Form CDC 57.113 CDC 57.113 Pediatric Ventilator-associated Event

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2022

www.cdc.gov/nhsn

Pediatric Ventilator-Associated Event (PedVAE)

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*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

*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:

COVID-19: Yes No

If Yes:Suspected□Confirmed □

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 25 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, v9.2

Pediatric Ventilator-Associated Event (PedVAE)

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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 ____Klebsiella aerogenes	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)

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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)

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Custom Fields
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