Download Antibiotic Prescribing Policy - Black Country Partnership NHS

Antibiotic Prescribing Policy
Antibiotic Prescribing Policy
Target Audience
Who should read this policy
All prescribing staff and clinical staff
Version 2.0. March 2016
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Antibiotic Prescribing Policy
Ref.
Contents
Page
1.0
Introduction
4
2.0
Purpose
4
3.0
Objectives
4
4.0
Prescribing Antibiotics
4
4.1
‘MicroGuide’
4
4.2
Antimicrobial Stewardship Programme
6
4.3
Start Smart
7
4.4
Then Focus
9
4.5
Stop
9
5.0
Procedures connected to this Policy
9
6.0
Links to Relevant Legislation
9
6.1
Links to Relevant National Standards
10
6.2
Links to other Key Policies
11
6.3
References
12
7.0
Roles and Responsibilities for this Policy
13
8.0
Training
15
9.0
Equality Impact Assessment
15
10.0
Data Protection and Freedom of Information
16
11.0
Monitoring this policy is working in practice
16
Appendices
1.0
High Risk Antipsychotic/Antibiotic Interactions to be aware of
17
2.0
Specific Prescribing Information
19
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Antibiotic Prescribing Policy
Explanation of terms used in this policy
Prescriber - A medical doctor or a registered nurse/pharmacist who has successfully undertaken a nonmedical prescribing qualification and who is legally authorised to undertake independent or
supplementary prescribing according to current legislation
Microbes - Are living microorganisms that multiply frequently and spread rapidly, they include bacteria,
viruses, fungi and parasites; some microbes cause disease and others exist in the body without causing
harm and may actually be beneficial
Antimicrobial - An agent that kills microbes or inhibits their growth; medicines can be grouped
according to the microorganisms they act primarily against e.g. antibacterials are used against bacteria
and antifungals are used against fungi
Antimicrobial (Drug) Resistance - Microbes are constantly evolving enabling them to efficiently
adapt to new environments; antimicrobial resistance is the ability of microbes to grow in the presence of
a chemical (drug) that would normally kill them or limit their growth, making it harder to eliminate
infections from the body as existing drugs become less effective
Antimicrobial stewardship - A co-ordinated programme that promotes the appropriate use of
antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and
decreases the spread of infections caused by multidrug-resistant organisms
Antibiotics - Are types of medications such as penicillin that destroy or slow down the growth of
bacteria; the Greek word anti means "against", and the Greek word bios means "life" (bacteria are life
forms)
Antibiotic resistance - Refers to the resistance of antibiotics that occurs in common bacteria that
cause infections
Topical antibiotics - Are applied directly to the skin to treat or prevent infection
Smartphone - A mobile phone that performs many of the functions of a computer, typically having
internet access, a touchscreen interface and an operating system capable of running downloaded apps
Apps (short for applications) - Just as the programs on a computer range from word processors to
games, apps come in all types: the purpose behind apps is to make life easier and tasks better suited to
mobile use; installing apps downloaded from the internet expands a smartphone's abilities beyond its
built-in apps.
MicroGuide - A smartphone app developed within the NHS for prescribers in NHS Trusts who prescribe
antibiotics to access the latest, most up to date sensitivity and prescribing information
http://microguide.horizonsp.co.uk/viewer
Algorithm - Step by step procedure designed to perform an operation with a definite beginning and a
definite end, and a finite number of steps; like a map or flowchart it will lead to the intended result if
followed correctly.
Empirical therapy - The initiation of treatment prior to determination of a firm diagnosis; it is most
often used when antibiotics are given to a person before the specific bacterium causing an infection is
known e.g. antibiotics given for pneumonia, urinary tract infections, and suspected bacterial meningitis
in newborns aged 0 to 6 months
MRSA – Meticillin-resistant staphylococcus aureus, a bacteria that is resistant to many antibiotics
Policy - Sets out the aims and principles under which services, divisions, or units will operate. A policy
outlines roles and responsibilities, defines the scope of the subject covered, and provides a high level
description of the controls that must be in place to ensure compliance
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Antibiotic Prescribing Policy
1.0 Introduction
Antibiotics are essential treatments for serious infections and remain one of the most
significant discoveries of modern medicine.
The NHS and health organisations across the world are trying to reduce the use of
antibiotics, to try to combat the problem of antibiotic resistance when a strain of
bacteria no longer responds to treatment with one or more types of antibiotics.
Antibiotic resistance can occur in several ways as strains of bacteria mutate over time
and become resistant to a specific antibiotic. Antibiotic prescribing and antibiotic
resistance are inextricably linked, and overuse and incorrect use of antibiotics are
major drivers of resistance. Antibiotics can also destroy many of the harmless strains of
bacteria that live in and on the body, which allows resistant bacteria to multiply quickly
and replace them.
Antibiotics are not as commonly prescribed within mental health trust inpatient wards
as in other hospitals and as people are not as physically unwell as in acute trusts,
complications of antibiotic treatment occur less often. Nonetheless, the Trust is
committed to continually monitor the appropriateness of antibiotic prescribing as
resistance makes infections more difficult to treat and can result in complications and
longer hospital stays.
2.0 Purpose
The aim of this policy is to provide direction and guidance for staff on the appropriate
and effective prescribing of antibiotics for the most common situations in which
antibiotic treatment is required.
