Form E Attachment E: Completion Guide for Team Antibiotic Revie

Form Approved
OMB No. 0935-0238
Exp. Date 09/30/2020

Attachment E: Completion Guide for Team Antibiotic Review Form

COMPLETION GUIDE FOR TEAM ANTIBIOTIC REVIEW FORM

Questions 1-6 should be answered for all patients on antibiotics that you evaluate. Teams should review at least 10 cases per month in real time, not retrospectively.

Question 1: Day of antibiotic therapy:

For the antibiotic or antibiotic regimen you are evaluating, day 1 is the first day that any antibiotic was started, day 2 is the second day, and so forth.

Question 2: Antibiotic regimen and indication:

Include all antibiotics that the patient is receiving (including those for surgical prophylaxis) except antibiotics being used for long-term prophylaxis (e.g., rifaximin for hepatic encephalopathy). Do not include doses.

Question 3: Based on your assessment at the time you are reviewing the case:

• If the patient has a suspected or confirmed infection that requires antibiotics, “yes” should be marked.

• If the patient does not have evidence of infection, “no” should be marked.

Question 4: Based on your assessment at the time you are reviewing the case:

• If the patient was suspected to have an infection for which cultures should have been collected before antibiotics were started and had all of those cultures collected, “yes” should be marked.

• If the patient was suspected to have an infection for which cultures should have been collected before antibiotics were started and did not have all of those cultures collected, “no” should be marked.

• If a patient had some but not all of the cultures collected, “no” should be marked (e.g., a patient with suspected urosepsis who received blood cultures but not urine cultures would be marked “no”).

• If the patient was suspected to have an infection for which cultures were not indicated, “N/A” should be marked.

Question 5: Based on your assessment at the time you are reviewing the case:

• If the patient has no antibiotic allergy, “N/A” should be marked.

• If the patient has antibiotic allergies and there is evidence in the chart that the specific antibiotic and associated reaction has been documented, “yes” should be marked.

• If the patient has antibiotic allergy but there is no evidence that the specific antibiotic and associated reaction has been documented, “no” should be marked.

Question 6: Based on the initial assessment of the patient and the suspected source of infection:

• If the empiric antibiotic or antibiotics were compliant with local guidelines, “yes” should be marked.

• If one or more of the empiric antibiotics were not compliant with local guidelines, “no” should be marked.

• If there are no local guidelines for the suspected infection, “N/A” should be marked.

Questions 7-14 should be answered for patients on antibiotics > 24 hours in addition to questions 1-6 above.

Question 7: Based on your assessment at the time you are reviewing the case:

• If the patient has a suspected or confirmed infection that requires antibiotics, regardless of whether the regimen itself is appropriate, “yes” should be marked.

• If the patient was found to have an alternate reason for presenting symptoms and/or has no need for continued therapy (e.g., the course of therapy is complete), “no” should be marked.

Question 8: Answer Question 8 ONLY if Question 7 is marked “no.”

• If a plan is formulated to stop antibiotics on the same day, “yes” should be marked.

• If there is no plan to stop antibiotics on the same day, “no” should be marked.

Question 9: Based on your assessment at the time you are reviewing the case:

• If the patient can be placed on a narrower regimen based on microbiological or clinical data (this could involve a complete change in antibiotic regimen or stopping one or more agents in a multi-agent regimen), “yes” should be marked.

• If the patient cannot be placed on a narrower regimen, “no” should be marked.

• If the patient is already placed on a narrower regimen at the time of review, “already narrowed” should be marked

Question 10: Answer Question 10 ONLY if Question 9 is marked “yes.”

• If a plan is formulated to narrow antibiotics on the same day, “yes” should be marked.

• If there is no plan to narrow antibiotics, a “no” answer should be marked.

Question 11: Based on your assessment at the time you are reviewing the case:

• If the patient can be placed on an oral regimen based on microbiological or clinical data, “yes” should be marked.

• If the patient cannot be placed on an oral regimen, “no” should be marked.

• If the patient is already on an oral regimen at the time of review, “already on PO” should be marked.

Question 12: Answer Question 12 ONLY if Question 11 is marked “yes.”

• If you plan to change to oral antibiotics on the same day, “yes” should be marked.

• If there is no plan to change to oral antibiotics, “no” should be marked.

Question 13: Based on your assessment at the time you are reviewing the case:

• If a planned duration of therapy has been documented in the chart or there is documentation that the duration is uncertain because not all clinical data are available to make the decision, “yes” should be marked.

• If there is no comment about duration of therapy, “no” should be marked.

Question 14: Answer Question 14 ONLY if Question 13 is marked “yes.”

• If the planned duration is consistent with local guidelines, “yes” should be marked.

• If the planned duration is not consistent with local guidelines, “no” should be marked.

• If there are no local guidelines for duration of therapy for the suspected infection, “N/A” should be marked.

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