance options. The Minimal surveillance option does not record case-based data

To enter CDI patient and infection data:

1. Click Patient / CDI / Microbiological data in the CDI main menu.

A form equivalent to the upper section of Form C opens.

2. Click the Add item icon or press Ctrl+N to open the form for editing.

3. Enter the patient’s age and gender and, optionally, an internal patient code.

The fields are described in Table 8. Mandatory fields are indicated by a red asterisk *. Required fields are indicated by a black asterisk *.

Important: please note that to avoid data privacy infringement, internal patient codes must be removed from any data submitted to ECDC/TESSy.

Table 8: CDI Form C variables, part 1

Variable | Description
Hospital code | The hospital identifier/code for the hospital selected for the survey. Inserted by the system.
CDI Surveillance option | Minimal, Light or Enhanced. From Form H.
Surveillance period from | The start date for the survey. From Form H.
To | The end date for the selected survey. From Form H. The field is blank if the end date has not yet been defined for this survey.
Patient counter | A system allocated sequential patient number for anonymised identification. In enhanced surveillance, this number should permit linkage of patient data with microbiological typing/susceptibility data and patient data from enhanced surveillance.
Internal patient code | For hospital internal use only. Optional. Must be removed from any data submitted to ECDC/TESSy.
Sex * | Gender of the patient: M (male), F (female).
Age in year(s) * | Patient’s age in years; if missing=unknown (UNK). Enter respectively 0 or 1 if the patient is less than two years old.
If age less than 2 years | Patient’s age in months. Mandatory if Age in years is less than 2 (note that you must also enter the baby’s Age in years).

4. Click Enter CDI episode data.

A form equivalent to the lower section of Form C opens.

Note that the Enter form M data button is only displayed for the Enhanced surveillance option. See also Form M - entering CDI microbiological data.

5. Enter the patient’s CDI data, see Table 9. Mandatory fields are indicated by a red asterisk *. Required fields are indicated by a black asterisk *.

6. Enter Yes, No, or Unknown for Microbiological data collected for this patient. If you have entered:

• No or Unknown – then click the Save icon or press Ctrl+S to save and exit.

• Yes and you are working in the Light option – then click the Save icon or press Ctrl+S to save and exit.

• Yes and you are working in the Enhanced option – click Enter form M Data and proceed to Entering CDI microbiological data.

If any mandatory or required data field is empty when you save, e.g. because you do not yet have the data, an error and/or warning message is shown and the field label is highlighted as a reminder - in red for a mandatory field (you cannot save) or blue for a required field. See Understanding reported errors.

You can now see the Form C data in the List of episodes tab (click Refresh).

Table 9: CDI Form C variables, part 2

Variable | Description
Hospital code | The hospital identifier/code for the hospital selected for the survey. Inserted by the system.
CDI surveillance option | Minimal, Light or Enhanced. From Form H.
Surveillance period from | The start date previously selected for the survey. From Form H.
To | The end date for the survey. From Form H. The field is blank if the end date has not yet been defined for this survey.
Patient counter | System assigned sequential patient number for anonymised identification. In Enhanced surveillance the counter links patient data with microbiological typing/susceptibility data.
Internal patient code | Optional. From Form C, part 1. Must be removed from any data submitted to ECDC/TESSy.
Sex | From Form C, part 1.
Age in year(s) | From Form C, part 1.
CDI episode counter | System assigned sequential number for episode identification.
Ward name/unit ID | Abbreviated name of hospital ward; it should be used consistently and should remain the same in different surveillance periods/years.
Ward specialty | Enter the code for the main ward specialty. See Protocol for the ward specialty code list.
Previous healthcare admission | Previous admission in a healthcare facility in the last three months relative to the onset of CDI: Yes/No/Unknown. If yes: admission in a hospital or another healthcare facility (long-term care, outpatient department, etc.). Collect from electronic records and/or patient notes, and/or by asking the patient.
Date of hospital admission * | Date patient was admitted to the hospital for the current hospitalisation (dd/mm/yyyy).
Patient/ consultant specialty | Enter the code for the specialty of the physician in charge of the patient; this may differ from the ward/unit specialty. See Protocol for the ward specialty code list.
McCabe score | Classification of the severity of underlying medical conditions. Disregard the influence of an active CDI, i.e. estimate the score the patient had before the infection. Some examples of diseases and their different McCabe score categories are shown in Table 6. These examples, in particular those of the second (ultimately fatal) category, are not meant to be exhaustive but rather to serve as a guidance tool for the current protocol.
Symptoms of CDI present on admission | Patient had CDI symptoms when admitted for this episode. Yes/No/Unknown.
Date of onset of CDI symptoms * | Mandatory if symptom onset was during current hospitalisation, but not recorded if signs/symptoms were present on admission. Record the date of the first signs or symptoms of the infection (dd/mm/yyyy). If unknown, record the date treatment was started for this infection or the date the first diagnostic sample was taken. If no treatment or sample, please estimate. If no date is entered, today’s date is selected by default. This date can later be changed.
Date of first positive sample | Date on which the first positive diagnostic stool sample was taken from the patient referred to on this form.
Recurrent CDI * | Choose yes if the patient had an episode of CDI (return of diarrhoeal stools with a positive laboratory test after the end of treatment) more than two weeks and less than eight weeks following the onset of a previous episode.
CDI case origin * | Choose one (for detailed definitions, see Definitions section): • Healthcare-associated CDI: A case with onset of symptoms on day three or later, following admission to a healthcare facility on day one, OR in the community within four weeks of discharge from any healthcare facility. This may apply to the current hospital or a previous stay in another healthcare facility, e.g. in another hospital, a long-term care facility or other healthcare facilities (e.g. outpatient departments etc.). • Community-associated CDI: A case with [onset outside of healthcare facilities, AND without discharge from a healthcare facility within the previous 12 weeks] OR [onset on the day of admission to a healthcare facility or on the following day AND not resident in a healthcare facility within the previous 12 weeks]. • Unknown association: A case discharged from a healthcare facility 4–12 weeks before symptom onset.
Complicated course of CDI * | Yes / No / Unknown. CDI leading to any of the following: • Admission to a healthcare facility for treatment of community-associated CDI. • Admission to an intensive care unit for treatment of CDI or its complications (e.g. for shock requiring vasopressor therapy). • Surgery (colectomy) for toxic megacolon, perforation or refractory colitis. • Death within 30 days after diagnosis if CDI is either a primary or contributing cause.
Patient outcome * | Status of the patient at hospital discharge or at end of follow-up in the hospital • Discharged alive: patient was discharged alive; OR patient was still in the hospital and alive at end of follow-up during this hospital stay. • Death, CDI definitely contributed to death: use this category if a causal link between CDI and death can be demonstrated.
Date of discharge/ in-hospital death | Date the patient was discharged from the hospital; OR date of end of follow-up if the patient was still hospitalised and alive; OR date of death if patient died during the current hospitalisation.
Microbiological data collected for this patient * | Yes/No/UNK. Indicate whether Form M has been completed.

More:

Case-based data User tab

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