Download measurement - Fungal Pharmacology

THERAPEUTIC DRUG MONITORING SERVICE RADBOUD UNIVERSITY NIJMEGEN MEDICAL CENTRE – CLINICAL PHARMACEUTICAL LABORATORY Geert Grooteplein 10, 6525 GA Nijmegen. T: +31243614163; Attn: Dr. Roger JM Brüggemann CONTACT DETAILS (for correspondence of results)
Dr:
Hospital
Tel. nr
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:…………………………………………………………………
:…………………………………………………………………
PATIENT IDENTIFICATION (add label or fill in data)
Name
Gender
Date of Birth
Weight
Length
:…………………………………………………………………
:…………………………………………………………………
:…………………………………………………………………
:…………………………………………………………………
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Female O Male O
dd/mm/yy
kg
cm
ANTIFUNGAL DRUG TO BE DETERMINED
O fluconazole
O itraconazole
O voriconazole
O posaconazole
O isavuconazole
O liposomal amphotericin B
O anidulafungin
O caspofungin
O micafungin
DRUG DATA ON USE
(must be fully completed)
Start of therapy
Time of last intake
Time of sample
O taken during meal
:…………………………………………………………
dd/mm/yy
:…………………………………………………………
dd/mm/yy ; hh:mm
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dd/mm/yy ; hh:mm
O taken after meal
O nutritional supplement O no meal given
REASON FOR TDM
(must be fully completed)
O sub-efficacy
O toxicity
O compliance
DOSE OF ANTIFUNGAL DRUG
O other (specify)
(must be fully completed)
O ……. mg ……….. times daily O other:
O intravenous administration O oral administration
INDICATION OF ANTIFUNGAL THERAPY
O primary prophylaxis
O secondary prophylaxis
O primary therapy
O secondary therapy
FOCUS OF INFECTION
O pulmonary
O hepatic
(multiple answers possible)
O cerebral
O other:………………………….……………………(please specify)
CAUSATIVE MICRO-ORGANISM
O Aspergillus
O Mucorales
O Candida
O other:………………………….…………………..……… (specify)
PREVIOUS ANTIFUNGAL TREATMENTS (last 30 days)
O fluconazole
O itraconazole
O voriconazole
O posaconazole
O isavuconazole
O liposomal amphotericin B
OTHER DRUG GIVEN CONCOMITTANTLY
O dexamethasone
O ranitidine
O anidulafungin
O caspofungin
O micafungin
(please specify)
O (es)omeprazole
O rifampin
O metoclopramide
O
PATIENT CHARACTERISTICS
O pantoprazole
O
(multiple answers possible)
O hematological malignancy: ……………………….…………………………………(please specify)
O neutropenia
O GvHD
O HSCT
O corticosteroid use
O other:………………………….…………………....(please specify)
Antifungal drug samples are preferably drawn in a Lithium Heparine tube without gel (dark green cap).
Please sent sample together with the completed sheet to the address mentioned in the header.
VERSION NUMBER 1.0