1. Training on use of antimicrobials in clinical practice
This training pack comprises 3 general sections plus a hospital practice section and a primary care section.
Training can be delivered during one lecture session or during several small group teaching sessions which will allow discussion of the content. Each section is supported by suggestions for CPD evidence that the practitioner may document to demonstrate an understanding of the key issues.
*Please note: SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of the training pack content once it has been amended or otherwise revised in any way by a territorial board/third party to reflect local policy and information.
Training on use of antimicrobials
in clinical practice 1

2. Contents
Section One - Policy context: National and local strategic approaches
Section Two - Diagnosis of infection and clinical decision making
Section Three - Prudent antimicrobial prescribing
Section Four - Antimicrobial use in hospital
Section Five - Antimicrobial use in primary care
Section Six - Nurses' role in antimicrobial management
This presentation is divided into sections each designed for a minute teaching session. For Foundation Year doctors’ initial induction training, a total of up to 10 slides should be chosen from sections 2, 3, and 4 to cover the key points, as agreed locally.
The notes in bold print give suggestions for discussion.
You can copy or reproduce the information in this training pack for use within NHSScotland and for educational purposes. You must not make a profit using information in this training pack. Commercial organisations must get our written permission before reproducing this training pack.
Training on use of antimicrobials
in clinical practice 2

3. Section One Policy context: National and local strategic approaches 3
In this section we will look at current approaches within Scotland to tackle antimicrobial resistance and highlight key points about local practice for practitioners using antibiotics.
Learning Outcomes
The practitioner will be able to:
Source current national strategic aims and guidance on antimicrobial prescribing
Describe the key priority areas of national strategic planning
Identify how national antimicrobial prescribing strategy is translated into local policy
Use national and local guidance/directives to influence personal prescribing practice
Section One
Policy context: National and local strategic approaches 3

4. 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 published in September 2013 and ScotMARAP refreshed in line with new UK objectives
ScotMARAP was produced by the HAI Taskforce of Scottish Government as a follow up to the document which advised on hospital practice – Antimicrobial Prescribing policy and Practice in Scotland, 2006.
ScotMARAP makes specific recommendations about NHS Board structures to support prudent prescribing, local antibiotic policies, data on prescribing and surveillance and education of staff across primary and secondary care. This document is the key driver for changes that you may see happening locally around the use of antibiotics. All clinical staff are responsible for ensuring they use antibiotics correctly to reduce antimicrobial resistance and preserve the usefulness of antibiotics in treating serious infections.
Ask practitioners what they understand by the term ‘antimicrobial resistance’ and why they think it is a problem which needs addressed.
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

5. 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
The Scottish Medicines Consortium is responsible for assessing the clinical effectiveness and cost-effectiveness all new medicines and new indications for existing medicines to decide if they should be used within NHS Scotland. SAPG is hosted by SMC and follows the same collaborative structure i.e. decisions that will influence practice at NHS Board level are made by NHS Board representatives. SAPG is responsible for producing national guidance and advice for NHS Boards to help implement the recommendations of ScotMARAP.
May be useful to highlight who the representative on SAPG is from your own Board.
Can also explain what national stakeholders do:
Health Protection Scotland coordinates national health protection including monitoring of infectious diseases and surveillance of bacterial resistance.
Information Services Division collects and analyses health service information including data on antibiotic use and prevalence of infections in the Scottish population.
NHS Education Scotland helps to provide better patient care by providing educational solutions for workforce development of all healthcare professionals.
Healthcare Improvement Scotland have a lead role in supporting NHS boards and their staff to improve the quality of healthcare in Scotland.
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

6. 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
Within Scotland the HAI Taskforce , set up by Scottish Government, is responsible for delivering the HAI Delivery Plan which addresses all issues relating to HAI - healthcare facilities, clinical practice, education of staff and public.
The HEI was set up as an independent body to inspect hospitals against a series of national standards to give public assurance that hospitals are clean, staff are properly trained in infection control, Board structures for Infection Control and Antimicrobial Management are working effectively and data management systems are used effectively to detect and prevent spread of HAI.
Discuss what practitioners understand by the term HAI. Get practitioners to discuss any personal experiences of HAI.
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

7. 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
AMT is a sub-group of the Area Drug & Therapeutics Committee (ADTC).
At local level ADTC makes decisions on all aspects of ‘use of medicines’. This includes evaluating advice from SMC to approve new drugs for use locally, reviewing and maintaining the local Formulary and prescribing guidelines, approving any new guidelines on use of medicines. ADTC is multidisciplinary , covers secondary and primary care and includes representatives from all key clinical specialties.
AMT is responsible for all aspects of antimicrobial use at local level.
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

8. Section One Policy context: National and local strategic approaches 8
This slide shows how the AMT should interact with various staff groups and committees.
Highlight links close to prescriber – communication with clinical pharmacists and Microbiology/ID essential for optimum use of antibiotics.
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

9. NHS your name AMT Lead doctor – Consultant Microbiologist –
Antimicrobial Pharmacist –
Prevention and Control of Infection representative –
Primary Care representative -
Highlight who these individuals are and their roles within the Board.
Although the AMT is made up of mainly hospital representatives its remit also covers use of antibiotics in primary care. The primary care representative on the AMT is usually a GP or a Prescribing Adviser and they should link with other Primary Care committees and groups to ensure that any initiatives are cascaded throughout all Community Health Partnerships within the Board.
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 9

10. 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).
Antimicrobial policies must contain key information, defined by SAPG, but format may vary between Boards.
Policies are reviewed annually and updated to reflect any new evidence and changes in local resistance patterns.
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 10

11. NHS your name Antimicrobial Policies
Details of access – booklets, intranet, posters
Hospital policy – key features of presentation of information
Show formats available in your Board as screenshots or bring along copies of booklets and posters.
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 11

12. Section Two Diagnosis of infection and clinical decision making 12
This section will look at how an infection should be diagnosed, treated and monitored and how to use Microbiology services effectively.
Learning Outcomes
The practitioner will be able to:
Outline the criteria for establishing that a patient has an infection
Relate patients’ history, signs and symptoms to decisions made to prescribe (or not to prescribe) antibiotics
Discuss the purpose and importance of microbiology samples in clinical decisions made to prescribe antibiotics
Section Two
Diagnosis of infection and clinical decision making 12

13. 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
Antibiotics are powerful medicines which can save lives but we must ensure we use them prudently.
Antibiotics should only be used where there is a clear indication and a definitive diagnosis of infection. SIRS criteria are key to diagnosing systemic infections.
Documentation of symptoms and of SIRS criteria in medical and nursing notes are important for clinical governance. While WCC takes time to obtain via lab, temperature, heart rate and respiratory rate are easily measured and should be part of routine clinical practice in both diagnosing serious infection and monitoring response to treatment.
Practitioners should be alert to the symptoms of severe sepsis which require the patient to be admitted to Intensive Care urgently.
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

14. 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
Microbiology samples can provide valuable information to support diagnosis and treatment of infection but microbiology services cost money and take time. It is therefore essential that microbiology services are used effectively to keep costs and time delays for essential samples to a minimum.
When sending samples to microbiology ensure that correct sample tube is used and that laboratory request form includes as much detail as possible: patient details, time and type of sample, reason for sending sample e.g. suspected site of infection, colonisation, infection screen.
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

15. 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?
Interpretation of microbiology results requires knowledge of the patient and their current clinical condition. Past medical history may also be important if the patient has previously had an HAI or has a recurrent infection. In primary care lab results may take longer to come back, if not available electronically, therefore samples should only be used in selected patients rather than to confirm that empirical treatment is suitable.
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 15

16. 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
Many factors may affect which antibiotic is used.
Discuss these with examples e.g. which organisms found in which part of body, antibiotics unsuitable for specific patient groups, narrow versus broad spectrum antibiotics.
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 16

17. Section Three Prudent antimicrobial prescribing 17
This section will consider how we can ensure that we use antibiotics wisely – only use when needed, select correct antibiotic and ensure appropriate duration of treatment.
Learning Outcomes
The practitioner will be able to:
Discuss the scale of antibiotic use within hospitals and the community in the UK
Outline the problems which may result from inappropriate use of antimicrobials
List the essential information required to correctly prescribe an antibiotic
Describe how a specific antibiotic is chosen for treatment of an infection
Explain the importance of the identification and recording of an appropriate indication and duration of antibiotic treatment
Identify commonly occurring errors made when prescribing antibiotics
Discuss the importance of patient concordance with antibiotic treatment
Section Three
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18. 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
Many studies in various countries have shown that 25-35% of patients in acute hospitals receive antibiotics during their in-patient stay. Many prescriptions for antibiotics are inappropriate – no clear diagnosis, wrong choice of antibiotic, extended course, treating lab result rather than clinical symptoms.
Surgical prophylaxis is the use of antibiotics in surgery to prevent wound infections. Evidence supports the use of a single dose administered pre-operatively but in many cases further doses are given and this may extend to several days of treatment. SIGN 104 provides guidance on which procedures require surgical prophylaxis and local antibiotic policies provide guidance on which agents to use.
Antibiotics can be expensive, especially IV formulations (up to £100 per day).
Adverse effects of inappropriate use result in increased cost due to increased length of stay.
The extent of use of antibiotics in primary care is less well documented but practice does vary significantly between GP Practices. About 80% of antibiotics use in human is in primary care therefore this has major impact on development of resistance and also on risk of C. difficile infection (CDI).
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
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19. 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
Documentation of decisions about using antibiotics are a critical clinical governance issue e.g. if a patient didn’t respond to treatment or developed C. difficile infection (CDI).
If unsure always seek advice from senior colleagues, microbiologist or clinical pharmacist.
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
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20. 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.
As mentioned previously documentation is a key requirement for clinical governance.
In Scotland, recent outbreaks of C. difficile infection (CDI) have resulted in patient records being scrutinised for evidence of how patient care has been delivered. Remember in this type of scenario if it isn’t written down it didn’t happen. In ward situation ask microbiologist or pharmacist to document their advice in the medical notes. If phoning a microbiologist or pharmacist for advice remember to write down in the medical/nursing notes what they advised you to do.
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
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21. 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
Medicine kardexes are also important sources of information for clinical governance. In the ward situation, clinical pharmacists will check that prescriptions for antibiotics comply with these requirements and will highlight any discrepancies to the prescriber. However, if nursing staff are aware that the prescription does not include any of these details they should also query this with the prescriber.
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
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22. 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
Duration of treatment is an important factor as extended duration can put patients at risk of cumulative adverse effects due to the antibiotic and can also increase the risk of HAI.
For most infections it is possible to decide the duration of treatment when the diagnosis is confirmed. In some cases of severe infection, it may be preferable to document a review date and decide on a stop date then.
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
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23. 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.
Medication errors are common and often go unreported. These are some common errors associated with antibiotic treatment.
Many patients say they are allergic to penicillin but many have experienced an adverse reaction that is not hypersensitivity.
Discuss possible reactions and definition of hypersensitivity. Discuss strategies for choosing antibiotics in patients who have true penicillin allergy and those with previous non-hypersensitivity reactions.
Empirical treatment is often with a broad spectrum antibiotic but this can often be changed to a narrow spectrum agent once microbiology results are confirmed.
Discuss what de-escalation is.
Patients with infections often require to leave the ward for procedures such as X-rays and may miss a dose of their antibiotic. This can have serious consequences, particularly for patients on antibiotics which are only administered once or twice daily. A missed dose can result in the blood level of the antibiotic falling below the concentration that will kill the pathogen which may result in treatment failure, delayed response to treatment and can also allow the organism to select for 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
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24. 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
Inappropriate use of antibiotics can have consequences for the individual patient and also the wider population.
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
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25. 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
Patients also have an important role to play in prudent use of antibiotics. If an antibiotic is prescribed patients must be advised of the need to complete the course- inadequate treatment can result in development of resistance.
Knowledge about when to take antibiotics in relation to food and information about adverse reactions and drug interactions can aid compliance.
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
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26. 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
There are many reference sources for information about antibiotics. The BNF is a good starting point for background information. For local information refer to your NHS Board antibiotic policy and be aware of local staff who can answer any queries.
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
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27. Section Four Antimicrobial use in hospital 27
In this section we will look at use of IV antibiotics, details of how to use gentamicin and vancomycin safely, and healthcare associated infections.
Learning Outcomes
The practitioner will be able to:
Provide a description of an IVOST policy (IV to oral switch therapy)
Describe the criteria for use of the intravenous route for administration of antibiotics
Outline when and how gentamicin should be used, including details of dosage, monitoring and potential toxicities
Outline when and how vancomycin should be used, including details of dosage, monitoring and potential toxicities
Discuss the rational and specific guidance for the use of antibiotics as prophylaxis in certain surgical procedures
Outline when and how antibiotics should be used in MRSA infection
Describe how the use of antibiotics may put patients at risk of C. difficile infection (CDI)
Identify the local availability of specialist advice on the use of antibiotics
Section Four
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28. 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
Intravenous antibiotics have the advantage of giving high blood levels quickly. In severe infection this can be life-saving.
Discuss disadvantages of IV antibiotics – risks of line problems, allergic reactions, complexity of preparation and administration.
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
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29. 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?
IV therapy carries more risk than oral and is also more expensive so patients should be switched onto oral therapy as soon as possible.
Extended IV therapy (> hours) is rarely indicated and carries risk of phlebitis, line infection or occlusion.
Some conditions may require longer term IV treatment e.g. endocarditis, meningitis, bone/joint 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 Four
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30. 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.
Gentamicin is the most frequently used of the aminoglycosides. It can only be given by the IV route and dosage is tailored to the individual patient’s requirements. Gentamicin use has increased recently due to changes in antibiotic policies which have restricted 4C agents which provide gram negative cover due to concerns about C. difficile infection (CDI).
More information about use of gentamicin is available via the Antibiotic Prescribing for Today’s Practitioners resources or the Gentamicin online module – see NES website, HAI online short course page.
Discuss the use of on-line calculators and/or Cockcroft-Gault equation.
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
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31. 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
Monitoring of levels is essential to ensure that peak gentamicin levels are high enough to be effective and that trough levels are low enough to prevent toxicity.
May want to present some examples of case studies that illustrate how to calculate dosage and adjust dosage.
Further training relating to Gentamicin is available on learnPro accessed via the HAI pages of the NHS Education for Scotland website
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
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32. 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
Vancomycin is a glycopeptide antibiotic used for treatment of gram positive infections, in particular MRSA.
Discuss use of online dose calculator and/or Cockcroft-Gault equation.
May want to present a case study of vancomycin dose calculation.
Vancomycin is complex to prepare and administer. Further details on vancomycin use are available within the Antimicrobial Prescribing for Today’s Practitioners resource or the vancomycin module. Resources are available on learnPro accessed via the HAI pages of the NHS Education for Scotland website.
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
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33. Vancomycin monitoring
Check level immediately before 3rd or 4th dose
Target level is mg/L (15-20mg/L for severe infections)
Seek advice from pharmacy or microbiology on dose adjustment.
Vancomycin monitoring is essential to ensure effective treatment and to minimise toxicity.
Further training relating to Vancomycin is available on learnPro accessed via the HAI pages of the NHS Education for Scotland website
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
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34. 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
Surgical prophylaxis is the use of antibiotics in surgery to prevent wound infections. Evidence supports the use of a single dose administered pre-operatively but in many cases further doses are given and this may extend to several days of treatment. SIGN 104 provides guidance on which procedures require surgical prophylaxis and local antibiotic policies provide guidance on which agents to 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 Four
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35. 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
MRSA is a resistant strain of Staph. aureus. Patients who are MRSA positive require to be isolated and standard infection control precautions maintained.
Highlight the difference between MRSA colonisation and infection.
Discuss local MRSA screening programmes and eradication regimens.
Further training is available via online training from the HAI pages of the NHS Education for Scotland website
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
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36. 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
MRSA is usually a healthcare associated infection in the UK. Patients with wounds and those who are immunocompromised are at particular risk.
In the USA community acquired MRSA is common.
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
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37. 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
C. Difficile Infection (CDI) is usually a healthcare associated infection which is monitored locally and rates are reported nationally.
Further training is available via online training from the HAI pages of the NHS Education for Scotland website
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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38. 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
Some patients are at increased risk of C. difficile Infection (CDI). Often antibiotic use in primary care can present a risk for elderly patients, those on chemotherapy and those with immunosuppression who are subsequently admitted to hospital.
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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39. 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)
C. difficile Infection (CDI) requires prompt treatment with an antibiotic. Choice of antibiotic is based on severity of symptoms.
Discuss policy for severity scoring.
When a patient is diagnosed with C. difficile Infection (CDI) medication should be reviewed – antibiotics (other than those to treat CDI) should where possible be stopped, proton pump inhibitors should be stopped if possible and any medicines for diarrhoea or constipation stopped.
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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40. Useful Websites Scottish Antimicrobial Prescribing Group (SAPG):
NHS Education for Scotland, HAI Programme
Pause:
These websites can provide further information on the work of SAPG and on HAI.
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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Antimicrobial use in hospital 40 40

