Associated Marine officers’ and Seamen's Union of the Philippines PTGWO-ITF (An afta ofthe International Transport Workers Federation London UK} ‘SEAMEN’S HOSPITAL - ILOILO fate St, Mando, oie Cay “To (039) $21-2460F 321-2498 921-2404 Teetax 321-9528 mal: shosp_lo@ yahoo.com. Document Change! Production Request Charher Requested by: RAR Y Date: March 5, 2019 Designation iv. / Dept / Section: susie Sees OFFI AMS TEA Reviewed by TYPE OF DOCUMENT: (_) Quality Manual (_) Procedures Manual () Hospital Manual (wim () Forms |For? — Mid |__Document No. Page No. [7® Day Antibiotic Stop Poli "shams on 7 7 Day Antibiotic Stop Policy Monitoring Tool SHE ANS 02 7 ICC Antibiotic Guidelines ~ SHI AMS 03 7 Daily Census of Isolates — SH ANS OF 7 Restricted Antibi fom — ‘AMS 08 a Culture Directed Antibiotic Guidance Audit Tool ‘SHI-AMS 06 Format for Monthly Report on Adherence to Surgical Prophylaxis ‘SHI-ANS OF 7 Guidelines Intravenous to Oral Antimirobial Therapy Switch SR ANS 0 i Pre-op Anuibioie Compliance Monitoring Form on Elesive OR Cases_| SHAMS 08 7 [Form A. Request form for 7 days use of Restricted Antibiotic (Initial) SH AWS 070 Form B. Request form for extension of Restricted Antibiotic beyond 7) SHAMS O11 7 days (Follow-up) DETAILS OF AMENDMENT/S OR NEW DOCUMENT: (Please see attach sample amended text or format of new document) Verified by: Approved by: ‘Quality Management Representative Hospital Director Date: Date: ‘SHL-QAD 02 Rev 01 08/03/12Associated Marine officers’ and Seamen’s Union of the Philippines PTGWO-ITF (Aafia ofthe International Transport Workers Federation London UK) 'SEAMEN’S HOSPITAL - ILOILO ‘Ofate St, Manduria, Hoo Cty “Tel (039) 321-2460 32-2430) 521-2408 Teel 321-3823, mal: shosp_lo@ yahoo.com. Document Change/ Production Request fon ings Requested by: MONICA SANTI Date: March 5, 2019 Designation Div. / Dept. / Section: nurs sERWCE OFFICE ANS TEAM Reviewed by. ‘TYPE OF DOCUMENT: ()Qualty Manual ) Procedures Manual (Hospital Manual ( ) WIM (0 Forms ie — T Form ane on |__ Document No. Ll (_SHI-AMS of ioomee "Day Antibiotic Stop Policy Monitoring Tool [SHI AMS 02 i Antibiotic Guidelines ‘SHI AMS 03 i Daily Census of Isolates SHI- AMS 04 i Restricied Antibiotic Request Form ma ‘SHI AMS 05 i Culture Directed Antibiotic Guidance Audit Tool ‘SHI AMS 06 1 Format for Monthly Report on Adherence to Surgical Prophylaxis ‘SHI-AMS 07 7 G Tniravenous to Oral Antimicrobial Therapy Switch ‘SHI ANS 08 z Pre-op Antibiotic Compliance Monitoring Form on Elective OR Cases | SHAMS 08 t Form A. Request form for 7 days use of Restricted Antibiotic (Initial) | SAF AMS 070 Form B. Request form for extension of Restricted Antibiotic beyond 7 | SHI AMS O17 7 days (Follow-up) DETAILS OF AMENDMENT/S OR NEW DOCUMENT: (Please see attach sample amended text or format of new document) VERIFICATION AND APPROVAL: Verified by: Approved by: ‘Quality Management Representative Hospital Director Date: Date: SHI-QAD 02 Rev 01 08/03/12f) Associated Marine officers’ and Seamen’s Union of the Philippines PTGWO-ITF (An affiate ofthe International Transport ‘Workers Federation London UK) SEAMEN'S HOSPITAL ~ ILOILO (Ofte St, Manduria, toi Cty Tel (089) 224-2400 21-2438/ 21-2404 Teele 321-9529 Ema: shosp_#0@ yahoo com. Document Change/ Production Request Requested by. iK SANT Date: March 5, 2019 Div. / Dept. / Section: wrsinc SERVICE OFFICE AMS TEAM Reviewed by Department Head ‘TYPE OF DOCUMENT: ()Quaity Manual ( ) Procedures Manual (Hospital Manual () WIM (I) Forms. | Form? = = Document No. Page No. 7 Day Antibiotic Stop Poli SHAMS 01 7 Day Antibiotic Stop Policy Monitoring Tool SHI AMS 02 TCC Antibiotic Guidelines SHI AMS 03 Daily Census of Isolates SHI. AMS 08 Resirited Antibiotic Request Form ‘SHI AMS 05 Culture Directed Antibiotic Guidance Ai SHI-AMS 08 Format for Monthly Report on Adherence to Surgical Prophylaxis SHI-AMS 07 Guidelines Intravenous to Oral Antimicrobial Therapy Switch SHL-AMS 08 7 Pre-op Antibiotic Compliance Monitoring Form on Elective OR Cases | SHI-AMS 089 7 Form A. Request form for 7 days use of Restricted Ant Form B, Request form for extension of Restricted Antibiotic beyond 7 days ( Follow-up) I DETAILS OF AMENDMENTIS OR NEW DOCUME! (Please see attach sample amended text or format of new document) Initial) | SHI-AMS O70 ‘SHI- AMS O77 7 Verified by: Approved by: ‘Quality Management Representative Hospital Director Date: Date: SHI-QAD 02 Rev 01 08/03/12{Associated Marine Officers’ and Seamen's Union of the Philippines PTGWO ~ ITF {An Affliate of the Intemational Transport Workers Federation London, UK) ‘SEAMEN’S HOSPITAL - ILOILO ‘Ofrate St. Mandurtiao, lolo City ‘el, (033) 321-2469/ $21-2498/ 321-2404 Telefax: 321-3523, Email: shosp_lo@yahoo.com PLEASE STOP AND REVIEW YOUR ANTIBIOTICS! 7™ DAY ANTIBIOTIC STOP POLICY Name of Patient: Hospital No. Address: Ward/ Room: Age: Sex: ‘Admission Date: Present working ID Diagnosi Current Antibiotics: 1 dose and route: frequency: dose and route: frequency: 3 dose and route: frequency: Is there a need to continue antibiotics? Yes No If Yes, state the reason and plan: Resident in charge: Jj Date Approved: (Service Consultant/Department Training Officer/ Department Chairperson) (Signature above printed name) Date SHI- AMS 01 Rev. 03/5/19‘Associated Marine Officers’ and Seamen's Union of the Philippines PTGWO ~ ITF (An Affiate ofthe international Traneport ‘Workers Federation London, UK) SEAMEN'S HOSPITAL - ILOILO Ofte St Mandurino, tole City “To. (033) 321-2460) 521-2438) 321-2494 Telafax 321-3823 mal: shosp_io@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE 7" DAY ANTIBIOTIC STOP MONITORING TOOL ‘WARD DATE { =n a ‘Ac Late completion PATIENTSNAME | ANTIBIOTICS = DATE DATE Resident in | Name of Nurse/s who continued to Bc No justification | | starte> | ENDED charge | give anti-Infectives onthe 8" dayand | Cc Without service | ‘onwards without the completed form consultant's / Training | Officer / Chairperson’ | _ |__ signature within 24hrs Monitored By: ~ Verified By: ‘SHI AMS 02 Rev. 03/5/19 Noted By:Associated Marine Officers’ and Seamen's Union of the Philippines PTGWO — ITF (An Affliate of the Intemational Transport Workers Federation London, UK) SEAMEN’S HOSPITAL - ILOILO ‘Offate St. Mandurriao, Holo City ‘Tel. (033) 321-2469/ 321-2438) 821-2494 Telefax: 321-9523, Email: shosp_llo@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE