57.113 PedVAE with GISAB edits in tracked changes

57.113_Pediatric VAE_November_2022.docx

[NCEZID] The National Healthcare Safety Network (NHSN)

57.113 PedVAE with GISAB edits in tracked changes

OMB: 0920-0666

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Form Approved

OMB No.

Exp. Date:

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:

Sex at Birth: F M Unknown

Gender Identity (Specify):

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

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)

Pathogen #

Gram-positive Organisms


Staphylococcus coagulase-negative


(specify species if available):

CEFOX/OX

S R N

VANC

S I R N








____Enterococcus faecium

____Enterococcus faecalis

____Enterococcus spp. (Only those not identified to the species level)

DAPTO

S I/S-DD NS R N

GENTHL§

S R N

LNZ

S I R N

VANC

S I R N






Staphylococcus aureus



CEFOX/METH/OX

S R N

CEFTAR

S S-DD I R N


CIPRO/LEVO/MOXI

S I R N

CLIND

S I R N

DAPTO

S NS N

DOXY/MINO

S I R N

GENT

S I R N

LNZ

S R N

RIF

S I R N

TETRA

S I R 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

CEFEP

S I R N

CEFTAZ/CEFOT/CEFTRX

S I R N

CIPRO/LEVO

S I R N

COL/PB

S R N

DORI/MERO

S I R N



DOXY/MINO

S I R N

GENT

S I R N

IMI

S I R N

PIPTAZ

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



CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N

CIPRO/LEVO/MOXI

S I R N

COL/PB

I R N

DORI/IMI/MERO

S I R N

DOXY/MINO/TETRA

S I R N

ERTA

S I R N

GENT

S I R N

IMIREL

S I R N

MERVAB

S I R N

PIPTAZ

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

AZT

S I R N

CEFEP

S I/S-DD R N

CEFOT/CEFTRX

S I R N

CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N


CIPRO/LEVO/MOXI

S I R N

COL/PB

I R N

DORI/IMI/MERO

S I R N

DOXY/MINO/TETRA

S I R N

ERTA

S I R N

GENT

S I R N

IMIREL

S I R N


MERVAB

S I R N

PIPTAZ

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

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

CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N

CIPRO/LEVO/MOXI

S I R N

COL/PB

I R N

DORI/IMI/MERO

S I R N

DOXY/MINO/TETRA

S I R N

ERTA

S I R N



GENT

S I R N

IMIREL

S I R N

MERVAB

S I R N

PIPTAZ

S I R N

TIG

S I R N

TMZ

S I R N

TOBRA

S I R N




Pathogen #

Gram-Negative Organisms (continued)


Pseudomonas aeruginosa

AMK

S I R N

AZT

S I R N

CEFEP

S I R N

CEFTAVI

S R N

CEFTAZ

S I R N

CEFTOTAZ

S I R N

CIPRO/LEVO

S I R N


COL/PB

S I R N

DORI/IMI/MERO

S I R N

GENT

S I R N

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 I R N

FLUCO

S S-DD R N

MICA

S I R N

VORI

S I R N




Pathogen #

Other Organisms


Organism 1 (specify) _____________

Drug 1

S I R N

Drug2

S I R N

Drug3

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

Drug2

S I R N

Drug3

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

Drug2

S I R N

Drug3

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 are based on CLSI M100-ED30:2020, Intermediate MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:

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


CEFTAZ = ceftazidime

FLUCO = fluconazole

MOXI = moxifloxacin





Pediatric Ventilator-Associated Event (PedVAE)

Page 4 of 4

Custom Fields

Label

Label

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.112_VAE
SubjectNHSN OMB Forms 2020
AuthorCDC/NCEZID/DHQP
File Modified0000-00-00
File Created2023-12-24

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