Prescribing Principles


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Antimicrobial Prescribing Principles


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Antimicrobial Prescribing Principles

Antimicrobial Prescribing Principles

  • Doses in these guidelines are for non-obese ADULTS with normal renal and liver function.
  • GUH have agreement to use the Children's Health Ireland (CHI) Antimicrobial Guidelines for patients less than 18 years old. The guidelines are available as part of the CHI (at Crumlin and Connolly) Paediatric Formulary app. Alternatively, the CHI website can be accessed via link . You may be asked to register an account using your email address. The lead contact is Dr. Edina Moylett.
  • Antimicrobials should only be started with clear clinical justification, and documentation in patient notes.
  • Always culture (blood, sputum, pus etc) as appropriate prior to commencing or changing antimicrobials.
  • Review antimicrobial therapy daily with culture results and clinical progress. If pathogen(s) identified, modify therapy accordingly.
  • For all patients labelled as penicillin allergic establish history, assess and document. See Penicillin Hypersensitivity .
  • Prescribers should be aware of contraindications, warnings, precautions, interactions and potential adverse effects of all drugs prescribed, including antimicrobial agents. These are outlined in the Summary of Product Characteristics (SPC) (available at HPRA ) and BNF.
  • Access  GUH Intravenous Medicines Administration Guide at http://medinfogalway.ie/ivguides for additional information on the safe prescription and administration of individual intravenous antimicrobials.
  • See Interactions Appendix 1 for online interaction checkers.
  • See Antimicrobial Prescribing in Renal impairment for dose adjustment.
  • The number of obese patients is increasing and the standard doses of some drugs may not achieve effective serum concentrations. Data on anti-antimicrobial dosing in the obese patient are gradually emerging, but only some drugs have been evaluated. If necessary, contact Pharmacy /Microbiology /Infectious Diseases regarding optimising antimicrobial dose in obese patients.
  • Switch IV to oral as soon as possible. See IV to PO switch therapy .
  • Stop antimicrobials as soon as possible based on clinical response.
  • Information Leaflet on antibiotics and diarrhoea available in Appendix 2
  • See Fluoroquinolone warning

Start Smart, then Focus Antibiotic Care Bundle

(click on image to enlarge)


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Fluoroquinolones

Systemic fluoroquinolones are associated with disabling and potentially permanent serious side-effects involving the tendons, muscles, joints, nerves, and aorta. The risk of tendinopathy is increased in elderly patients – or those with concomitant steroid use, renal disease, or post-transplant (heart/lung/kidney). Fluoroquinolone use is also associated with QTc prolongation (which can lead to torsades de pointes and ventricular fibrillation), C. difficile colitis, aortic aneurysm rupture/dissections and heart valve regurgitation/ incompetence. See SPC for full product information. Patients should be informed of the risks and advised to stop treatment and contact prescriber if they experience pain or swelling in tendons/joints/muscle or neuropathy


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Note Regarding Multi-drug Resistant Organisms (MDRO)


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MDRO general information

  • MDRO are organisms exhibiting resistance to one or more groups of antimicrobials. They include Gram-negative organisms such as extended-spectrum beta-lactamase (ESBL)-producing bacteria and carbapenemase-producing Enterobacteriaceae (CPE), and Gram-positive organisms such as methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococci (VRE).
  • Patients at risk for acquisition of MDRO include:
  • Prior and prolonged hospitalisation.
  • Residents of long term care facilities.
  • Exposure to multiple antimicrobials, especially broad spectrum antimicrobials.
  • The presence of indwelling medical devices, particularly urinary catheters.
  • Discuss with Microbiology or Infectious Diseases if patient suspected or known to be colonised with MDRO - as alternative regimens for treatment or surgical prophylaxis may be required.

