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ADULT ANTIBIOTIC POLICY Version 10.1b Date approved Feb 2018 V10.1 June 2017 V10 June 2016 Date to be reviewed June 2019 Reviewed by Antimicrobial Stewardship Group Ratified by Medicines Management Group 1 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b 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 10.1 Description of Removal of GUM guidelines, which are now a separate policy found under the Trust’s intranet. Amendment(s): Addition of “adult” to the title. Font size amended to 11, as per Trust procedure. 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 e.g. C.diff and MRSA Policy Area: Antibiotic Policy Document Reference: ECT002533 Version Number: 10.1b Effective Date: Feb 2018 Issued By: Chair of Medicines Management Review Date: June 2019 Group Authors: Consultant Microbiologist & Impact Assessment Twice a year Antibiotic Pharmacists Date: APPROVAL RECORD Version 10 Committees / Group Date Consultation: Policy V10 and list of amendments from previous By email May 2016 version circulated to all consultants and SpRs Antimicrobial Stewardship Group Members by agenda for 18 th May 16 Specialist Advice (when required) Dr Rajendran Approved by Committee: Antimicrobial Stewardship Group 18th May 2016 Medicines Management Group 14th June 2016 Version 10.1 Consultation, replacement of Policy V10.1 and list of amendments from previous By email May 2017 piperacillin/tazobactam (due to supply version circulated to all consultants, SASs and SpRs issues): Version 10.1 Approved by committee: Antimicrobial Stewardship Group Members May 2017 Medicines Management Group Aug 2017 Ratified by Committee: (due to lack of stock Medicines Management Group 13 June 2017 implemented May 2017 as agreed by Kashif Haque, deputy chair MMG) Version 10.1b At the request of ASG & MMG following new & Feb 2018 separate GUM guidelines approval (Oct 2017) 2 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b Feb 2018 Review June 2019 EAST CHESHIRE NHS TRUST ANTIBIOTIC POLICY ................................................................................................................................................................................................................ 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 ........................................................................................................................................................................ 41 Cholecystitis and Cholangitis ......................................................................................................................................................... 42 3 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b 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) ......................................................................................................................................................... 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 4 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b 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 .......................................................................................................................................................................... 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 pregnancy............................................................................................................................... 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 5 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b Feb 2018 Review June 2019 Post-partum haemorrhage ............................................................................................................................................................. 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 V10.1 ................................................................................................................................................ 99 2c Description of amendments V10.1b ............................................................................................................................................ 100 Equality Analysis (Impact assessment) .............................................................................................................................................. 101 6 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b 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. 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. 7 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b 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. 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. 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. 8 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b Feb 2018 Review June 2019 α In accordance with surviving sepsis patient safety alert http://www.england.nhs.uk/wp-content/uploads/2014/09/psa-sepsis.pdf β 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) 9 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b 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. Ensure the nurse is informed so that administration is actioned. The subsequent dose(s) can be scheduled to continue at the next drug round or that dose crossed if interval is due soon. Mark the required box for commencement of regular administration.  The prescriber must write the indication on the drug chart, in the “Additional Instructions” box, for each antibiotic. This should be as specific as is known at the time e.g. "simple UTI", and should be updated as more information is available. It is important that other medical staff and healthcare professionals are able to review the antibiotic and sort out any problems related to its use or treatment of the infection. If, for confidentiality reasons, it is not appropriate to write the indication on the drug chart, then add "see notes" to the drug chart and document the indication clearly in the medical notes.  The prescriber must write either a stop date (if known) or review date (48 hours is usually a reasonable initial duration), on the drug chart, see example on the next page.  For all prescriptions for antibiotics where a definite number of doses is known, indicate the number of days of treatment in the stop date box of the drug chart and also block off the remaining section after the correct number of days in the administration section of the chart - see example on the next page.  Ensure the indication is clearly documented in the medical notes together with the intended duration of therapy and any other information on plans e.g. awaiting sensitivities or step-up / step-down decisions.  Patients and/or carers should be informed that they have been prescribed an antimicrobial and the indication should be explained to the patient where appropriate. Patients and their carers should also be given information about likely side effects, the duration and the risks of taking the antimicrobial. This is especially important at the point of discharge.  If a senior clinician has a good reason to prescribe a non-protected antibiotic outside the policy then this should be documented in the medical notes and the prescription endorsed with the indication and “see notes”. 10 East Cheshire NHS Trust Adult Antibiotic Policy V10.1b Feb 2018 Review June 2019

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This policy provides guidance to all staff in East Cheshire NHS Trust regarding prudent prescribing of antibiotics. All staff should Gastrointestinal Surgery . Vestibular signs include dizziness, nausea and vomiting, oscillipsia (visual blurring when moving the head, which can stop patients drivi
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This policy provides guidance to all staff in East Cheshire NHS Trust regarding prudent prescribing of antibiotics. All staff should Gastrointestinal Surgery . Vestibular signs include dizziness, nausea and vomiting, oscillipsia (visual blurring when moving the head, which can stop patients drivi

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