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Training on use of antimicrobials
in clinical practice
1
Contents
• Section One - Policy context: National and local strategic approaches
3
• Section Two - Diagnosis of infection and clinical decision making
12
• Section Three - Prudent antimicrobial prescribing
19
• Section Four - Antimicrobial use in hospital
29
• Section Five - Antimicrobial use in primary care
41
• Section Six - Nurses' role in antimicrobial management
52
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Training on use of antimicrobials
in clinical practice
2
Section One
Policy context: National and local strategic approaches
3
ScotMARAP
• Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) issued in 2008
• Made recommendations for NHS Boards to address the growing problem of antimicrobial
resistance
• UK Antimicrobial Resistance Strategy for 2013-18 published in September 2013 and ScotMARAP
refreshed in line with new UK objectives
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
4
SAPG
• The Scottish Antimicrobial Prescribing Group (SAPG) was set up to ensure national delivery of
ScotMARAP
• Members include representatives from regional NHS Boards and national NHS stakeholders
(HPS, ISD, NES, HIS) and Scottish Government
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
5
Antimicrobials and HAI
• Healthcare Associated Infection (HAI) is currently a priority area for all NHS Boards
• The Healthcare Environment Inspectorate was set up in 2009 to ensure Boards complied
with Infection Control Standards
• Antimicrobial prescribing is included within the standards
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
6
Antimicrobial Management Teams (AMT)
Core activities:
• Develop and implement local antimicrobial policies for hospital and primary care
• Monitor antimicrobial use at local level– antibiotic usage data and compliance with antimicrobial
policy
• Ensure clinical staff educated and trained in use of antimicrobials
• Feed back data on antimicrobial use and surveillance to prescribers
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
7
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
8
NHS your name AMT
• Lead doctor –
• Consultant Microbiologist –
• Antimicrobial Pharmacist –
• Prevention and Control of Infection representative –
• Primary Care representative -
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
9
Antimicrobial policies
• Separate policies for hospital and primary care
• Evidence-based guidance on empirical treatment of common infections
• Alternative choices for penicillin-allergic patients
• Antibiotic name, dose, frequency, route and duration
• Hospital – guidance on IV to oral switch therapy (IVOST)
• Must be reviewed by AMT regularly (usually every 2 years).
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
10
NHS your name Antimicrobial Policies
• Details of access – booklets, intranet, posters
• Hospital policy – key features of presentation of information
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section One
Policy context: National and local strategic approaches
11
Section Two
Diagnosis of infection and clinical decision making
12
Diagnosis of infection
Definition of sepsis and infection severity indicators
Sepsis: Clinical symptoms of infection (pyrexia, sweats, chills, rigors)
Plus – 2 or more of the SIRS* criteria:
Temperature < 36 or > 38 °C
Heart rate > 90 bpm
Respiratory rate > 20/minute
WCC < 4 or > 12 x 109/L
Severe sepsis: Sepsis + organ dysfunction/hypoperfusion (oliguria, confusion, acidosis, hypotension)
Note: The above features may be masked in specific situations e.g. immunosuppression,
The elderly and in patients on certain medications (β-blockers, corticosteroids, etc.)
*SIRS = Systematic Inflammatory Response Syndrome
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Two
Diagnosis of infection and clinical decision making
13
Microbiology samples
• Will a sample aid diagnosis and management of the suspected infection?
• What sample(s) are required? – blood culture, urine, sputum, wound swab?
• Take sample before starting empirical treatment (except suspected meningitis)
• In severe infections empirical treatment should be started without waiting for the microbiology
results
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Two
Diagnosis of infection and clinical decision making
14
Interpreting Microbiology reports
• Is the microbiology report relevant?
• Does the patient need antibiotics?
• Which antibiotics should be used?
• Do I need to discuss this case with a microbiologist?
