Please Enter Your Name And Family
Module 1: Complete on Hospital Admission
1.A Inclusion Criteria
1. Presence of signs or symptoms suggestive of COVID-19
No
yes
unknown
2. Laboratory confirmation of COVID-19
No
yes
unknown
If yes: then ask question 3, else: skip to the next section
3. date of confirmation?
1.B Demographics
1. Sex at birth
male
female
intersex
unknown
2. Age
3. preterm birth
No
yes
unknown
4. weight at birth (in kg)
5. low birth weight
No
yes
unknown
6. race/ethnicity
Asian
African/black
Caucasian/white
Hispanic/latino
Other
Unknown
7. is the patinet in contact with a health-worker?
No
yes
unknown
8. is the patient currently pregnant?
No
yes
unknown
If yes: ask question 9, else: ask question 10
9. How old is the pregnancy?
10. Was the patient pregnant within 22-42 days from admission?
No
yes
unknown
1.C Vaccination status for COVID-19
1. Did the patient receive a COVID-19 vaccine?
No
yes
unknown
If yes: then ask questions 2 to 8, else: skip to question 9
2. The number of doses
Select
one dose
two doses
three doses and more
unknown
3. Brand of dose 1
select
Pfizer
Moderna
Janssen
AZ
Sinovac
Sinopharm
Bharat
Sputnik
Other
Unknown
4. Date of dose 1
5. Brand of dose 2
select
Pfizer
Moderna
Janssen
AZ
Sinovac
Sinopharm
Bharat
Sputnik
Other
Unknown
6. Date of dose 2
7. Brand of dose 3
select
Pfizer
Moderna
Janssen
AZ
Sinovac
Sinopharm
Bharat
Sputnik
Other
Unknown
8. Date of dose 3
9. The source of vaccination information
select
documented
recall
1D: Vital signs upon addmission
1. symptoms onset
2. admission date at Mofid hospital
3. was the patient referred to Mofid Hospital from another facility?
No
yes
unknown
4. Temperature upon admission (oC)
5. Heart rate upon admission (bpm)
6. Respiratory rate upon admission (breaths/min)
7. Systolic Blood pressure upon admission (mmHg)
8. Diastolic Blood pressure upon admission (mmHg)
9. oxygen saturation upon admission (%)
10. oxygenation condition upon admission
Select
room air
oxygen therapy
unknown
11. weight upon admission (kg)
12. height upon admission (cm)
13. mid-upper arm circumference (mm)
1E: Co-morbidities existing upon admission
1. Chronic cardiac disease (not hypertension)
No
yes
unknown
2. Chronic hypertension
No
yes
unknown
3. Chronic pulmonary disease
No
yes
unknown
4. Asthma
No
yes
unknown
5. chronic kidney disease
No
yes
unknown
6. Chronic liver disease
No
yes
unknown
7. Auto-immune disease
No
yes
unknown
8. Chronic neurological disease
No
yes
unknown
9. immunodeficiency
No
yes
unknown
10. Dementia
No
yes
unknown
11. Diabets mellitus
No
yes
unknown
12. current smoking
No
yes
unknown
13.Tuberculosis(active)
No
yes
unknown
14.Tuberculosis(previous)
No
yes
unknown
15. carebrovascular disease
No
yes
unknown
16. Malignant neoplasm(actice , past 6 months)
No
yes
unknown
17. Malignant neoplasm(remission > 6 months)
No
yes
unknown
(actice , past 6 months)
No
yes
unknown
18. mental health disorder
No
yes
unknown
19. other
No
yes
unknown
if yes , specify
20. HIV
No
yes but no antiviral therapy
unknown
= yes and under antiviral
1.F Reinfection with COVID-19
1. Reinfection
No
yes
unknown
If yes, then ask the questions 2 to 4, if no skip to 1.G
2. Date of onset of the previous episode?
3. Was the previous episode of COVID-19 confirmed by a laboratory test?
No
yes
unknown
4. was the patient admitted to a hospital during the previous episode?
No
yes
unknown
1.G Signs and symptoms upon admission
1. History of fever?
No
yes
unknown
2. Cough?
No
yes
unknown
If yes: ask 3 and 4, else: skip to 5
3. Cough with sputum?
No
yes
unknown
4. Haemoptysis?
No
yes
unknown
5. Sore_throat?
No
yes
unknown
6. Runny nose?
No
yes
unknown
7. wheezing?
