Antibiotic Prescribing Policy

Transcription

1 Antibiotic Prescribing Policy Who should read this policy Target Audience All prescribing staff and clinical staff Version 2.0. March 2016

2 Ref. Contents Page 1.0 Introduction Purpose Objectives Prescribing Antibiotics MicroGuide Antimicrobial Stewardship Programme Start Smart Then Focus Stop Procedures connected to this Policy Links to Relevant Legislation Links to Relevant National Standards Links to other Key Policies References Roles and Responsibilities for this Policy Training Equality Impact Assessment Data Protection and Freedom of Information Monitoring this policy is working in practice 16 Appendices 1.0 High Risk Antipsychotic/Antibiotic Interactions to be aware of Specific Prescribing Information 19 Version 2.0. March

3 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 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 Version 2.0. March

4 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 Provide a simple, empirical approach to the treatment of common infections for patients on inpatient wards Minimise the incidence of healthcare associated infections within inpatient units Improve awareness and understanding of antimicrobial resistance Promote the safe and effective use of antibiotics 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 Version 2.0. March

5 situations outside a prescriber s immediate area of expertise. The application provides integrated local formularies for all areas in which the trust operates: Sandwell and West Birmingham Hospitals NHS Trust The Royal Wolverhampton NHS Trust The Dudley Group NHS Foundation Trust/Dudley CCG 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: supporting a reduction in use of high-risk broad-spectrum antibiotics contributing to a reduction in clostridium difficile infections treatments are better tailored to individual patient needs 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 - Respiratory Tract Infections - ENT Infections - Gastrointestinal Infections - Urinary Tract infections - Antimicrobials used for ocular infections - Cellulitis and Wound Infections - Human & Animal bites - Diabetic Foot Infections - Herpes Zoster (Shingles) - 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). Version 2.0. March

6 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 Version 2.0. March

7 4.3 Start Smart A Start Smart -then Focus approach is recommended for all antibiotic prescriptions 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 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 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 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 Version 2.0. March

8 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 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 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 Direct Line Via switchboard Sandwell Sandwell & West Birmingham Hospitals Wolverhampton New Cross Hospital Walsall Manor Hospital Dudley Russells Hall Hospital Other Top Tips Dr Natasha Ratnaraja Dr Nimal Wickramasinghe Dr Donald Dobie Dr Mike Cooper x x8250 Dr S Jones x6489 Dr Liz Rees x2471 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 Version 2.0. March

9 Monitor antibiotic drug levels when relevant e.g. vancomycin 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: Increases the pressure for resistance to develop Increases likelihood of super-infection e.g. with candida species, clostridium difficile Increases cost unnecessarily 5.0 Procedures connected to this Policy Security of FP10 Prescription Pads 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. Version 2.0. March

10 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 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. Version 2.0. March

11 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. 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. 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. Version 2.0. March

12 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 Department of Health Antimicrobial Stewardship: Start smart- then focus Department of Health November 2011 Code of practice for the prevention and control of healthcare associated infections 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 Version 2.0. March

13 7.0 Roles and Responsibilities for this Policy Title Role Key Responsibilities Medical and Non- Medical Prescribers Registered Nurses Adherence and Implementation Adherence and Administration - 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 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 Version 2.0. March

14 Title Role Key Responsibilities Clinical Pharmacy Team Infection Prevention and Control Team Consultant Microbiologist Clinical Directors/ Heads of Nursing/ General Managers Deputy Director of Nursing Group Quality and Safety Groups Consultant Medical Staff Monitoring, advice and support Specialist advice and support Expert Leadership and advice Operational Leadership Trust Non- Medical Prescribing Lead Monitoring Antibiotic Prescribing Policy - 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 Implementation - 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 Version 2.0. March

15 Title Role Key Responsibilities Chief Pharmacist Medicines 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 Medicines Management Committee Scrutiny and Performance - 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 Medical Director Executive Lead - 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 As circumstances dictate Who will ensure and monitor that staff have this training? 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 or EqualityImpact.assessment@bcpft.nhs.uk Version 2.0. March

16 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 Monitoring this policy is working in practice What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened 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 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 This will be monitored on a continual basis Planned audits will also be undertaken This will be monitored during ward reviews Planned audits will also be undertaken This will be monitored on a continual basis Planned audits will also be undertaken This will be monitored on a continual basis Planned audits will also be undertaken Ward Pharmacy Technicians Pharmacy Team Ward manager/ consultant Pharmacy Team Ward Pharmacy Technicians Pharmacy Team Ward Pharmacy Technicians Pharmacy Team As part of their routine work Annually As part of their routine work Annually As part of their routine work Annually As part of their routine work Annually Medicines Management Committee Medicines Management Committee Medicines Management Committee Medicines Management Committee Medicines Management Committee Medicines Management Committee Medicines Management Committee Medicines Management Committee Reports and minutes of meetings Reports and minutes of meetings Reports and minutes of meetings Reports and minutes of meetings Version 2.0. March

