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Antibiotics Policy

Date of issue/ratification: November 2006

Review date: July 2009

Next review date: July 2012

Policy no: P 45

Point of Reference: Chief Pharmacist

Category Clinical

Policy produced by Trust Pharmacy Services


DOCUMENT CONTROL SUMMARY

Issue Date Amended Page Author/Amended Summary of


by Change
1 24 Aug 2009 9 & 10 Andrea Morkah MRSA protocol /
wound care
2 26 Aug 2009 2 Andrea Morkah General
principles
3 26 Aug 2009 3 Andrea Morkah Ratification and
review
4 26 Aug 2009 3 Andrea Morkah Distribution
5 8 Sept 2009 8 Andrea Morkah Throat infections

Policy produced by Trust Pharmacy Services


Contents
1. Introduction 2

2. Aim 3

3. Ratification and Review of Policies and Procedures 3

4. Distribution 3

5. Responsibilities 4

6. Combinations 5

7. Length of treatment 5

8. Availability 5

9 Penicillin allergy 5

10. Further information 6

11. General conditions 7


Cellulitis 7
Bites (animal/human) 7
Lower UTI 7
Throat infections 8
Acute exacerbation of Chronic Obstruction Airways 8
Disease
Sinusitis 8
Antibiotic Associated Colitis (Clostridium Difficile) 8
Pneumonia 9

12 Vaccinations 9
13 Methicillin Resistant Staphylococcus Aureus (MRSA) 10
14 References 13

Appendix 1: Equality Impact Assessment 14

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ANTIBIOTICS POLICY
1. Introduction
Antimicrobial drugs are widely prescribed for the treatment and
prophylaxis of infections. Use of antibiotics in one patient can
compromise their efficacy in another due to the emergence of resistant
strains of microorganisms. Emergence of resistance may be particularly
likely and be of particular importance in environments where high
antibiotic usage is associated with the presence of particularly
susceptible patients.
The total quantity and spectrum of antimicrobials prescribed should be
the minimum compatible with effective therapy.
Local policies help to reduce the development of resistant organisms.
They may indicate a range of drugs for general use and permit other
drugs only on the advice of the microbiologist or physician responsible
for the control of infectious diseases.

The Trust is required to demonstrate that Clostridium difficile (C.difficile)-


associated colitis is being monitored as outlined by The Health Act 2006 Code of
Practice for the Prevention and Control of Health Care Associated Infections.
Please refer to the Trust Policy for Clostridium difficile Infection for further
information.

Broad spectrum antibiotics particularly cephalosporins and quinolones are


notorious for causing C. difficile associated diseases and therefore these drugs
have been removed from the policy and can only be prescribed on the
recommendation of the Consultant Microbiologist (either from North Middlesex
Hospital (NMH) or Barnet and Chase Farm Hospital (BCF)).

1.1. General Principles of Antibiotic Prescribing


Before selecting an antibiotic, clinicians MUST first consider factors such
as:

• Allergy history
• Renal and hepatic functions
• Whether immunocompromised or not
• Ability to tolerate drugs by mouth
• Severity of illness
• Ethnic origin
• Age
• Other medications
• If female, whether they are pregnant, breast-feeding or on oral
contraceptives.
• The known or likely causal organism and it antibacterial sensitivity

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ANTIBIOTICS POLICY
The final choice will depend on the microbiological, pharmacological
and toxicological properties of the antibiotic.

2. Aims
The aims of the policy is to:

• To encourage the rational and cost effective use of antibiotics for


common infections.
• To minimise the emergence of bacterial resistance.
• To minimise adverse drug reactions

3. Ratification and review of policies and procedures


3.1 The Drug and Therapeutics Committee will agree the policy and
then ultimately the Trust Policy Development Group must ratify
this policy.
3.2 The policy will be reviewed every three years and amended as
necessary.
3.3 The policy may be reviewed before this time if for example, any
new procedures, guidelines or policies (whether locally or
nationally) are introduced.

4. Distribution

4.1 This policy is applicable to all BEHMHT adult wards or units and
should be read by any healthcare professionals likely to be
involved in antibiotic prescribing, administering or dispensing
process.

4.2 A copy will be held in all clinical areas and may also be accessed
via the Trust intranet.

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5. Responsibilities

5.1 Prescriber

• All antibiotics should be clearly prescribed giving dosage and


frequency and if necessary the duration of therapy.
• The rationale for the antibiotics prescribed should be recorded in
the medical notes/ RiO.
• Prescribing of antibiotics in Mental Health is most likely to be with
broad-spectrum drugs.
• Unless a clear indication is present antibiotic therapy should be
stopped after 5-7 days.
• Antibiotic therapy should be reviewed as microbiology results
become available, if applicable.

5.2 Nurse

• Nurses should ensure that prescribed antibiotics are given at the


right time and recorded in the drug chart.
• They should also ensure that any monitoring required, while
patients are on antibiotics, is done.
• Nurses should ensure that the antibiotics are written clearly on the
chart to prevent administration errors.

5.3 Pharmacist

• Ward pharmacists have the responsibility of ensuring that


antibiotics are written clearly on the drug chart with dose,
frequency and duration of therapy, if appropriate
• They should ensure that antibiotics are discontinued after the
prescribed/ specified number of days.
• Ward pharmacist will query unduly prolonged antibiotic
prescriptions if no clear reason for continued treatment is given in
the patient notes/ RiO.
• Ward Pharmacists are responsible for giving advice about
prescribed antibiotics.
• Prescription monitoring should be done to ensure local guidelines
are being adhered to.

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6. Combinations
Combinations of antibiotics may be used to achieve a broader spectrum
of activity, synergy or for other reasons. However the combination of
antibiotics with similar spectrum of activity should usually be avoided.

7. Length of treatment
Specific advice regarding length of therapy is available for example from
the British National Formulary (B.N.F), and if necessary from your local
microbiology department for certain conditions. In the absence of such
advice, treatment should be discontinued after five days if a satisfactory
clinical response has been obtained.

8. Availability of antibiotics
It is expected that inpatients of the Mental Health Trust will only be
prescribed broad-spectrum antibiotics. All other antibiotics can only be
prescribed if specified by NMH or BCF microbiology.
Patients needing IV antibiotics are likely to be transferred to acute
general wards as opposed to being treated on mental health wards.
Day Hospital and outpatients should see their General Practitioner for
treatment of community-acquired infections.

9. Penicillin Allergy
Please follow general ‘Medicines Management Policy’ guidance as for all
allergies. See below:

9.1 On admission, patients should be asked specifically for any history


of drug allergies or adverse drug reactions (A.D.R.s). This should
be documented in the medical notes/RiO and on the prescription
chart (in the drug sensitivity/drug allergy box). Where no
allergies/A.D.R.s are known, this should also be documented in the
medical notes/RiO and on the prescription chart.

9.2 If, after thorough investigations it cannot be ascertained whether


or not the patient has a drug allergy, then this too must be
documented in the patients’ notes/RiO and their prescription chart
endorsed: “NOT KNOWN”.

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9.3 It is the responsibility of the prescriber to ensure this section of the
prescription chart is completed and that details are transferred
onto subsequent charts. The prescriber must also sign and date
their entry on the prescription chart.

9.4 On discharge, all allergies/A.D.R.s should be included on the


discharge form/letter. Where available, this should be included on
the TTA (To Take Away) medication form.

9.5 If a patient experiences an adverse drug reaction to a medicine, it


should be documented in their notes/RiO and on their prescription
chart. The doctor, pharmacist or nurse should complete a yellow
card (if appropriate) and send it to the Medicines and Healthcare
Products Regulatory Agency (MHRA). Yellow cards are available at
the back of the BNF.

9.6 In cases of penicillin allergy, do not give the contra-indicated


antibiotics: Amoxicillin, Ampicillin, Co-amoxiclav/Augmentin ®
®
(Amoxicillin), Benzylpenilcillin, Flucloxacillin, Heliclear
(Amoxicillin), Penicillin G, Penicillin V, Phenoxymethylpenicillin and
Tazocin ®
(Piperacillin)

9.7 10% of patients allergic to penicillin can experience cross-


sensitivity when given cephalosporins (e.g. Cefalexin, Cefotaxime,
Ceftriaxone, Cefuroxime) so care must be taken.

10. Further information


For further information please contact:
• Your ward Clinical Pharmacist
• Lead Nurse Infection Control
Tel: 0208 732 6341

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11. General Conditions
All drugs and doses indicated are for oral treatment, if intramuscular or intravenous treatment is required please
contact microbiology of your local acute Trust.

Condition Drug Dose Notes


Cellulitis Phenoxymethylpenicillin 500mg – 1g qds According to response. Usually 7-
+ Flucloxacillin 500mg qds 10 days
If penicillin allergic, In more severe cases, please
Erythromycin 500mg qds contact microbiology for advice.

