Download NICE GUIDELINE (Redacted): Antimicrobial Stewardship -prescribers

Prescribers: antimicrobial stewardship
NICE Pathways bring together everything NICE says on a topic in an interactive
flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/antimicrobial-stewardship
NICE Pathway last updated: 20 April 2021
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
Antimicrobial stewardship
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Prescribers: antimicrobial stewardship
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NICE Pathways
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Prescribers: antimicrobial stewardship
1
NICE Pathways
Prescribers
No additional information
2
Clinical assessment
When prescribing any antimicrobial, undertake a clinical assessment and document the clinical
diagnosis (including symptoms) in the patient's record and clinical management plan.
For patients in hospital who have suspected infections, take microbiological samples before
prescribing an antimicrobial and review the prescription when the results are available.
For patients in primary care who have recurrent or persistent infections, consider taking
microbiological samples when prescribing an antimicrobial and review the prescription when the
results are available.
For patients who have non-severe infections, consider taking microbiological samples before
making a decision about prescribing an antimicrobial, providing it is safe to withhold treatment
until the results are available.
Consider point-of-care testing in primary care for patients with suspected lower respiratory tract
infections as described in the recommendations on tests in primary care in the NICE Pathway
on pneumonia.
See the NICE Pathways on self-limiting respiratory tract and ear infections – antibiotic
prescribing and neonatal infection: antibiotics for prevention and treatment.
Integrated multiplex PCR tests for identifying gastrointestinal pathogens
The following recommendations are from NICE diagnostics guidance on integrated multiplex
PCR tests for identifying gastrointestinal pathogens in people with suspected gastroenteritis
(xTAG Gastrointestinal Pathogen Panel, FilmArray GI Panel and Faecal Pathogens B assay).
There is currently insufficient evidence to recommend the routine adoption in the NHS of the
integrated multiplex polymerase chain reaction tests, xTAG Gastrointestinal Pathogen Panel,
FilmArray GI Panel and Faecal Pathogens B assay, for identifying gastrointestinal pathogens in
people with suspected gastroenteritis.
Antimicrobial stewardship
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The tests show promise but further research is recommended on their effect on health
outcomes and resource use in clinical practice (see section 6 of NICE diagnostics guidance 26).
Tests for rapidly identifying bloodstream bacteria and fungi
The following recommendation is from NICE diagnostics guidance on SepsiTest assay for
rapidly identifying bloodstream bacteria and fungi.
There is currently insufficient evidence to recommend the routine adoption in the NHS of the
SepsiTest assay for rapidly identifying bloodstream bacteria and fungi. The tests show promise
and further research to provide robust evidence is encouraged, particularly to demonstrate the
value of using the test results in clinical decision making (see sections 5.18 to 5.22 of NICE
diagnostics guidance 20).
Procalcitonin testing
The following recommendations are from NICE diagnostics guidance on procalcitonin testing for
diagnosing and monitoring sepsis.
The procalcitonin tests (ADVIA Centaur BRAHMS PCT assay, BRAHMS PCT Sensitive Kryptor
assay, Elecsys BRAHMS PCT assay, LIAISON BRAHMS PCT assay or VIDAS BRAHMS PCT
assay) show promise but there is currently insufficient evidence to recommend their routine
adoption in the NHS. Further research on procalcitonin tests is recommended for guiding
decisions to:
stop antibiotic treatment in people with confirmed or highly suspected sepsis in the
intensive care unit or
start and stop antibiotic treatment in people with suspected bacterial infection presenting to
the emergency department.
Centres currently using procalcitonin tests to guide these decisions are encouraged to
participate in research and data collection (see section 6.25 of NICE diagnostics guidance 18).
See the NICE Pathway on sepsis.
Medtech innovation briefings
NICE has published medtech innovation briefings on:
FebriDx for C-reactive protein and myxovirus resistance protein A testing
Fungitell for antifungal treatment stratification
Antimicrobial stewardship
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eazyplex SuperBug kits for detecting carbapenemase-producing organisms
Xpert Carba-R to identify people carrying carbapenemase-producing organisms
BD MAX Enteric Bacterial Panel for identifying pathogens in contagious gastroenteritis.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
3.
