ANTIBIOTIC POLICY V10 - East Cheshire NHS Trust

1 1 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 ADULT ANTIBIOTIC POLICY Version Date approved Feb 2018 June 2017 V10 June 2016 Date to be reviewed June 2019 Reviewed by Antimicrobial Stewardship Group Ratified by Medicines Management Group 2 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 POLICY Title: East Cheshire NHS Trust ANTIBIOTIC POLICY Executive Summary: This POLICY provides guidance to all staff in East Cheshire NHS Trust regarding prudent prescribing of antibiotics All staff should refer to this Trust ANTIBIOTIC POLICY and prescribe according to these recommendations and restrictions Supersedes: V Description of Amendment(s): Removal of GUM guidelines, which are now a separate POLICY found under the Trust s intranet. Addition of adult to the title. Font size amended to 11, as per Trust procedure.

2 This POLICY will impact on: All health professionals involved in the prescribing and administering of antibiotics Financial Implications: Reduce inappropriate ANTIBIOTIC prescribing and risk of healthcare associated infections and MRSA POLICY Area: ANTIBIOTIC POLICY Document Reference: Version Number: Effective Date: Feb 2018 Issued By: Chair of Medicines Management Group Review Date: June 2019 Authors: Consultant Microbiologist & ANTIBIOTIC Pharmacists Impact Assessment Date: Twice a year APPROVAL RECORD Version 10 Committees / Group Date Consultation: POLICY V10 and list of amendments from previous version circulated to all consultants and SpRs By email May 2016 Antimicrobial Stewardship Group Members by agenda for 18 th May 16 Specialist Advice (when required) Dr Rajendran Approved by Committee: Antimicrobial Stewardship Group Medicines Management Group 18th May 2016 14th June 2016 Version Consultation, replacement of piperacillin/tazobactam (due to supply issues): POLICY and list of amendments from previous version circulated to all consultants, SASs and SpRs By email May 2017 Version Approved by committee: Antimicrobial Stewardship Group Medicines Management Group Members May 2017 Aug 2017 Ratified by Committee: (due to lack of stock implemented May 2017 as agreed by Kashif Haque, deputy chair MMG) Medicines Management Group 13 June 2017 Version At the request of ASG & MMG following new & separate GUM guidelines approval (Oct 2017) Feb 2018 ECT0025333 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 EAST Cheshire NHS Trust ANTIBIOTIC POLICY .

3 1 IMPLEMENTATION OF THE POLICY .. 7 ANTIMICROBIAL STEWARDSHIP PRINCIPLES .. 8 Role of the Prescriber: .. 10 Role of the Nurse: .. 13 Role of the Pharmacist: .. 13 ANTIBIOTIC ALLERGY .. 14 Penicillin Hypersensitivity .. 14 GUIDANCE FOR INTRAVENOUS TO ORAL SWITCH .. 15 FORMULARY .. 17 PROTECTED ANTIBIOTICS .. 18 GENTAMICIN .. 20 Extended Interval Gentamicin Protocol .. 21 1 Prescribing Gentamicin .. 21 2 Gentamicin Monitoring .. 24 3 Use of Gentamicin in Severe Sepsis with AKI .. 25 4 Toxicity .. 25 Traditional gentamicin regimen .. 26 VANCOMYCIN .. 27 Prescribing Vancomycin .. 28 Administration .. 30 Monitoring and Dose Adjustment .. 30 TEICOPLANIN .. 33 TREATMENT GUIDELINES .. 34 Gastro-Intestinal System .. 34 Gastro-enteritis .. 34 Clostridium difficile Infection (CDI) .. 35 Helicobacter Pylori Eradication .. 38 Variceal GI bleed .. 39 Diverticulitis .. 39 Appendicitis .. 40 Severe Pancreatitis.

4 41 Cholecystitis and Cholangitis .. 42 4 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 Pyogenic Liver Abscess .. 43 Spontaneous Bacterial Peritonitis .. 44 Cardio-Vascular System .. 45 Endocarditis .. 45 Respiratory Tract .. 46 Bronchitis .. 46 Community acquired pneumonia (CAP) .. 47 Non Severe CAP (CURB-65 score 0-2): .. 48 Severe CAP (CURB-65 Score of 3 or greater): .. 49 Aspiration Pneumonia .. 49 Hospital Acquired Pneumonia (HAP) .. 50 Ventilator Associated Pneumonia (VAP) .. 52 Pneumocystis pneumonia (PCP) .. 53 Lung abscess, Empyema .. 54 Pulmonary tuberculosis .. 54 Central Nervous System .. 55 Meningitis .. 55 Brain Abscess .. 56 Severe sepsis .. 57 Sepsis 6 Care Bundle .. 58 Neutropenic sepsis (<1 neutrophil x 109/L) .. 59 MRSA (Methicillin resistant Staphylococcus aureus) .. 60 Genito-Urinary System .. 62 Urinary Tract Infections (UTI).

5 62 Pyelonephritis (Upper UTI) or Severe Lower UTI .. 63 ANTIBIOTIC Prophylaxis for Catheter Change .. 64 Acute Prostatitis .. 65 Musculo-Skeletal System .. 66 Septic Arthritis .. 66 Acute osteomyelitis .. 67 Skin .. 68 Cellulitis .. 68 Severe cellulitis .. 68 Diabetic Foot Ulcer .. 69 Human OR Animal bites .. 70 Breast Infections .. 71 Mastitis or Breast wound infections .. 71 5 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 Breast Abscess .. 71 SURGICAL PROPHYLAXIS .. 72 Introduction .. 72 General Principles .. 74 Indication for additional doses .. 74 Orthopaedics .. 75 General Surgery .. 76 Gastrointestinal Surgery .. 76 PEG insertion .. 76 Hepatobiliary Surgery .. 77 Abdominal Surgery .. 78 Lower Gastrointestinal .. 79 GI Procedures NOT routinely requiring ANTIBIOTIC prophylaxis: .. 79 Breast Surgery .. 80 Urological Surgery .. 81 Urology procedure.