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Two
Diagnosis of infection and clinical decision making
15
Factors affecting choice of antibiotic
• Likely organism and site of infection
• Culture and sensitivity results
• Patient characteristics e.g. diseases, allergies, medication, renal/hepatic function, pregnancy,
breastfeeding
• Infection/severity indicators
• Spectrum of antimicrobial activity
• Formulations available
• Relevant cautions/contra-indications/side effects
• Risk of C. difficile
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Two
Diagnosis of infection and clinical decision making
16
Section Three
Prudent antimicrobial prescribing
17
Some facts about antibiotics
• 1/3 of hospital inpatients receive antibiotics
• 1/3 to 1/2 are inappropriate
• Up to 30% of all surgical prophylaxis is inappropriate
• Antimicrobials account for 30% of hospital pharmacy budgets
• Inappropriate use leads to resistance, C. difficile, increased morbidity & mortality, increased cost
and litigation
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
18
Using antibiotics prudently
• Is an antibiotic required?
• What is optimum choice and duration?
• Minimise risk to patient – HAI, drug toxicity
• Document decision making
• Ask for advice if unsure
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
19
Requirements for medical notes
• Document indication for antibiotic treatment and antibiotic(s) prescribed
• Document duration or review date - unnecessarily long courses of antibiotics put patients at risk of
HAI and antimicrobial resistance
• Document any advice received from microbiology or pharmacy.
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
20
Requirements for antibiotic prescriptions
• Correct choice of drug – as per local policy
• Correct dose – inadequate dosage results in ineffective treatment and selects for resistance
• Correct frequency – essential for effective treatment
• Correct duration – as per local policy
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
21
Duration of antibiotic treatment
• Duration depends on site of infection and infecting organism
• Antimicrobial policies always state recommended duration
• Most common infections do not require treatment for longer than 7 days
• Some exceptions are atypical pneumonias, endocarditis, UTIs in males, meningitis
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
22
Common problems with antibiotic prescribing and administration
• Wrong antibiotic – drug, dose, frequency, route, duration
• Penicillin-allergic patients prescribed a penicillin
• Empirical antibiotics not reviewed when microbiology results available
• Missed doses – can have serious consequences.
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
23
Problems caused by inappropriate use of antibiotics
Patient:
• Drug toxicity or ineffective treatment
• Allergic and adverse reactions
• Healthcare associated infection – MRSA or C. difficile infection (CDI)
Population (society):
• Emerging antimicrobial resistance
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
24
Concordance
• Concordance with antibiotic treatment is important in reducing resistance
• Patients need information about antibiotics
- course length, when to take, potential adverse effects, interactions with food or other
medicines
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
25
Information on use of antimicrobials
• Local antimicrobial policy – intranet link
• Microbiology – names /phone & bleep numbers
• Antimicrobial pharmacist – name /phone & bleep number
• Infectious Diseases consultant – name /phone & bleep number
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Three
Prudent antimicrobial prescribing
26
Section Four
Antimicrobial use in hospital
27
Indications for IV antibiotics
• Sepsis, severe sepsis or deteriorating clinical condition
• Febrile with neutropenia/immunosuppression
• Deep-seated/specific infections: bone/joint, moderate to severe cellulitis, deep abscess,
endocarditis, meningitis
• Oral route compromised: vomiting, nil by mouth, severe diarrhoea, swallowing disorder,
unconscious, malabsorption
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
28
IV to oral switch therapy (IVOST) policy
• Review patient daily
• If answer to all of following questions is NO, switch to oral route
- Oral route compromised?
- Continuing sepsis or deteriorating condition?
- Special indication for IV therapy?
- Antimicrobial only available in an IV formulation?
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
29
Gentamicin
• Indicated for treatment of gram negative infections and in surgical prophylaxis
• High or prolonged dosage can lead to renal or ototoxicity
• Dosage based on weight and renal function - on-line calculator should be used where possible.
See local policy for details.