3.0 Objectives
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Provide a simple, empirical approach to the treatment of common infections for
patients on inpatient wards
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Minimise the incidence of healthcare associated infections within inpatient units
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Improve awareness and understanding of antimicrobial resistance
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Promote the safe and effective use of antibiotics
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Comply with best practice and current legislation
4.0 Prescribing Antibiotics
4.1 ‘MicroGuide’
The process for adherence to the Trust’s antibiotic prescribing guidance is based on
access to the internet-available software ‘MicroGuide,’ which provides a simple
approach to the effective treatment of common infections and with the minimum risk of
healthcare associated infections.
‘MicroGuide’ is available as a smartphone ‘app’ developed within the NHS and used by
many hospital trusts; to use the software, prescribers will need to install the
‘MicroGuide’ app on an iOS or Android smartphone. The application will assist
prescribing staff to choose the most appropriate antibiotic to control an infection,
tailored to the patient’s needs, while reducing high-risk prescribing that can spread
antimicrobial resistance.
‘MicroGuide’ will also aid prescribers in deciding on alternative treatments for patients
who have already developed resistance to common antibiotics, or provide support in
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situations outside a prescriber’s immediate area of expertise. The application provides
integrated local formularies for all areas in which the trust operates:
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Sandwell and West Birmingham Hospitals NHS Trust
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The Royal Wolverhampton NHS Trust
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The Dudley Group NHS Foundation Trust/Dudley CCG
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Walsall Healthcare NHS Trust
The application is always up to date, when local trusts update their formularies; it
updates the app automatically, thereby negating the requirement to search for the most
up to date antibiotic prescribing guidance.
The benefits to patients when using the app to access the local formulary include:
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supporting a reduction in use of high-risk broad-spectrum antibiotics
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contributing to a reduction in clostridium difficile infections
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treatments are better tailored to individual patient needs
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fewer adverse reactions and side effects
In addition, evidence suggests that decision-support on handheld devices can reduce
antimicrobial use by 17% and in turn reduce spend on antimicrobial agents; there is
also the potential to save bed days with reduced lengths of stay each year.
Information on antibiotic prescribing for specific infections can be found on ‘MicroGuide’
for up-to-date advice on treating the following infections:-
Restricted Antibiotics
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Respiratory Tract Infections
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ENT Infections
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Gastrointestinal Infections
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Urinary Tract infections
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Antimicrobials used for ocular infections
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Cellulitis and Wound Infections
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Human & Animal bites
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Diabetic Foot Infections
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Herpes Zoster (Shingles)
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Infestations
Alternatively, the appendices to this policy provide a summary of recommended
antibiotic prescribing, but prescribers are directed to always refer to ‘MicroGuide’ for the
latest sensitivity and prescribing information (MicroGuide Viewer).
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4.2 Antimicrobial Stewardship Programme
A growing body of evidence demonstrates that hospital based programmes dedicated
to improving antibiotic use, can help clinicians improve the quality of patient care and
patient safety through the reduction of healthcare associated infections and by slowing
the development of antimicrobial resistance.
Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare
Associated Infection Algorithm
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4.3 Start Smart
A ‘Start Smart -then Focus’ approach is recommended for all antibiotic prescriptions.
4.3.1 Allergy to Penicillin or other Antibiotics
BEFORE any drugs are prescribed or administered, the patient should be consulted
about the nature of their allergy and the allergy box MUST be completed on the drug
chart and details recorded in the medical/nursing notes.
4.3.2 Only prescribe an antibiotic where there is likely to be a clear clinical
benefit
Patients who receive antibiotic therapy are at increased risk of colonisation and
infection from multi-resistant pathogens such as MRSA. Patients should not be
subjected to this increase risk without reasonable evidence of infection or established
prophylactic benefit.
4.3.3 Collect specimens for microbiological investigations before prescribing an
antibiotic
Obtaining cultures and sending them to the microbiology lab is important to isolate the
infecting organism and determine the presence of antimicrobial resistance. Knowing
the susceptibility of an infecting organism can lead to narrowing of broad-spectrum
therapy, changing therapy to effectively treat resistant pathogens, and stopping
antibiotics when cultures suggest an infection is unlikely. By contrast, collection after
the start of therapy is almost certainly worthless and may be misleading.
Antimicrobial therapy should not be delayed in an emergency, but every effort should
be made to obtain all necessary appropriate specimens before therapy starts.
4.3.4 Avoid prescribing broad-spectrum antibiotics
Use simple generic antibiotics if possible. Avoid prescribing broad-spectrum antibiotics
e.g. Co-amoxiclav, Quionolones and Cephalosporins as they increase the risk of
healthcare-associated infections e.g. MRSA, Clostridium difficile and resistant UTI’s
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4.3.5 Prescribing an Appropriate Dose
Antibiotics must be prescribed at an appropriate dose as recommended in the BNF and
these guidelines. The dose must be appropriate for the patient’s height, weight and
renal function and always check for possible interactions with other drugs.
N.B. Unless otherwise stated the suggested antibiotics and doses in these guidelines
refer to adults with normal renal function. Doses may need reviewing in patients with
renal or hepatic impairment.
4.3.6 Duration of Treatment
To prevent unnecessary use, all antibiotics must be prescribed with a course length or
review date on the prescription - prescribe the shortest antibiotic course likely to be
effective
4.3.7 Consult your Local Infection Experts
Where there are no guidelines or whenever a prescriber is uncertain, seek appropriate
advice from a Consultant Microbiologist
Where an antibiotic has failed or special circumstances exist, Consultant Microbiologist
advice must be obtained
Prophylactic long-term antibiotics should only be prescribed following clear
recommendation from a Consultant Microbiologist and reasons must be clearly
documented in the clinical notes including the name and contact details of the
consultant.