6 81 Transrectal prostate biopsy .. 81 Other procedures .. 81 Cardiac Pacemaker insertion .. 81 OBSTETRIC & GYNAECOLOGY SECTION .. 82 OBSTETRIC INFECTIONS .. 82 Asymptomatic bacteriuria / UTI in pregnancy .. 82 Pyelonephritis / complicated UTI in pregnancy .. 82 Maternal Sepsis / Genital sepsis in 83 Pre-term Pre-labour Prolonged Rupture of Membranes (PPROM) (prophylaxis only) .. 84 Pre-term Pre-labour Prolonged Rupture of Membranes (for patient with signs of infection) .. 84 OBSTETRIC INFECTIONS PERI- DELIVERY .. 85 Term Prolonged Rupture of Membranes .. 85 Group B streptococcus in labour .. 85 OBSTETRIC SURGERY .. 86 Assisted / Instrumental delivery/manual delivery .. 86 Caesarean Section .. 86 Perineal tear .. 87 Inverted Uterus .. 87 Manual removal of Retained Placenta .. 88 OBSTETRIC INFECTIONS POST-PARTUM .. 89 Post-partum sepsis (Endometritis) .. 89 6 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 Post-partum haemorrhage.

7 90 Infected caesarean wound OR Episiotomy .. 90 Removal of retained Products of Conception ( Surgical or Manual ) .. 91 GYNAECOLOGICAL SURGERY .. 92 GYNAECOLOGICAL PROCEDURES .. 92 GYNAECOLOGICAL INFECTIONS .. 93 Genital sepsis .. 93 Pelvic Inflammatory Disease .. 94 MEDICAL PROPHYLAXIS .. 95 Meningococcal infection .. 95 Pneumococcal infection .. 95 Prophylaxis against infective endocarditis .. 96 APPENDIX 1: GUM GUIDELINES .. 97 APPENDIX 2 Amendments .. 98 2a: Description of amendments V10 .. 98 2b Description of amendments .. 99 2c Description of amendments .. 100 Equality Analysis (Impact assessment) .. 101 7 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 IMPLEMENTATION OF THE POLICY All staff should refer to this Trust ANTIBIOTIC POLICY and prescribe according to these recommendations and restrictions. This POLICY will be monitored by the consultant microbiologist and the pharmacy team.

8 It will be reviewed every 2 years by the Antimicrobial Stewardship Group and the Medicines Management Group and a report submitted through the Standards, Quality and Safety (SQS) Committee to the Trust Board. Directorate Clinical Governance Groups should ensure, in co-operation with the ANTIBIOTIC pharmacists and the consultant microbiologist, that audits of ANTIBIOTIC use in their directorate are conducted and discussed regularly. Compliance of the POLICY will be audited as part of ANTIBIOTIC Ward Rounds and by an annual point prevalence audit. 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 and other individual patient factors such as co-morbidities, previously used antibiotics, and drug interactions may require specific consideration. 8 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 ANTIMICROBIAL STEWARDSHIP PRINCIPLES An Antimicrobial Stewardship Programme aims to improve the safety and quality of patient care and to contribute significantly to reductions in the emergence and spread of Antimicrobial Resistance (AMR) and is a key component in the reduction of healthcare associated infections.

9 A Start Smart Then Focus approach is recommended for all ANTIBIOTIC prescriptions. Antibiotics do not merely treat infections but affect the microbial environment within and beyond the patient. They must be used appropriately and with care. Do not start antimicrobial therapy unless there is clear evidence of infection. Antimicrobial resistance is a threat to the effective treatment of infections. To lower the risk of developing ANTIBIOTIC resistance, antibiotics which are likely to be bactericidal to the pathogen at the site of infection should be chosen. They should be used in adequate doses and for an adequate duration. Inappropriate use of broad spectrum antibiotics must be avoided because it promotes the overgrowth of Clostridium difficile. Always choose the narrowest spectrum ANTIBIOTIC . Antibiotics must be prescribed for the shortest duration necessary. All ANTIBIOTIC prescriptions must therefore be for a defined duration.

10 For all infections document in the medical notes the specific diagnosis and the indicators for making the diagnosis ( WCC, temp >38 C, evidence of inflammation, fluid collection, CRP etc). Review all sensitivity results daily and always change to the sensitive ANTIBIOTIC with the narrowest spectrum. ANTIBIOTIC doses should not be missed unless unavoidable. Missed doses are everyone s responsibility and should be investigated and the treatment route, formulation or dose reviewed as necessary to ensure administration and compliance. 9 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 In accordance with surviving sepsis patient safety alert According to weight/age in children refer to local formulary or BNFc # Use appropriate route in line with severity/patient factors *Outpatient Parenteral ANTIBIOTIC Therapy = Home IV Therapy (HITS at ECT) 10 East Cheshire NHS Trust Adult ANTIBIOTIC POLICY Feb 2018 Review June 2019 Role of the Prescriber: Start Smart Prescribe the first dose as a STAT dose on the front of the prescription chart stating the time to be given so that treatment is started promptly.