No
yes
unknown
8. Chest pain?
No
yes
unknown
9. Muscle aches?
No
yes
unknown
10. Joint pain?
No
yes
unknown
11. Fatigue/malaise?
No
yes
unknown
12. Loss of taste?
No
yes
unknown
13. Loss of smell?
No
yes
unknown
14. Shortness of breath?
No
yes
unknown
15. lover chest indrawing
No
yes
unknown
16. headache
No
yes
unknown
17. Altered consciousness
No
yes
unknown
18. seizures
No
yes
unknown
19. vomiting/rausea
No
yes
unknown
20. diarrhoea
No
yes
unknown
21. conjunctivitis
No
yes
unknown
22. skin rash
No
yes
unknown
23. intracerebral haemorrhage
No
yes
unknown
24. ischaemic stroke
No
yes
unknown
25. lymphadenopathy
No
yes
unknown
26. inability to walk
No
yes
unknown
27. Blurrry vision
No
yes
unknown
28. pelling or swelling of oral mucosa hands/feet
No
yes
unknown
29. Other?
No
yes
unknown
If yes: ask 16, If no: skip to 1.H
16. Specify other symptoms?
1.H Pre-admission and chronic medication taken within 14 days of admission
1. Oxygen therapy?
No
yes
unknown
2. Colchicine?
No
yes
unknown
3. Hydroxychloroquine?
No
yes
unknown
4. Ivermectin?
No
yes
unknown
5. Systemic Corticosteroids?
No
yes
unknown
6. Antifungals?
No
yes
unknown
7. Antivairals?
No
yes
unknown
If yes: ask question 8, else: skip to 9
8. Specify the drug?
Select
Fluvoxamine
Molnupinavir
Oseltamivir
Other
Unknown
9. Antibiotics?
No
yes
unknown
If yes: ask question 10, else: skip to 1.I
10. specify the antibiotic?
Select
Azithromycin
Ciprofloxacin/Levofloxacin
Amoxicillin/Clavulanic acid,
Other
Unknown
1.I medication: on the day of admission, did the patient receive any of the following?
1. Blood-derived products received?
No
yes
unknown
If yes: ask question 2, else: skip to 4
2. specifiy the blood product?