Where a prescriber is considering a larger dose or longer course in severe or recurrent
cases, this must first be discussed with a Consultant Microbiologist.
Contact details for expert advice
Area
Consultant Microbiologist
Sandwell
Direct Line
Via switchboard
Sandwell & West
Birmingham Hospitals
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Dr Natasha Ratnaraja
Dr Nimal Wickramasinghe
Wolverhampton
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Dr Donald Dobie
Dr Mike Cooper
01902 307999 x8253
01902 307999 x8250
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Dr S Jones
01922 721172 x6489
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Dr Liz Rees
01384 456111 x2471
New Cross Hospital
Walsall
Manor Hospital
Dudley
Russells Hall Hospital
0121 750 4824
0121 750 6486
0121 553 1831
4.3.8 Other Top Tips
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Use the oral route wherever possible
Consider no treatment, or a delayed antibiotic strategy for acute self-limiting upper
respiratory tract infections
Limit prescribing over the phone to exceptional cases
Avoid widespread use of topical antibiotics (especially those that are also
available as systemic preparations, such as fusidic acid)
Use antimicrobial susceptibility data to de-escalate / substitute / add agents and to
switch from intravenous to oral therapy
Always select agents to minimise collateral damage i.e. selection of multi-resistant
bacteria / Clostridium difficile
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Monitor antibiotic drug levels when relevant e.g. vancomycin
4.3.9 Documentation
The reason for prescribing an antibiotic must be clear and easy to find in medical notes.
It is important that other medical staff and healthcare professionals are able to review
the antibiotic and sort out any problems related to its use or treatment of the infection.
Therefore always ensure that:
The clinical indication, duration or review date, route and dose are clearly
documented in the patient’s medical notes and on the drug chart
Reasons for any deviations from empirical treatment guidelines are recorded in
the patient’s medical notes
Allergies are recorded on the front of the drug chart and in the medical records,
along with the nature of the reaction
4.4 Then Focus
Always review regularly and adjust therapy in accordance with microbiology findings
and patient response. Use the narrowest spectrum antibiotic appropriate to reduce
resistance problems. All review and changes in therapy must be documented in the
patient’s medical notes with reasons.
Review the clinical diagnosis and the continuing need for antibiotics by 48 hours from
the first antibiotic dose. The 5 Antimicrobial Prescribing Decision options are: Stop,
Switch IV (intravenous) to Oral, Change, Continue, and Outpatient Parenteral Antibiotic
Therapy.
4.5 Stop
Stop antibiotics appropriately. Many infections have resolved after 3 to 7 days antibiotic
treatment. Inappropriate prolongation of courses:
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Increases the pressure for resistance to develop
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Increases likelihood of super-infection e.g. with candida species, clostridium
difficile
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Increases cost unnecessarily
5.0 Procedures connected to this Policy
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Security of FP10 Prescription Pads
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Medicines Management in Crisis Resolution and Home Treatment Teams
6.0 Links to Relevant Legislation
 The
Human Medicines Regulations 2012
The regulations replaced most of the Medicines Act 1968 and about 200 statutory
instruments with a simplified set of rules following a review of the UK’s medicines
legislation.
The regulations implemented European directive 2001/83/EC relating to medicinal
products for human use (the medicines directive) and set out a comprehensive regime
for the authorisation of medicinal products for human use; for the manufacture, import,
distribution, sale and supply of those products; for their labelling and advertising; and
for pharmacovigilance. The regulations also introduced greater involvement of patients
and healthcare professionals in reporting medicine safety issues.
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Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
(Part 3)
These regulations introduce the new fundamental standards, which describe
requirements that reflect the recommendations made by Sir Robert Francis following
his inquiry into care at Mid Staffordshire NHS Foundation Trust. They enable the Care
Quality Commission to pinpoint more clearly the fundamental standards below which
the provision of regulated activities and the care provided to people must not fall, and to
take appropriate enforcement action where we find it does.
Part 3 has two sections: Section 1 describes the requirements relating to persons
carrying on or managing a regulated activity.
Section 2 introduces the fundamental standards below which the provision of regulated
activities and the care people receive must never fall. They came into force for all
health and adult social care services on 1 April 2015.
Regulation 8: General
Regulation 9: Person-centred care
Regulation 10: Dignity and respect
Regulation 11: Need for consent
Regulation 12: Safe care and treatment
Regulation 13: Safeguarding service users from abuse and improper treatment
Regulation 14: Meeting nutritional and hydration needs
Regulation 15: Premises and equipment
Regulation 16: Receiving and acting on complaints
Regulation 17: Good governance
Regulation 18: Staffing
Regulation 19: Fit and proper persons employed
Regulation 20: Duty of candour
Regulation 20A: Requirement as to display of performance assessments
6.1 Links to Relevant National Standards

Care Quality Commission’s Fundamental Standards introduced 1 April 2015
Regulation 11: Need for consent
Where a person lacks mental capacity to make an informed decision, or give consent,
staff must act in accordance with the requirements of the Mental Capacity Act 2005 and
associated code of practice.
Discussions about consent must be held in a way that meets people’s communication
needs. This may include the use of different formats or languages and may involve
others such as a speech language therapist or independent advocate. Consent may be
implied and include non-verbal communication such as sign language or by someone
offering their hand when asked if they would like help to move. Consent must be
treated as a process that continues throughout the duration of care and treatment,
recognising that it may be withheld and/or withdrawn at any time.
