Form CDC 57.113 CDC 57.113 Pediatric Ventilator-Associated Event (VAE)

The National Healthcare Safety Network (NHSN)

57.113_Pediatric VAE_BLANK.DOCX

57.113 Pediatric Ventilator-Associated Event (PedVAE)

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

Pediatric Ventilator-Associated Event (PedVAE)

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: PedVAE

*Date of Event:

Post-procedure PedVAE: Yes No

Date of Procedure:

NHSN Procedure Code:

ICD-10-PCS or CPT 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:

Risk Factors


* Location of Mechanical Ventilation Initiation: ______________

*Date Initiated: __ /__ /_____

*If NICU: Birth Weight (grams): __________ *Gestational Age (weeks):______________

Event Details

*Specific Event:

PedVAC

*Specify Criteria Used:

Daily min FiO2 increase ≥ 0.25 (25 points) for ≥ 2 days

OR

Daily min Mean Airway Pressure (MAP) ≥ 4 cm H2O for ≥ 2 days

after 2+ days of stable or decreasing daily minimum values.


Clinical event associated with the PedVAE? Yes No Unknown If Yes, check all that apply:

Ventilator-associated Pneumonia

Sepsis or Septic Shock

Atelectasis

Neonatal Respiratory Distress Syndrome (RDS)

Acute Respiratory Distress Syndrome (ARDS)

Bronchopulmonary Dysplasia/Chronic Lung Disease

Pulmonary Hypertension

Reopened Patent Ductus Arteriosus (PDA)

Pulmonary Edema

Weaning from mechanical ventilation or other change in mechanical ventilation approach without clinical worsening

Pulmonary Hemorrhage

Other (specify) _______________


Antimicrobial agent(s) administered?

Yes

No

If Yes, select up to 3 antimicrobial agents:

Drug1:__________________; Drug1 start date: __ /__ /_____

Drug2:__________________; Drug2 start date: __ /__ /_____

Drug3:__________________; Drug3 start date: __ /__ /_____

Pathogen identified from one or more of the listed specimens? Yes No If Yes, specify pathogen on pages 2-3

If Yes, which specimen type? (check all that apply)

Lower Respiratory Upper Respiratory Lung Tissue Pleural Fluid

Urine for Legionella or Streptococcus pneumoniae antigen testing

Pathogen identified from BLOOD? Yes No

**Died: Yes No

PedVAE contributed to death: Yes No

Discharge Date:

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 30 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 57.113 (Front), R1, V8.8

Pediatric Ventilator-Associated Event (PedVAE)

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/S-DD 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/S-DD 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

pneumoniae


____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/S-DD 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


Pediatric Ventilator-Associated Event (PedVAE)

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


Pediatric Ventilator-Associated Event (PedVAE)

Page 4 of 4

Custom Fields

Label

Label

______________________

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_______________________

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_________________________

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.112_VAE
SubjectNHSN OMB FORM 2018
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
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