Amrita Institute of Medical Sciences and Research Centre (an ISO 9001/14001/18001/NABH/NABL/NAAC certified hospital) ANTIBIOTIC STEWARDSHIP COMMITTEE
Data Collection Form
1. Name of the patient
2. MRD No:
3. Date of Admission				4. Date of Review
5. Age in years				6. Sex: Male/Female
7. Location
8. Admitting Doctor
9. Admission Diagnosis
10. Suspected focus of infection
(a) Pneumonia
(b) UTI
(c) CNS
(d) Skin and Soft Tissue
(e) Abdominal
(f) Bacteremia
(g) Catheter/Lines/Stents
(h) Other:
11. Cultures
(A) Culture sent- Yes/No
(B) Date and time of culture sent:
(C) Sample sent for culture
a. Blood
b. Urine
c. Stool
d. Sputum
e. Mini Bal
f. CSF
g. Ascitic fluid
h. Pleural fluid
i. Tissue
j. Pus
(D) Provisional report of culture—after 48 h of sending (To include culture and sensitivity report if available)
12. S. Creatinine (mg/dL)
13. Antibiotics used
Antibiotic		Dose	Route	Frequency	Date of initiation	Loading dose	Infusion
14. Clinical Signs correlating with Antibiotic initiation (prior 48 h)
Temp (°F)-
BP (mmHg)-
RR (per minute)-
O2 saturation (%)-
WBC (K/uL)-
CRP (mg/L)-
Procalcitonin (ng/mL)-
Lactate (mmol/L)-
At 48 h
Antibiotics changed