Select
IVIG
Convalescent plasma
Other
If other: ask question 3, else: skip to 4
3. What other bood product was received?
4. Hydrosychloroquine received?
No
yes
unknown
5. Ivermectin received?
No
yes
unknown
6. Experimental agents received?
No
yes
unknown
7. IL-1 antagonists received?
No
yes
unknown
If yes: ask question 8, else, skip to 9
8. Specify the IL-1 antagonist
Select
Anakinra
Canakinumab
Other
Unknown
9. IL-6 antagonists received?
No
yes
unknown
If yes: ask question 10, else, skip to 11
10. Specify the IL-6 antagonist
Select
Siltuximab
Sarilumab
Tocilizumab
Other
Unknown
11. Janus kinase inhibitors received?
No
yes
unknown
If yes: ask question 12, else, skip to 13
12. Specify the Janus kinase inhibitor?
Select
Acalabrutinib
Ibrutinib
Zanubrutinib
Baricitinib
Ruxolitinib
Tofacitinib
Other
Unknown
13. Neutralizing monoclonal antibodies received?
No
yes
unknown
If yes: ask question 14, else, skip to 15
14. Specify the neutralizing monoclonal antibody?
Select
Casirivimab/Indevimab
Sotrovimab
Bamlanivimab
Other
Unknown
15. Steroids received?
No
yes
unknown
If yes: ask question 16, else, skip to question 17
16. Specify the steroid
Select
Dexamethasone
Hydrocortisone
Prednisone
Methylprednisolone
Unknown
17. Anti-thrombotic or anticoagulant received?
No
yes
unknown
If yes: ask question 18, else, skip to 19
18. Specify the steroid
Select
Unfractionated Heparin
Warfarin
Direct oral anticoagulant
Other
Unknown
19. Antiviral drugs received?
No
yes
unknown
If yes: ask question 20, else, skip to 21
20. Specify the antiviral drug
Select
Remdesivir
Lopinavir/Ritonavir
Molnupiravir
Favipiravir
Acyclovir/Gancyclovir
Fluvoxamine
Other
Unknown
21. HIV positive?
No
yes
unknown
If yes: ask question 22, else, skip to question 24
22. ART received?
No
yes
unknown
If yes: ask question 23, else, skip to question 24
23. Specify the ART received
Select
2 NRTI + Dolutegravir
2 NRTI + NNRTIs,
2 NRTI + Raltegravir,
2 NRTI + protease inhibitor,
Unknown
24. Antibiotic received?
No
yes
unknown
If yes: ask question 25, else, skip to question 26
25. Specify the Antibiotic
Select
Macrolide
Fluroquinolone
3rd or 4th gen Cephalosporine,
5th gen cephalosporine,
Ceftazidime/Avibactam,
Carbapenems,
Piperacillin-Tazobactam,
Amoxicillin-Clavulanic acid,
Cotrimoxazole,
Colistin
Gentamycin or Amikacin,
Vancomycin or Teicoplanin,
Daptomycin,
Linezolid or Tedizolid,
other,
unknown
26. Antifungal received?
No
yes
unknown
If yes: ask question 27, else, skip to next section (1.J)
27. Specify antifungal
Select
Amphotericin B,
Fluconazole,
Itraconazole,
Flucytosine,
other
Unknown
1.J Supportive care: On the admission day, did the patient undergo any of the following?
1. ICU or high dependency unit admission?
No
yes
unknown
If yes: proceed to the next question, else, skip to next section (1.k)
2. Source of Oxygen?
Select
piped
cylinder
Concentrator
Unknown
3. Oxygen therapy?
No
yes
unknown
If yes: ask question 4, else, skip to question 13
4. Specify the interface for oxygen therapy at the highest care received
Select
Nasal prongs,
HF nasal canula,
Simple face mask,
Venturi mask,
Mask with reservoire,
CPAP/BiPAP,
Intubated,
Unknown
If the answer is Nasal prongs, or simple face mask, or venturi mask, or mask with reservoire: ask question 5
ELSE
if HF nasal canula: ask question 6 and 7
If CPAP/BiPAP: ask question 8 and 9 and 10
If Intubated: ask question 11 and 12
If Unknown: skip to question 13
5. Specify max O2 flow?
Select
1-5 L/min,
6-10 L/min,
11-15 L/min,
over 15 L/min,
Unknown
6. Specify max FiO2?
7. Specify max O2 flow rate?
8. Specify max IPAP?
9. Specify max EPAP?
10. Specify max FiO2?
11. Specify max PEEP?
12. Specify max FiO2?
13. Extracorporeal (ECMO) support?
No
yes
unknown
14. Inotropes or Vasopressors?
No
yes
unknown
15. Blood transfusion?
No
yes
unknown
16. Prone position?
No
yes
unknown
17. Renal replacement therapy?
No
yes
unknown
18. Plasma exchange therapy?
No
yes
unknown
1.K Laboratory results on admission
1. Haemoglobin
2. WBC count
3. Haematocrit
4. Neutrophils
5. Platelets
6. APTT/APTR
7. PT
8. INR
9. ALT/SGPT
10. AST/SGOT
11. Total Bilirubin
12. BUN
13. Lactate
14. Creatinine
15. Sodium
16. Potassium
17. Fibrinogen
18. Procalcitonin
19. CRP
20. LDH
21. Creatine Kinase
22. Troponine
23. ESR
24. D-diemr
25. Ferritin
26. IL-6
Module 2: ICU admission or ICU transfer
1. symptoms onset
2. Was the patient transferred to the ICU on this day?
No
yes
unknown
2.A Vital signs
1. Temperature upon admission
2. Heart rate upon admission
3. Respiratory rate upon admission
4. Systolic Blood pressure upon admission
5. Diastolic Blood pressure upon admission
6. AVPU
7. oxygen saturation upon admission
8. oxygenation condition upon admission
Select
room air
oxygen therapy
unknown
2.B Laboratory results on admission (to ICU)
1. Haemoglobin
2. WBC count
3. Haematocrit
4. Neutrophils
5. Platelets
6. APTT/APTR
7. PT
8. INR
9. ALT/SGPT
10. AST/SGOT
11. Total Bilirubin
12. BUN
13. Lactate
14. Creatinine
15. Sodium
16. Potassium
17. Fibrinogen
18. Procalcitonin
19. CRP
20. LDH
21. Creatine Kinase
22. Troponine
23. ESR
24. D-dimer
25. Ferritin
26. IL-6
2.C Medication: on the day of ICU admission, did the patient receive any of the following?
