guidelines for use of antibiotics

278 Pages·2014·2.9 MB·English

Copyright © 2006. Revised 2010 Merseyside and Cheshire Palliative Care Network Audit Group
All rights reserved.
This work is registered with the UK Copyright Service: Registration Number 259229
CONTENTS

Contents …………………………………………………..………………….. i
Acknowledgements ………………………………………..………………….. iii
Preface to the Fourth Edition ………………………………..……………….. iv
Introduction …………………………………..……………….……………….. v
Disclaimer…………………………..………………………………………….. vi
List of Abbreviations ……………………..…………………………………….. vii

Standards and Guidelines Page number
1. Agitation …………………………………………..………….………….. 1
2. Antibiotics ……………………………………………………………….. 7
3. Anticoagulation ………………………………………………...……….. 15
4. Antiepileptics ………………………………………………..………….. 22
5. Ascites ……………………………………………………….………….. 28
6. Bereavement Services ……………………………………….………….. 33
7. Bisphosphonates ……………………………..………………..……....... 37
8. Blood Transfusions ……………………………………………….…….. 44
9. Bowel Obstruction …………………………………..………………….. 49
10. Breathlessness …………………………………..……….……….…….. 54
11. Cardiopulmonary Resuscitation ……………………….……………….. 59
12. Constipation …………………………………..…………….………….. 65
13. Corticosteroids …………………………………..…………..………….. 71
14. Delirium …………………………………..…………………………….. 79
15. Depression …………………………………..………………………….. 86
16. Diabetes …………………………………..…………………………….. 96
17. Drugs at the End Of Life ………………………..……………..……….. 101
18. Fatigue …………………………………..………………………..…….. 108
19. Fentanyl in the Dying Patient …………………………………………….. 113
20. Genograms …………………………………..………………………….. 115
21. Hydration in the Dying Patient …………………….………………..….. 123
22. Hypercalcaemia …………………………………..…………………….. 126
23. Insomnia …………………………………..………………………..….. 132
24. Interventional Pain Techniques…………………………………………. 137
25. Major Haemorrhage ……………………..………………………..…….. 142
26. Methadone …………………………………..………………………….. 147
27. Nausea and Vomiting …………………………………………….…….. 151
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December 2009
Page i
28. Neuropathic Pain …………………………………..………………..…….. 158
29. Non-Steroidal Anti-Inflammatory Drugs ………..…………………….….. 165
30. Opioid Substitution ……………………………..……………….…..…….. 173
31. Oral Care …………………………………..…………………...………….. 182
32. Pathological Fractures …………………………………..………..……….. 191
33. Pleural Effusions …………………………………..…………...………….. 197
34. Pruritus …………………………………..……………………….……….. 201
35. Psychological Services …………………………………………...……….. 207
36. Psychostimulants ……………………..……………..…………………….. 211
37. Renal Failure ……………………………….………..…………………….. 216
38. Sexual Health …………………………..…………..……………….…….. 225
39. Spinal Cord Compression ……………………………...………………….. 229
40. Spiritual Care ……………………………………………………………… 234
41. Substance Misuse…………………………………………………………. 238
42. Syringe Drivers ………………………….…………..…………………….. 243
43. Urinary Incontinence………………………………………………………. 248
Appendix A Abstracts and Publications ………………….…………………….. 253
Appendix B Levels of Evidence and the Development of Clinical Guidelines .… 260
Appendix C Merseyside and Cheshire Palliative Care Audit Group. Programme 264
of Audits……………………………………………………………………………………

Merseyside and Cheshire Palliative Care Network Audit Group
December 2009
Page ii
ACKNOWLEDGEMENTS

This book would not exist without the hard work and support of many colleagues.

Firstly we would like to thank all of the contributors whose efforts and good-natured
responses to our entreaties ensured that this book has been published. We would also like to
thank the external reviewers who willingly gave their time and expertise to review the
individual guidelines and whose support for this project is very much appreciated.

We would like to thank Mrs Agnes Noble, Dr Graham Whyte, Dr Carolyn Watt,
Dr Helen Bonwick, Dr Melanie Brooks, Mrs Cath Baldry, Mrs Ann Astley, Dr Kate Marley
and Mr Steve Simpson for painstakingly proof reading the manuscript and ensuring that the
text is as accurate as possible.

Special thanks are due to Karen Ross, Sarah Griffiths, Pauline Webster and Mike Turner for
their administrative and secretarial support and to Dr Charles Shepherd for his expert
computer skills.

Finally we would particularly like to thank all the members of the Merseyside and Cheshire
Palliative Care Network Audit Group who participated in the individual audit projects and
without whom, this book would never have been published.

Editorial Team

December 2009

Merseyside and Cheshire Palliative Care Network Audit Group
December 2009
Page iii
PREFACE TO THE FOURTH EDITION

We are pleased to introduce the fourth edition of the Merseyside and Cheshire Palliative Care
Network Audit Group Standards and Guidelines. Since the publication of the third edition in
2006, every chapter has been extensively reviewed by members of the group and experts from
across the United Kingdom. This edition sees the inclusion of six new guidelines: drugs at the
end of life; interventional pain techniques; major haemorrhage; spiritual care; substance
misuse and urinary incontinence.

As the list of subjects continues to grow, the emphasis of the audit programme has developed
to reflect the importance of closing the audit loop, by re-auditing and updating guidelines.
Over the past three years this has included: agitation / delirium, antibiotics, bisphosphonates
blood transfusions, constipation, corticosteroids, diabetes, hydration at the end of life, opioid
substitution and pleural effusions. Standards and guidelines which have not been re-audited
since the last publication have been extensively updated and reviewed for inclusion in this the
4th edition. A full description of the audit programme is now included in Appendix C.

The referencing for each chapter is comprehensive. The Scottish Intercollegiate Guidelines
Network system has been introduced and there are now levels of evidence throughout the
guidelines and grades of recommendation for all the standards in each of the 43 chapters.

This book is intended as an information resource for qualified medical staff and other health
professionals caring for patients where palliative care is appropriate. The guidance is
applicable to patients with cancer and other forms of advanced disease. It is important that
health care professionals ensure that the information is suitable before using it in any clinical
situation.

The book encourages the setting and monitoring of standards in palliative care and promotes
clinical excellence in end of life care. We are very grateful for the motivation, dedication and
commitment of the group members and our external experts and would like to thank them for
making this book possible.

Dr Alison Coackley
Dr Julie Bellieu
Dr Emer McKenna
Mr Andrew Dickman
Professor John Ellershaw

Editorial Team
December 2009

Merseyside and Cheshire Palliative Care Network Audit Group
December 2009
Page iv
INTRODUCTION

This book represents the collaborative work of the Merseyside and Cheshire Palliative Care
Network Audit Group. One of the main objectives of the group is to use audit projects to
develop standards and guidelines, which can be in turn be used to support specialist palliative
care professionals and empower those working in other areas of health care.

Initially formed in 1995, the group consists of individuals involved in specialist palliative care
across the network in home, hospital and hospice settings. The strength of the group lies in the
multidisciplinary representation and the willingness of individual units and services to
participate in the audit programme. Over the past fourteen years the group has continued to
expand and develop and now holds bimonthly audit meetings throughout the year. In May, the
whole group plans the audit programme for the coming twelve months, thus helping to
maintain ownership of the audit process and enthusiasm for the projects. Five audit projects
are chosen, three of which are identified as regional audits and based on a previously audited
topic. One of these audits may be expanded to include the wider locality as a „supra-regional‟
audit. There are a further two new audit topics, one of which is designated as non-symptom
control.

Each audit meeting attracts approximately 60 health care professionals from across the
network. The meetings begin with the presentation of a literature review of the designated
topic, followed by results from the individual audit. An open discussion then allows the group
to formulate standards and guidelines. An external expert is invited to contribute to both the
presentation and discussion. The guidelines are formatted, fully referenced, and the evidence
is graded before a final review by the group and the external expert.

