Data collection form

prospective study

Date: Gender:
Date of admission: Male (0)
Patient ID:
Patient code: Birth date:
The number of days in the hospital prior to vancomycin Age:
therapy: Age category:
Gestational age (in weeks): -30 days) (0)
Preterm Full-term - 2years) (1)
Height (cm): -12 years) (2)
Weight (kg): - 16 years) (3)
BSA:
Efficacy outcomes:
Dosing data: Trough concentration (mcg/ml)
Initial dose of vancomycin:
Sample time (after dose)
Total daily dose (TDD):
Drop in temperature 38 c
Dose per kg (DKg): Yes (0) / No (1)
Time when start vancomycin(if yes):
frequency (Tau):
Q4hr(0) Q6hr(1) Q8hr(3) Q12hr(4) Decrease in WBC count below 25% from the baseline
Q24hr(5) Yes (0) / No(1)
Infusion time (ti): min Time when start vancomycin(if yes):

Current medical issue:

Type of infection being diagnosed:
Past medical history:
Empirical
Documented
- Site of infection :

- Type of bacteria:
MIC:
Bacteriological clearance : ( Yes(0)/No(1))
Time:

Diagnosis :

Temperature at start:
WBC at start:
Cardiopulmonary bypass procedure
(Yes(0) /no(1))
Bp at start: HR at start:
RR at start:
Current medication: Antimicrobial medication:

Sensitive/resista
Medication name Dose Frequency Drug name Use or not (check
nce
for Yes)
(S /R)

Steroid If yes: Duration:

(corticosteroids) Dose:

TAZOcin

Gentamycin

AMIKacin

Amphotericin

ACYCLOVIR
Panadol

paracetamol

Ciprofloxacin

Clindamycin

Trimethoprim/Sulfa

cefotaxime
Amoxicillin/Clavulanate

Ampicillin

Azithromycin

Mupirocin(bactroban
cream)
Linezolid

Tetracycline

Rifampin

CUFROXIME

ibuprofen

Name of Antibiotics:
Other Antibiotics
 Date baseline

Srcr

WBC

Temp

BUN

Platelets

RR

HR

BP

Crcl

At least two or three sequent rising in serum creatinine by 0.5 mg/dl, or at least (25%-50%) rise from the baseline
Yes (0)
(1)

Calture:

Name of researcher:

Site:
Time: