GUH Reserve Antimicrobial Agents Policy Summary

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Reserve Antimicrobials

Reserve antimicrobials are antibiotics and antifungals that are restricted to indications in the GUH antimicrobial prescribing guidelines or may be prescribed following advice from a Specialist Registrar or Consultant in Department of Microbiology or Infectious Diseases (ID).

”Red light” antimicrobials are a sub-category of reserve antimicrobials in GUH that require pre -authorisation by Microbiology or ID prior to use 24 hours / 7 days a week.

Background

Appropriate use of antimicrobials reduces the risk of patient harm from avoidable adverse reactions and interactions with other drugs, as well as reducing the risk of infection with multi-drug resistant organisms and Clostridioides difficile . Additionally, as antimicrobial resistant organisms can spread readily in a hospital setting, the antimicrobial prescribing practice of each individual impacts on the care of all patients.

HSE policy requires that each hospital’s antimicrobial prescribing guidelines must include a list that stipulates which antimicrobials are restricted (approval of a specialist is required) or only permitted for specific conditions. Criteria for restricted antimicrobials include spectrum of activity, potential toxicity, misuse or cost.

The GUH Reserve Antimicrobial Agents policy was approved by the Chief Clinical Director in 2015. Meropenem restriction was introduced in 2017. The list of GUH Reserve antimicrobials is included in Table 1 below. ”Red light” antimicrobials are highlighted in red.

Table 1: GUH Reserve & “Red Light” Antimicrobials List

”Red light” antimicrobials are highlighted in red and require Microbiology or Infectious Diseases pre -authorisation (Primary team to document in patient notes).

Antifungals

Broad Spectrum

Gram-positive

Gram-negative

Ambisome ®

CefTAROLine (red light)

Dalbavancin (red light)

Amikacin

Anidulafungin

CefTAZidime

Daptomycin (red light)

Aztreonam

Caspofungin

CefTAZidime/avibactam (red light)

Fidaxomicin (red light) (C. difficile)

Posaconazole

Ceftolozane/tazobactam (red light)

Linezolid (red light)

Voriconazole

CefTRIAXone

Teicoplanin

Isavuconazole (red light)

CefoTAXime

Vancomycin

Chloramphenicol

Ciprofloxacin

Colistin  (other than Cystic Fibrosis) (red light)

Fosfomycin po

Fosfomycin IV (red light)

Levofloxacin (red light) (exception: where indicated for Community Acquired Pneumonia and H. pylori in GUH guidelines)

Meropenem (red light) (exception: neutropenic sepsis in patients with a penicillin allergy with a delayed onset, non-severe reaction)

Moxifloxacin (red light) (exception: TB)

Tige cycline (red light)

The use of GUH reserve antimicrobial agents should be restricted to indications in the hospital antimicrobial guidelines or otherwise as follows:

Non-consultant prescribers should not prescribe reserve agents for any indication OTHER than those suggested in these guidelines without consultation with the Specialist Registrar or Consultant medical staff in the Department of Microbiology or Department of Infectious Diseases.   A note of this consultation should be made in the patient’s medical record. Otherwise, they may be subject to an automatic stop order (i.e. may not be dispensed from pharmacy).

The Consultant with lead responsibility for care of the patient has the right to prescribe the agent he/she considers in the best interest of the patient contrary to the advice of the Specialist Registrar or Consultant medical staff in the Department of Microbiology or Department of Infectious Diseases.

This prescription must be written and signed by the Consultant herself/himself OR supported by a note in the medical record written and signed by the Consultant herself/himself.  This authority to override the policy on reserve antimicrobial agents may NOT be delegated to non-consultant staff.

GUH “Red light” antimicrobial pre-authorisation process

  1. The following “red light” reserve antimicrobials require pre-authorisation by a Consultant or Specialist Registrar in Infectious Diseases or Microbiology prior to use 24 hours / 7 days a week.
  2. If a Consultant or Registrar (following discussion with their consultant) wishes to prescribe a red-light agent (including meropenem), they must directly contact a Microbiology or ID Consultant or Registrar, for pre-authorisation. An exception is the use of meropenem for the treatment of neutropenic sepsis in patients with a penicillin allergy with a delayed onset, non-severe reaction as per GUH Antimicrobial Guidelines.
  3. The discussion with Microbiology or ID must be conducted by the Registrar or Consultant. This function should not be delegated to a more junior colleague.
  4. The primary team must document the name of the Infection Specialist who has given authorisation in the patient’s notes and on the drug chart, and inform the nurse without delay.
  5. Following authorisation the Microbiology or ID Consultant or Registrar must inform pharmacy of pre-authorisation by sending a text to the Red Light Phone.

Red Light Antimicrobials List

CefTAROLine

Daptomycin

Linezolid

CefTAZidime/avibactam

Fidaxomicin

Meropenem (exception: Neutropenic sepsis in patients with a penicillin allergy with a delayed onset, non-severe reaction)

Ceftolozane/tazobactam

Fosfomycin IV

Colistin (exception: Cystic fibrosis)

Isavuconazole

Moxifloxacin (exception: TB)

Dalbavancin

Levofloxacin (exception: where indicated for Community acquired  pneumonia & H. pylori in GUH guidelines)

Tigecycline

Supply of “Red light” antimicrobials in GUH

  1. Patient name, board / PID number and confirmation of pre-authorisation is required for supply of all red-light agents from pharmacy.
  2. A first dose of meropenem is kept as stock on all wards to enable the first dose of meropenem to be given as soon as possible following pre-authorisation and prescribing. Subsequent doses must be ordered without delay from pharmacy.
  3. Other than the following exceptions, “red light” agents will NOT be supplied in GUH UNTIL pre-authorisation is confirmed:

a) Patients in Critical Care (ICU/HDU/CTICU)

b) Patients post discharge from Critical Care for a period of 48 hours to allow time for review by Microbiology/ID

c) Patients with cystic fibrosis

d) Meropenem for the treatment of neutropenic sepsis in a patient with a penicillin allergy with a delayed onset, non-severe reaction as per the GUH Antimicrobial Guidelines

The GUH Meropenem & Red Light Antimicrobials Ward Poster below summarises the pre-authorisation process.

(click on image to enlarge)