Regional audits complete the audit cycle by assessing the group‟s performance against
previously developed standards. Dissemination of the audit projects has been achieved by
presentations and publications at national and international level.

The aim of this book is to collate the work undertaken by the group. It is designed both for the
purposes of education and to facilitate the production of other group standards and guidelines.
The guidelines are not standard protocols and are by no means prescriptive.

Experts from across the UK have externally reviewed all of the standards and guidelines and
their comments have been incorporated. The group aim to update the book every three years.
Suggestions and comments are welcomed for the next edition which is due in 2012.

Merseyside and Cheshire Palliative Care Network Audit Group
December 2009
Page v
DISCLAIMER

The editors cannot be held responsible for any liability incurred as a consequence of the use
or application of any contents of this book. Recommendations contained in this book cannot
be appropriate for every situation and so professionals using this book should make their own
decisions regarding safe and appropriate patient care.

The editorial team make no representation, express or implied, that the drug dosages in this
book are correct. Readers must therefore always check the product information and data
sheets provided by the manufacturers and the most recent codes of conduct and safety
regulations. Mention of specific product brands does not imply endorsement.

Every effort has been made to ensure the accuracy of this text. However the editorial team do
not accept responsibility or legal liability for any errors in the text, or for the misuse or
misapplication of material in this work.

December 2009

Merseyside and Cheshire Palliative Care Network Audit Group
December 2009
Page vi
LIST OF ABBREVIATIONS

General

ACE Angiotensin converting enzyme

ADRT Advance Decision to Refuse Treatment

AED Anti-epileptic drugs

AEDs Automated external defibrillators

BNF British National Formulary

BP Blood pressure

BUN Blood urea nitrogen
Ca2+ Calcium

CBG Capillary blood glucose

CBT Cognitive behaviour therapy

CKD Chronic kidney disease
CNG Cancer Network Group
CNS Central nervous system
CQC Care Quality Commission
COPD Chronic Obstructive Pulmonary Disease

COX Cyclo-oxygenase

CPR Cardiopulmonary resuscitation

CSCI Continuous subcutaneous infusion

CSM Committee on Safety of Medicines (now part of Commission on
Human Medicines)

CT Computerised tomography

CXR Chest X-ray

D Dopamine type 2 receptor
2

DIC Disseminated intravascular coagulation

DM Diabetes mellitus

DNACPR Do Not Attempt Cardiopulmonary Resuscitation

DNAR Do Not Attempt Resuscitation

DSM Diagnostic and Statistical Manual of Mental Disorders

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December 2009
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DVT Deep venous thrombosis
e/c Enteric coated
ECG Electrocardiogram

ECT Electroconvulsive therapy

ECOG Eastern Cooperative Oncology Group
eGFR Estimated Glomerular Filtration Rate
FBC Full blood count
FDA Food and Drug Administration (USA)
FEV Forced expiratory volume in one second
1
GABA Gamma-aminobutyric acid
GI Gastrointestinal

Hb Haemoglobin

HbA1c Glycosylated haemoglobin

H , H Histamine type 1, type 2 (receptor)
1 2
HR Heart Rate
5HT 5 hydroxytryptamine

HIV Human Immunodeficieny Virus

ICD International Classification of Diseases

ICN Integrated Care Network

IMCA Independent Mental Capacity Advocate

INR International Normalised Ratio

IVI Intravenous infusion

LCP Liverpool Care of the Dying Pathway

LFT Liver function test

LMWH Low molecular weight heparin
LPA Lasting Power of Attorney
MAOI Mono-amine oxidase inhibitor
MARI Mono-amine oxidase re-uptake inhibitor

MCV Mean cell volume

MDT Multidisciplinary team meeting

MEN Multiple endocrine neoplasia

MHRA Medicines and Healthcare products Regulatory Agency

MRI Magnetic resonance imaging

MRSA Methicillin-resistant staphylococcus aureus

MSCC Malignant spinal cord compression

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