ICC ANTIBIOTIC GUIDELINES This form is part of the hospital's Antimicrobial Stewardship Program. Date of admission | Working Diagnosis Gram Stain Result (if applicable): Antibiotic History Antibiotic Date started and stopped Patient's Present Clinical Status ‘Supporting Laboratory Parameters: ICC Recommendations © Continue present antibiotics 1 Shift antibiotics «Discontinue antibiotics ICC Resident: (Signature above printed name) ‘Approved by ICC Chairperson/Infectious Disease Consultant: SHI- AMS 03, Rev. 03/5/19‘Associated Marine Officers’ and Seamen’s Union of the Philippines PTGWO— (An Affilate of the International Transport Workers Federation London, UK) ‘SEAMEN’S HOSPITAL - ILOILO Ofiate St. Mandurriao, lloilo City Tel, (083) 321-2469) 321-2438/ 321-2404 Telefax: 321-3523, Email: shosp llo@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE DAILY CENSUS OF ISOLATES 7 a ATE 5 | Comments Date Specimen Date Date | NAME admitted | A6e/sex | Ward Specimen pee (ee) ey Organism tebe Mle up by | Received by: Released by: Received by: SHI- AMS 04 Rev. 03/5/19Union of the Philippines PTGWO. (An affiliate of th Workers Federation London, UK) ‘SEAMEN’S HOSPITAL - ILOILO ‘Ofrate St. Mandurriao, Holo City Associated Marine Officers’ and Seamen's TF international Transport Tel. (033) 321-2469/ 321-2436/ 321-2404 Telefax: 321-3523, Email: shosp_llo@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE RESTRICTED ANTIBIOTIC REQUEST FORM This form is part of the hospital's Antimicrobial Stewardship Program. PATIENT'S NAME AGE SEX | DEPT: Male | WARD/RM NUMBER: uastame | —_FIRSTNAME | MIDDLE NAME Female | Patient Hospital | Clinical Diagnosis/ Name of Surgery. ‘Weight | Creatinine Creatinine Clearance ] J DRUGS REQUESTED - _ — ‘Drug Description Dose / Frequency Duration Quantity Requested (qhr) (days) {tab/amp/vial) TUSTIFICATION FOR REQUESTS aProphylactic SEmpiric 1 Definitive/Culture-guided Reason for Request: = SITE OF INFECTION [aos Reproductive 1 Blood 3 9 Catheter Related (Urine/IV) ca Respiratory Gut ' Others, please specily ScNs Sof Tissue ‘CULTURE SENSITIVITY RESULT: (if indeaton for requests DEFINTTVE) Date ‘Specimen /Source Gram Stain | ‘solate(s) “Sensitivity Pattern | Requered by : l “Signature over Printed Name of Physician — ‘DO NOT WRITE BELOW THIS LINE RECOMMENDATION: _ : eStart Continue [sDiscontinue [Revise a follows 7 Bross Dose/Frequeney | Duration Requested Quantity — | (ahour) (ts/days) (tab/amp/val) T I 1 Disapproved (State reason) Department Chairman / ICC Chairman /ID Consultant (Please see list of restricted antibiotics at th SHI- AMS 05, Rev. 03/5/19 e Back)Associated Marine Officers’ and Seamen's Union of the Philippines PTGWO — ITF (An Affiliate of the Intemational Transport ‘Workers Federation London, UK) ‘SEAMEN’S HOSPITAL - ILOILO Ofate St. Manduriao, llolo City Tel. (033) 321-24691 321-2438/ 921-2494 Telefax: 921-3523, Email: shosp llo@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE CULTURE-DIRECTED ANTIBIOTIC GUIDANCE AUDIT TOOL NAME OF PATIENT Dates of Culture | Ward SPECIMEN | ONGOING 4, What are the ICC Recommendations? =| REMARKS and Sensitivity AND ANTIBIOTICS Recommendation Type* z & _ ORGANISMS | 2. Prior to 5. (De-escalate/Escalate/Continue/Stop) 2 2 3 | REVIEW BY and DEPARTMENT ‘ADM. | REQ. | REL. | 1. Creatinine Recommendations | 6. (Dose & Frequency: Increased/ | 35 2| pate (meal) 3. During Review | Decreased/Continued) Bae 7. Date of ICC Recommendation ja 8 8. Recommendations Carried Out? (Y/N) _| ® SHI- AMS 06 Rev. 03/5/19‘Associated Marine Officers’ and Seamen's Union ofthe Philippines PTGWO — ITF (an Alta fe erator Tanepert Wertere Federation Landon UK) ‘SEAMEN'S HOSPITAL ILOILO Format for Monthly Report on Adherence to Surgical Prophylaxis Guidelines ‘Surgery Monitored Number of Cases ‘Compliance 10 Recommended Guidelines No. of Cases Compliant ‘to Recommended Antibiotics (A) Compliance (A) ] No. of Cases Compliant | 10 Pre-op Dose Timing © ‘Compliance (B) No. of Cases Compliant to Post op antibiotic Use © ‘Compiance (C) - SHI-AMS 07 Rev. 03/5/19Associated Marine Officers’ and Seamen's. Union of the Philippines PTGWO ~ ITF {An Affliate of the Intemational Transport Workers Federation London, UK) ‘SEAMEN’S HOSPITAL - ILOILO ‘Ofiate St. Mandurriao, lolo City ‘el, (033) 321-2489/ 321-2436/ 321-2404 Telefax 321-3523, Email: shosp_lo@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE INTRAVENOUS TO ORAL (IV-PO) ANTIMICROBIAL THEREAPY SWITCH This form is part of the hospital’s Antimicrobial Stewardship Program. Dear Or. Date: Patient Name: Ward: Hospital No. Current IV antimicrobial: C Wvazithromycin C WCiprofloxacin C1 WVclindamycin C WLevofioxacin © WvCotrimoxazole Cl IvMoxifloxacin O vFluconazole C1 ivFluconazole O Wuinezotid others: Dose: Start date Indication: Your patient fulfills the following criteria to switch to oral (PO) antimicrobial. Clinical stability: CO Afebrile Downward trend or normalization of inflammatory markers (reactive protein, white blood cel count, procaletonin) O Stable vital signs Able to tolerate oral intake: 1D Patient is not nil by mouth CF Tolerating oral diet, medications and/or enteral feeds 1 Oral absorption is not compromised (Wo unexplained tachycardia, hypotension, achypnes) cans Vonni of asittan/mausbicapon Gastiar. Kindly consider switching to: 1D PO Azithromycin PO Ciprofloxacin D1 PO Clindamycin OD PoLevofioxacin D1 PO Cottrimoxazole 1D PO Moxifloxacin 1 Po Fluconazole 1 PO Fluconazole 1D POtinezolid CO other: Dose: End date: ‘The above antimicrobials have excellent oral bioavailability. They are equally effective when given orally in patients who are clinically stable and able to tolerate orally. Oral administration reduces (a) nursing time for IV drug preparation and IV line care, (b) length of stay, (c) healthcare cost, and (d) potential complications from IV access; without adversely impacting clinical outcomes. Thank you for reviewing the patient IV-to-PO switch. Yours sincerely, Name: Designation: SHI- AMS 08 Rev. 03/5/19Associated Marine Officers’ and Seamen's Union of the Philippi jines PTGWO - ITF (An Affiliate of the Intemational Transport Workers Federation London, UK) ‘SEAMEN’S HOSPITAL - ILOILO Ofiate St. Mandurtia, lloilo City Tel. (033) 321-2489/ 321-2438) 321-2404 Telefax: 321-3623 Email: shosp_llo@yahoo.com ANTIMICROBIAL STEWARDSHIP COMMITTEE PRE-OP ANTIBIOTIC COMPLIANCE MONITORING FORM on ELECTIVE OR CASES FOR THE MONTH OF YEAR 20, ] ~ Was he same | % Pre-op preoperative anitiotc g Antibiotic used 24 hours after Date of | : : (Gener Name, | Cuting | Closing | closing time? (VIN) | Sst? | Monitored Sect} ramet |r| neon | msc | fe | fet | ome | om we | | 3 ‘dat and time Ifyes, write dose, route | & ‘iven) ‘and timing ofthe = 1 - antibiotic SHI-AMS 09 Rev. 03/5/19Patient Satisfaction Survey' Associated Marine Officers’ and Seamen's Union ofthe Philippines PTGWO - ITF (in Affiliate ofthe International Transport Workers Federation London, UK) ‘SEAMEN'S HOSPITAL - ILOILO Seta) ae eo St 28 91.266 Tl 321-9525 not soon iat zon FORM A ~ REQUEST FORM FOR 7 DAYS USE OF RESTRICTED ANTIBIOTIC (INITIAL) Age & Sex: ‘Area of Confinement: Date and Time of Referral Wt (Kgs) History of Allergy: Creatinine Clearance: SGPT: Working Diagnosis: Indication for Use: Prophylaxis, Empire Therapy Definitive Therapy Restriction Antibiotic Requested: [£2 imipenem [> cefipime — Vancomycin Meropenem Other 4" Gen Cephalosporin Linezolid trons 4 oc ican TS) Sher EE] Selita icra) FF) in Specify: Speaty Specify Other Restricted, Dose and Duration of Therapy: [1 Treatment of moderate to severe infection Community acquired pneumonia Urosepsis Preumonia in immunecompromised host Intraabdominal Abscess Infections in immunocompromised host Intravascular catheter related infections Infection in patients at extreme of age Others (specify) Previous broad spectrum antibiotic therapy within preceding 3 months ( specify): Previous hospitalization for >5 days within preceding 3 months Satisfy criteria for sepsis ‘Treatment of infections caused by resistant microorganism based on culture and sensitivity results ‘Treatment of infections in patients with marked allergies to beta-lactam antibiotics ‘Treatment of CNS infections Failure to respond to current antibiotic regimen ( specify antibiotics): Empiric therapy of patient who developed nosocomial infection pending culture results Others: Culture Isolate (s) and Sensitivity: 1. Date: Isolate: Sensitive: Specimen Resistant: 2. Date: Isolate: Sensitive: Specimen Resistant: Previous and Current Antibiotie(s) use Date Started Date Discontinued ‘Dutcome of Verbal Approval Requesting Physician's Name & Contact No. PRE-APPROVAL FOR RESTRICTED ANTIMICROBIAL ONLY (Trove Ino aPproven No. of says Approved for Use: — Reason: ‘Approvers Remarks: | Name & signature: Date: si awso10 fev. 03/5/19Name of Antibio Designated AMS Approver ‘A. MONITORED ANTIBIOTICS 1. Ceftriaxone Cefotaxime Ceftazidime Ampicillin-Sulbactam All Aminoglycosides lindamycin IV Piperacillin- Tazobactam NOY RYN | Subsequent extension of duration | beyond 7 days will require approval from ICC Head/ ID | Specialist/ Department Chairman (Adult Pedia) RESTRICTED ANTIBIOTICS . Cefipime Non PNDF . Cefpirome 1. Linezolid . Cefoperazone-Sulbactam 2. Tigecycline 3. Moxifloxacin . Ertapenem 4, Fosfomycin Meropenem. Imepenem Levofloxacin IV/PO 9. Ciprofloxacin IV/PO 10. Ofloxacin IV/PO 11. Amphotericin B 12. Voriconazole 13. Vancomycin 14. Colistin 15. Acycloir 16. Valacyclovir 17. Valganciclovir 18. Fluconazole 1V/PO Lb 1 2, 3, 4. Aztreonam 5, 6 7 8 siansox0 Rev.03/5/19 | Usage beyond 24 hours will ‘warrant approval from approval from ICC Head/ ID Specialist/ Department Chairman (Adult/ Pedia), ‘Associated Marine Officers’ and Seamen's Union of the Philippines PTGWO ~ TF (An Afiiate ofthe International Transport Workers Federation London, UK) SEAMEN’S HOSPITAL - ILOILO fate arto, el Oy Sees 3 uo 321200 21.266 Tot 92-9820, Eat eee ogra com FORM B ~ REQUEST FORM FOR EXTENSION OF RESTRICTED ANTIBIOTICS BEYOND 7 DAYS (Follow-up) Patient's Name: Age & Sex: ‘Area of Confinement: Date of Admission: Date and Time of Referral ‘we (Kes) History of Allergy: Creatinine Clearance: SGPT: ‘Working Diagnosis: Indication for Use: Prophylaxis Empiric Therapy Definitive Therapy Restriction Antibiotic Requested: imipenem Cefipime Vancomycin Meropenem Other 4” Gen Cephalosporin Linezolid Entrapenem Specify Atceonam [= othercarbapenems [=] wantfungals (Allexcept Fluconazole) Colistin Specity Specity Specty Other Restricted Dose and Duration of Therapy [1 Treatment of moderate to severe infection Community acquired pneumonia Urosepals Pneumonia in mmuncompromised host Infections in immunocompromised host Infection in patients at extreme of age Others {specify Previous broad spectrum antibiotic therapy within preceding 3 months ( specify) Previous hospitalization for >5 days within preceding 3 months Satisfy criteria for sep: Treatment of infections in patients with marked allergies to beta-lactam antibiotics Treatment of CNS infections Failure to respond to current antibiotic regimen (specify antibiotics): Empiric therapy of patient who developed nosocomial infection pending culture results Other Culture Isolate (s) and Sensitivity: 1. Date: Intraabdominal Abscess Intravascular catheter related infections Treatment of infections caused by resistant microorganism based on culture and sensitivity results Isolate: Sensitive: Specimen Resistant, 2. Date: Isolate: Sensitive: Specimen Resistant: Previous and Current Antibiotics) use Date Started Date Discontinued ‘Outcome of Verbal Approval Requesting Physician’s Name & Contact No. PRE-APPROVAL FOR RESTRICTED ANTIMICROBIAL ONLY (CT arroveo T—Tnorapproven Waa ay Approved for Use _ aoe | Aoprovers Remark 1 Name & Signature: “pate: | SHIAMS O11 Rev.03/5/18C. MONITORED ANTIBIOTICS 8. Ceftriaxone 9. Cefotaxime 10. Ceftazidime 11. Ampicillin-Sulbactam 12. All Aminoglycosides 13. Clindamycin IV 14. Piperacillin- Tazobactam Designated AMS Approver Subsequent extension of duration beyond 7 days will require approval from ICC Head/ 1D Specialist/ Department Chairman (Adult/ Pedia) RESTRICTED ANTIBIOTICS 19. Cefipime 20. Cefpirome 21. Cefoperazone-Sulbactam 22. Aztreonam 23. Ertapenem 24, Meropenem 25. Imepenem 26, Levofloxacin IV/PO 27. Ciprofloxacin IV/PO 28. Ofloxacin IV/PO 29, Amphotericin B 30, Voriconazole 31. Vancomycin 32. Colistin 33. Acycloir 34, Valacyclovir 35. Valganciclovir 36, Fluconazole IV/PO SHIAMS 011 Rev. 03/5/19 Non PNDF 1. Linezolid 2. Tigecycline 3. Moxifloxacin 4 Fosfomycin Usage beyond 24 hours will ‘warrant approval from approval from ICC Head/ ID Specialist! Department Chairman (Adult/ Pedia)