Alkem

Feropenem

A multicenter, retrospective, real world evidence study to evaluate the effectiveness of Faropenem in the management of pediatric patients suffering from Upper Respiratory Tract Infections (URTIs).

Subject ID *

Subject Initials *

Investigator *

Centre *

ASSESSMENT 1 - START OF THERAPY

Date of Assessment *

DEMOGRAPHICS and ANTHROPOMETRY

Subject Initials *

OPD *

Yes No

IPD *

Yes No

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

MEDICAL AND SURGICAL HISTORY

Any Bacterial Species isolated *

Yes No

Clinical Signs and Symptoms *

Clinical Diagnosis *

Duration of current illness *

Previous antibiotics used (if any)

CONCOMITANT DISEASE and MEDICATION

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

MICROBIOLOGICAL DATA (if available)

Any Bacterial Species isolated

Yes No

Sensitivity results (if available)

VITALS

PULSE (Bpm)

BP (mmhg)

RR (pm)

TEMPERATURE (°F)

SPO2 (%)

Specify others (if available)

LABORATORY PARAMETERS Reports & Value (if available)

Hb (gm%)

RBC (cumm)

WBC (cumm)

Platelets (cumm)

CRP (mg/L)

ESR

Specify others (if any)

TREATMENT OF CURRENT MEDICAL ILLNESS

Faropenem prescribed *

Yes No

Brand Name *

Marketing Company Name *

Dose *

Frequency *

Duration *

Other medications prescribed for T/t

Medication	Dose	Frequency	Duration

ASSESSMENT 2 - FOLLOW-UP VISIT

DATE OF ASSESSMENT

Date of Assessment *

Duration of Hospital Stay days (if IPD patient) *

Total Duration of Therapy (days) *

VITALS

PULSE (Bpm)

BP (mmhg)

RR (pm)

TEMPERATURE (°F)

SPO2 (%)

Specify others (if available)

LABORATORY PARAMETERS Reports & Value (if available)

Hb (gm%)

RBC (cumm)

WBC (cumm)

Platelets (cumm)

CRP (mg/L)

ESR

Specify others (if any)

MICROBIOLOGICAL DATA (if available)

Any Bacterial Species isolated?(if available)

Yes No

Sensitivity results (if available)

CLINICAL DATA

Clinical Signs and Symptoms (if any)

Cure Improvement Worsening Mortality

Any secondary infections during hospital stay (details if yes)

Relapse of infection (details if yes)

ADVERSE EVENTS

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
Severity: 1- Mild; 2- Moderate; 3- Severe; +Action Taken: 1- No Change in IP, 2- IP Temporarily Interrupted, 3- IP Permanently Discontinued, 4- Other, specify *If Treatment given is ticked as 'Yes' then relevant information should be captured on Prior and concomitant Medication Form. Relationship: 1= Related, 2= Not Related ++Outcome: 1 = Resolved, 2= Recovered/ Resolved with Sequelae, 3= Recovering/ Resolving, 4=Not Recovered/ Not Resolved, 5= Fatal/ result in death, 6= Unknown