Antibiotic Induction

February 2015

Contents

• Quiz• How to prescribe antibiotics• Start Smart then Focus• Monthly audits and data collection• Allergies• Resources• Choosing the right antibiotic• Clostridium difficile Infection• Questions

What is wrong with this prescription?

Answers

• Allergy Box not signed• No indication• No duration• Illegible handwriting• Co-amoxiclav• Capitals• Bleep No.

Indications

• ALL antibiotic prescriptions MUST have a documented indication

• Even if you do not know the indication• ?CAP or ?LRTI

Stop/Review Dates

• ALL antibiotic prescriptions MUST have a documented stop or review date

• If the duration is not known – add a review date and review daily

Allergy Box

• ALL antibiotic prescriptions MUST have the allergy box signed

• The allergy status of the patient MUST be checked before antibiotics are prescribed

Start Smart and Then Focus

Start Smart

• Do not start antibiotics in the absence of clinical evidence of bacterial infection.

• If there is evidence of a bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment.

• Document on the drug chart AND in the medical notes: – Clinical indication.– Duration or review date.– Route.– Dose.

• Obtain cultures first.• Prescribe single doses of antibiotics for surgical prophylaxis;

where antibiotics have been shown to be effective.

Then Focus

• Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action – the ‘Antimicrobial Prescribing Decision’.

• The FIVE Antimicrobial Prescribing Decisions are:– Stop.– Switch from IV to oral. – Change to another antibiotic.– Continue – Review daily.– Start OPAT.

• It is essential that the review and decision is clearly documented in the medical notes.

Antibiotic Stewardship

• Antibiotic prescribing data is monitored by CCG and the Trust board

• Monthly antibiotic prescribing audits are carried out on ALL wards

• Junior Drs collect the data if ward not achieving 100% over seen by Dr Hubbard (Medical Director)

• This information is fed back to each clinical unit leads, consultants, matrons, MSG, ASG, IPCC and the Trust Board.

Monthly Data Collection

• One day on the 3rd week every month• If ward not achieving 100% = Drs• Ward achieving 100% = Emma collects the

data• Prescribing will be under surveillance by ward

pharmacists• Audit forms will be sent via email• Send forms back to Emma in Pharmacy

Allergies

• The nature of the allergy should be questioned and documented in the medical notes and on the drug chart

• Patients with a type 1 allergic reaction (anaphylaxis, urticarial rash or rash immediately after antibiotic) to penicillin should not receive Beta-lactam antibiotics (Penicillins, Cephalosporins, Carbapenems)

Penicillin Allergy

• Up to 17% of the population report a penicillin allergy

• Only 10% of these patients actually have a genuine reaction

• Most adverse drug reactions are side effects of the antibiotic (diarrhoea, nausea, vomiting and rash when amoxicillin is given for viral infections)

Assessing the AllergyTaking a History of Penicillin Allergy: Questions to Ask• What antibiotics has the patient reacted to in the past?• What antibiotics has the patient taken and tolerated since the allergy diagnosis (in

particular penicillins and cephalosporins)?• When did the reaction take place (estimated date)?• What was the nature of the reaction (e.g. diarrhoea, rash, swelling, breathing

difficulties etc.)?• If the reaction was a rash:

– Describe the type of rash (e.g. maculo-papular, pustular, bullous, urticarial etc.)

– Could the rash be due to the underlying condition (i.e. viral rash or meningococcal septicaemia)?

– Could the rash be related to an interaction with other medication?– How long after commencing the antibiotic did the rash appear?

• Why was the patient taking the antibiotic?• Did the reaction result in hospitalisation or movement to ICU/HDU?• Did the reaction resolve on cessation of the antibiotic?

Antibiotic Microsite

Antibiotic Smartphone App

• Download from the app store• ‘Rx guidelines’• Download Hinchingbrooke guidelines to

phone• Prescribing information• Dosing information• Contact information• Encyclopaedia for Antimicrobials

Antibiotic Guidelines

Formulary and BNF

Choosing the Right Antibiotic

• Choose empirical treatment based on the type of infection and likely organism

• Choose an antibiotic and dose based on patient factors (weight, PMH, allergies, interactions, pregnancy, breast feeding, past sensitivities and micro results etc.)

• Route depends on bioavailability of drug, NBM, IV access, severity of infection

• Duration based on infection type and if patient is responding to treatment

Avoiding the 4Cs

High risk of C.diff

Cephalosporins

Clindamycin

Co-amoxiclav

Ciprofloxacin

Clostridium difficile Infection

• C.diff trajectory (13 out of 7) - £10K fines/pt>7• Spore forming gram +ve anaerobic bacillus• Toxin producing • Patients must ingest spores to become +ve• Hand hygiene (especially before pts eat)• Abx can disrupt bowel flora allowing colonisation

with C.diff.• C.diff growth is normally inhibited by gut flora• Risk factors: Age, Antibiotics, Duration, Poor IC

Any Questions?

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