Form M - ECDIS

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Transcript Form M - ECDIS

Form M: Strain shipment data sheet (enhanced protocol)
(one for each strain)
Network-Id:
Hospital code:
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Surveillance period: From (dd/mm/yyy):
Surveillance period: To (dd/mm/yyy):
Patient counter:
Age in years:
If < 2 years old, age in months:
Laboratory code:
Microbiological results:
Performed by the national reference laboratory:
yes
no
Production of toxins A and/or B:
positive
negative
Presence of binary toxin genes:
positive
negative
yes
no
PCR ribotype of C. difficile isolate:
Form Version 0.3
Performed by the national reference laboratory:
MIC determination to metronidazole: mg/l:
by:
MIC determination to vancomycin: mg/l:
by:
MIC determination to moxifloxacin: mg/l:
by:
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