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Ø 4C TOOL: Pipercillan/Tazobactam De-Escalation Form

Tools and Resources

Purpose: Forms for tracking piperacillin/tazobactam audit/feedback. The tracking forms give a way to track number of patients with criteria for review and then a way to document stewardship interventions.

Source: Y Guo & B. Ostrowsky, Montefiore Medical Center.

Instructions: This 2-page form may be tailored for possible use at your facility; review and adapt as appropriate.

Antimicrobial Stewardship Team (AST) Suggestions

  1. Run/obtain daily list of piperacillin/tazobactam utilization report.
  2. Select patient who has been on piperacillin/tazobactam for >72 hours without ID consult.
  3. Review Carecast/chart for indication, duration, culture susceptibility, etc., to determine the appropriateness of piperacillin/tazobactam usage.

Date: _________________________

Total number of patients who have been on piperacillin/tazobactam: ________________________

Total number of patients who have been on piperacillin/tazobactam for >72 hours: _______

Total number of patients who have been on piperacillin/tazobactam >72 hours with ID consult 

Total number of patients who have been on piperacillin/tazobactam >72 hours without ID consult 

From patients who have been on piperacillin/tazobactam >72 hours without ID consult, number of patients reviewed:



 

Date: ________ Patient name: _________________________ MR#__________ Unit/room _______

Presumptive diagnosis:

  • ___ Culture documented pseudomonas/gram negative resistant infection.
    • Site of documented culture ________________________________
  • ___ Healthcare-associated pneumonia (continued empiric coverage).
  • ___ Healthcare-associated intra-abdominal infection (continued empiric coverage).
  • ___ Healthcare-associated urinary tract infection (continued empiric coverage).
  • ___ Necrotizing soft tissue infection (not cellulitis) (continued empiric coverage).
  • ___ Other healthcare-associated sepsis/infection. List syndrome ____________________________
  • ___ Other. List syndrome _________________________________________________________

Piperacillin/tazobactam (dose/frequency/duration):

__________________________________________________________________________________

Based on information available, we suggest the following modifications to your patient's antimicrobial therapy.

  1. _____________________________________________________________________________
  2. _____________________________________________________________________________
  3. _____________________________________________________________________________

These changes are recommended based on:

  • ___ Culture/sensitivity data.
  • ___ Drug toxicities/side effects.
  • ___ Opportunity to change to oral therapy.
  • ___ More narrow spectrum antibiotic regimen.
  • ___ Specific diagnosis.
  • ___ Others: __________________________________________

Comments:


Notes left in the chart:
___ Yes       ___ No

Did the team accept your recommendation?
___ Yes       ___ No

If a thorough analysis of this case is desired, please request an ID consultation.

 

_______________________________________________________
Pharmacist   

Return to Question 4

Page last reviewed September 2012
Internet Citation: Ø 4C TOOL: Pipercillan/Tazobactam De-Escalation Form: Tools and Resources. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/cdifftoolkit/cdiffl2tools4c.html