Prepared by; Lee Stewart, Antimicrobials Pharmacist, South Glasgow, August 2014.

Checked by; Fiona Robb, Antimicrobials Pharmacist, West Glasgow, August 2014.

Ensuring antibiotics are used appropriately; 6 things nurses can do to help

Background While antibiotics can be life-saving, inappropriate antibiotic use has serious negative consequences, including; • Treatment failure with increased morbidity/mortality, longer duration of hospital stay and increased costs

• Increased risk of Healthcare Associated Infection (HAI), including MRSA and Clostridium difficile

• Development and spread of antibiotic resistance, threatening our future ability to treat and prevent infections

• Direct patient harm through adverse drug reactions and allergy

Inappropriate antibiotic use takes a variety of forms, which include; • Starting antibiotics unnecessarily (e.g. for viral infections or using 2 or more antibiotics where only 1 is needed)

• Using antibiotics unlikely to cover the suspected infection based on the likely causative organism and its resistance patterns

• Overuse of broad-spectrum antibiotics (e.g. inappropriate initial choice and/or failure to narrow the antibiotic spectrum based on culture/test results)

• Failing to switch IV antibiotics to oral when appropriate

• Continuing antibiotics unnecessarily (e.g. failing to stop when a non-infectious diagnosis is confirmed or exceeding recommended course lengths)

• Failing to recognise actual/potential safety concerns (e.g. failure to take account of allergies or to monitor for/recognise toxicity)

NHSGGC has a range of policies designed to ensure that antibiotics are used appropriately and ALL healthcare professionals have a

role to play in ensuring that these policies are followed.

Do YOU………………

1. Promote compliance with the empiric Infection Management Guidelines

2. Promote compliance with the Alert Antibiotic Policy

3. Ensure allergies are documented and checked before administering antibiotics

4. Ensure IV antibiotics are used appropriately

5. Ensure vancomycin and gentamicin are used safely and appropriately

6. Promote recording of intended antibiotic duration on medicines kardexes

To ensure antibiotics are used safely, effectively and prudently, nurses should……

Prepared by; Lee Stewart, Antimicrobials Pharmacist, South Glasgow, August 2014.

Checked by; Fiona Robb, Antimicrobials Pharmacist, West Glasgow, August 2014.

1. Promote compliance with the empiric Infection Management Guidelines

The NHSGGC empiric Infection Management Guidelines aim to treat infections effectively while limiting the use of the

‘4c Antibiotics’ (co-amoxiclav, ciprofloxacin/other quinolones, clindamycin and cephalosporins), which are those most

likely to cause HAIs. The guidelines specify which antibiotics should be used for the initial treatment of the most

common types of infection, and also give recommended antibiotic course lengths.

The most common examples of non-compliance with the empiric Infection Management Guidelines include using; � 2 antibiotics (i.e. clarithromycin + amoxicillin/co-amoxiclav) for exacerbations of COPD or mild pneumonia. Only 1 antibiotic is recommended.

� Co-amoxiclav for COPD exacerbation or mild pneumonia. Narrower spectrum therapy with amoxicillin or doxycyline or clarithromycin is recommended.

� Amoxicillin for empiric treatment of UTI. Resistance to amoxicillin is too high among E coli for this to be relied upon for blind treatment of UTI.

� Co-amoxiclav for ?LRTI/UTI. Until the diagnosis is clarified, the patient should be managed using both the individual guidelines for LRTI and UTI.

Action points

Ensure that the current version of the empiric Infection Management Guideline poster is displayed prominently in

your ward and challenge non-compliance with the policy (in the absence of a documented reason).

2. Promote compliance with the Alert Antibiotic Policy

The NHSGGC Alert Antibiotic Policy restricts the use of selected antibiotics to defined permitted indications or on the

advice of an infection specialist (i.e. Infectious Diseases (ID) or Microbiology). The Alert Antibiotics are identified

through being broad spectrum and/or high cost and/or potentially toxic. They are valuable agents indicated only in

certain special situations. Overuse will promote resistance and diminish their usefulness in the future. The Alert

Antibiotic Policy aims to preserve their usefulness.

The most commonly overused Alert Antibiotics include piperacillin-tazobactam (Tazocin®) and meropenem. These are

very broad spectrum and we are already seeing bacteria which have developed resistance to them in NHSGGC

hospitals. If this trend continues we could soon see infections which can only be treated by very toxic antibiotics, or

even infections which are untreatable.

Pharmacy can only supply an Alert Antibiotic when an Alert Antibiotic Form (available from Pharmacy and StaffNet) has

been completed by a doctor or pharmacist. Nurses must send a completed Alert Form to pharmacy with the 1st indent

and include the patient’s name & CHI number on all indents for Alert Antibiotics. DO NOT miss/delay doses; pharmacy

will give an ‘emergency supply’ if you cannot get a form completed without an unacceptable delay.

Do not order an Alert Antibiotic without either sending a fully completed Alert Antimicrobial Monitoring Form with

the indent, or confirming that a completed form has been sent to pharmacy previously. If a form has not been

completed then ask medical staff (or the ward pharmacist) to complete one without delay.