When a person using a service or a person acting lawfully on their behalf refuses to
give consent or withdraws it, all people providing care and treatment must respect this.
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Regulation 12: Safe care and treatment
The intention of this regulation is to prevent people from receiving unsafe care and
treatment and prevent avoidable harm or risk of harm. Providers must assess the risks
to people’s health and safety during any care or treatment and make sure that staff
have the qualifications, competence, skills and experience to keep people safe.
Medicines must be supplied in sufficient quantities, managed safely and administered
appropriately to make sure people are safe.
6.2 Links to other Key Policies

Medicines Prescribing Policy
The Trust is committed to managing medicines safely, efficiently and effectively as a
key component for the delivery of high quality patient centred care. Medicines play a
significant role in the care of the people who use our services and creating an effective
system for managing medicines in an appropriate and timely manner is a vital
component of providing the best possible care, positive outcomes and reducing
incidents of harm.
The aim of the policy is to describe the procedures and good practice that should be
used by staff when prescribing medication to people who use our services and to make
clear the legal and professional standards that are expected from them.
Where there is a specific prescribing related activity not covered in the core document,
a written standard operational procedure (SOP) will have been produced to assist staff
who prescribe.
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Medicines Errors Policy
Medication is the most common medical intervention within the NHS and particularly
within mental health. Whilst every care is taken by individuals and the organisation
when managing medication, errors involving medicines are sometimes inevitable due to
human involvement. Medication errors are defined as patient safety incidents involving
medicines in which there has been an error in the process of prescribing, dispensing,
preparing, administering, monitoring, or providing medicine advice, regardless of
whether any harm occurred
This policy describes the procedure that must be followed when a medication error
occurs. The procedure describes the immediate action to be taken to ensure patient
safety, the grading of errors (where appropriate) and longer term actions to ensure that
individuals, teams and the wider organisation can learn lessons.
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Non-Medical Prescribing Policy
Prescribing practice within the NHS today consists of medical prescribing by doctors
and non-medical prescribing by specially trained nurses, pharmacists and allied health
professionals such as physiotherapists. The policy explains how non-medical
prescribing operates within the Trust. Non-medical prescribing can improve patient care
by ensuring timely access to medicines and treatment for patients who would otherwise
have to wait to see a doctor; it also releases doctors to care for patients with more
complex health care needs.
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The aim of the policy is to promote legal, safe and effective non-medical prescribing
and to support the development and implementation of non-medical prescribing
throughout the Trust.
6.3 References

UK Five Year Antimicrobial Resistance Strategy 2013-18. Department of Health
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Antimicrobial Stewardship: “Start smart- then focus” Department of Health
November 2011

Code of practice for the prevention and control of healthcare associated infections
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The Health and Social Care Act 2008

British National Formulary (Current Edition) (Section 5: Infections). British Medical
Association and the Pharmaceutical Society of Great Britain, London

Antibiotic prescribing guidelines (2014) Sandwell & West Birmingham Hospitals
NHS Trust (accessed from MicroGuide)

Saving Lives: reducing infection, delivering clean and safe care. Antimicrobial
prescribing. A summary of best practice Department of Health 2007
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7.0 Roles and Responsibilities for this Policy
Title
Role
Key Responsibilities
Medical and NonMedical Prescribers
Adherence and
Implementation
-
Registered Nurses
Adherence and
Administration
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adhere to the antibiotic prescribing guidelines and co-operate with any action plan to influence antibiotic prescribing in their
own clinical areas
always check the current British National Formulary (BNF) for any contraindications, cautions or interactions to the
recommended antibiotics in this guidance
to request microbiological specimens for investigation as appropriate
always state the number of days an antibiotic is prescribed for on the in-patient prescription chart
always record in the patients clinical records the reason for prescribing the antibiotics, the name of the antibiotic prescribed
and the duration of the course
responsible for monitoring the patient’s progress and recording in the patients clinical records any changes to the
prescribed antibiotics and the reason for change
as with all involvement with medicines he/she is expected to work within their own sphere of competencies
have a responsibility to familiarise themselves with this policy and adhere to its principles in order to be able to respond to
the immediate needs of patients and service users
attend training applicable to their role
ensuring they are competent to carry out their prescribing responsibilities and be accountable for their actions
compliance with all Trust policies is a condition of employment and a breach of this policy may result in disciplinary action
any errors or incidents relating to this policy and area of practice are reported on DATIX, the Trust’s electronic incident
reporting system.
