Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
Pediatric Ventilator-Associated Event (PedVAE)
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*required for saving **required for completion |
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Facility ID: |
Event #: |
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*Patient ID: |
Social Security #: |
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Secondary ID: |
Medicare #: |
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Patient Name, Last: |
First: |
Middle: |
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*Gender: F M Other |
*Date of Birth: |
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Ethnicity (Specify): |
Race (Specify): |
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*Event Type: PedVAE |
*Date of Event: |
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Post-procedure PedVAE: Yes No |
Date of Procedure: |
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NHSN Procedure Code: |
ICD-10-PCS or CPT Procedure Code: |
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*MDRO Infection Surveillance: |
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□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module |
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□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module |
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*Date Admitted to Facility: |
*Location: |
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Risk Factors |
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* Location of Mechanical Ventilation Initiation: ______________ |
*Date Initiated: __ /__ /_____ |
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*If NICU: Birth Weight (grams): __________ *Gestational Age (weeks):______________ |
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Event Details |
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*Specific Event: |
□ PedVAC |
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*Specify Criteria Used: |
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□ Daily min FiO2 increase ≥ 0.25 (25 points) for ≥ 2 days† OR □ Daily min Mean Airway Pressure (MAP) ≥ 4 cm H2O for ≥ 2 days† |
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†after 2+ days of stable or decreasing daily minimum values. |
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Clinical event associated with the PedVAE? □ Yes □ No □ Unknown If Yes, check all that apply:
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Antimicrobial agent(s) administered? |
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□ Yes |
□ No |
If Yes, select up to 3 antimicrobial agents: |
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Drug1:__________________; Drug1 start date: __ /__ /_____ |
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Drug2:__________________; Drug2 start date: __ /__ /_____ |
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Drug3:__________________; Drug3 start date: __ /__ /_____ |
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Pathogen identified from one or more of the listed specimens? □ Yes □ No If Yes, specify pathogen on pages 2-3 |
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If Yes, which specimen type? (check all that apply) |
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□ Lower Respiratory □ Upper Respiratory □ Lung Tissue □ Pleural Fluid |
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□ Urine for Legionella or Streptococcus pneumoniae antigen testing |
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Pathogen identified from BLOOD? □ Yes □ No |
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**Died: Yes No |
PedVAE contributed to death: Yes No |
Discharge Date: |
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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)
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Pathogen # |
Gram-positive Organisms |
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_______ |
Staphylococcus coagulase-negative |
VANC S I R N |
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(specify species if available): ____________ |
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_______ |
____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 |
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_______ |
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 |
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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 |
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Pathogen # |
Gram-negative Organisms |
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_______ |
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 |
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GENT S I R N |
IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TETRA/DOXY/MINO S I R N |
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TMZ S I R N |
TOBRA S I R N |
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_______ |
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 |
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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 |
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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 |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
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 |
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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 |
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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 |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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_______ |
____Klebsiella pneumoniae
____Klebsiella oxytoca
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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 |
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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 |
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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 |
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TIG S I R N |
TMZ S I R N |
TOBRA S I R N |
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Pediatric Ventilator-Associated Event (PedVAE)
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Pathogen # |
Gram-negative Organisms (continued) |
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_______ |
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 |
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IMI S I R N
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MERO/DORI S I R N |
PIP/PIPTAZ S I R N |
TOBRA S I R N |
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Pathogen # |
Fungal Organisms |
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_______ |
Candida (specify species if available) ____________
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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 |
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Pathogen # |
Other Organisms |
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_______ |
Organism 1 (specify) ____________
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_______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 |
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_______ |
Organism 1 (specify) ____________
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_______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 |
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_______ |
Organism 1 (specify) ____________
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_______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: |
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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 |
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Pediatric Ventilator-Associated Event (PedVAE)
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.112_VAE |
Subject | NHSN OMB FORM 2018 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |