Inclusion, exclusion and audit criteria

DEMO DATA

Customise who to include and who to exclude for this audit cycle. Edits are saved automatically to your workspace.

Inclusion criteria
  • Adults aged 16 years or older, unless locally adapted
  • Patients prescribed a systemic antibiotic (oral or IV) during the audit period
  • Antibiotic course expected to continue for at least 48 hours at the time of first dose
  • Patients admitted to hospital or reviewed in an acute assessment setting during the audit period
  • Patients managed in the selected wards, units, departments or pathways
  • Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
  • Patients under 16 years old unless locally adapted
  • Antibiotics given for a single dose only (e.g. single-dose surgical prophylaxis)
  • Topical or purely inhaled antibiotics
  • Patients receiving long-term suppressive antibiotic therapy managed by a specialist team
  • End-of-life care where antibiotic review has been consciously deferred and documented
  • Duplicate admissions or duplicate records
  • Records outside the selected audit period
  • Records unavailable for review
  • Records where local governance approval is required but has not been obtained
  • Direct patient identifiers must not be entered into the tool
Audit criteria (24)
Aligned with NICE NG15, UKHSA Start Smart – Then Focus and local antimicrobial policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C1
    Indication for antibiotic documented on the prescription.
    Target ≥ 95% · auto-computed from submissions
  2. C2
    Antibiotic review completed at 48–72 hours from first dose.
    Target ≥ 90% · auto-computed from submissions
  3. C3
    CARES decision (Continue / Amend / Refer / Escalate / Stop / Switch) documented at review.
    Target ≥ 90% · auto-computed from submissions
  4. C4
    Review completed within the 48–72 hour window.
    Target ≥ 90% · auto-computed from submissions
  5. C5
    Allergy status documented on the prescription.
    Target ≥ 95% · auto-computed from submissions
  6. C6
    Duration or planned stop / review date documented.
    Target ≥ 90% · auto-computed from submissions
  7. C7
    Cultures / relevant samples obtained before first antibiotic dose where clinically appropriate.
    Target ≥ 85% · auto-computed from submissions
  8. C8
    Source control considered and documented where relevant.
    Target ≥ 85% · auto-computed from submissions
  9. C9
    Microbiology / laboratory results reviewed and acted on.
    Target ≥ 90% · auto-computed from submissions
  10. C10
    Antibiotic regimen adjusted per culture / sensitivity where relevant.
    Target ≥ 85% · auto-computed from submissions
  11. C11
    IV-to-oral switch considered where clinically appropriate.
    Target ≥ 85% · auto-computed from submissions
  12. C12
    Dose appropriate for renal / hepatic function and weight.
    Target ≥ 90% · auto-computed from submissions
  13. C13
    Empirical antibiotic choice in line with local antimicrobial guideline.
    Target ≥ 90% · auto-computed from submissions
  14. C14
    Sepsis pathway followed where clinically applicable.
    Target ≥ 95% · auto-computed from submissions
  15. C15
    Microbiology / infection specialist advice sought where required by policy.
    Target ≥ 90% · auto-computed from submissions
  16. C16
    Monitoring plan (bloods, response, side effects) documented.
    Target ≥ 85% · auto-computed from submissions
  17. C17
    OPAT / ambulatory antimicrobial pathway completed where indicated.
    Target ≥ 85% · auto-computed from submissions
  18. C18
    Critical care escalation completed where indicated.
    Target ≥ 90% · auto-computed from submissions
  19. C19
    Clinical response to antibiotic therapy documented.
    Target ≥ 85% · auto-computed from submissions
  20. C20
    Discharge summary documents the antibiotic course, indication and stop date.
    Target ≥ 90% · auto-computed from submissions
  21. C21
    GP / community handover of the antimicrobial plan documented where relevant.
    Target ≥ 85% · auto-computed from submissions
  22. C22
    Patient information / advice on antibiotics documented where relevant.
    Target ≥ 75% · auto-computed from submissions
  23. C23
    Reason for delayed or missed 48–72h review documented where applicable.
    Target ≥ 85% · manual review
  24. C24
    Any antimicrobial safety concern was escalated or actioned where identified.
    Target ≥ 100% · manual review