if a member of staff has concerns about the way this policy is being implemented or about this area of practice in general,
they should raise this with their line manager. If they feel unable to raise the matter with them, he/she may write to an
Executive Director. If they feel unable to raise the matter with an Executive Director, he/she may write to the Chairman or
a Non-Executive Director. If he/she is unsure about raising a concern or requires independent advice or support, they can
contact:- their Trade Union representative
- the relevant professional body
- the NHS Whistleblowing Helpline - 08000 724 725
administer antimicrobials as prescribed and promptly report any adverse effects to the prescriber/duty doctor and record
details in the patients records - immediately contact the prescriber if any prescription does not have a stated stop date
liaise with infection control, clinical pharmacists and microbiologists as required
to obtain specimens as requested and send to the laboratory
co-operate with any action plan to influence antibiotic prescribing in their own clinical areas
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Antibiotic Prescribing Policy
Title
Role
Key Responsibilities
Clinical Pharmacy Team
Monitoring,
advice and
support
-
Infection Prevention
and Control Team
Specialist advice
and support
Consultant
Microbiologist
Expert Leadership
and advice
Clinical Directors/
Heads of Nursing/
General Managers
Operational
Leadership
Deputy Director of
Nursing
Trust NonMedical
Prescribing Lead
Group Quality and
Safety Groups
Monitoring
Consultant Medical
Staff
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Implementation
-
monitor the use of antibiotics and check the patients allergy status for antimicrobials by regularly reviewing prescription
charts during routine visits to clinical areas
ensure antimicrobials are prescribed according to the best practice guidance provided within this policy; highlight problems
and challenge prescribers on cases that are not, refer to the Chief Pharmacist/Medical Director if further support is needed
ensure that an adequate supply of antimicrobials are available on the wards to ensure that doses are not missed
educate relevant clinical staff on antibiotic prescribing
monitor the use of antibiotics across the Trust and any effects of this on healthcare associated infection
provide relevant data on antibiotic usage for individual clinical areas
assist with the implementation of targeted action plans to influence antibiotic prescribing in specific clinical areas
undertake an annual point prevalence audit of antibiotic usage and report findings to the Medicines Management &
Infection Prevention and Control Committees, sharing lessons learnt with the Quality and Safety Steering Group
provide relevant data on healthcare associated infections
assist with the implementation of targeted action plans to influence antibiotic prescribing in specific clinical areas
to review laboratory results and advise clinical staff in relation to preventing HCAIs
provide advice to clinical staff on the prevention and control of healthcare associated infections
seek advice from the Consultant Microbiologist as required
assist with the review of this policy
provide expert leadership and advice, in conjunction with the Chief Pharmacist, on the use of antimicrobial medicines and
the management of specific patients and infections, including those not specified in the guidelines
be integrally involved in the development of antimicrobial medicine prescribing guidelines
provide teaching and training to other healthcare professionals regarding antimicrobial stewardship
to ensure policy distribution, implementation and compliance throughout relevant wards, units and services
staff have received sufficient training and/or are competent to implement the policy
professional standards of record keeping are maintained
lead discussions around this topic area and policy at Group Quality and Safety Group meetings
oversee the completion of audits in respect of this topic area and policy
provide updates on this area of practice and policy within their Group to the Quality and Safety Steering Group
leads on the strategic development of the implementation of non-medical prescribing throughout the organisation
lead on strategies and innovations to improve current practice
Chair of the trust-wide Non-Medical Prescribers Forum
monitor and review all incidents, complaints and claims relating to this area of practice and policy within their Group
review prescribing practice to ensure that it is applied appropriately and in line with this policy
receive the results and recommendations of all related completed clinical audits and be responsible for monitoring action
plans to implement changes to current practice until completion
ensure that their medical team receives, implements and complies with this policy
lead discussions around this topic area and policy with their medical team
undertake clinical audits to review and improve current prescribing practice
implement strategies and innovations to improve current prescribing practice
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Antibiotic Prescribing Policy
Title
Role
Key Responsibilities
Chief Pharmacist
Medicines Lead
Medicines Management
Committee
Scrutiny and
Performance
-
Medical Director
Executive Lead
-
the policy lead/author with primary responsibility for the development, implementation, monitoring and review of this policy
ensure the Trust complies with national guidance relating to the prescribing of medicines
ensure that Groups are fully informed of their role in maintaining the required standards of practice relating to prescribing
day to day management for all aspects of the safe and secure handling of medicines within the Trust
lead on strategies and innovations to improve current prescribing practice
provide multidisciplinary advice and guidance on medicines management within the Trust
ensure that antibiotics are utilised across the Trust in a way which results in optimal treatment of infections with minimal
risk of healthcare associated infections
ensure the Antibiotic prescribing guidelines are reviewed annually and kept up to date
lead responsibility for the implementation of this policy
allocation of resources to support the implementation of this policy
Chair of the Trust’s Medicines Management Committee
any serious concerns regarding the implementation of this policy are brought to the attention of the Board of Directors
8.0 Training
What aspect(s)
of this policy will
require staff
training?
Which staff groups
require this
training?
Is this training covered in the
Trust’s Mandatory and Risk
Management Training Needs
Analysis document?
All prescribers are expected to be competent in prescribing.
Additional education may be required as part of any action plans to
influence antibiotic prescribing in specific clinical areas where there are
significant problems with healthcare-associated infections
If no, how will the
training be delivered?
These targeted education
strategies may include
written guidance,
presentations at divisional
meetings, educational
seminars and one-to-one
instruction
Who will deliver the
training?
Pharmacy Team
How often will
staff require
training
Who will ensure and
monitor that staff have
this training?
As circumstances
dictate
Chief Pharmacist who will
inform the Medicines
Management Committee
9.0 Equality Impact Assessment
Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff
reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact
Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print,
Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]
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10.0 Data Protection and Freedom of Information
This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work
within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust’s activities in respect of service
users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in
certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business
activities but reserves the right not to disclose information where relevant legislation applies.
11.0 Monitoring this policy is working in practice
What key elements will be
monitored?
(measurable policy objectives)
Patients will have their
allergy status documented
on the prescription chart
Prescribers will record in the
medical record the reason
for prescribing anitbiotic
treatment, the start date and
course length
Patients will have the review
date or stop date recorded
for all prescribed antibiotics
on the prescription chart
Prescription charts will
include the patients full
name, address, DOB, Unit or
NHS number
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Where
described in
policy?
Sections 4.2;
5.0; 10.0
Sections 4.2;
5.0; 10.0
Sections 4.2;
5.0; 10.0
Sections 4.2;
5.0; 10.0
How will they be
monitored?
(method + sample size)
Who will
undertake this
monitoring?
How
Frequently?
This will be monitored on
a continual basis
Ward Pharmacy
Technicians
As part of their
routine work
Planned audits will also
be undertaken
This will be monitored
during ward reviews
Pharmacy Team
Annually
Ward manager/
consultant
As part of their
routine work
Planned audits will also
be undertaken
This will be monitored on
a continual basis
Pharmacy Team
Annually
Ward Pharmacy
Technicians
As part of their
routine work
Planned audits will also
be undertaken
This will be monitored on
a continual basis
Pharmacy Team
Annually
Ward Pharmacy
Technicians
As part of their
routine work
Planned audits will also
be undertaken
Pharmacy Team
Annually
Group/Committee
that will receive and
review results
Group/Committee
to ensure actions
are completed
Evidence
this has
happened
Medicines
Management
Committee
Medicines
Management
Committee
Reports and
minutes of
meetings
Medicines
Management
Committee
Medicines
Management
Committee
Reports and
minutes of
meetings
Medicines
Management
Committee
Medicines
Management
Committee
Reports and
minutes of
meetings
Medicines
Management
Committee
Medicines
Management
Committee
Reports and
minutes of
meetings
16
Antibiotic Prescribing Policy
Appendix 1
High Risk Antipsychotic/Antibiotic Interactions to be aware of
(Always check for possible interactions in British National Formulary before initiating
treatment)


Some pharmacokinetics interactions can lead to toxic concentrations of
psychotropic drugs or sub-therapeutic concentration of antibiotics.
These interactions are caused by inhibition or induction of the hepatic cytochrome
P450 enzyme system.
Antipsychotic + antibiotics
Combination
Clozapine
Risk
Many antibiotics co-administered
with clozapine may increase the
risk of neutropenia
If antibiotics are required
seek advice
+ Clarithromycin / Erythromycin
+ Ciprofloxacin
Increases clozapine levels, need to
be alert for evidence of toxicity
May increase clozapine levels, an
isolated report of increased levels
Increased risk of seizures even in
patients with no history of seizures
+ Clarithromycin / Erythromycin
Increased risk of arrhythmias
+ Quinolone antibiotics
(Ciprofloxacin, Levofloxacin)
QT prolongation potential makes
combination a contra-indication
Carbamazepine +antibiotics
Combination
Risk
Carbamazepine
+ Doxycycline
Doxycycline metabolism is
accelerated by carbamazepine
reducing efficiency of doxycycline.
Consider increasing dosage of
doxycycline or use oxytetracycline
Phenothiazines
+ Clarithromycin



+ Erythromycin
+ Metronidazole
Version 2.0. March 2016


Carbamazepine doses should
be reduced by 30-50% during
treatment with clarithromycin
Monitoring of carbamazepine
levels should be done within 3-5
days of starting treatment
Monitor for signs of toxicity
Avoid if possible
Toxic symptoms can develop
within 24 hours
Monitor for toxicity. A case of levels
rising by 60% has been reported;
If adding or withdrawing
metronidazole, always monitor the
outcome for changes in serum
carbamazepine levels
17
Antibiotic Prescribing Policy
Valproate + antibiotics
Combination
Risk
Valproate
+ Erythromycin
CNS toxicity possible, valproate
levels may rise 3 fold. Observe for
toxic effects, usually uneventful
Antidepressants + antibiotics
Combination
Risks
Duloxetine
+ Ciprofloxacin
Is contra-indicated in the UK
specific product characteristics.
increases duloxetine levels
Lithium + antibiotics
Combination
Risk
Lithium
+ Tetracycline/Doxycycline
Observe for signs of lithium toxicity.
Monitor serum lithium levels.
Tetracycline known to have
nephrotoxic potential
+ Co-trimoxazole
Lithium toxicity has been reported
with this combination. Monitor
clinical response for toxicity
+ Metronidazole
Lithium toxicity has been reported
with this combination. Monitor
serum lithium levels. Frequent
monitoring of Urea and Electrolytes
during and for 2 weeks after
completing a course of
metronidazole
+ Trimethoprim
Lithium toxicity has been reported
with this combination. Monitor
serum lithium levels
Version 2.0. March 2016
18
Antibiotic Prescribing Policy
Appendix 2
Specific Prescribing Information
Section 1: Restricted antibiotics
The following are all antibiotics which although useful in some circumstances, Microbiology
and Acute Trusts’ Medicines Management Committees do not believe should be generally
available:
Intravenous
Ciprofloxacin
Teicoplanin
Meropenem
Imipenem
Ceftriaxone
Linezolid
Fusidic acid (oral fusidic acid is freely available)
Piperacillin/Tazobactam
Oral
Cefixime (Cefpodoxime can be used)
Linezolid
Moxifloxacin
Vancomycin (except according to C. difficile protocol following failure of metronidazole)
Note that all medical wards at the acute hospitals ban cephalosporins (cefalexin, cefuroxime,
cefpodoxime, ceftazidime and cefotaxime (except for meningitis), as well as Co-amoxiclav
(Augmentin) and Clindamycin (except for specific circumstances).