Action points

Prepared by; Lee Stewart, Antimicrobials Pharmacist, South Glasgow, August 2014.

Checked by; Fiona Robb, Antimicrobials Pharmacist, West Glasgow, August 2014.

3. Ensure allergies are documented and checked before administering antibiotics

Poor documentation of allergies and intolerances can result in the administration of inappropriate medicines to

patients, with potentially fatal consequences. A recent audit within NHSGGC found that; • Almost 1 in 5 patients did not have the allergy section completed on their medicine chart

• Almost 1 in 5 patients with a blank allergy status on their medicine chart had a known allergy

• Almost 1 in 6 patients with a blank allergy status were prescribed and given a penicillin, a group known to cause potentially serious allergic reactions

These results indicate that patients may be prescribed and administered antibiotics without their allergy status being

known/documented, which puts them at risk of harm.

When checking allergies take particular care when medicines are prescribed by brand name; • Augmentin® (co-amoxiclav) contains penicillin

• Tazocin® (piperacillin-tazobactam) contains penicillin

• Septrin® (co-trimoxazole) contains trimethoprim and sulfamethoxazole (a sulfonamide)

Check the patient’s allergy status carefully before prescribing or administering any medicine.

DO NOT take a blank allergy status as an indication that the patient has no known allergies.

4. Ensure IV antibiotics are used appropriately

IV antibiotics must be administered promptly as mortality from sepsis increases with each hour of delay in initiating IV

antibiotic therapy. If a patient is to be moved, administer the antibiotic in the clinical area where infection has been

recognised: do not delay until arrival at the destination ward. Act quickly to resolve any antibiotic stock supply issues.

While IV antibiotic therapy can save lives, prolonging IV antibiotics unnecessarily has negative consequences including; � Increased risk of IV site infections and bacteraemia � Increased demands on nursing staff time

� Increased duration of hospital stay � Increased antibiotic expenditure

The Adult Antibiotic IV to Oral Switch Therapy (IVOST) Guideline has been developed to help switch to oral antibiotic

therapy appropriately. Previous audits have shown it to reduce duration of therapy, duration of stay and expenditure.

The indications for IV antibiotic therapy include (see IVOST poster on wards for full details); • Inability to swallow/absorb oral medication

• Ongoing sepsis/worsening clinical condition

• Special indication (e.g. CNS infection, bone/joint infection, S aureus bacteraemia, immunocompromised + fever, unresolving skin/soft tissue infection)

With IV antibiotics the route should be reviewed DAILY and switched to oral in the absence of an indication for IV.

Action points

Administer IV antibiotics promptly. Review the IV route DAILY and alert medical staff if IV antibiotics are being given

and the IVOST policy suggests there is no indication for the IV route.

Action points

Prepared by; Lee Stewart, Antimicrobials Pharmacist, South Glasgow, August 2014.

Checked by; Fiona Robb, Antimicrobials Pharmacist, West Glasgow, August 2014.

5. Ensure vancomycin and gentamicin are used safely and appropriately

When given by injection gentamicin and vancomycin can be toxic, causing renal failure and ototoxicity (problems with

hearing and balance). Signs of toxicity may include; � Worsening urine output/increasing serum creatinine � Dizziness/unsteadiness on feet

� Tinnitus/hearing loss � Oscillating vision

Gentamicin ototoxicity is more likely with a prolonged (>1 week) course. Patients receiving gentamicin for >3-4 days

should be discussed with an infection specialist, and referred to audiology for assessment if gentamicin exceeds 7 days.

Accurate recording of IV gentamicin/vancomycin infusion start times is essential if drug blood concentration results are

to be interpreted meaningfully. Failure to do so increased the risk of toxicity/treatment failure.

Nurses should ideally undertake the vancomcyin and gentamicin LearnPro modules at http://ow.ly/zalCp

Action points

Record all IV gentamicin and vancomycin infusion start times accurately. Ensure that gentamicin and vancomcyin

prescribing charts are used and completed appropriately. Be alert for signs of toxicity and ensure that patients

receiving >3-4 days of gentamicin are discussed with an infection specialist (microbiology or ID physician).

6. Promote recording of intended antibiotic duration on medicines kardexes

Antibiotics in hospitals are often continued unnecessarily because clinicians caring for the patient do not have

information indicating why the antibiotics were commenced and how long they were planned to be continued.

Ensuring that all antibiotic prescriptions are always accompanied by an indication and a clear duration or review date

will help clinicians change or stop therapy when appropriate.

Action points

Prompt for the treatment duration to be added to the medicine kardex for all patients receiving oral antibiotics. For

IV antibiotics the prescription should be reviewed daily in line with the IVOST policy (see Point 4 above).

Further information can be obtained from;

���� The antibiotic policy posters which should be displayed in all wards

���� The NHSGGC Therapeutics Handbook

���� StaffNet (����Click ‘Clinical info’ then ‘Clinical Guidelines’ then ‘Infections’)

���� Your local Antimicrobials Pharmacist: