Alkem

Subject ID *

Subject Initials *

Investigator *

Centre *

Date of Assessment *

Subject Initials *

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Clinical/Surgical Diagnosis *

Clinical Presentation *

Duration of current illness *

Prophylactic antibiotics prior to surgical procedure (if any)

Post-surgical infection diagnosis *

Any antibiotics given for post-surgical infection

Need for ICU admission for the post-surgical infection *

Yes No

PULSE (Bpm)

BP (mmhg)

RR (pm)

TEMPERATURE (ºF)

SPO2 (%)

Specify others (if available)

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Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

Microbiological culture isolated *

Yes No

Laboratory tests performed for the confirmation of microbiological culture isolates?

Which specific organism is isolated? (If available)

Other Sensitivity results (if available)

Hb (gm/dL)

RBC (millions/cumm)

WBC (cumm)

Platelets (cumm)

CRP (mg/L)

Bilirubin (T/D/I) (mg/dL)

SGPT (U/L)

SGOT (U/L)

ALP (U/L)

Protein (T/A/G) (g/dL)

S.Cr (mg/dL)

BUN (mg/dL)

eGFR (mL/min/1.73m²)

Specify others (if available)

Piperacillin-Tazobactam prescribed *

Yes No

Brand Name *

Dose *

Frequency *

Duration *

Other medications prescribed for T/t

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Medication	Dose	Frequency	Duration

Date of Assessment *

Total Duration of Therapy (days) *

Signs and Symptoms *

Cure Improvement Worsening Mortality

Need for surgical intervention (if any)

Need for ICU admission for the post-surgical infection *

Microbiological culture isolated *

Yes No

Laboratory tests performed for the confirmation of microbiological culture isolates?

Which specific organism is isolated? (If available)

Other Sensitivity results (if available):

PULSE (Bpm)

BP (mmhg)

RR (pm)

TEMPERATURE (ºF)

SPO2 (%)

Specify others (if available)

Hb (gm/dL)

RBC (millions/cumm)

WBC (cumm)

Platelets (cumm)

CRP (mg/L)

Bilirubin (T/D/I) (mg/dL)

SGPT (U/L)

SGOT (U/L)

ALP (U/L)

Protein (T/A/G) (g/dL)

S.Cr (mg/dL)

BUN (mg/dL)

eGFR (mL/min/1.73m²)

Specify others (if available)

Adverse events noted due to study medication *

Yes No

ADVERSE EVENT(S)
AE. No	Adverse Event Term	Date of onset (DD/MM/YYYY)	Severity	Action Taken	Treatment given	Relationship with Study Drug	Outcome	Serious Adverse Event
1					Yes No			Yes No
2					Yes No {{-- --}}			Yes No {{-- --}}
3					Yes No {{-- --}}			Yes No {{-- --}}
4					Yes No {{-- --}}			Yes No {{-- --}}

Date of Assessment

Total Duration of Therapy (days)

Signs and Symptoms

Cure Improvement Worsening Mortality

Need for surgical intervention (if any)

Need for ICU admission for the post-surgical infection

Microbiological culture isolated

Yes No

Laboratory tests performed for the confirmation of microbiological culture isolates?

Which specific organism is isolated? (If available)

Other Sensitivity results (if available):

Adverse events noted due to study medication

Yes No

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ADVERSE EVENT(S)
AE. No	Adverse Event Term	Date of onset (DD/MM/YYYY)	Severity	Action Taken	Treatment given	Relationship with Study Drug	Outcome	Serious Adverse Event
{{ $j++ }}					Yes No			Yes No

Piperacillin Tazobactam

ASSESSMENT 1 - START OF THERAPY

DEMOGRAPHICS and ANTHROPOMETRY

MEDICAL AND SURGICAL HISTORY

VITALS

CONCOMITANT DISEASE and MEDICATION

MICROBIOLOGICAL DATA

LABORATORY PARAMETER (test & Results)

TREATMENT OF POST-SURGICAL INFECTION

ASSESSMENT 2 - END OF THERAPY

DATE OF ASSESSMENT

CLINICAL DATA

MICROBIOLOGICAL DATA

VITALS

LABORATORY PARAMETER (test & Results)

ADVERSE EVENTS

ASSESSMENT 3 - DISCHARGE

CLINICAL DATA

MICROBIOLOGICAL DATA

VITALS

LABORATORY PARAMETER (test & Results)

ADVERSE EVENTS