Antimicrobial Use Audit Form

1. Name of patient : Date:

2. Filed by: Specialty:
3. Name & Designation: Diagnosis:
4. Antibiotics used in hospital
Name of antibiotic Date Started Date Stopped Total Days Route Dose

5. Previous Antibiotics Used (Before admission to Garg Hospital)

Name of antibiotic Date Started Date Stopped Total Days Route Dose

6. Indication of current IV Therapy

Temperature: Systolic BP:
≥38° or ≤36° ≤90mmHg
Heart rate: Diastolic BP:
≥90bpm ≤ 60mmHg
Respiratory rate: Urea:
≥20/mm ≥7mmol/L
WBC Count. PO2 ≤8kPa
≤4 or ≥ 12*108/L
CRP
Evidence of infection in other investigation
(soecify)_____________________________________________________________
7. Use of IV route: Complete the information based on the patient’s condition in the preceding 24 Hours
Oral route compromised Yes No Unknown
Eg ↓swallow, ↓absorption, vomiting, unconscious, nil by mouth
Deteriorating clinical condition Yes No Unknown
Patient immunosuppressed? Yes No Unknown
If Yes, please tick the appropriate reason: Malignancy HIV Steroids Other
Immunosuppressive
Any other Yes No Unknown
8. Antibiotic Allergy Recorded
1.
2.
3.
9. Antibiotic Indication

Micro Biologist Sign. Clinician Sign

GH/F136/2016
GH/F136/2016