Ventilator-Associated Event (VAE) (≥18)

www.cdc.gov/nhsn

IDENTITAS PASIEN
*MDRO Infection Surveillance :
□ Ya, patogen infeksi berhubungan dengan lokasi □ Tidak, patogen infeksi bukan dari lokasi yang berhubungan
Tgl MRS : Unit/Bangsal :
Lokasi pemasangan Mechanical Ventilation : _______ Tgl psg: Tgl lepas: *APRV: Ya Tdk
Detail Kejadian
*Spesifik Event: □ VAC □ IVAC □ Possible VAP □ Probable VAP
*Kriteria yang digunakan:
STEP 1: VAC (≥1 REQUIRED)
□ FiO min harian meningkat ≥ 0.20 (20 points) ≥ 2 hari
2
†
ATAU □ PEEPmin harian meningkat ≥ 3 cm H2O ≥ 2 hari †
†
setelah 2 hari/lebih nilai minimum harian stabil atau menurun

STEP 2: IVAC
□ Suhu > 38°C atau < 36° ATAU □ Hitung sel darah putih ≥ 12,000 or atau≤ 4,000 cells/mm 3

DAN
□ Dimulainya gol. antimicrobial baru, dan dilanjutkan sampai ≥ 4 days
STEP 3: Possible VAP STEP 3: Probable VAP

□Sekresi purulent respiratory (definisi sekresi dari paru- □ Sekresi purulent respiratory
paru, bronchi, atau trachea mengandung >25 neutrophils DAN salah satu dibawah ini (memenuhi ambang batas
dan <10 squamous sel epithelial cells per low power field kuantitatif atau semi-kuantitatif yang dituangkan dalam
[lpf, x100], atau equivalent semi-quantitative results) protokol):‡
ATAU □ positive kultur sputum ≥105 CFU/ml
□ Salah satu dibawah ini (qualitative, semi-quantitative □ positive kultur pada aspirasi endotracheal ≥105 CFU/ml
atau quantitative):‡ □ positive kultur pada bronchoalveolar lavage ≥105 CFU/ml
□ positive kultur sputum □ positive kultur pada jaringan paru-paru ≥105 CFU/ml
□ positive kultur pada aspirasi endotracheal □ positive kultur pada protected specimen brushing ≥105
□ positive kultur pada bronchoalveolar lavage CFU/ml
□ positive kultur pada jaringan paru-paru ATAU
□ positive kultur pada protected specimen brushing □ Salah satu dibawah ini(tanpa persyaratan untuk sekresi
pernapasan purulen),
□ Kultur cairan pleura Positive
□ histopathology paru-paru positive
□ Positive diagnostic test untuk Legionella spp.
□ Positive diagnostic test untuk viral pathogens
‡
Diambil setelah 2 hari terpasang ventilasi mekanis dan dalam +/- 2 hari sejak timbulnya peningkatan FiO2 atau PEEP.
*Secondary Bloodstream Infection: Ya Tidak
Meninggal: Ya Tidak VAE yang menyebabkan kematian: Ya Tidak
Tgl Pulang: *Pathogens teridentifikasi: Ya Tidak Jika Ya, spesifik 2-3
Tanda tangan klinisi

Pathogen # Identifikasi Patogen

Organism 1
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 2
(specify) _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN
 Ventilator-Associated Event (VAE)
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Pathogen
#
Gram-positive Organisms

_______
Staphylococcus VANC
SIRN
coagulase-negative
(specify): ________________________

_______
Enterococcus AMP CIPRO/LEVO/MOXI DAPTO DOXY/MINO GENTHL§ LNZ
SIRN SIRN S NS N SIRN SRN SIRN
spp.( specify):
___________ STREPHL§ TETRA TIG VANC
SRN SIRN S NS N SIRN

_______
Enterococcus AMP CIPRO/LEVO/MOXI DAPTO DOXY/MINO GENTHL§ LNZ
SIRN SIRN S NS N SIRN SRN SIRN
faecium
QUIDAL STREPHL§ TETRA TIG VANC
SIRN SRN SIRN S NS N SIRN

_______
Staphylococcus CHLOR CIPRO/LEVO/MOXI CLIND DAPTO DOXY/MINO ERYTH GENT
SIRN SIRN SIRN S NS N SIRN SIRN SIRN
aureus
LNZ OX/CEFOX/METH QUIDAL RIF TETRA TIG TMZ VANC
SRN SIRN SIRN SIRN SIRN S NS N SIRN SIRN
Pathogen
#
Gram-negative Organisms