Refs:

  1. HPSC Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO) excluding MRSA in the healthcare setting 2014


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Note Regarding Carbapenemase-Producing Enterobacteriaceae (CPE)

  • CPE are multi-drug resistant Gram-negative bacteria carried in the gut that are resistant to carbapenems (e.g. meropenem) and many other antibiotics. CPE are mostly K. pneumoniae, E. coli , and Enterobacter but other species of bacteria may also have this mechanism of resistance.
  • Patients who are colonised with CPE isolated from rectal screening samples without signs of infection do not need specific treatment.
  • Treatment options in cases of infection with CPE are limited. If a patient with CPE from a rectal screen and/or clinical sample develops clinical evidence of an infection ALWAYS discuss antibiotic therapy with Microbiology or Infectious Diseases.

Refs:

  1. HPSC Guidelines for the Prevention and Control of Multi-drug resistant organisms (MDRO) excluding MRSA in the healthcare setting 2014
  2. HPSC Carbapenemase Producing Enterobacterales (CPE) in Ireland: 2017


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Note Regarding Extended-Spectrum Beta-Lactamase (ESBL) producing bacteria

Note Regarding Extended-Spectrum Beta-Lactamase (ESBL) producing bacteria

  • ESBL-producing bacteria are an increasing problem in this region and throughout the world.  ESBL-producing bacteria are mostly E. coli or K. pneumoniae but other species of bacteria may also have this mechanism of resistance.
  • The ESBL mechanism makes the bacteria resistant to many penicillins and cephalosporins.
  • Most are susceptible to nitrofurantoin (only prescribed for cystitis) and many remain susceptible to piperacillin/tazobactam, gentamicin and restricted agents such as Meropenem and Tigecycline.
  • ESBL transmission associated with nursing homes has been a problem and therefore empiric cover for ESBL blood stream infection with Meropenem should be considered in patients admitted from nursing homes who are critically ill with sepsis . Discuss with Microbiology or Infectious Diseases as required.


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Note Regarding Methicillin Resistant Staphylococcus aureus (MRSA)

Note Regarding Methicillin Resistant Staphylococcus aureus (MRSA)

For infection at almost any site you should suspect infection with MRSA if:

  • Patient has been previously colonised with MRSA.
  • Patient has recently been hospitalised (within 90 days).
  • Patient has transferred from another hospital or long-term care facility.
  • Patient is on a ward with a current epidemic or endemic MRSA problem.

For patients with serious/life threatening infection who are at risk for MRSA infection, empiric treatment with Vancomycin is indicated in addition to the other components of therapy recommended in this guideline. Discuss with Microbiology or Infectious Diseases as required.


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Documentation of Antimicrobial Use

Documentation of Antimicrobial Use

Accurate documentation is a key component of appropriate antimicrobial prescribing. It improves communication between medical, nursing and pharmacy staff and between different medical practitioners who may review therapy throughout the prescribed course and subsequently. It also facilitates multidisciplinary audit of antimicrobial prescribing within and between hospitals, to inform and improve education and action plans to improve antimicrobial practices.

Key elements to consider and document when prescribing antimicrobials are:

R - Route : Please review all IV antimicrobials DAILY

I - Indication for the antimicrobial e.g. pneumonia

D - Duration/Review Date e.g. 7 days for hospital acquired pneumonia

Always document the treatment indication and treatment duration or review date in both the appropriate box in the antimicrobial section of the drug chart (example shown below) AND in the patient’s medical notes.

Example of antimicrobial section of drug chart with indication and duration documented


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Topical Antibacterial Agents

Topical Antibacterial Agents

Not routinely recommended

Rationale for restricting use in hospitals

Exceptions

Any topical antibacterial e.g. Bactroban ®

Flamazine ®

Fucidin ®

Naseptin ®

Polyfax ®

Emergence of resistance

An infection that needs to be treated should generally be treated systemically

· Bactroban ® nasal ointment as first line treatment for MRSA decolonisation

· Naseptin ® as second line treatment for MRSA decolonisation

· Naseptin ® use by ENT

· Topical antibacterial use by dermatology

· Flamazine ® use by Plastics