1. Blood-derived products received?
No
yes
unknown
If yes: ask question 2, else: skip to 4
2. specifiy the blood product?
Select
IVIG
Convalescent plasma
other
If other: ask question 3, else: skip to 4
3. What other bood product was received?
4. Hydrosychloroquine received?
No
yes
unknown
5. Ivermectin received?
No
yes
unknown
6. Experimental agents received?
No
yes
unknown
7. IL-1 antagonists received?
No
yes
unknown
If yes: ask question 8, else, skip to 9
8. Specify the IL-1 antagonist
Select
Anakinra
Canakinumab
Other
Unknown
9. IL-6 antagonists received?
No
yes
unknown
If yes: ask question 10, else, skip to 11
10. Specify the IL-6 antagonist
Select
Siltuximab,
Tocilizumab,
Other
Unknown
11. Janus kinase inhibitors received?
No
yes
unknown
If yes: ask question 12, else, skip to 13
12. Specify the Janus kinase inhibitor?
Select
Acalabrutinib,
Ibrutinib,
Zanubrutinib,
Baricitinib,
Ruxolitinib,
Tofacitinib,
Other,
unknown
13. Neutralizing monoclonal antibodies received?
No
yes
unknown
If yes: ask question 14, else, skip to 15
14. Specify the neutralizing monoclonal antibody?
Select
ICU_NMAtype
Casirivimab/Indevimab,
Sotrovimab,
Bamlanivimab
Other,
unknown
15. Steroids received?
No
yes
unknown
If yes: ask question 16, else, skip to question 17
16. Specify the steroid
Select
Dexamethasone
Hydrocortisone
Prednisone,
Methylprednisolone
unknown
17. Anti-thrombotic or anticoagulant received?
No
yes
unknown
If yes: ask question 18, else, skip to question 19
18. Specify the steroid
Select
Unfractionated Heparin,
LMW Heparin,
Warfarin,
Direct oral anticoagulant,
other,
unknown
19. Antiviral drugs received?
No
yes
unknown
20. Specify the antiviral drug
Select
Remdesivir
Lopinavir/Ritonavir,
Molnupiravir
Favipiravir,
Acyclovir/Gancyclovir,
Fluvoxamine,
Other,
unknown
21. HIV positive?
No
yes
unknown
22. ART received?
No
yes
unknown
23. Specify the ART received
Select
2 NRTI + Dolutegravir,
2 NRTI + NNRTIs,
2 NRTI + Raltegravir,
2 NRTI + protease inhibitor,
Unknown
24. Antibiotic received?
No
yes
unknown
25. Specify the antiviral drug
Select
Macrolide,
Fluroquinolone
3rd or 4th gen Cephalosporine,
5th gen cephalosporine,
Ceftazidime/Avibactam,
Carbapenems,
Piperacillin-Tazobactam,
Amoxicillin-Clavulanic acid,
Cotrimoxazole,
Colistin,
Gentamycin or Amikacin,
Vancomycin or Teicoplanin,
Daptomycin,
Linezolid or Tedizolid,
Other,
unknown
26. Antifungal received?
No
yes
unknown
27. Specify antifungal
Select
Amphotericin B,
Fluconazole,
Itraconazole,
Flucytosine,
other
Unknown
2.D Supportive care: On the admission day, did the patient receive any of the following?