It is recommended that we should follow their decision.
Section 2: Respiratory tract infections
Treatment for respiratory infections in medical patients must avoid the use of betalactam antibiotics
(co-amoxiclav (Augmentin), cefuroxime and cefotaxime), which are associated with the development
of Clostridium difficile diarrhoea. Amoxicillin and Clarithromycin are much less likely to cause
problems.
Illness
Comments
Hospital
acquired
pneumonia
Avoid beta-lactam
antibiotics
Drug
Exacerbation
of COPD
Mostly viral
1st Choice: Doxycycline
2nd Choice: Co-trimoxazole
1st Choice: Doxycycline
2nd Choice: Amoxicillin
Dose
Duration
200mg stat, then
100mg once daily
960mg BD
200mg stat, then
100mg once daily
500mg TDS
5 days
5 days
5 days
5-7 days
Section 3: ENT Infections
Antibiotics only reduce the duration of symptoms in sore throat by 8 hours. Treatment should only be
given in severe pharyngitis with proven bacterial cause. Antibiotics can be effective treatment for acute
sinusitis but no one regime is any better than any other.
Illness
Comments
Drug
Dose
Duration
Acute
pharyngitis &
tonsillitis
Acute bacterial
sinusitis
80% viral.
Most need no
antibiotic
Mostly viral.
Most need
analgesia only
1st Choice: Penicillin V
2nd Choice:(if penicillin allergic)
Clarithromycin XL
1st Choice: Co-amoxiclav
2nd Choice: (if penicillin
allergic) Doxycycline
500mg QDS
500mg OD
7 days
7 days
625mg TDS
200mg stat then
100mg daily
7 days
7 days
Version 2.0. March 2016
19
Antibiotic Prescribing Policy
Section 4: Gastrointestinal Infections
Illness
Comments
Drug
Gastroenteritis
Antibiotics NOT usually
indicated. Oral rehydration is
treatment of choice. Any
patient with diarrhoea must
be isolated in side room.
If Clostridium difficile
is suspected, follow
the clostridium
difficile treatment
pathway
Metronidazole
Giardiasis
Dose
Duration
2gm daily
400mg TDS
3 days
5 days
Section 5: Urinary Tract infections (UTI)
All urinary catheters will become colonised with bacteria so treatment should only be started in a
patient with clear signs of sepsis. Systemic therapy will rarely eliminate infection. Antibiotics will not
eradicate bacteriuria but will increase side effects and increase antibiotic resistance. Maintenance of a
good urine output is important. If catheter associated septicaemia is suspected, take blood cultures
and remove the catheter if possible.
Illness
Comments
Drug
Dose
Duration
Uncomplicated
UTI
In pregnant women,
course length is 7
days
1st Choice:
Nitrofurantoin
50-100mg QDS
3 days
2nd Choice:
Trimethoprim
200mg BD
3 days
UTI in
catheterised
patients
Complex UTI or
pyelonephritis
Mostly viral. Most
need analgesia only
Discuss with
microbiology
Section 6: Antimicrobials used for ocular infections
Illness
Comments
Drug
Dose
Duration
Bacterial
conjunctivitis
In pregnant
women course
length is 7 days
1st Choice: Chloramphenicol
Apply 2 hourly
reducing to QDS
after 48 hours,
for 5 days.
Alternatively 1%
ointment can be
used at night or
QDS during the
day.
If the patient is
allergic to
Chloramphenicol,
alternative
treatment is
Fusidic acid eye
drops 1% twice a
day for five to
seven days
(although this
has a narrow
spectrum of
antibacterial
activity) or for
patients in whom
compliance is a
problem
Azithromycin eye
drops 1.5% twice
a day for three
days
5 days
2nd Choice: Fusidic acid or
Azithromycin
Version 2.0. March 2016
Fusidic acid
eye drops –
5-7 days
Azithromycin
eye drops –
3 days
20
Antibiotic Prescribing Policy
Section 7: Human & Animal Bites
Surgical toilet is most important but antibiotic prophylaxis is recommended especially if >50years,
puncture or hand wound.
Illness
Comments
Bites
Drug
Dose
Duration
1st Choice: Co-amoxiclav
2nd Choice:(penicillin
allergic): Clindamycin
625mg TDS
450 mg four
times daily by
mouth
7 days
7 days
Section 8: Cellulitis & Wound Infections
There is little evidence on the treatment of cellulitis. (Clinical Knowledge Summaries, NICE, 2014)
Expert opinion is that patients with severe cellulitis should have about 7 days of intravenous therapy
before oral switch to minimise the chances of relapse. Flucloxacillin is used as a single agent for
empirical therapy as it covers both Staphylococcus aureus and Streptococcus pyogenes. Infections
known to be caused by Streptococcus pyogenes can be treated with benzylpenicillin.
Illness
Comments
Cellulitis
Drug
Dose
Duration
1st Choice:
Flucloxacillin
500 mg -1g four
times daily by mouth
7-14 days
If MRSA-positive
Doxycycline
200 mg stat then 100
mg once daily by
mouth
450 mg four times
daily by mouth
2nd Choice:
(penicillin allergic):
Clindamycin
Wound
infections
Any patient known to be
colonised with MRSA
should be treated as
though this is the cause of
the wound infection unless
there is evidence to the
contrary. All doses should
be increased if the patient
septicaemic. It is
recommended that advice
is taken from physicians or
the microbiologist.
