Fillable Printable 57.112 Vae Blank
Fillable Printable 57.112 Vae Blank
57.112 Vae Blank
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
Ventilator-Associated Even t (VAE)
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: VAE *Date of Event:
Post-procedure VAE: Yes No Date of Procedure:
NHSN Procedure Cod e: ICD-10-PCS or CPT Proc edure Code:
*MDRO Infection S urveillance:
□ Yes, this infection’s pathogen & locat i on are in-plan for Infection Surveillance in the MDRO/CDI Module
□ No, this infection’s pat hogen & location are not in-plan for Inf ection Surveillance in t he M DRO/CDI Module
*Date Admitted to Facili t y: *Location:
* Location of Mechanical Ventilation Initiation: ______________ *Date Initiated: __ /__ /_____ *APRV: Yes No
Event Details
*Specific Event:
□ VAC □ IVAC □ PVAP
*Specify Criteria U sed:
STEP 1: VAC (≥1 REQUIRED)
□ Daily min FiO
2
increase ≥ 0.20 (20 points) for ≥ 2 days
†
OR □ Daily min PEEP increase ≥ 3 cm H
2
O for ≥ 2 days
†
†
after 2+ days of stable or decreasing dai l y minimum values.
STEP 2: IVAC
□ Temperature > 38°C or < 36° OR □ White blood cell count ≥ 12,000 or ≤ 4,000 cells/mm
3
AND
□ A new antimicrobial agent(s) is started, and is continued for ≥ 4 days
STEP 3: PVAP
□ Criterion #1: Positive culture of one of the following specimens, meeting quantitative or semi -qu anti tati ve threshold s as
outlined in protocol,
‡
without requireme nt for purulent respiratory s ecreti ons:
□ Endotracheal aspirate □ Lung tissue
□ Bronchoalveolar lavage □ Protected specim en brush
OR
□ Criterion #2: Purulent respiratory secret i ons
‡
(defined in the protocol) plus organism(s) identified f rom one of the
following specimens:
‡
□ Sputum □ Lung tissue
□ Endotracheal aspirate □ Protected specimen bru sh
□ Bronchoalveolar lav age
OR
□ Criterion #3: One of t he following positiv e tests (as outlined in the protocol):
‡
□ Organism(s) identified f rom
pleural fluid
□ Diagnostic test for Legionella species
□ Lung histopathology □ Diagnostic test for selected viral pathogens
‡
collected after 2 days of mechanical ventilat i on and within +/- 2 days of onset of increase in FiO
2
or PEEP.
*Secondary Bloodstream Infection: Y es No
**Died: Yes No VAE Contributed t o Deat h: Yes No
Discharge Date: *Pathogens Ident ified: Yes No *If Yes, specify on pages 2-3
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 informa ti on is esti m ated 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 57.112 (Front), Rev 5 v8.6
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.112 (Back), Rev 5, v8.6
Ventilator-Associated Event (VAE)
Page 2 of 4
Pathogen
#
Gram-positive Organisms
_______
Staphylococcus coagulase-negative
VANC
S I R N
(specify species if available):
____________
_______
____Enterococ cus faecium
____Enterococ cus 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
pneumonia
____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
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.112 (Back), Rev 5, v8.6
Ventilator-Associated Event (VAE)
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 Cod es
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependen t N = Not tested
§
GENTHL results: S = Susceptible/Synerg istic and R = Resist ant/Not Synergi stic
†
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
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.112 (Back), Rev 5, v8.6
Ventilator-Associated Event (VAE)
Page 4 of 4
Custom Fields
Label Label
______________________ ____/____/____ _______________________ ____/____/_____
_______________________ _____________ _______________________ ______________
_______________________ _____________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
_________________________ ______________ _______________________ ______________
Comments