1. ICU or high dependency unit admission?
No
yes
unknown
2. Source of Oxygen?
Select
piped
cylinder
Concentrator
Unknown
3. Oxygen therapy?
No
yes
unknown
4. Specify the interface for oxygen therapy at the highest care received
Select
Nasal prongs,
HF nasal canula,
Simple face mask,
Venturi mask,
Mask with reservoire,
CPAP/BiPAP,
Intubated,
Unknown
5. Specify max O2 flow?
Select
1-5 L/min,
6-10 L/min,
11-15 L/min,
over 15 L/min,
Unknown
6. Specify max FiO2?
7. Specify max O2 flow rate?
8. Specify max IPAP?
9. Specify max EPAP?
10. Specify max FiO2?
11. Specify max PEEP?
12. Specify max FiO2?
13. Extracorporeal (ECMO) support?
No
yes
unknown
14. Inotropes or Vasopressors?
No
yes
unknown
15. Blood transfusion?
No
yes
unknown
16. Prone position?
No
yes
unknown
17. Renal replacement therapy?
No
yes
unknown
18. Plasma exchange therapy?
No
yes
unknown
Module 3: Complete at discharge
3.A Diagnostic/pathogen testing during hospitalization
1. Chest X-ray/CT performed?
No
yes
unknown
2. Infiltrate present?
No
yes
unknown
3. Was pathogen testing done during this illness episode?
No
yes
unknown
4. SARS-CoV-2 tests done at any time during hospital stay?
No
yes
unknown
5. Was sequencing of SARS-CoV-2 performed?
No
yes
unknown
6. Is the patient infected with a variant of concern (VOC)?
No
yes
unknown
7. Indicate the Variant of concern?
Select
alpha
Beta
Gamma
Delta
Omicron
other
8. if VOC is identified, select the method used:
Select
sequencing
proxy maker
9. If proxy marker is used select method
Select
S-gene target failure (SGTF) by PCR
PCR-based SNP assay
other
10. Specify the other method?
11. Another virus detected?
No
yes
unknown
12. Specify the other virus?
Select
Influenza
HIV
RSV
HBV
HCV
other
unknown
13. Last HIV viral load?
14. Last CD4
15. if no-VOC, Indicate the variant of no-VOC?
16. was a culture to identify bacteria performed?
No
yes
unknown
17. Pseudomonas Aeruginosa detected?
No
yes
unknown
18. Specify the body site of culture?
Select
blood
lungs
soft tissue
urinary tract
other
unknown
19. Carbapenem resistant P. aeruginosa (CRPA)?
No
yes
unknown
20. Colistin resistant P. aeruginosa?
No
yes
unknown
21. Acinetobacter baumannii detected?
No
yes
unknown
22. Body site of Acinetobacter culture?
Select
blood
lungs
soft tissue
urinary tract
other
unknown
23. Carbapenem resistant A. baumannii?
No
yes
unknown
24. Colistin resistant A. baumannii?
No
yes
unknown
25. Enterobactriaceae (e.g., Escherichia coli, Klebsiella, Proteus) detected?
No
yes
unknown
26. Body site of Enterobactriaceae culture?
Select
blood
lungs
soft tissue
urinary tract
other
unknown
27. Enterobactriaceae resistant to 3rd and 4th generation Cephalosporines? (e.g., ceftriaxone, cefotaxime, ceftazidime, cefepime)
No
yes
unknown
28. Carbapenem resistant Enterobactriaceae?
No
yes
unknown
29. Colistin resistant Enterobactriaceae?
No
yes
unknown
30. Staphylococcus aureus detected?
No
yes
unknown
31. methicillin resistant staphylococcus aureus?
No
yes
unknown
32. Vancomycin resistant staphylococcus aureus?
No
yes
unknown
33. Enterococcus feacium or E. faecalis detected?
No
yes
unknown
34. vancomycin resistant enterococcus?
No
yes
unknown
35. Haemophilus influenza detected?
No
yes
unknown
36. Ampicillin resistant Haemophilus influenza?
No
yes
unknown
37. Helicobacter pylori detected?
No
yes
unknown
38. Clarythromycin resistant H. pylori?
No
yes
unknown
39. Streptococcus pneumoniae detected?
No
yes
unknown
40. Penicillin resistant S. pneumoniae?
No
yes
unknown
41. total number of body sites where bacteria were cultured during hospital stay?
Select
1
2
3
4
more than 4
unknown
42. Was bacterial colonization (without signs of infection) by multi-drug resistant organisms identified during hospital stay?
No
yes
unknown
43. Pseudomonas carrbapenem resistant?
No
yes
unknown
44. Acinetobacter baumannii carbapenem resistant?
No
yes
unknown
45. Enterobacteriaceae (E. koli, Klebsiella, Proteus) Carbapenem resistant?
No
yes
unknown
46. MRSA?
No
yes
unknown
47. Enterococci Vancomycin resistant?
No
yes
unknown
48. Multidrug resistant Tuberculosis detected?
No
yes
unknown
49. Fungi detected?
No
yes
unknown
50. Site of detection of fungal pathogen?
Select
blood
lungs
soft tissue
urinary tract
other
unknown
51. Was there a Candida resistant to Fluconazole, Amphotericin B or Voriconazole?
No
yes
unknown
52. Aspergillus detected?
No
yes
unknown
53. Mucorales detected?
No
yes
unknown
3.B Complications during hospitalization, did the patient experience:
1. Shock?
No
yes
unknown
2. Seizure?
No
yes
unknown
3. Meningitis/Encephalitis?
No
yes
unknown
4. Pulmonary embolism?
No
yes
unknown
5. Cardiac arrythmia?
No
yes
unknown
6. Cardiac arrest?
No
yes
unknown
7. Deep vein thrombosis?
No
yes
unknown
8. Bronchiolitis?
No
yes
unknown
9. Acute respiratory distress syndrome (ARDS)?
No
yes
unknown
10. Ischaemic stroke?
No
yes
unknown
11. Haemorrhagic stroke?
No
yes
unknown
12. Bacteaemia?
No
yes
unknown
13. Bleeding?
No
yes
unknown
14. Endocarditis?
No
yes
unknown
15. Myocarditis/Pericarditis?
No
yes
unknown
16. Acute renal injuri?
No
yes
unknown
17. Pancreatitis?
No
yes
unknown
18. Liver dysfunction?
No
yes
unknown
19. Cardiomyopathy?
No
yes
unknown
20. Transfusion?
No
yes
unknown
21. Mental health disorder?
No
yes
unknown
22. Other complications?
No
yes
unknown
23. Specify other complications if present?
24. was the patient diagnosed with an infection during the hospital stay?
No
yes
unknown
25. upper respiratory infection?
No
yes
unknown
26. Lower respiratory infection?
No
yes
unknown
27. urinary tract infection?
No
yes
unknown
28. Skin and soft tissue infection?
No
yes
unknown
29. Bone and joint infection?
No
yes
unknown
30. Blood stream infections?
No
yes
unknown
31. Gastrointestinal infections?
No
yes
unknown
32. Intraabdominal infections?
No
yes
unknown
33. cardiovascular infection?
No
yes
unknown
34. Central Nervous System infection?
No
yes
unknown
35. Co-diagnoses at the time of discharge? (ICD-10 Code:)
3.C Medication during hospitalization, did the patient receive any of the following:
1. Blood-derived products received?
No
yes
unknown
2. specifiy the blood product?
