[Facility Logo] Resident Label Antibiotic Therapy Checklist Current Therapy: Drug 1: Dose: Route: Frequency: Start Date: End Date: Drug 2: Dose: Route: Frequency: Start Date: End Date: Drug 3: Dose: Route: Frequency: Start Date: End Date: Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Parameters for Review __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ Yes Yes Yes Yes Yes Yes Yes Has an infection been identified? Unclear Unclear Unclear Unclear Unclear Unclear Unclear [If NO, STOP ANTIBIOTICS] No No No No No No No What infection is treated? Yes Yes Yes Yes Yes Yes Yes Are culture data available? Not sent Not sent Not sent Not sent Not sent Not sent Not sent Not back Not back Not back Not back Not back Not back Not back Should regimen be adjusted based on additional clinical/micro data? Yes Yes Yes Yes Yes Yes Yes [If YES, provide reason and new No No No No No No No regimen below] Is regimen appropriate based on Yes Yes Yes Yes Yes Yes Yes renal/hepatic functions? No No No No No No No [If NO, provide new regimen below] Yes Yes Yes Yes Yes Yes Yes If IV, can it be converted to PO? No No No No No No No [If YES, provide new regimen below] PO only PO only PO only PO only PO only PO only PO only Is duration shortest possible to Yes Yes Yes Yes Yes Yes Yes resolve infection? No No No No No No No [If NO, provide new duration below] Reason(s) for Adjusting Antibiotic Regimen: Yes, due to bug-drug mismatch Yes, therapy can be streamlined using fewer agents □ □ Yes, narrower spectrum agent can be used Yes, due to adverse drug reactions, toxicity, or interaction □ □ Recommended New Antibiotic Regimen: Drug 1: Dose: Route: Frequency: Date of Change: Drug 2: Dose: Route: Frequency: Date of Change: Drug 3: Dose: Route: Frequency: Date of Change:
[Facility Logo] Antibiotic Therapy Checklist Resident Label Current Therapy: Drug 1: Dose: Route: Frequency: Start Date: End Date: Drug 2: Dose: Route: Frequency: Start Date: End Date: Drug 3: Dose: Route: Frequency: Start Date: End Date: Parameters for Review Day 1 __/__/__ Day 2 __/__/__ Day 3 __/__/__ Day 4 __/__/__ Day 5 __/__/__ Day 6 __/__/__ Day 7 __/__/__ Has an infection been identified? [If NO, STOP ANTIBIOTICS] Yes Unclear No Yes Unclear No Yes Unclear No Yes Unclear No Yes Unclear No Yes Unclear No Yes Unclear No What infection is treated? Are culture data available? Yes Not sent Not back Yes Not sent Not back Yes Not sent Not back Yes Not sent Not back Yes Not sent Not back Yes Not sent Not back Yes Not sent Not back Should regimen be adjusted based on additional clinical/micro data? [If YES, provide reason and new regimen below] Yes No Yes No Yes No Yes No Yes No Yes No Yes No Is regimen appropriate based on renal/hepatic functions? [If NO, provide new regimen below] Yes No Yes No Yes No Yes No Yes No Yes No Yes No If IV, can it be converted to PO? [If YES, provide new regimen below] Yes No PO only Yes No PO only Yes No PO only Yes No PO only Yes No PO only Yes No PO only Yes No PO only Is duration shortest possible to resolve infection? [If NO, provide new duration below] Yes No Yes No Yes No Yes No Yes No Yes No Yes No Reason(s) for Adjusting Antibiotic Regimen: □ Yes, due to bug-drug mismatch □ Yes, therapy can be streamlined using fewer agents □ Yes, narrower spectrum agent can be used □ Yes, due to adverse drug reactions, toxicity, or interaction Recommended New Antibiotic Regimen: Drug 1: Dose: Route: Frequency: Date of Change: Drug 2: Dose: Route: Frequency: Date of Change: Drug 3: Dose: Route: Frequency: Date of Change:
Daily-antibiotic-therapy-checklist-template.docx