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
30
Gentamicin monitoring
• Blood sample should be taken 6-14 hours after first dose
• Level interpreted using a nomogram (Glasgow or Hartford) – see local policy for details
• Subsequent doses given every 24, 36 or 48 hours
• Seek advice from microbiology or Infectious Diseases before continuing treatment beyond 72
hours
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
31
Vancomycin
• First line agent for MRSA infections and may be used for surgical prophylaxis in patients at risk of
MRSA
• Loading dose given based on body weight then subsequent doses based on renal function
• Must be administered by slow IV infusion to avoid shock-like syndrome and thrombophlebitis
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
32
Vancomycin monitoring
• Check level immediately before 3rd or 4th dose
• Target level is 10 -20mg/L (15-20mg/L for severe infections)
• Seek advice from pharmacy or microbiology on dose adjustment.
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
33
Surgical prophylaxis
• Single dose antibiotic prophylaxis recommended in SIGN 104
• List of procedures where prophylaxis is recommended
• Avoid cephalosporins where possible due to C. difficile risk
• Consult local policy for details
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
34
MRSA colonisation
• MRSA screening used to detect MRSA colonisation
• MRSA colonises skin and mucous membranes
• Colonisation presents risks for patients with open wounds and those undergoing surgical
procedures
• Hospital patients who are MRSA positive may receive decolonisation therapy – disinfection of skin
and nasal passages
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
35
Managing MRSA infection
• At one time up to 40% of Staph. aureus infections in UK were due to MRSA but during the past 5
years this level has decreased to less than 10%
• Most common site is skin and soft tissues
• MRSA pneumonia, UTI and bacteraemia are less common
• First line treatment is IV vancomycin
• Alternatives include teicoplanin and linezolid – see local policy
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
36
C. difficile Infection (CDI)
• Gram positive, spore forming anaerobic bacillus which produces 2 main toxins, A and B
• Carried by 2% adults as part of normal large bowel flora and carriage increases with age
• C. difficile infection (CDI) is associated with significant morbidity and mortality
• Symptoms - diarrhoea with characteristic foul odour, abdominal pain, pyrexia, raised WCC and
raised serum creatinine
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
37
Risk factors for C. difficile Infection (CDI)
• > 65 years of age
• Antibiotic exposure, especially ‘4C’ (clindamycin, cephalosporins, co-amoxiclav, ciprofloxacin)
• Prescription of proton pump inhibitors e.g. omeprazole, lansoprazole
• Serious underlying disease / surgery
• Prolonged hospital stay
• Inadequate cleaning of ward facilities and equipment
• Poor Hand Hygiene by patients and staff
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
38
Managing Clostridium difficile Infection (CDI)
• Isolation with transmission based precautions
• Assess severity factors then prescribe either
- Metronidazole 400mg TDS PO 10-14/7
(can be given IV if patient is NBM)
or
- Vancomycin 125mg QDS PO 10-14/7
(can only be given orally)
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
39
Useful Websites
• Scottish Antimicrobial Prescribing Group (SAPG):
www.scottishmedicines.org.uk/SAPG/Scottish_Antimicrobial_Prescribig_Group_SAPG
• NHS Education for Scotland, HAI Programme
www.nes-hai.info/
• Pause:
www.pause-online.org.uk/
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Four
Antimicrobial use in hospital
40
Section Five
Antimicrobial use in primary care
41
Antimicrobials in primary care
• 80% of total antimicrobial use in humans is in primary care
• 60% of that is for respiratory infections
• Antibiotics are often prescribed for self-limiting viral infections
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
42
Upper respiratory tract infections (URTI)
• Most URTI are self-limiting and do not require antibiotics
• 92% of patients with acute rhino sinusitis are still prescribed antibiotics in primary care despite
evidence that antibiotic therapy does not offer clinically significant benefit
• Antibiotics should be reserved for patients with severe or prolonged symptoms and evidence
based criteria should be used to identify patients who are likely to benefit from treatment
• Doctors over-estimate patient demand for antibiotics
• Immediate prescriptions for conditions such as sore throats increase future consultations.