Select
IVIG
Convalescent plasma
other
3. What other bood product was received?
4. Hydrosychloroquine received?
No
yes
unknown
5. Ivermectin received?
No
yes
unknown
6. Experimental agents received?
No
yes
unknown
7. IL-1 antagonists received?
No
yes
unknown
8. Specify the IL-1 antagonist
Select
Anakinra
Canakinumab
other
unknown
9. IL-6 antagonists received?
No
yes
unknown
10. Specify the IL-6 antagonist
Select
Siltuximab
Sarilumab
Tocilizumab
other
unknown
11. Janus kinase inhibitors received?
No
yes
unknown
12. Specify the Janus kinase inhibitor?
Select
Acalabrutinib
Ibrutinib
Zanubrutinib
Baricitinib
Ruxolitinib
Tofacitinib
other
unknown
13. Neutralizing monoclonal antibodies received?
No
yes
unknown
14. Specify the neutralizing monoclonal antibody?
Select
Casirivimab/Indevimab
Sotrovimab
Bamlanivimab
other
unknown
15. Steroids received?
No
yes
unknown
16. Specify the steroid
Select
Dexamethasone
Hydrocortisone
Prednisone
Methylprednisolone
unknown
17. Anti-thrombotic or anticoagulant received?
No
yes
unknown
18. Specify the steroid
Select
Unfractionated Heparin
LMW Heparin
Warfarin
Direct oral anticoagulant
other
unknown
19. Antiviral drugs received?
No
yes
unknown
20. Specify the antiviral drug
Select
Remdesivir
Lopinavir/Ritonavir
Molnupiravir
Favipiravir
Acyclovir/Gancyclovir,
Fluvoxamine
other
unknown
21. HIV positive?
No
yes
unknown
22. ART received?
No
yes
unknown
23. Specify the ART received
Select
ARTyp
2 NRTI + Dolutegravir,
2 NRTI + NNRTIs,
2 NRTI + Raltegravir,
2 NRTI + protease inhibitor,
unknown
24. Antibiotic received?
No
yes
unknown
25. Specify the Antibiotic
Select
Macrolide
Fluroquinolone
3rd or 4th gen Cephalosporine,
5th gen cephalosporine,
Ceftazidime/Avibactam,
Carbapenems,
Piperacillin-Tazobactam,
Amoxicillin-Clavulanic acid,
Cotrimoxazole,
Colistin,
Gentamycin or Amikacin,
Vancomycin or Teicoplanin,
Daptomycin,
Linezolid or Tedizolid,
other
unknown
26. Antifungal received?
No
yes
unknown
27. Specify antifungal
Select
Amphotericin B,
Fluconazole
Itraconazole,
Flucytosine,
other,
unknown
Antibiotics received during hospitalization:
28. Antibiotic agent known?
No
yes
unknown
29. Specify the antibiotic:
30. Macrolides?
No
yes
unknown
31. If macrolides were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
32. Macrolides administered for more than 72 hours?
No
yes
unknown
33. Fluroquinolones?
No
yes
unknown
34. If fluroquinolones were administred, specify the type of therapy?
Select
Empiric
Targeted
unknown
35. Fluoroquinolones administered for more than 72 hours?
No
yes
unknown
36. 3rd and 4th generation Cephalosporines? (e.g., Ceftriaxone, Cefotaxime, Ceftazidime, Cefepime)
No
yes
unknown
37. If 3rd and 4th generation Cephalosporines were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
38. 5th generation Cephalosporines? (e.g., Ceftolozane/Tazobactam)
No
yes
unknown
39. If 5th generation Cephalosporines were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
40. 5th generation Cephalosporines administered for more than 72 hours?
No
yes
unknown
41. Ceftazidime/Avibactam?
No
yes
unknown
42. If Ceftazidime/Avibactam were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
43. Carbapenems? (Imipenem/Meropenem)
No
yes
unknown
44. If Carbapenems were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
45.Piperacillin-Tazobactam?
No
yes
unknown
46. If Piperacillin-Tazobactam were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
47. Amoxicillin-Clavulanic acid?
No
yes
unknown
48. If Amoxicillin-Clavulanic acid were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
49. Cotrimoxazole?
No
yes
unknown
50. If Cotrimoxazole were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
51. Colistin?
No
yes
unknown
52. If colistin were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
53. Gentamycin or Amikacin?
No
yes
unknown
54. If Gentamycin or Amikacin were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
55. Vancomycin?
No
yes
unknown
56. If Vancomycin were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
57. Daptomycin?
No
yes
unknown
58. If Daptomycin were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
59. Linezolid?
No
yes
unknown
60. If Linezolid were used, specify the type of therapy:
Select
Empiric
Targeted
unknown
61. Other antibiotics?
No
yes
unknown
3D. Supportive care during hospital stay, did the patient receive undergo:
1. ICU or high dependency unit admission?
No
yes
unknown
2. total duration of stay?
3. Date of ICU admission?
4. date of ICU discharge?
5. Oxygen therapy?
No
yes
unknown
6. source of oxygen?
Select
piped
cylinder
concentrator
7. Specify max O2 flow?
Select
1-5 L/min,
6-10 L/min,
11-15 L/min,
over 15 L/min,
unknown
8. Specify the interface for oxygen therapy at the highest care received
Select
Nasal prongs,
HF nasal canula,
Simple face mask,
Mask with reservoire,
CPAP/NIV mask
9. Non-invasive ventilation (BiPAP or CPAP?
No
yes
unknown
10. Durarion of non-invasive ventilation (days)?
11. Invasive ventilation?
No
yes
unknown
12. Durarion of non-invasive ventilation (days)?
13. Extracorporeal (ECMO) support?
No
yes
unknown
14. Total duration:
15. Inotropes or Vasopressors?
No
yes
unknown
16. Total duration:
17. Prone position?
No
yes
unknown
18. Total duration:
19. Renal replacement therapy?
No
yes
unknown
3E. Outcome
1. Outcome
Select
discharged
referred to other facility with higher level of care
referred to other facility with lower level of care
Palliative discharge
unknown
In-hospital death
Still hospitalized
2. Outcome date
3. If discharge, impairmaent compared with before current illness (tick all that apply)
Select
Physical
Cognitive
Mental
Swallowing
None
Unknown
4. If discharged, ability to self-care at discharge compared with before illness?
Select
Same as before
Worse
Better
None
5. If discharged, referred to outpatient rehabilitation:
No
yes
unknown
6. Were there any sequealae present at the time of discharge?
No
yes
unknown