Recording information
4.
Microbiological samples
3
Discussion with the patient and/or their family members or carers
Prescribers should take time to discuss with the patient and/or their family members or carers
(as appropriate):
the likely nature of the condition
why prescribing an antimicrobial may not be the best option
alternative options to prescribing an antimicrobial
their views on antimicrobials, taking into account their priorities or concerns for their current
illness and whether they want or expect an antimicrobial
the benefits and harms of immediate antimicrobial prescribing
what they should do if their condition deteriorates (safety netting advice) or they have
problems as a result of treatment
whether they need any written information about their medicines and any possible
outcomes.
Consider using computer prompts or decision support aids to prompt healthcare professionals
to share information with people on the appropriate use of antimicrobials, self-care and safety
netting. See antimicrobial stewardship interventions.
Also see health and social care practitioners.
NICE has written information for the public on antimicrobial stewardship.
See the NICE Pathways on medicines optimisation and patient experience in adult NHS
services.
Antimicrobial stewardship
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Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
1.
4
Advice on self-limiting conditions
Provide advice on managing self-limiting infections
When people ask about managing self-limiting infections:
Share advice on self-care for each of the symptoms.
Use and share resources that provide written advice to encourage people to change their
behaviour (see local system-wide approaches for clinical commissioning groups ).
Verbally emphasise the key messages given in the written resources.
Display resources that provide or signpost to advice and information about self-care; for
example NHS Choices, 111 and local advice or helplines.
Signpost them to further information to read at home, such as online advice.
Discuss with them whether taking or using an antimicrobial is the most appropriate option –
see discussion with the patient [See page 5].
Raise awareness of community pharmacists as an easily accessible first point of contact for
advice about managing a self-limiting infection.
Share safety-netting advice with everyone who has an infection (regardless of whether or not
they are prescribed or supplied with antimicrobials). This should include:
how long symptoms are likely to last with and without antimicrobials
what to do if symptoms get worse
what to do if they experience adverse effects from the treatment
when they should ask again for medical advice.
See the NICE Pathway on sepsis.
5
Decide if an antimicrobial is needed
When deciding whether or not to prescribe an antimicrobial, take into account the risk of
antimicrobial resistance for individual patients and the population as a whole.
Do not issue an immediate prescription for an antimicrobial to a patient who is likely to have a
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self-limiting condition.
See the NICE Pathway on wound management.
6
Immediate prescription is not the most appropriate option
If immediate antimicrobial prescribing is not the most appropriate option, discuss with the
patient and/or their family members or carers (as appropriate) other options such as:
self-care with over-the-counter preparations
back-up (delayed) prescribing (see the NICE Pathway on self-limiting respiratory tract and
ear infections – antibiotic prescribing)
other non-pharmacological interventions, for example, draining the site of infection.
Give people verbal advice and share written information that they can take away about how to
manage their infection themselves. See also provide advice on managing self-limiting infections
[See page 6].
If the person has been given a back-up (delayed) prescription, tell them:
How to self-care to manage their symptoms.
What the antimicrobials would be used for, if needed.
How to recognise whether they need to use the antimicrobials, and if so:
how to get them
when to start taking or using them
how to take or use them.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
2.
7
Back-up (delayed) prescribing
Antimicrobial is needed
When prescribing antimicrobials, prescribers should follow local (where available) or national
guidelines on:
Antimicrobial stewardship
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prescribing the shortest effective course
the most appropriate dose
route of administration.
When a decision to prescribe an antimicrobial has been made, take into account the benefits
and harms for an individual patient associated with the particular antimicrobial, including:
possible interactions with other medicines or any food and drink
the patient's other illnesses, for example, the need for dose adjustment in a patient with
renal impairment
any drug allergies (these should be documented in the patient's record; also see the NICE
Pathway on drug allergy)
the risk of selection for organisms causing healthcare-associated infections, for example, C.
difficile.