_______
Acinetobacter AMK AMPSUL AZT CEFEP CEFTAZ CIPRO/LEVO COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN SIRN
spp. (specify):
____________ GENT IMI MERO/DORI PIP/PIPTAZ TETRA/DOXY/MINO
SIRN SIRN SIRN SIRN SIRN

TMZ TOBRA
SIRN SIRN

_______
Escherichia coli AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
SIRN SIRN SIRN SIRN SIRN SIRN SIRN

CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB

SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

_______
Enterobacter AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
SIRN SIRN SIRN SIRN SIRN SIRN SIRN
spp. (specify):
____________ CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

_______
Klebsiella spp. AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
SIRN SIRN SIRN SIRN SIRN SIRN SIRN
(specify):
____________ CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

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Pathogen
#
Gram-negative Organisms (continued)

_______
Serratia AMK AMP AMPSUL/AMXCLV AZT CEFAZ CEFEP CEFOT/CEFTRX
SIRN SIRN SIRN SIRN SIRN SIRN SIRN
marcescens
CEFTAZ CEFUR CEFOX/CETET CHLOR CIPRO/LEVO/MOXI COL/PB
SIRN SIRN SIRN SIRN SIRN SIRN

ERTA GENT IMI MERO/DORI PIPTAZ TETRA/DOXY/MINO

SIRN SIRN SIRN SIRN SIRN SIRN

TIG TMZ TOBRA

SIRN SIRN SIRN

Pseudomonas AMK AZT CEFEP CEFTAZ CIPRO/LEVO COL/PB GENT

_______ SIRN SIRN SIRN SIRN SIRN SIRN SIRN
aeruginosa
IMI MERO/DORI PIP/PIPTAZ TOBRA
SIRN SIRN SIRN SIRN

_______
Stenotrophomonas LEVO TETRA/MINO TICLAV TMZ
SIRN SIRN SIRN SIRN
maltophilia
Pathogen
#
Fungal Organisms
Candida spp.
(specify): ANID CASPO FLUCO FLUCY ITRA MICA VORI
_______ SIRN S NS N S S-DD R N SIRN S S-DD R N S NS N S S-DD R N
____________
Pathogen
#
Other Organisms
Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Organism 1 _______ _______ ______ _______ _______ ______ ______ ______ ______
_______ (specify) Drug 1 Drug 2 Drug 3 Drug 4 Drug 5 Drug 6 Drug 7 Drug 8 Drug 9
____________ SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN SIRN

Result Codes
S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested
§
GENTHL and STREPHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

Drug Codes:
STREPHL = streptomycin –
AMK = amikacin CEFTRX = ceftriaxone ERYTH = erythromycin MICA = micafungin
high level test
AMP = ampicillin CEFUR= cefuroxime FLUCO = fluconazole MINO = minocycline TETRA = tetracycline
TICLAV = ticarcillin/clavulanic
AMPSUL = ampicillin/sulbactam CETET= cefotetan FLUCY = flucytosine MOXI = moxifloxacin
acid
CHLOR=
AMXCLV = amoxicillin/clavulanic acid GENT = gentamicin OX = oxacillin TIG = tigecycline
chloramphenicol
GENTHL = gentamicin –high TMZ =
ANID = anidulafungin CIPRO = ciprofloxacin PB = polymyxin B
level test trimethoprim/sulfamethoxazole
AZT = aztreonam CLIND = clindamycin IMI = imipenem PIP = piperacillin TOBRA = tobramycin
CASPO = caspofungin COL = colistin ITRA = itraconazole PIPTAZ = piperacillin/tazobactam VANC = vancomycin
CEFAZ= cefazolin DAPTO = daptomycin LEVO = levofloxacin QUIDAL = quinupristin/dalfopristin VORI = voriconazole
CEFEP = cefepime DORI = doripenem LNZ = linezolid RIF = rifampin
CEFOT = cefotaxime DOXY = doxycycline MERO = meropenem
CEFOX= cefoxitin ERTA = ertapenem METH = methicillin
CEFTAZ = ceftazidime

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Comments

CDC 57.112 (Back), v7.1