Bites Co-amoxiclav 625mg tds For 7 days – Duration of treatment


(animal/human) If penicillin allergic, is often determined by clinical
Doxycycline 100mg bd response.
+ Metronidazole 400 mg tds For 7 days
Tetanus prophylaxis
If marked cellulitis also consider
parenteral therapy.

Lower UTI Trimethoprim 200mg bd Women –


Or Nitrofurantoin 50-100mg qds 3-5 days
(if no renal impairment) Men –
Microbiological investigation
required, may need up to 14 days
treatment.
Pregnancy –
Microbiological investigation
required. Cefalexin drug of choice.

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Condition Drug Dose Notes
Throat infections Phenoxymethylpenicillin 500mg qds Most throat infections do not
If penicillin allergic require antibiotics because they are
Erythromycin 500mg qds caused by viruses.
Antibacterial should be considered
if history of valvular heart disease,
marked systemic upset,
peritonsillar cellulitis or abscess, or
if at increased risk from acute
infection.

Acute exacerbation Amoxicillin 500mg tds


of Chronic If penicillin allergic
Obstructive airways Erythromycin 500mg qds
disease (COPD)
Sinusitis Amoxicillin 500mg tds
If penicillin allergic
Erythromycin 500mg qds

Clostridium difficile 1st line - Metronidazole 400mg tds 7-10 days


diarrhoea 2nd line - Vancomycin 125mg qds (po)

Pneumonia
Basic principles
Management of pneumonia depends on whether it is acquired outside the hospital, i.e. community
acquired pneumonia or inside the hospital, i.e. nosocomial or hospital acquired pneumonia.

Treatment with antibiotics should be for at least one week provided response is satisfactory and the
patient should have been afebrile for at least 48 hours at the time of discontinuing treatment. Treatment
should be by the oral route. Intravenous therapy may be necessary when oral administration is
impossible, e.g. vomiting or in severe pneumonia until 24 hours after the fever has settled. Initial

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antibiotic therapy is generally started without results of microbiological tests, i.e. initial treatment is on a
best guess.

Condition Drug Dose Notes


Community Acquired Amoxicillin 500mg oral For 7 days
Pneumonia - Mild tds

For penicillin allergic


Erythromycin 500mg oral
bd
Hospital Acquired Pneumonia (mild – moderate) – microbiological investigation (throat swab, blood cultures and
sputum required). Consider transfer to acute/general hospital.

12. Vaccinations

Influenza Annual vaccination for all persons aged 65 years and over as well as younger
people in established “high-risk” groups (those living in long-stay residential
and nursing homes or other long-stay facilities, persons with chronic heart
disease, chronic respiratory disease including asthma, chronic renal disease,
diabetes mellitus and immuno-suppression due to disease or treatment).
Pneumococcal Once only, for people 65+

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13. Methicillin Resistant Staphylococcus aureus
(MRSA)

Five-day course Eradication Protocol for MRSA Colonisation


(Patients in hospital)

The treatment should be given for 5 days and then stopped

Treatment Frequency and site


Chlorhexidine 4% (needs to be Daily: Hair wash and whole
prescribed) body wash

Bactroban nasal ointment (needs Three times a day: to anterior


to be prescribed) nares

Wounds Use an appropriate dressing for


the type of wound. Debriding may
be needed to speed up healing

NB. During the treatment it is essential that no other toiletries


be used, as this may adversely affect the treatment and, in
addition, the patient’s bed linen and night clothes should be
changed on a daily basis

For MRSA infection in soft tissue, chest or urinary tract, systemic


antibiotics may be necessary. The patient’s clinician should
discuss the appropriate treatment with a Consultant
Microbiologist.

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Method of application of the topical treatment of MRSA

The treatment protocol below should be given for 5 full days. It may
only be repeated once for a further 5 days. Subsequent treatment of
patients who persist to be MRSA positive must be discussed with the
ICL.

1. Bactroban® (Muprocin 2%) nasal ointment

The ointment is applied to the anterior nares, 3 x daily for 5 days.

• Unscrew the cap and squeeze a small amount of ointment, about


the size of a match-head, onto a gloved little finger or a cotton
bud
• Apply the ointment to the inside of both nostrils
• Close the nostrils by pressing the sides of the nose together for a
moment to spread the ointment inside each nostril
• Remove gloves or discard the cotton bud
• Wash hands

2. Chlorhexidine 4%

a) Chlorhexidine 4% is used daily for washing the whole body instead of


soap.

• Wet the skin before applying


• Apply to the skin using wet flannel or sponge as for liquid soap or
shower gel. This is the correct method of application rather than
diluting it in a bowl of water
• Pay particular attention to skin folds, axillae, groin and behind the
knees
• Rinse thoroughly to prevent dry or itchy skin

b) Chlorhexidine 4% is also used on the hair daily during the 5-day


protocol

• Use as a shampoo, again ensuring that hair is thoroughly rinsed,


to remove all traces

NB. For patients with sensitivity to Chlorhexidine please contact the


Infection Control Lead (ICL) for an alternative treatment.

3. Wound care

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The most effective method of eradicating MRSA from a wound is to heal
the wound and every effort should be made to achieve this.

• The basic principles of wound care including assessment and


dressing choice should be applied
• A small lesion e.g. stoma, PEG site, sutured wound, may be
treated with Bactroban nasal ointment. This should not be used
for any other types of wounds.
• All wounds should be occluded wherever possible, to reduce
environmental contamination with MRSA e.g. with Granuflex® or a
semi permeable film dressing
• Sloughy or necrotic wounds need to be debrided as appropriate.
• Alginate or foam dressings, which absorb high level of exudates,
should be used for heavily exuding wounds
• An antibacterial dressing such as a Povidone Iodine-impregnated
gauze may be appropriate in the eradication of MRSA from
superficial wounds.
However, this may be contra-indicated in some cases, please seek
further advice.

Follow Up Screening

The patient should be screened for MRSA 48 hours after stopping the
topical treatment, by taking swabs or specimens from the following
sites:

• Nose
• Perineum or groin
• Sputum if productive
• Catheter specimen of urine if patient is catheterised
• Any breaks in the skin including pressure sores or leg ulcers

Please see Trust policy IC03 (MRSA Policy March 2009), available on the
Intranet, for further information on the treatment of MRSA.

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ANTIBIOTICS POLICY
14. References

1. North Middlesex Hospital Trust - Antibiotics Policy August 2008

2. Barnet and Chase Farm Hospitals Trust – Adult Antibiotics Guidelines


April 2007

3. British National Formulary 57 March 2009

4. Barnet, Enfield and Haringey Mental Health Trust - MRSA Policy


March 2009

5. Barnet, Enfield and Haringey Mental Health Trust – Medicines


management Policy January 2009

6. Barnet, Enfield and Haringey Mental Health Trust – Policy for


Clostridium difficile Infection June 2007

7. Management of Infection Guidance for GP’s in Primary Care Haringey


Teaching Primary Care Trusts – April 2009

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ANTIBIOTICS POLICY
Appendix 1
EQUALITY IMPACT ASSESSMENT
Name of the policy/service/function being assessed: Antibiotics Policy
Person responsible for carrying out the assessment: Gbemi Kuforiji/ Andrea Morkah
Main aim, objectives and intended outcomes of the policy / function / service
development?
Aim:
To provide a detailed guide for the use of antibiotics within Barnet Enfield and Haringey Mental
Health Trust.
Objective:
• To encourage and ensure the rational and cost effective use of antibiotics for common
infections.
• To minimise the emergence of bacterial resistance
• To minimise adverse drug reactions
Intended outcomes:
To treat infections in a cost effective manner while minimizing the risk of emergence of
resistant bacteria.
Is there reason to believe that the policy / function / service development could
have a negative impact on a group or groups? YES / NO: NO
Which group or groups may be disadvantaged / experience negative impact?
Race: YES/NO NO
Disability: YES/NO NO
Gender: YES/NO NO
Age: YES/NO NO
Sexual Orientation: YES/NO NO
Religion/Belief: YES/NO NO
Other: YES/NO
What evidence do you have and how has this been collected?
None: NONE
Some:
Substantial:
Have you explained your policy / function / service development to people who
might be affected by it? YES or NO? If YES, please give further details.
No. This is an update of the previous antibiotic policy.
If the policy / function / service development positively promotes equality, please
explain how?
Patients are assessed and prescribed the appropriate antibiotic for their infection.
From the screening process, do you consider the policy / function / service
development will have a positive or negative impact of equality groups?
Please rate the level of impact and summarise the reason for your decision.
NEUTRAL
IMPACT: no specific impact or is not relevant to equalities.
POSITIVE: likely to promote equality and improve relationship between groups. POSITIVE
NEGATIVE: where a function results in inequalities.
Reasons for your decisions:
Patients needing to be treated for infections will be given the appropriate antibiotic.
Date completed: 19/08/09
Print Name: Gbemi Kuforiji / Andrea Morkah

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