Transcript Antibiotic Update for INPs

Antibiotic Induction
February
2015
Contents
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Quiz
How to prescribe antibiotics
Start Smart then Focus
Monthly audits and data collection
Allergies
Resources
Choosing the right antibiotic
Clostridium difficile Infection
Questions
What is wrong with this prescription?
Answers
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Allergy Box not signed
No indication
No duration
Illegible handwriting
Co-amoxiclav
Capitals
Bleep No.
Indications
• ALL antibiotic prescriptions MUST have a
documented indication
• Even if you do not know the indication
• ?CAP or ?LRTI
Stop/Review Dates
• ALL antibiotic prescriptions MUST have a
documented stop or review date
• If the duration is not known – add a review
date and review daily
Allergy Box
• ALL antibiotic prescriptions MUST have the
allergy box signed
• The allergy status of the patient MUST be
checked before antibiotics are prescribed
Start Smart and Then Focus
Start Smart
• Do not start antibiotics in the absence of clinical evidence
of bacterial infection.
• If there is evidence of a bacterial infection, use local
guidelines to initiate prompt effective antibiotic treatment.
• Document on the drug chart AND in the medical notes:
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Clinical indication.
Duration or review date.
Route.
Dose.
• Obtain cultures first.
• Prescribe single doses of antibiotics for surgical prophylaxis;
where antibiotics have been shown to be effective.
Then Focus
• Review the clinical diagnosis and the continuing need
for antibiotics by 48 hours and make a clear plan of
action – the ‘Antimicrobial Prescribing Decision’.
• The FIVE Antimicrobial Prescribing Decisions are:
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Stop.
Switch from IV to oral.
Change to another antibiotic.
Continue – Review daily.
Start OPAT.
• It is essential that the review and decision is clearly
documented in the medical notes.
Antibiotic Stewardship
• Antibiotic prescribing data is monitored by CCG
and the Trust board
• Monthly antibiotic prescribing audits are carried
out on ALL wards
• Junior Drs collect the data if ward not achieving
100% over seen by Dr Hubbard (Medical Director)
• This information is fed back to each clinical unit
leads, consultants, matrons, MSG, ASG, IPCC and
the Trust Board.
Monthly Data Collection
• One day on the 3rd week every month
• If ward not achieving 100% = Drs
• Ward achieving 100% = Emma collects the
data
• Prescribing will be under surveillance by ward
pharmacists
• Audit forms will be sent via email
• Send forms back to Emma in Pharmacy
Allergies
• The nature of the allergy should be
questioned and documented in the medical
notes and on the drug chart
• Patients with a type 1 allergic reaction
(anaphylaxis, urticarial rash or rash
immediately after antibiotic) to penicillin
should not receive Beta-lactam antibiotics
(Penicillins, Cephalosporins, Carbapenems)
Penicillin Allergy
• Up to 17% of the population report a penicillin
allergy
• Only 10% of these patients actually have a
genuine reaction
• Most adverse drug reactions are side effects
of the antibiotic (diarrhoea, nausea, vomiting
and rash when amoxicillin is given for viral
infections)
Assessing the Allergy
Taking a History of Penicillin Allergy: Questions to Ask
• What antibiotics has the patient reacted to in the past?
• What antibiotics has the patient taken and tolerated since the allergy diagnosis (in
particular penicillins and cephalosporins)?
• When did the reaction take place (estimated date)?
• What was the nature of the reaction (e.g. diarrhoea, rash, swelling, breathing
difficulties etc.)?
• If the reaction was a rash:
– Describe the type of rash (e.g. maculo-papular, pustular, bullous, urticarial
etc.)
– Could the rash be due to the underlying condition (i.e. viral rash or
meningococcal septicaemia)?
– Could the rash be related to an interaction with other medication?
– How long after commencing the antibiotic did the rash appear?
• Why was the patient taking the antibiotic?
• Did the reaction result in hospitalisation or movement to ICU/HDU?
• Did the reaction resolve on cessation of the antibiotic?
Antibiotic Microsite
Antibiotic Smartphone App
• Download from the app store
• ‘Rx guidelines’
• Download Hinchingbrooke guidelines to
phone
• Prescribing information
• Dosing information
• Contact information
• Encyclopaedia for Antimicrobials
Antibiotic Guidelines
Formulary and BNF
Choosing the Right Antibiotic
• Choose empirical treatment based on the type of
infection and likely organism
• Choose an antibiotic and dose based on patient
factors (weight, PMH, allergies, interactions,
pregnancy, breast feeding, past sensitivities and
micro results etc.)
• Route depends on bioavailability of drug, NBM, IV
access, severity of infection
• Duration based on infection type and if patient is
responding to treatment
Avoiding the 4Cs
Cephalosporins
Ciprofloxacin
High
risk of
C.diff
Co-amoxiclav
Clindamycin
Clostridium difficile Infection
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C.diff trajectory (13 out of 7) - £10K fines/pt>7
Spore forming gram +ve anaerobic bacillus
Toxin producing
Patients must ingest spores to become +ve
Hand hygiene (especially before pts eat)
Abx can disrupt bowel flora allowing colonisation
with C.diff.
• C.diff growth is normally inhibited by gut flora
• Risk factors: Age, Antibiotics, Duration, Poor IC
Any Questions?
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