IV Antibiotics Prompt Review

• Clinical Area

• Site

• Conducted on

  Date

• Data Collected By

Anti-Microbial 1

• MRN Number

• Consultant

• Anti-Microbial:

  Select Amoxicillin Benzylpenicillin Ciprofloxacin Ceftriaxone Ceftazidime Co-Amoxiclav Co-Trimoxazole Clarithromycin Flucloxacillin Gentamicin Meropenem Metronidazole Piperacillin/Tazobactam Vancomycin Other (enter in comments)

  • Amoxicillin
  • Benzylpenicillin
  • Ciprofloxacin
  • Ceftriaxone
  • Ceftazidime
  • Co-Amoxiclav
  • Co-Trimoxazole
  • Clarithromycin
  • Flucloxacillin
  • Gentamicin
  • Meropenem
  • Metronidazole
  • Piperacillin/Tazobactam
  • Vancomycin
  • Other (enter in comments)

• Type of Infection:

  Select CNS GI Respiratory GU Eyes Sepsis - unknown origin Skin, soft tissue, bone & joint Head & neck Other (enter in comments)

  • CNS
  • GI
  • Respiratory
  • GU
  • Eyes
  • Sepsis - unknown origin
  • Skin, soft tissue, bone & joint
  • Head & neck
  • Other (enter in comments)

• Has the prescription been changed?

  Yes

  No

• If changed:

• Duration (administered before change):

  < 24 hours

  24-48 hours

  48-72 hours

  3-5 days

  > 5 days (enter in comments)

• How Changed:

  Select Stopped Changed from IV to Oral Changed to a different antimicrobial Other (enter in comments)

  • Stopped
  • Changed from IV to Oral
  • Changed to a different antimicrobial
  • Other (enter in comments)

• If NOT changed:

• Duration (administered so far):

  Select < 24 hours 24-48 hours 48-72 hours 3-5 days > 5 days (enter in comments)

  • < 24 hours
  • 24-48 hours
  • 48-72 hours
  • 3-5 days
  • > 5 days (enter in comments)

• Is there documentation in the medical notes

  Yes

  No

• If yes (tick all that apply):

  Select For further review at a later date Planned long IV course Awaiting surgical intervention Other (enter in comments)

  • For further review at a later date
  • Planned long IV course
  • Awaiting surgical intervention
  • Other (enter in comments)

• Comments:

Anti-Microbial 2

• MRN Number

• Consultant

• Anti-Microbial:

  Select Amoxicillin Benzylpenicillin Ciprofloxacin Ceftriaxone Ceftazidime Co-Amoxiclav Co-Trimoxazole Clarithromycin Flucloxacillin Gentamicin Meropenem Metronidazole Piperacillin/Tazobactam Vancomycin Other (enter in comments)

  • Amoxicillin
  • Benzylpenicillin
  • Ciprofloxacin
  • Ceftriaxone
  • Ceftazidime
  • Co-Amoxiclav
  • Co-Trimoxazole
  • Clarithromycin
  • Flucloxacillin
  • Gentamicin
  • Meropenem
  • Metronidazole
  • Piperacillin/Tazobactam
  • Vancomycin
  • Other (enter in comments)

• Type of Infection:

  Select CNS GI Respiratory GU Eyes Sepsis - unknown origin Skin, soft tissue, bone & joint Head & neck Other (enter in comments)

  • CNS
  • GI
  • Respiratory
  • GU
  • Eyes
  • Sepsis - unknown origin
  • Skin, soft tissue, bone & joint
  • Head & neck
  • Other (enter in comments)

• Has the prescription been changed?

  Yes

  No

• If changed:

• Duration (administered before change):

  < 24 hours

  24-48 hours

  48-72 hours

  3-5 days

  > 5 days (enter in comments)

• How Changed:

  Select Stopped Changed from IV to Oral Changed to a different antimicrobial Other (enter in comments)

  • Stopped
  • Changed from IV to Oral
  • Changed to a different antimicrobial
  • Other (enter in comments)

• If NOT changed:

• Duration (administered so far):

  Select < 24 hours 24-48 hours 48-72 hours 3-5 days > 5 days (enter in comments)

  • < 24 hours
  • 24-48 hours
  • 48-72 hours
  • 3-5 days
  • > 5 days (enter in comments)

• Is there documentation in the medical notes

  Yes

  No

• If yes (tick all that apply):

  Select For further review at a later date Planned long IV course Awaiting surgical intervention Other (enter in comments)

  • For further review at a later date
  • Planned long IV course
  • Awaiting surgical intervention
  • Other (enter in comments)

• Comments:

Anti-Microbial 3

• MRN Number

• Consultant

• Anti-Microbial:

  Select Amoxicillin Benzylpenicillin Ciprofloxacin Ceftriaxone Ceftazidime Co-Amoxiclav Co-Trimoxazole Clarithromycin Flucloxacillin Gentamicin Meropenem Metronidazole Piperacillin/Tazobactam Vancomycin Other (enter in comments)

  • Amoxicillin
  • Benzylpenicillin
  • Ciprofloxacin
  • Ceftriaxone
  • Ceftazidime
  • Co-Amoxiclav
  • Co-Trimoxazole
  • Clarithromycin
  • Flucloxacillin
  • Gentamicin
  • Meropenem
  • Metronidazole
  • Piperacillin/Tazobactam
  • Vancomycin
  • Other (enter in comments)

• Type of Infection:

  Select CNS GI Respiratory GU Eyes Sepsis - unknown origin Skin, soft tissue, bone & joint Head & neck Other (enter in comments)

  • CNS
  • GI
  • Respiratory
  • GU
  • Eyes
  • Sepsis - unknown origin
  • Skin, soft tissue, bone & joint
  • Head & neck
  • Other (enter in comments)

• Has the prescription been changed?

