Form
Approved
OMB No.
Exp. Date:
www.cdc.gov/nhsn
Pediatric Ventilator-Associated Event (PedVAE)
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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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Sex at Birth: F M Unknown |
Gender Identity (Specify): |
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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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*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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*COVID-19: Yes No |
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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 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 |
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Staphylococcus coagulase-negative
(specify species if available): |
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____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level) |
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Staphylococcus aureus
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Pathogen # |
Gram-negative Organisms
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Acinetobacter (specify species) ____________ |
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Escherichia coli
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Enterobacter (specify species) ____________
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____Klebsiella pneumoniae ____Klebsiella oxytoca ____Klebsiella aerogenes |
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Pathogen # |
Gram-Negative Organisms (continued) |
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Pseudomonas aeruginosa |
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Pathogen # |
Fungal Organisms |
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Candida (specify species if available) ______________ |
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Pathogen # |
Other Organisms |
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Organism 1 (specify) _____________ |
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Organism 1 (specify) _____________ |
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Organism 1 (specify) _____________ |
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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 are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2
and Resistant MIC ≥ 4
Drug Codes: |
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AMK = amikacin |
CEFTAR = ceftaroline |
GENT = gentamicin |
OX = oxacillin |
AMP = ampicillin |
CEFTAVI = ceftazidime/avibactam |
GENTHL = gentamicin –high level test |
PB = polymyxin B |
AMPSUL = ampicillin/sulbactam |
CEFTOTAZ = ceftolozane/tazobactam |
IMI = imipenem |
PIPTAZ = piperacillin/tazobactam |
AMXCLV = amoxicillin/clavulanic acid |
CEFTRX = ceftriaxone |
IMIREL = imipenem/relebactam |
RIF = rifampin |
ANID = anidulafungin |
CIPRO = ciprofloxacin |
LEVO = levofloxacin |
TETRA = tetracycline |
AZT = aztreonam |
CLIND = clindamycin |
LNZ = linezolid |
TIG = tigecycline |
CASPO = caspofungin |
COL = colistin |
MERO = meropenem |
TMZ = trimethoprim/sulfamethoxazole |
CEFAZ= cefazolin |
DAPTO = daptomycin |
MERVAB = meropenem/vaborbactam |
TOBRA = tobramycin |
CEFEP = cefepime |
DORI = doripenem |
METH = methicillin |
VANC = vancomycin |
CEFOT = cefotaxime |
DOXY = doxycycline |
MICA = micafungin |
VORI = voriconazole |
CEFOX= cefoxitin |
ERTA = ertapenem |
MINO = minocycline |
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CEFTAZ = ceftazidime |
FLUCO = fluconazole |
MOXI = moxifloxacin |
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Pediatric Ventilator-Associated Event (PedVAE)
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |