Alkem

IPD Protocol

A multicenter, retrospective, real world evidence study to assess the utilization of antibiotic among hospitalized patients.

Subject ID *

Subject Initials *

Investigator *

Centre *

No. of Beds in Hospital *

ASSESSMENT OF THERAPY PRESCRIBED

Date of Assessment *

DEMOGRAPHICS and ANTHROPOMETRY

Subject Initials *

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Geographical location *

Allergy *

Yes No

Smoking history *

Yes No

Occupation *

Family history *

Past significant medical and/or surgical history *

MEDICAL AND SURGICAL HISTORY

Patients prescribed with parenteral antibiotics in IPD *

Yes No

Date of IPD admission *

Chief complaints *

Clinical Diagnosis *

Microbial culture sensitivity test results (with date)

@for ($i = 1; $i <= 5; $i++) @endfor

Date of test	Findings

Duration of current illness *

Severity of disease *

Previous Antibiotic used (if any)

VITALS

@for ($i = 29; $i <= 34; $i++) @endfor

Date of Assessment	Parameters	Results
	@if ($i == 34) Specify others (if available) @else @switch($i) @case(29) PULSE (Bpm) @break @case(30) BP (mmhg) @break @case(31) RR (pm) @break @case(32) TEMPERATURE (°F) @break @case(33) SPO2 (%) @break @endswitch @endif

TREATMENT OF CURRENT MEDICAL ILLNESS

Parenteral and/or oral antibiotics being used for Current Medical Condition

@for ($i = 1; $i <= 7; $i++) @for ($j = 1; $j <= 9; $j++) @endfor @endfor

Generic Name	Brand Name	Class	Dose	Frequency	Route	Duration	Indication	Empiric OR Definitive

Any Specific Changes in treatment regimen (if available)

CONCOMITANT DISEASE and MEDICATION

@for ($i = 1; $i <= 4; $i++) @for ($j = 1; $j <= 5; $j++) @endfor @endfor

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

LABORATORY PARAMETERS (as available)

@for ($i = 38; $i <= 52; $i++) @endfor

Date of Assessment	Tests	Results
	@switch($i) @case(38) Hb (gm/dL) @break @case(39) RBC (millions/cumm) @break @case(40) WBC (/cumm) @break @case(41) Platelets (/cumm) @break @case(42) CRP (mg/L) @break @case(43) ESR (mm/hr) @break @case(44) Bilirubin (T/D/I) (mg/dL) @break @case(45) SGPT (U/L) @break @case(46) SGOT (U/L) @break @case(47) ALP (U/L) @break @case(48) Protein (T/A/G) (g/dL) @break @case(49) S. Cr (mg/dL) @break @case(50) BUN (mg/dL) @break @case(51) eGFR (mL/min/1.73m2) @break @default Specify Others (if any) @endswitch

ADVERSE EVENTS

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