17 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 Risk Clozapine If antibiotics are required seek advice Phenothiazines + Clarithromycin / Erythromycin + Ciprofloxacin Many antibiotics co-administered with clozapine may increase the risk of neutropenia 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) Carbamazepine +antibiotics Combination Risk QT prolongation potential makes combination a contra-indication Carbamazepine + Doxycycline Doxycycline metabolism is accelerated by carbamazepine reducing efficiency of doxycycline. Consider increasing dosage of doxycycline or use oxytetracycline + Clarithromycin + Erythromycin 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 + Metronidazole 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 Version 2.0. March

18 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

19 Appendix 2 Section 1: Restricted antibiotics Specific Prescribing Information 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 Drug Dose Duration Hospital acquired pneumonia Exacerbation of COPD Avoid beta-lactam antibiotics Section 3: ENT Infections 1st Choice: Doxycycline 200mg stat, then 100mg once daily 5 days 2nd Choice: Co-trimoxazole 960mg BD 5 days Mostly viral 1st Choice: Doxycycline 200mg stat, then 5 days 100mg once daily 2nd Choice: Amoxicillin 500mg TDS 5-7 days 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 500mg QDS 7 days 2nd Choice:(if penicillin allergic) Clarithromycin XL 500mg OD 7 days 1st Choice: Co-amoxiclav 625mg TDS 7 days 2nd Choice: (if penicillin 200mg stat then 7 days allergic) Doxycycline 100mg daily Version 2.0. March

20 Section 4: Gastrointestinal Infections Illness Comments Drug Dose Duration Gastroenteritis Antibiotics NOT usually If Clostridium difficile indicated. Oral rehydration is is suspected, follow treatment of choice. Any the clostridium patient with diarrhoea must be isolated in side room. difficile treatment pathway Giardiasis Metronidazole 2gm daily 400mg TDS 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 UTI in catheterised patients Complex UTI or pyelonephritis In pregnant women, course length is 7 days Mostly viral. Most need analgesia only Discuss with microbiology 1st Choice: Nitrofurantoin 2nd Choice: Trimethoprim Section 6: Antimicrobials used for ocular infections mg QDS 200mg BD 3 days 3 days Illness Comments Drug Dose Duration Bacterial 1st Choice: Chloramphenicol 5 days conjunctivitis In pregnant women course length is 7 days 2nd Choice: Fusidic acid or Azithromycin 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 3 days 5 days Fusidic acid eye drops 5-7 days Azithromycin eye drops 3 days Version 2.0. March

21 Section 7: Human & Animal Bites Surgical toilet is most important but antibiotic prophylaxis is recommended especially if >50years, puncture or hand wound. Illness Comments Drug Dose Duration Bites 1st Choice: Co-amoxiclav 625mg TDS 7 days 2nd Choice:(penicillin allergic): Clindamycin Section 8: Cellulitis & Wound Infections 450 mg four times daily by mouth 7 days 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 Drug Dose Duration Cellulitis 1st Choice: 500 mg -1g four 7-14 days Flucloxacillin times daily by mouth If MRSA-positive Doxycycline 2nd Choice: (penicillin allergic): Clindamycin 200 mg stat then 100 mg once daily by mouth 450 mg four times daily by mouth 7-14 days 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. Section 9: Diabetic Foot Infections 1st Choice: Flucloxacillin 2nd Choice: (penicillin allergic): Clindamycin 2nd Choice (MRSA): Vancomycin 500mg qds IV or po (depending on severity) Clindamycin mg qds po or IV 1g bd IV 5-7 days 5-7 days 5-7 days 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 2nd Choice: (Penicillin allergic) Clindamycin 500 mg -1g QDS 200 mg stat then 100 mg once daily Mild infection: 450 mg QDS Moderate infection: 600mg QDS 7 days 7 days Version 2.0. March

22 Infected ulcer non limb threatening Section 10: Herpes Zoster (Shingles) & Herpes Simplex (Cold sores) Antibiotic Prescribing Policy 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 Aciclovir 800mg 5x daily 7 days Cold sores Definition: Size <30mm 2, skin only or skin and subcutaneous tissue, no or minimal cellulitis, no evidence of severe vascular compromise, (SAD score 3-7). 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. Section 11: Infestations 1st Choice: Co-amoxiclav 2nd Choice: (penicillin allergic): Clindamycin with ciprofloxacin 2nd Choice (MRSA): Vancomycin Aciclovir 5% cream 625mg TDS mg qds +500mg BD 1g bd IV 5x daily 5-7 days 5-7 days 5-7 days 5 days 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 Scabies 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% Permethrin 5% cream 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. 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 See dose For the latest sensitivity and dosing information, go to: MicroGuide Viewer Version 2.0. March

23 Policy Details Title of Policy Unique Identifier for this policy State if policy is New or Revised Antibiotic Prescribing Policy BCPFT-MM-POL-05 Revised Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * N/A Medicines Management Medical Director Deputy Chief Pharmacist (in collaboration with the Infection Prevention and Control Lead) Medicines Management Committee February 2016 Month/year policy approved March 2016 Month/year policy ratified and issued March 2016 Next review date March 2019 Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Key Words for this policy Yes Yes Yes B can be disclosed to patients and the public 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 2.0 Mar 2016 Details of Change 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