41. Section Five Antimicrobial use in primary care 41
In this section we will look at the management of common infections in primary care and highlight key points about local practice for practitioners using antibiotics.
Learning Outcomes
The practitioner will be able to:
explain the use of antibiotics in self-limiting conditions
describe the value of patient information leaflets and delayed prescribing
outline how primary care practice in use of antibiotics may influence healthcare associated infection and development of antimicrobial resistance
identify local antibiotic choices for common infections
explain the national prescribing indicators for antimicrobials and how these can be used to evaluate local practice
identify the local availability of specialist advice on the use of antibiotics.
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42. 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
Hospitals have been the focus for recent changes in the use of antibiotics in Scotland. However the majority of antibiotic use is within primary care. Respiratory infections represent a significant proportion of GP workload particularly during the winter months. Use of antibiotics for viral infections remains a significant problem and impacts on development of antimicrobial resistance at local level.
ScotMARAP makes specific recommendations about NHS Board structures to support prudent prescribing, local antibiotic policies, data on prescribing and surveillance and education of staff across primary and secondary care. This document is the key driver for changes that you may see happening locally around the use of antibiotics. All clinical staff are responsible for ensuring they use antibiotics correctly to reduce antimicrobial resistance and preserve the usefulness of antibiotics in treating serious infections.
Ask practitioners what they understand by the term ‘antimicrobial resistance’ and why they think it is a problem which needs addressed.
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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43. 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.
Evidence supports not prescribing antibiotics for URTI except in specific circumstances.
Discuss the quality indicator for reduction of total antibiotic use introduced in 2013 and the Scottish Reduction of Antimicrobial Prescribing (ScRAP) educational programme.
Children under 2 years with Bilateral Otitis Media
• Acute otitis media in children with otorrhoea
• Acute sore throat with 3 or more CENTOR criteria (tonsillar exudate, tender anterior cervical lymphadenopathy, lymphadenitis, fever and an absence of cough)
• Systemically very unwell
• Pre-existing co morbidity
• Those who are over 65 with at least two of the following, or over 80 and at least one of the following: Admission to hospital in past 12months; Diabetes; LVF; glucocorticoids.
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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44. 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
Studies have shown that patient satisfaction is not compromised by not getting an antibiotic. Patients want to be examined fully and given advice. Receiving antibiotics for viral infections medicalises their illness and increases repeat consultation rate. It is better to give patients advice on self-management of symptoms and the likely course of their illness. It is also useful to highlight the potential side-effects of antibiotics and development of resistant organisms.
Discuss the group’s experience of patient expectations and delayed prescriptions
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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45. 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
HAI is a major public health issue and current priority for NHS boards.
Although rarely encountered in primary care, use of antibiotics in the community has implications for subsequent development of HAI such as MRSA and C. difficile infection (CDI).
Local antibiotic policies reflect current best practice in restricting the use of antibiotics that are associated with a high risk of C. difficile infection (CDI). By following your local policy you can reduce the risk of your patients developing an HAI if they are admitted to hospital.
Explore the group’s personal/professional experience of HAI
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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46. 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
Antimicrobial resistance is a major public health issue and current priority throughout the world.
Resistance develops to most antibiotics in regular use.
Although encountered less frequently in primary care than in hospital practice, use of antibiotics in the community impacts on development of resistance at individual patient and population level.
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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47. 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 -
Local antibiotic policies provide advice on empirical treatment of common infections and are reviewed regularly.
Policy choices are based on clinical evidence and local resistance patterns.
Discuss the local choices and explore whether group currently uses these.
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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48. 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 non-policy 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
The national prescribing indicators were developed to standardise the monitoring of antibacterial use in primary care. This allows boards to be compared with each other and also for GP Practices within a board or CHP to be compared. The local Antimicrobial Management Team and Primary Care Prescribing Support staff work together to evaluate reports on theses indicators and identify priorities for further analysis and discussion with prescribers.
Discuss local data on a selection of the prescribing indicators.
PRISMS – is the web-based prescribing information system for NHSScotland
CHP – Community Health Partnership