Do not issue repeat prescriptions for antimicrobials unless needed for a particular clinical
condition or indication. Avoid issuing repeat prescriptions for longer than 6 months without
review and ensure adequate monitoring for individual patients to reduce adverse drug reactions
and to check whether continuing an antimicrobial is really needed.
Provide information and advice
Share verbal advice and written information that people can take away about how to use
antimicrobials correctly, including:
not sharing prescription-only antimicrobials with anyone other than the person they were
prescribed or supplied for
not keeping them for use another time
returning unused antimicrobials to the pharmacy for safe disposal and not flushing them
down toilets or sinks.
See also provide advice on managing self-limiting infections [See page 6].
Prescribing intravenous antimicrobials
Use an intravenous antimicrobial from the agreed local formulary and in line with local (where
available) or national guidelines for a patient who needs an empirical intravenous antimicrobial
for a suspected infection but has no confirmed diagnosis.
Consider reviewing intravenous antimicrobial prescriptions at 48–72 hours in all health and care
settings (including community and outpatient services). Include response to treatment and
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microbiological results in any review, to determine if the antimicrobial needs to be continued
and, if so, whether it can be switched to an oral antimicrobial.
8
Documentation in patient records
When an antimicrobial is a treatment option, document in the patient's records (electronically
wherever possible):
the reason for prescribing, or not prescribing, an antimicrobial
the plan of care as discussed with the patient, their family member or carer (as appropriate),
including the planned duration of any treatment.
When prescribing is outside local (where available) or national guidelines, document in the
patient's records the reasons for the decision.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
3.
Recording information
6.
Electronic prescribing systems: developmental
9
NICE Pathway on ensuring adults have the best experience of NHS
services
See Patient experience in adult NHS services
Antimicrobial stewardship
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Glossary
antimicrobial resistance
(loss of effectiveness of any anti-infective medicine, including antiviral, antifungal, antibacterial
and antiparasitic medicines)
antimicrobial
(any anti-infective therapy (antiviral, antifungal, antibacterial and antiparasitic medicines) and
any formulation (oral, parenteral and topical agents))
antimicrobials
(all anti-infective therapies (antiviral, antifungal, antibacterial and antiparasitic medicines) and all
formulations (oral, parenteral and topical agents))
resources
(evidence-based materials that have been developed through a research-based approach with
the target audience, wherever possible; they may be in a variety of formats, including posters,
leaflets, digital and online resources)
safety-netting
(advising people what to do if their condition deteriorates or does not improve within a certain
time, or if they develop adverse effects as a result of the treatment)
self-care
(approaches a person can use to look after themselves in a healthy way; for example, drinking
plenty of fluids and getting sufficient rest when you have a cold)
self-limiting infections
(infections that resolve on their own and have no long-term harmful effect on a person's health
(assuming that they are not immunosuppressed); examples include colds, flu, oral thrush, winter
vomiting bug)
Antimicrobial stewardship
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Sources
Antimicrobial stewardship: changing risk-related behaviours in the general population (2017)
NICE guideline NG63
Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use
(2015) NICE guideline NG15
Integrated multiplex PCR tests for identifying gastrointestinal pathogens in people with
suspected gastroenteritis (xTAG Gastrointestinal Pathogen Panel, FilmArray GI Panel and
Faecal Pathogens B assay) (2017) NICE diagnostics guidance 26
SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (2016, updated 2020)
NICE diagnostics guidance 20
Procalcitonin testing for diagnosing and monitoring sepsis (ADVIA Centaur BRAHMS PCT
assay, BRAHMS PCT Sensitive Kryptor assay, Elecsys BRAHMS PCT assay, LIAISON
BRAHMS PCT assay and VIDAS BRAHMS PCT assay) (2015) NICE diagnostics guidance 18
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
Antimicrobial stewardship
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should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional procedures
guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Antimicrobial stewardship
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Commissioners and/or providers have a responsibility to implement the recommendations, in
their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Antimicrobial stewardship
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