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
43
Strategies to reduce antibiotic use for URTIs
• Take detailed history, carry out full examination and ask directly about patient’s expectation for antibiotics. Do
not prescribe antibiotics via telephone consultation.
• Reassure patients that antibiotics are not needed because they will make little difference to the symptoms and
may have side-effects. Use a patient information leaflet to back up this advice.
• Consider using a delayed prescription if symptoms are not settling within a recognised time frame and give
symptom management advice.
• Advise patients on the likely timescale for the illness:
Acute otitis media – 4 DAYS
Acute sore throat – 1 WEEK
Acute rhino sinusitis – 2 ½ WEEKS
Acute bronchitis – 3 WEEKS
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
44
Healthcare Associated Infections
• Healthcare associated infections (HAI) present in mainly in hospital and may also occur in the
community in Care Homes and other long term care facilities
• Prescribing of antibiotics within primary care can influence development of HAI
• The development of C. difficile infection (CDI) can be driven by antibiotic use in the preceding 12
weeks, which is often in primary care
• Antibiotics associated with a high risk of C. difficile infection (CDI) are cephalosporins, quinolones,
clindamycin and co-amoxiclav
• Prescribers should follow the local antibiotic policy and where possible avoid the use of high risk
antibiotics particularly in those patients over 65 years
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
45
Antimicrobial resistance
• Antibiotic use causes resistance through selective pressure
• Broad spectrum antibiotics select for resistant pathogens by eradicating natural flora
• Current problems with resistant organisms include:
MRSA - methicillin resistant Staphylococcus aureus
VRE vancomycin resistant enterococci
ESBL - extended spectrum betalactamase
CPE –
carbapenemase-producing enterobacteriaceae
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
46
Common infections: local antimicrobial policy choices
• Acute sore throat –
• Acute otitis media –
• Acute rhino sinusitis –
• Acute bronchitis –
• Exacerbation of COPD –
• Community acquired pneumonia –
• Urinary tract infection (women) –
• Cellulitis SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
47
National prescribing indicators
• In 2009 a set of 41 prescribing indicators for antibacterials were developed within PRISMS
• Provide an overview of quantity and quality of antibacterial prescribing at NHS board, CHP and
GP Practice level
• Can be used to identify outliers in terms of quantity of antibacterials prescribed and use of nonpolicy agents
• Total use of antibiotics is an example of a quantitative quality indicator and a target level for
reduction of this measure was set by Scottish Government in 2013
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
48
Your local information on use of antimicrobials
• Local antimicrobial policy – intranet link
• Microbiology – names /phone & bleep numbers
• Antimicrobial pharmacist – name /phone & bleep number
• Infectious Diseases consultant – name /phone & bleep number
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
49
Useful resources on use of antibiotics in primary care
• Health Protection Agency guidance on primary care management of infections
www.hps.org.uk/HPS/Topics/InfectiousDiseases/InfectionsAZ/1197637041219
• Scottish Antimicrobial Prescribing Group – Prudent antimicrobial use
www.scottishmedicines.org.uk/files/sapg/Respiratory.pdf
• National Prescribing Centre Information on URTIs
www.npci.org.uk/therapeutics/common_infections/respiratory/resources/pda_rti_general.pdf
• NHS Education for Scotland – ScRAP programme
http://www.nes.scot.nhs.uk/education-and-training/by-discipline/pharmacy/about-nes-pharmacy/educationalresources/resources-by-topic/infectious-diseases/antibiotics/scottish-reduction-in-antimicrobial-prescribing(scrap)-programme.aspx
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Five
Antimicrobial use in primary care
50
Section Six
Nurses' role in antimicrobial management
51
Antimicrobial management
• Optimising the use of antimicrobials is an important patient safety issue.
• A multi-professional approach is required as all members of the clinical team have a role to play.
