Linezolid Zyvox Data Collection
LINEZOLID (ZYVOX) DATA COLLECTION SHEET
*Indicates Required Fields  
*Patient Name : Admitting diagnosis :
Acct # : Attending MD :
Age : Prescribing MD :
Sex : Service line :
Admit Date : Discharge date :
Allergies :
 
Indication for Use (check all that apply)

Approved Indications


FDA-Approved Indications

Nosocomial pneumonia caused by:


Community acquired pneumonia caused by:


Complicated skin and skin structure infections caused by:


Uncomplicated skin and skin structure infections caused by:


Other Reasons for Use (please describe in detail)



Was organism confirmed by culture?    Yes No

Was culture obtained before drug initiated?    Yes No

Contraindications

   Hypersensitivity to linozolid or any of its components

Dose and Administration
Date therapy initiated : Date therapy ended :
IV Therapy PO Therapy
Dose Given: Dose Given:

Date patient eligible for PO therapy:

Date patient changed to PO therapy:

Did PHh recommend IV to PO conversion? Yes No

Durg Interactions  (Does patient receive concomtantly)

Monitoring
Date
WBC
S/B
Temp
H/H
Plt

Adverse Effects  (Check any/all that apply and describe reaction)

   Hematologic (anemia, thrombocytopenia, leukopenia, pancytopenia, etc.):

   Cardiovascular (HTN):

   CNS (headache, neuropathy):

   GI (n/v, diarrhea, abd pain):

  Oral or vaginal yeast infection:

  Dermatologic reactions:

  Other:

Outcomes
Signs/symptoms of infection improved? Yes No
Repeat cultures demonstrate organism eradication? Yes No
Treatment discontinued due to (select all that apply):
Inadequate response comments:

Other comments:


Other Pertinent Patient Information




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