1. Antibiotic Induction
February
2015

2. 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

3. What is wrong with this prescription?

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

5. Indications
ALL antibiotic prescriptions MUST have a documented indication
Even if you do not know the indication
?CAP or ?LRTI

6. 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

7. Allergy Box
ALL antibiotic prescriptions MUST have the allergy box signed
The allergy status of the patient MUST be checked before antibiotics are prescribed

8. Start Smart and Then Focus

9. 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.

10. 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.

11. 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.

12. 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
Send forms back to Emma in Pharmacy

13. 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)

14. 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)

15. Assessing the Allergy
Taking 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?

16. Antibiotic Microsite

17. Antibiotic Smartphone App
Download from the app store
‘Rx guidelines’
Download Hinchingbrooke guidelines to phone
Prescribing information
Dosing information
Contact information
Encyclopaedia for Antimicrobials

18. Antibiotic Guidelines

19. Formulary and BNF

20. 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

21. High risk of C.diff Avoiding the 4Cs Cephalosporins Clindamycin
Co-amoxiclav
Ciprofloxacin

22. 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

23. Any Questions?
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