CODE  TEXT

First start antimicrobial(s):

\antibstart

 \antibstart 
NAME OF ANTIMICROBIAL(S): 
INDICATION: 
PROPOSED DURATION (days): 
Complete the \antibreview every 72 hours for all antimicrobials. 

Review antimicrobial(s): 

\antibreview

 \antibreview 
NAME OF ANTIMICROBIAL(S): 
TOTAL NUMBER OF DAYS ON ANTIMICROBIALS 
TO DATE (total = IV and oral): 
Can antibiotics stop?
Can they switch to oral therapy?
What is the planned further duration (in days)? 
See Local Antimicrobial Guidelines for IVOST options, and further information. 
Vancomycin: \Vanc \Vanc
VANCOMYCIN REVIEW-Intermittent Infusion
INDICATION: 
NUMBER OF DAYS ON VANCOMYCIN TO DATE: 
Propose duration: 
Target trough levels: 
LAST TROUGH LEVEL RESULT, AND DATE: 
Outcome
Is a dose adjustment required based on the level (not applicable for initial prescription)? 
WHEN IS THE NEXT TROUGH LEVEL PLANNED, DATE AND TIME? 
Do not delay dose administration while pending trough level results.
Gentamicin: \Gent INDICATION:
Initial planned total treatment duration:
Day of treatment course:
LEVEL REVIEWED AND DOSING INTERVAL CONFIRMED:
NEXT LEVEL DUE AT:
Gentamicin level should be checked along with U&Es after each dose. 
Review IV to oral switch daily. After five days of gentamicin if oral route available discuss with microbiology.
Synergistic Gentamicin:
\Syngent
SYNERGISTIC GENTAMICIN DOSING CALCULATIONS
Height (cm):
Weight (kg):
Creatinine (micromol/L):
Dosage:
Frequency:
Day of first trough level:
Day of first peak level:
SIGNED:
Checked with pharmacist [Y/N]:
Teicoplanin for OPAT:
\Teicopat		 TEICOPLANIN DOSING CALCULATIONS FOR OPAT
Height (cm): 
Weight (kg): 
Creatinine (mmol/L): 
Body weight used in calculations: IDEAL/ACTUAL (delete one)
Calculated creatinine clearance (ml/min):
Loading doses:
Loading days (3 consecutive days):
Maintenance dose: 
Day of first maintenance dose: 
Has OPAT accepted patient: Y/N (WGH/SJH)
Amikacin: \amikacin AMIKACIN DOSING CALCULATIONS
Height (cm):
Weight (kg):
Creatinine (mmol/l):
MAXIMUM or ACTUAL body weight used in calculations (whichever is lower): 
Dosage:
Day of first trough/peak level:
SIGNED:
Checked with pharmacist (Y/N):
Daptomycin: \Dapto Infection indication for Daptomycin:
Recommended dosing (6mg/kg or 10mg/kg):
BMI > 30mg/kg(Y/N): (If Y use adjusted body weight to calculate dose)
CrCl < 30ml/min (Y/N): (If Y see antimicrobial companion guidance)
Actual Dose (Round to full vial where possible.)
CK at baseline:
Next CK level dose:
Any cautions/drug interactions (Y/N):
Checked with pharmacist (Y/N): (If N, please contact pharmacy to review at next opportunity.)
FOR PHARMACY USE
C.diff Pharmacy review
Code: \PCDiff 

C.Diff : PHARMACY REVIEW
1. Is treatment compliant with Antimicrobial Companion?
Recommendation:
2. Is the course length CDI treatment stated?

3. Have doses been missed of CDI treatment?
If missed doses - was stock available on ward?
4. Review PPI/ H2 antagonists. Stop where possible
Reason if to continue:
5. Review laxatives and all anti-motility drugs. Stop where possible.
Reason if to continue:
6. Review other antimicrobials for ongoing need;particularly if antibiotics are in “Watch or “Reserve” categories. 

If clinical team uncertain contact Microbiology.