Data collection form

Retrospective 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:
Peak concentration: (mcg/ml)
Total daily dose (TDD):
Sample time (after dose)
Dose per kg (DKg):
Sample time( before dose)
frequency (Tau):
Q4hr(0) Q6hr(1) Q8hr(3) Q12hr(4) Time between level : hr
Q24hr(5)
Infusion time (ti): min Drop in temperature 38 c
Yes (0) / No (1)
Current medical issue: Time when start vancomycin(if yes):

Type of infection being diagnosed: Decrease in WBC count below 25% from the baseline
Empirical Yes (0) / No(1)
Time when start vancomycin(if yes):
Documented
- Site of infection :
Past medical history:

- 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))
Current medication: Antimicrobial medication:

Sensitive/resist
Medication name Dose Frequency Drug name Use or not (check for
ance
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

Crcl

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

Culture:

Name of researcher:

Site:

Time: