Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship
Ø 4C TOOL: Pipercillan/Tazobactam De-Escalation Form
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
- Run/obtain daily list of piperacillin/tazobactam utilization report.
- Select patient who has been on piperacillin/tazobactam for >72 hours without ID consult.
- Review Carecast/chart for indication, duration, culture susceptibility, etc., to determine the appropriateness of piperacillin/tazobactam usage.
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 _______
- ___ 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 _________________________________________________________
Based on information available, we suggest the following modifications to your patient's antimicrobial therapy.
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: __________________________________________
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.
Page originally created September 2012