• Integrated within national programmes – Scottish Patient Safety Programme (SPSP); HAI Quality Improvement
Tools; HAI Performance targets (HEAT); Leading Better Care
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
52
Why nurses' role is important
Nurses' routine professional practice includes:
• Supporting pharmacists in regular review of medication charts
• Regular clinical review and interaction with patients
• Consistent role at point of care for patients and families
• Primary role to administer medications safely and effectively
• Safe administration of IV therapy and drug calculations
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
53
Responsibility and accountability
• Nurses have a duty of care to ensure patients get the correct medication.
• Nurses and midwives are accountable for their role in medicines management under the NMC
‘Standards for Medicines Management’ (2007) and ‘Standards of Proficiency for Nurse and
Midwife Prescribers’ (2006)
• Required to keep knowledge and skills up to date and demonstrate this through competency
assessment
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
54
How nurses can impact on antimicrobial management
Six key issues to ensure safe and effective antibiotic use
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
55
Administration route
• Review of ongoing need for IV medication, including antibiotics, included in PVC maintenance
bundle.
• Early switch from IV to oral therapy reduces length of hospital stay, reduces risk of antimicrobial
resistance (AMR) and decreases nursing workload
• Nurses can monitor IV antimicrobial therapy and consider de-escalation to oral therapy in
collaboration with colleagues
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
56
Treatment choice
•
•
•
•
Use of broad spectrum antibiotics contributes the development of C. difficile Infection (CDI) and antimicrobial
resistance.
Compliance with local antibiotic policies ensures patients get the most effective treatment for their infection.
Check patients with a documented allergy are prescribed an antibiotic that is safe for them
Be mindful of microbiology results being available and prompt their review by the team to ensure empirical
treatment is appropriate
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
57
Treatment duration
•
•
•
•
Prolonged duration of antimicrobial treatment is a risk factor for C. difficile Infection (CDI) and antimicrobial
resistance
Local antibiotic policies specify recommended duration for each infection type
In collaboration with doctors and pharmacists, nurses can ensure antimicrobials are prescribed for
appropriate duration
Highlight to prescribers if antibiotic prescribed longer than indicated on chart
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
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Timing of administration
• Administration of antibiotics at the recommended dosage interval is an important factor in their
effectiveness
• Prompt and timely administration of antimicrobials is associated with improved clinical outcomes
for patients
• In patients with sepsis administration of an IV antibiotic within 1 hour of diagnosis increases
survival
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
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Nurses' role in antimicrobial management
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Therapeutic monitoring
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Patients on gentamicin or vancomycin require serum blood levels for safe and effective treatment
Ensure samples need to be taken at the appropriate time to get meaningful results
Ensure details of samples are documented correctly in the patient’s notes and on the lab request form
Nurses can contribute to monitoring of blood results and dose adjustment - understand when to withhold a
dose until results available (gentamicin) and when to give dose with levels informing the subsequent dose
(vancomycin)
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
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Nurses' role in antimicrobial management
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Discharge planning
• Review need for antibiotics on discharge to complete course
• Ensure patients understand directions for antibiotics to be completed on discharge
• Contribute to consideration of patients for Out-patient Parenteral Antibiotic Therapy where
prolonged IV therapy is required
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
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Potential benefits for patients of enhanced Nurses' role in antimicrobial management
• Less intense medical treatment
• Reduction in isolation procedures
• Decreased need for IV drug administration
• Decrease in length of stay and associated costs
• Improved patient experience of healthcare: increases public confidence and trust
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
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Challenges in enhancing Nurses' role in antimicrobial management
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Time
Resources
Knowledge and skills
Motivation
Ability to discuss or challenge decisions associated with constructs of knowledge and power
Prescribing etiquette: refers to prescribers reluctance to change colleagues decisions
Edwards, R, et al. (2011) Covering more Territory to Fight Resistance: considering nurses’ role in antimicrobial stewardship. J.
Infection Prevention 12: 6-10
SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the
training pack by a territorial board/third party to reflect local policy and information.
Section Six
Nurses' role in antimicrobial management
63