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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49. 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
There are many reference sources for information about antibiotics. The BNF is a good starting point for background information. For local information refer to your NHS Board antibiotic policy and be aware of local staff who can answer any queries.
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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50. Useful resources on use of antibiotics in primary care
Health Protection Agency guidance on primary care management of infections
Scottish Antimicrobial Prescribing Group – Prudent antimicrobial use
National Prescribing Centre Information on URTIs
NHS Education for Scotland – ScRAP programme
These websites can provide further information on antibiotic use in primary 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.
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51. Section Six Nurses' role in antimicrobial management 51
This section details the contribution that nursing staff can make towards a multi-professional approach to antimicrobial management.
Learning Outcomes
The practitioner will be able to:
• Describe the importance of the nurse role
• Outline the nurse’s responsibility and accountability
• Describe how the nurse role can have an impact on antimicrobial management
• Identify potential benefits of this role
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52. 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
The 3 dimensions of the Scottish Government Healthcare Quality Strategy are safe, effective and person-centred care.
Appropriate use of antibiotics is essential to ensure patients with infections are treated safely and effectively.
Unnecessary use of antibiotics and failure to follow local policies can result in patient harm through inadequate treatment, adverse effects from antibiotics and development of antimicrobial resistance both at a patient and population level.
Antibiotic use is an important feature within many national programmes of work.
Like Healthcare Associated Infections, Antibiotic management is ’everyone’s business’ and all healthcare professional plus patients and the public have a role to play.
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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53. 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
Within the healthcare team nurses spend the most amount of time with patients and deliver much of their hands-on care.
They administer medicines and are well placed to evaluate a patient’s response to their medication.
In the case of antibiotics this involves monitoring routine observations which are affected by infection – temp, pulse rate, blood pressure, respiratory rate.
They are also well placed to assess clinical symptoms such as: are wounds improving, coughs settling, urinary symptoms clearing etc.
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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54. 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
Nurses’ role in antimicrobial management is supported by NMC professional accountability and responsibility standards and national programmes.
NMC Code principles
• Provide a high standard of practice and care at all times
• Keep your skills and knowledge up to date
• Keep clear legible and accurate records
• What Matters:
- Translating policy objectives and ambition into best practice at the frontline with the supporting evidence
- The quality of service we provide and the most efficient and safest way we provide the service
- The opinion and feedback we receive from the patient and public
- The opportunity to demonstrate continuing professional development
Evidence of safe practice
• Knowledge Skill Competence approach and maintenance
• What do I have to be knowledgeable about and what skills must I have
• How will I know when I am competent
Leading Better Care components
• Underpinning the role of the senior Charge Nurse
• Ensuring Safe and effective practice
• Person centredness to enhance the patient experience
• Being Effective (manage and develop the performance of the team)
• Contributing to the delivery of the organisation’s 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.
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55. How nurses can impact on antimicrobial management
Six key issues to ensure safe and effective antibiotic use
To ensure optimal antimicrobial therapy for a patient there are six key dimensions of antimicrobial management which should be considered by the multi-disciplinary team. Nurses can have a role in each of these six dimensions in collaboration with medical and pharmacy 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.
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56. 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
Many patients with serious infections being treated in hospital will require IV antibiotics initially. However most patients in general wards can be switched to oral therapy after hours and may be suitable for discharge to complete their course of treatment at home.
Early switch to oral therapy has several advantages for both the patient and ward staff. Removal of IV catheters reduces the risk of adverse events such as phlebitis and the potential for line infection and bacteraemia. Patients are also less restricted in their movement and activities once lines are removed.
From a Nurse's perspective time for line checks and care is no longer required and time for medicines administration is reduced with oral therapy.
Within the clinical team, since nurses have most direct patient contact they are well placed to assess their patient’s response to antibiotic therapy and can prompt de-escalation during multi-disciplinary team meetings/ward rounds.
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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57. Treatment choice Section Six
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
The majority of patients are commenced on empirical antibiotic treatment, pending microbiology results (if a sample has been obtained).
