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Antibiotic Stewardship Audit
Antibiotic Stewardship Audit
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Created by Brandi Vela, RN, BSN at Delta Health
Infection Prevention
Customer Created
Table of Contents
Audit Form
Audit Form
Antibiotic Stewardship Audit
Required
Observed Date
Antibiotic Indication
UTI
Pneumonia
Skin/Soft Tissue
Other
Provider initiating abx
Last Name 1
Last Name 2
Empiric Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Second Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Third Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Fourth Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
First Escalated Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Second Escalated Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Third Escalated Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
First De-escalated Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Second De-escalated Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Third De-escalated Antibiotic/Dose/Freq
Do not enter protected health information (PHI)
Total days/duration of inpatient antibiotic(s)
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Initial culture collected
Select an Option
Second Initial culture collected
Select an Option
Third initial culture collected
Select an Option
Elevated PCT
Yes
No
N/A
Comments
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Antibiotic Stewardship Audit Checklist
Mark all as...
Appropriate Antibiotic(s) for dx?
Yes
No
Antibiotic adjusted as needed after culture results received?
Yes
No
N/A
Antibiotic de-escalated / escalated / narrowed / broadened / optimized appropriately?
Yes
No
N/A
Was patient symptomatic?
Yes
No
Diagnostic tests ordered?
Yes
No
Initial culture ordered
Yes
No