  Yes

  No

• If changed:

• Duration (administered before change):

  < 24 hours

  24-48 hours

  48-72 hours

  3-5 days

  > 5 days (enter in comments)

• How Changed:

  Select Stopped Changed from IV to Oral Changed to a different antimicrobial Other (enter in comments)

  • Stopped
  • Changed from IV to Oral
  • Changed to a different antimicrobial
  • Other (enter in comments)

• If NOT changed:

• Duration (administered so far):

  Select < 24 hours 24-48 hours 48-72 hours 3-5 days > 5 days (enter in comments)

  • < 24 hours
  • 24-48 hours
  • 48-72 hours
  • 3-5 days
  • > 5 days (enter in comments)

• Is there documentation in the medical notes

  Yes

  No

• If yes (tick all that apply):

  Select For further review at a later date Planned long IV course Awaiting surgical intervention Other (enter in comments)

  • For further review at a later date
  • Planned long IV course
  • Awaiting surgical intervention
  • Other (enter in comments)

• Comments:

Anti-Microbial 4

• MRN Number

• Consultant

• Anti-Microbial:

  Select Amoxicillin Benzylpenicillin Ciprofloxacin Ceftriaxone Ceftazidime Co-Amoxiclav Co-Trimoxazole Clarithromycin Flucloxacillin Gentamicin Meropenem Metronidazole Piperacillin/Tazobactam Vancomycin Other (enter in comments)

  • Amoxicillin
  • Benzylpenicillin
  • Ciprofloxacin
  • Ceftriaxone
  • Ceftazidime
  • Co-Amoxiclav
  • Co-Trimoxazole
  • Clarithromycin
  • Flucloxacillin
  • Gentamicin
  • Meropenem
  • Metronidazole
  • Piperacillin/Tazobactam
  • Vancomycin
  • Other (enter in comments)

• Type of Infection:

  Select CNS GI Respiratory GU Eyes Sepsis - unknown origin Skin, soft tissue, bone & joint Head & neck Other (enter in comments)

  • CNS
  • GI
  • Respiratory
  • GU
  • Eyes
  • Sepsis - unknown origin
  • Skin, soft tissue, bone & joint
  • Head & neck
  • Other (enter in comments)

• Has the prescription been changed?

  Yes

  No

• If changed:

• Duration (administered before change):

  < 24 hours

  24-48 hours

  48-72 hours

  3-5 days

  > 5 days (enter in comments)

• How Changed:

  Select Stopped Changed from IV to Oral Changed to a different antimicrobial Other (enter in comments)

  • Stopped
  • Changed from IV to Oral
  • Changed to a different antimicrobial
  • Other (enter in comments)

• If NOT changed:

• Duration (administered so far):

  Select < 24 hours 24-48 hours 48-72 hours 3-5 days > 5 days (enter in comments)

  • < 24 hours
  • 24-48 hours
  • 48-72 hours
  • 3-5 days
  • > 5 days (enter in comments)

• Is there documentation in the medical notes

  Yes

  No

• If yes (tick all that apply):

  Select For further review at a later date Planned long IV course Awaiting surgical intervention Other (enter in comments)

  • For further review at a later date
  • Planned long IV course
  • Awaiting surgical intervention
  • Other (enter in comments)

• Comments:

Anti-Microbial 5

• MRN Number

• Consultant

• Anti-Microbial:

  Select Amoxicillin Benzylpenicillin Ciprofloxacin Ceftriaxone Ceftazidime Co-Amoxiclav Co-Trimoxazole Clarithromycin Flucloxacillin Gentamicin Meropenem Metronidazole Piperacillin/Tazobactam Vancomycin Other (enter in comments)

  • Amoxicillin
  • Benzylpenicillin
  • Ciprofloxacin
  • Ceftriaxone
  • Ceftazidime
  • Co-Amoxiclav
  • Co-Trimoxazole
  • Clarithromycin
  • Flucloxacillin
  • Gentamicin
  • Meropenem
  • Metronidazole
  • Piperacillin/Tazobactam
  • Vancomycin
  • Other (enter in comments)

• Type of Infection:

  Select CNS GI Respiratory GU Eyes Sepsis - unknown origin Skin, soft tissue, bone & joint Head & neck Other (enter in comments)

  • CNS
  • GI
  • Respiratory
  • GU
  • Eyes
  • Sepsis - unknown origin
  • Skin, soft tissue, bone & joint
  • Head & neck
  • Other (enter in comments)

• Has the prescription been changed?

  Yes

  No

• If changed:

• Duration (administered before change):

  < 24 hours

  24-48 hours

  48-72 hours

  3-5 days

  > 5 days (enter in comments)

• How Changed:

  Select Stopped Changed from IV to Oral Changed to a different antimicrobial Other (enter in comments)

  • Stopped
  • Changed from IV to Oral
  • Changed to a different antimicrobial
  • Other (enter in comments)

• If NOT changed:

• Duration (administered so far):

  Select < 24 hours 24-48 hours 48-72 hours 3-5 days > 5 days (enter in comments)

  • < 24 hours
  • 24-48 hours
  • 48-72 hours
  • 3-5 days
  • > 5 days (enter in comments)

• Is there documentation in the medical notes

  Yes

  No

• If yes (tick all that apply):

  Select For further review at a later date Planned long IV course Awaiting surgical intervention Other (enter in comments)

  • For further review at a later date
  • Planned long IV course
  • Awaiting surgical intervention
  • Other (enter in comments)

• Comments: