Form 57.112 Ventilator-associated Event

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Ventilator-Associated Event (VAE)

Page 1 of 4							*required for saving **required for completion
Facility ID:					Event #:
*Patient ID:					Social Security #:
Secondary ID:					Medicare #:
Patient Name, Last:					First:					Middle:
*Gender: F M Other					*Date of Birth:
Ethnicity (Specify):					Race (Specify):
*Event Type: VAE					*Date of Event:
Post-procedure VAE: Yes No					Date of Procedure:
NHSN Procedure Code:					ICD-9-CM Procedure Code:
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
*Date Admitted to Facility:					*Location:
* Location of Mechanical Ventilation Initiation: ______________									*Date Initiated: __ /__ /_____		*APRV: Yes No
Event Details
*Specific Event:	□ VAC	□ IVAC		□ Possible VAP				□ Probable VAP
*Specify Criteria Used:
STEP 1: VAC (≥1 REQUIRED)
□ Daily min FiO2 increase ≥ 0.20 (20 points) for ≥ 2 days†						OR □ Daily min PEEP increase ≥ 3 cm H2O for ≥ 2 days†
†after 2+ days of stable or decreasing daily minimum values.
STEP 2: IVAC
□ Temperature > 38°C or < 36° OR □ White blood cell count ≥ 12,000 or ≤ 4,000 cells/mm3
AND
□ A new antimicrobial agent(s) is started, and is continued for ≥ 4 days
STEP 3: Possible VAP							STEP 3: Probable VAP
□ Purulent respiratory secretions‡ (defined as secretions from the lungs, bronchi, or trachea that contain >25 neutrophils and <10 squamous epithelial cells per low power field [lpf, x100], or equivalent semi-quantitative results)							□ Purulent respiratory secretions‡ AND one of the following (meeting quantitative or semi- quantitative threshold as outlined in protocol):‡ □ Positive culture of endotracheal aspirate □ Positive culture of bronchoalveolar lavage □ Positive culture of lung tissue □ Positive culture of protected specimen brushing OR □ One of the following results(without requirement for purulent respiratory secretions), as outlined in protocol:‡ □ Positive pleural fluid culture □ Positive lung histopathology □ Positive diagnostic test for Legionella spp. □ Positive diagnostic test for viral pathogens
OR □ One of the following (qualitative, semi-quantitative or quantitative):‡ □ Positive culture of sputum □ Positive culture of endotracheal aspirate □ Positive culture of bronchoalveolar lavage □ Positive culture of lung tissue □ Positive culture of protected specimen brushing
‡collected after 2 days of mechanical ventilation and within +/- 2 days of onset of increase in FiO2 or PEEP.
*Secondary Bloodstream Infection: Yes No
**Died: Yes No			VAE Contributed to Death: Yes No
Discharge Date:			*Pathogens Identified: Yes No *If Yes, specify on pages 2-3
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 22 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.112 (Front), Rev 2 v8.0

Ventilator-Associated Event (VAE)

Page 2 of 4
Pathogen #	Gram-positive Organisms
_______	Staphylococcus coagulase-negative			VANC S I R N
	(specify species if available): ____________
_______	____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level)			DAPTO S NS N	GENTHL§ S R N		LNZ S I R N	VANC S I R N
_______	Staphylococcus aureus	CIPRO/LEVO/MOXI S I R N		CLIND S I R N	DAPTO S NS N	DOXY/MINO S I R N		ERYTH S I R N	GENT S I R N	LNZ S R N
		OX/CEFOX/METH S I R N		RIF S I R N	TETRA S I R N	TIG S NS N		TMZ S I R N	VANC S I R N
Pathogen #	Gram-negative Organisms
_______	Acinetobacter (specify species) ____________	AMK S I R N	AMPSUL S I R N	AZT S I R N	CEFEP S I R N	CEFTAZ S I R N		CIPRO/LEVO S I R N		COL/PB S I R N
		GENT S I R N	IMI S I R N	MERO/DORI S I R N		PIP/PIPTAZ S I R N			TETRA/DOXY/MINO S I R N
		TMZ S I R N	TOBRA S I R N
_______	Escherichia coli	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N		CEFAZ S I R N	CEFEP S I R N	CEFOT/CEFTRX S I R N
		CEFTAZ S I R N	CEFUR S I R N	CEFOX/CETET S I R N		CIPRO/LEVO/MOXI S I R N			COL/PB† S R N
		ERTA S I R N	GENT S I R N	IMI S I R N	MERO/DORI S I R N			PIPTAZ S I R N	TETRA/DOXY/MINO S I R N
		TIG S I R N	TMZ S I R N	TOBRA S I R N
_______	Enterobacter (specify species) ____________	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N		CEFAZ S I R N	CEFEP S I R N	CEFOT/CEFTRX S I R N
		CEFTAZ S I R N	CEFUR S I R N	CEFOX/CETET S I R N		CIPRO/LEVO/MOXI S I R N			COL/PB† S R N
		ERTA S I R N	GENT S I R N	IMI S I R N	MERO/DORI S I R N			PIPTAZ S I R N	TETRA/DOXY/MINO S I R N
		TIG S I R N	TMZ S I R N	TOBRA S I R N
_______	____Klebsiella pneumonia ____Klebsiella oxytoca	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N		CEFAZ S I R N	CEFEP S I R N	CEFOT/CEFTRX S I R N
		CEFTAZ S I R N	CEFUR S I R N	CEFOX/CETET S I R N		CIPRO/LEVO/MOXI S I R N			COL/PB† S R N
		ERTA S I R N	GENT S I R N	IMI S I R N	MERO/DORI S I R N			PIPTAZ S I R N	TETRA/DOXY/MINO S I R N
		TIG S I R N	TMZ S I R N	TOBRA S I R N

Ventilator-Associated Event (VAE)

Page 3 of 4

Pathogen #

Gram-negative Organisms (continued)

_______

Pseudomonas aeruginosa

AMK S I R N

AZT S I R N

CEFEP S I R N

CEFTAZ S I R N

CIPRO/LEVO S I R N

COL/PB S I R N

GENT S I R N

IMI S I R N

MERO/DORI S I R N

PIP/PIPTAZ S I R N

TOBRA S I R N

Pathogen #

Fungal Organisms

_______

Candida (specify species if available) ____________

ANID S I R N

CASPO S NS N

FLUCO S S-DD R N

FLUCY S I R N

ITRA S S-DD R N

MICA S NS N

VORI S S-DD R N

Pathogen #

Other Organisms

_______

Organism 1 (specify) ____________

_______Drug 1 S I R N

_______ Drug 2 S I R N

______ Drug 3 S I R N

_______ Drug 4 S I R N

_______Drug 5 S I R N

______ Drug 6 S I R N

______ Drug 7 S I R N

______ Drug 8 S I R N

______ Drug 9 S I R N

_______

Organism 1 (specify) ____________

_______Drug 1 S I R N

_______ Drug 2 S I R N

______ Drug 3 S I R N

_______ Drug 4 S I R N

_______Drug 5 S I R N

______ Drug 6 S I R N

______ Drug 7 S I R N

______ Drug 8 S I R N

______ Drug 9 S I R N

_______

Organism 1 (specify) ____________

_______Drug 1 S I R N

_______ Drug 2 S I R N

______ Drug 3 S I R N

_______ Drug 4 S I R N

_______Drug 5 S I R N

______ Drug 6 S I R N

______ Drug 7 S I R N

______ Drug 8 S I R N

______ Drug 9 S I R N

Result Codes

S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested

^§ GENTHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

^† Clinical breakpoints have not been set by FDA or CLSI, Sensitive and Resistant designations should be based upon epidemiological cutoffs of Sensitive MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:
AMK = amikacin	CEFTRX = ceftriaxone	FLUCY = flucytosine	OX = oxacillin
AMP = ampicillin	CEFUR= cefuroxime	GENT = gentamicin	PB = polymyxin B
AMPSUL = ampicillin/sulbactam	CETET= cefotetan	GENTHL = gentamicin –high level test	PIP = piperacillin
AMXCLV = amoxicillin/clavulanic acid	CIPRO = ciprofloxacin	IMI = imipenem	PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin	CLIND = clindamycin	ITRA = itraconazole	RIF = rifampin
AZT = aztreonam	COL = colistin	LEVO = levofloxacin	TETRA = tetracycline
CASPO = caspofungin	DAPTO = daptomycin	LNZ = linezolid	TIG = tigecycline
CEFAZ= cefazolin	DORI = doripenem	MERO = meropenem	TMZ = trimethoprim/sulfamethoxazole
CEFEP = cefepime	DOXY = doxycycline	METH = methicillin	TOBRA = tobramycin
CEFOT = cefotaxime	ERTA = ertapenem	MICA = micafungin	VANC = vancomycin
CEFOX= cefoxitin	ERYTH = erythromycin	MINO = minocycline	VORI = voriconazole
CEFTAZ = ceftazidime	FLUCO = fluconazole	MOXI = moxifloxacin

Ventilator-Associated Event (VAE)

Page 4 of 4
Custom Fields
Label		Label
______________________	____/____/____	_______________________	____/____/_____
_______________________	_____________	_______________________	______________
_______________________	_____________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
_________________________	______________	_______________________	______________
Comments