To ensure they receive the safest and most effective treatment for their infection it is important to follow the local antibiotic policy. These policies are evidence-based and reflect effective choice, dosage and duration of antibiotic whilst minimising the risk of adverse effects such as C. difficile Infection (CDI) and antimicrobial resistance.
Allergy to antibiotics is an important factor in choosing an antibiotic for a patient. Penicillin allergy is relatively common but often patients documented as allergic have experienced an adverse reaction to a penicillin that is not a true allergy.
Despite allergies being documented, patients do sometimes still receive an antibiotic to which they are allergic. Antibiotics which are penicillins may not appear obviously so from their name e.g. co-amoxiclav, Tazocin. Always check if unsure.
Empirical treatment should always be reviewed when microbiology results become available to check that the patient is on the most appropriate antibiotic. Often the initial broad spectrum antibiotic can be changed to a narrower spectrum one or an initial combination of 2 or 3 antibiotics can be reduced to just one.
Occasionally the empirical treatment may not be active against the causative organism and a change of 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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58. Treatment duration Section Six
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
Correct duration of therapy is essential to ensure that the infection is adequately treated but that adverse effects are minimised. Most common infections require treatment for a maximum of 7 days. Exceptions are meningitis, some types of pneumonia, bone and joint infections and endocarditis.
Prolonging antibiotic treatment beyond the recommended duration leads to emergence of resistant strains.
Ideally the duration should be recorded on the Kardex and in the case notes. If duration is unknown at the start of therapy then a review date should be specified – this should be within 72 hours of starting treatment.
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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59. 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
Timing is more important for antibiotics than for many other medicines because they are usually administered several times per day. The time between doses affects whether the invading organism is killed or not and also influences development of resistant strains.
Timing may not be ideal for staff administering the antibiotics or patient sleep patterns. Antibiotics given 3 or 4 times per day should be given at regularly spaced intervals
Prompt administration of antibiotics is essential in patients diagnosed with sepsis as each hour of delay significantly reduces survival. This is addressed by the Scottish Patient Safety Programme/Scottish Antimicrobial Prescribing Group collaborative on Sepsis which aims to improve both recognition and management of sepsis.
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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60. Therapeutic monitoring
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)
Gentamicin is commonly used both in treatment of infections and for surgical prophylaxis to provide gram-negative cover.
Vancomycin is mainly used to treat MRSA but also for other gram positive infections in penicillin allergic patients.
Blood samples for therapeutic blood monitoring are required to ensure that dosage is high enough to treat the infection but not too high as to cause adverse effects on renal function and hearing (gentamicin).
Local policies specify when samples should be taken and the procedure for recording details of these samples.
Once levels have been measured interpretation is necessary to assess whether a change in dose or dosage interval is required.
Pharmacy and microbiology colleagues provide advice on how to respond to levels.
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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61. 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
Completion of antibiotic course is an important issue to consider when a patient’s discharge is being planned. Often patients will require to continue their antibiotics for a few days after they go home. Supply of the correct quantity of antibiotics and discussion of how to take them with the patient will ensure that the treatment is completed correctly.
Many NHS boards now offer an OPAT service whereby certain patient groups can attend hospital on a daily basis to receive a dose of an IV antibiotic. Nursing staff are in a suitable position to assess whether patients may be suitable for this type of treatment – they need to be mobile and motivated to ensure they attend daily appointments.
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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62. 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
Enhancing Nurses' role in antimicrobial management has many benefits for patients, the clinical team and the NHS board.
Despite the apparent increased workload there are also benefits for nursing 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.
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63. Challenges in enhancing Nurses' role in antimicrobial management
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
There are challenges with enhancing Nurses' role in antimicrobial management. However this is a very patient-focused role with clear benefits for patient safety and effective treatment.
Enhanced role is aligned with NMC code and with Leading Better Care programme.
Management support is required to break down barriers to change and to empower nurses to take a more active role in antimicrobial management. Many practitioners may already be doing this to a greater or lesser extent.
Team working is the way forward to deliver quality improvements in patient care.
Awareness of the key issues relating to antimicrobial management will allow nurses to develop into this role.
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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