7-14 days
1st Choice:
Flucloxacillin
500mg qds IV or po
(depending on
severity)
5-7 days
2nd Choice:
(penicillin allergic):
Clindamycin
Clindamycin 300600mg qds po or IV
5-7 days
2nd Choice
(MRSA):
Vancomycin
1g bd IV
5-7 days
Section 9: Diabetic Foot Infections
If prolonged oral treatment is needed for an infected ulcer, clindamycin can be replaced by other
agents (please contact a microbiologist to discuss the options).
Illness
Comments
Drug
Dose
Duration
Superficial,
neuropathic
ulceration
Definition: Skin intact /
superficial neuropathic
ulcer <10mm2, no
systemic toxicity,
cellulitis <2cm from
edge of ulcer, no
ischaemia (pulses
palpable), (SAD score
<4).
Clindamycin is almost
100% bioavailable, so
the intravenous route is
not usually required. It
also has excellent
anaerobic activity, so
metronidazole is not
required
1st Choice:
Flucloxacillin
or if MRSApositive
Doxycycline
500 mg -1g QDS
7 days
2nd Choice:
(Penicillin allergic)
Mild infection:
450 mg QDS
Clindamycin
Moderate
infection:
600mg QDS
Version 2.0. March 2016
200 mg stat then
100 mg once daily
7 days
21
Antibiotic Prescribing Policy
Infected ulcer
– non limb
threatening
Definition: Size
2
<30mm , skin only or
skin and subcutaneous
tissue, no or minimal
cellulitis, no evidence of
severe vascular
compromise, (SAD
score 3-7).
1st Choice:
Co-amoxiclav
625mg TDS
5-7 days
2nd Choice:
(penicillin allergic):
Clindamycin with
ciprofloxacin
2nd Choice
(MRSA):
Vancomycin
300-600mg qds
+500mg BD
5-7 days
1g bd IV
5-7 days
Section 10: Herpes Zoster (Shingles) & Herpes Simplex (Cold sores)
There is no clear evidence that Aciclovir reduces the incidence of post-herpetic neuralgia (Clinical
Evidence 9, BMJ Publications, 2003). Treatment should only be given to patients >50 years and if
started in the first 72 hours. Simple analgesia can be prescribed for pain. Patients with ophthalmic
zoster and the immunocompromised should also be treated.
Illness
Comments
Drug
Dose
Duration
Shingles
Start at the first sign of
infection. It is NOT
effective if lesions
already visible.
Cold sores resolve after
7-10 days even without
treatment. The benefits
of topical antivirals
are small and applied
prodomally reduce
duration by ~12-24hrs.
Aciclovir
800mg 5x daily
7 days
Aciclovir 5%
cream
5x daily
5 days
Cold sores
Section 11: Infestations
The instructions on the products must be adhered to carefully to ensure the best chance of eradication
of head lice. For both head lice and scabies treatments, the applications should be 7 days apart. Close
contacts may also need treatment.
Illness
Comments
Drug
Dose
Duration
Head lice
Wet combing after
application of
conditioner, every 4
days for 2 weeks is an
alternative to insecticide
treatment. Wet combing
should be continued
until no live lice are
found for 3 consecutive
sessions.
Treat the whole body
including scalp, face,
neck, ears, and under
nails. Aqueous
preparations are
preferable to alcoholic
lotions, which can
cause skin irritation and
wheezing in asthmatics.
Malathion 0.5%
Rub preparation
into dry hair and
scalp, allow to dry
naturally, remove
by washing after
12 hours (see also
notes above);
repeat application
after 7 days.
See dose
Permethrin 5%
cream
Apply over whole
body (from the
neck down) leave
in contact with the
skin for 12 hours.
(Re-apply to any
area of washed
skin during this
time). Bath or
shower after the
12 hours to
remove. Repeat
application after 7
days.
See dose
Scabies
For the latest sensitivity and dosing information, go to: MicroGuide Viewer
Version 2.0. March 2016
22
Antibiotic Prescribing Policy
Policy Details
Title of Policy
Antibiotic Prescribing Policy
Unique Identifier for this policy
BCPFT-MM-POL-05
State if policy is New or Revised
Revised
Previous Policy Title where applicable
N/A
Policy Category
Clinical, HR, H&S, Infection Control etc.
Executive Director
whose portfolio this policy comes under
Policy Lead/Author
Job titles only
Medicines Management
Medical Director
Deputy Chief Pharmacist (in collaboration with
the Infection Prevention and Control Lead)
Committee/Group responsible for the
approval of this policy
Medicines Management Committee
Month/year consultation process
completed *
February 2016
Month/year policy approved
March 2016
Month/year policy ratified and issued
March 2016
Next review date
March 2019
Implementation Plan completed *
Yes
Equality Impact Assessment completed *
Yes
Previous version(s) archived *
Yes
Disclosure status
‘B’ can be disclosed to patients and the public
Key Words for this policy
antibiotic, prescribing, medicines, infection
control, infections, resistant, organisms,
antimicrobial, bacteria, AMR, MRSA, MDRO
* For more information on the consultation process, implementation plan, equality impact assessment,
or archiving arrangements, please contact Corporate Governance
Review and Amendment History
Version Date
Details of Change
2.0
Mar 2016
Significant revision of policy to align practice and comply with the
latest guidance
1.0
Aug 2012
Policy for the new organisation BCPFT
Version 2.0. March 2016
23