Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy
Version
6
Name of responsible (ratifying) committee
Infection Prevention and Control Management
Committee and Antimicrobial Management Group
Date ratified
1st March 2013
Document Manager (job title)
Infection Control Doctor and Trust Antimicrobial
Pharmacist
Date issued
4th March 2013
Review date
January 2015
Electronic location
Policies, Infection Prevention and Control
Related Procedural Documents
Key Words (to aid with searching)
Antimicrobial prescribing
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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CONTENTS
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QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 4
DEFINITIONS .............................................................................................................................. 5
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
PROCESS ................................................................................................................................... 6
TRAINING REQUIREMENTS ...................................................................................................... 8
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 8
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS .............................................................................................................................. 8
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. All antimicrobial prescribing should be rational, appropriate and safe
2. Antimicrobial therapy should only be started with clear clinical justification which should be
documented in the patient’s clinical notes. The prescription should be compliant with Trust
empirical guidance ie “start smart”
3. Always culture (blood, sputum, urine etc) as appropriate prior to commencing or changing
antibiotics
4. Antimicrobials should be started promptly on suspicion of infection, and within one hour of
diagnosis of severe sepsis and potentially life-threatening infection
5. Review antimicrobial therapy daily with culture results and clinical progress
6.
Switch intavenous therapy to oral as soon as possible based on clinical response
7.
Stop antibiotics as soon as possible based on clinical response and culture results
8. After 48 hours a clear plan of action should be made. The five “Antimicrobial prescribing
decisions” are to stop, switch, change, continue or OPAT
9. Always check antimicrobial dosage in presence of renal or hepatic dysfunction and
compatibility with other medication in the current edition of the British National Formulary
10. For all patients labeled as penicillin allergic, establish history and assess risk.
Cephalosporins and Carbapenems may be given if minor allergy e.g. rash but not for patients
with documented anaphylactic response
11. Support for antimicrobial prescribing is available from the antimicrobial pharmacist on bleep
1973 or from microbiology ext 1718. A consultant-led microbiology service is available 24
hours a day, 7 days a week.
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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INTRODUCTION
Appropriate use of antimicrobials may be life-saving, but unnecessary overuse may be fatal and is contributing
to the ever-increasing burden of antimicrobial resistance. Many healthcare-associated infections are
precipitated by inappropriate antibiotic use e.g. Clostridium difficile, the leading cause of nosocomial diarrhoea.
Inappropriate antibiotic prescribing has been shown to contribute to MRSA acquisition.
Prudent use of antimicrobials is essential in the control of development of antimicrobial resistance and in the
control of healthcare associated infections.
Antibiotic resistant organisms are more difficult to treat (and may be untreatable), they prolong hospital
admission and often cause increased morbidity and mortality.
The World Health Organisation and many countries worldwide including the UK have produced strategies for
the containment of antimicrobial resistance. Prudent antimicrobial use, along with infection control and
improved cleanliness, surveillance of antimicrobial resistance with feedback to providers, education of
professionals and the public, and making healthcare associated infection a key feature of quality and patient
safety programs are all key areas for the prevention and containment of antimicrobial resistance.
This document sets out the aims for antimicrobial prescribing within PHT.
This policy has the full support of microbiology, pharmacy and infection prevention and control.
1. PURPOSE
This policy defines the processes to ensure that antimicrobial prescribing within PHT is prudent, appropriate
and safe.
Proposed outcomes
 By adhering to this policy, antimicrobial prescribing within the Trust will be prudent, safe and appropriate,
and based on the antibiotic susceptibility of diagnosed or likely pathogens.
 Prescribing and education on the diagnosis, management and treatment of infection will be supported by
microbiology / infection experts in liaison with pharmacy and infection prevention and control.
 Use of intravenous antimicrobials will be minimised thereby minimising cannula-related infections
including nosocomial bacteraemias.
 Use of antimicrobials especially broad spectrum antibacterials will be minimised thereby reducing the
selection pressure for the development of resistant pathogens and for the development of antibioticassociated diarrhoea, particularly C difficile.
 Antimicrobial prescribing practice will be supported by active surveillance and education provided by
microbiology and infection control in liaison with pharmacy.
2. SCOPE
This policy applies to all prescribers of antimicrobial agents within PHT.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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3. DEFINITIONS
Antibacterial agent
A substance which selectively inhibits the growth of bacteria (bacteriostatic) or selectively kills bacteria
(bacteriocidal)
Antibiotic
A substance produced by a micro-organism which is antagonistic to the growth or life of others in high
dilution. Many antimicrobial agents are now synthetically or semi-synthetically synthesized and are thus
not true antibiotics. Nevertheless the term antibiotic is widely used to refer to an antimicrobial.
Antimicrobial agent
A drug which is antagonistic to the growth or life of infectious pathogens, whether these are bacteria,
viruses, fungi or parasites
Audit
The process of assessing current practices in comparison to a recognised standard
Health Protection Agency
Formerly the Public Health Laboratory Service, a national agency whose role is to protect the public from
infection and other hazards.
Hospital-acquired, healthcare associated or nosocomial infection
Infection acquired in healthcare institutions.
Infection Prevention and Control Team (IPCT)
A group of experienced staff responsible for advising on hospital infection prevention and control. The
IPCT has direct access to the Director of Infection Prevention and Control and is responsible to the
Infection Prevention and Control Management Committee (IPCMC)
Microbiology
The study of micro-organisms
Microbiologist
A medical doctor qualified in the diagnosis, management and prevention of infection
Microbiology ward round
Also known as an antimicrobial ward round. This is a regular multi-disciplinary ward round undertaken by
a microbiologist or infection specialist and a pharmacist and with a clinician who has responsibility for the
patient. A member of the infection control team or a trainee microbiologist or pharmacist may also be
present. The purpose of the ward round is to clinically assess the appropriateness of the antimicrobials
prescribed for individual patients. All assessments take into account the current clinical situation and
investigation results including any microbiology findings. Any recommendation to change the
antimicrobials prescribed is discussed with the clinical staff on the wards and documented in the medical
notes. The prescription chart may be actively changed by the microbiologist.
Out-patient Antimicrobial Therapy (OPAT)
A service provided by infection specialists to provide out-patient intravenous antimicrobial therapy
Pharmacist
Person qualified in the delivery, action and side-effects of medicinal drugs
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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4. DUTIES AND RESPONSIBILITIES
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All prescribers have a duty to comply with current antimicrobial prescribing guidance available on the
intranet and in the British National Formulary. All prescribers should carry the empirical antimicrobial
prescribing guide behind their Trust ID badge
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All prescribers must assess the patient’s current clinical condition and current medications, their renal
and liver function and any history of allergy before prescribing an antimicrobial agent
All prescribers must review their prescriptions on a regular (preferably daily) basis and rationalise any
antimicrobial prescription according to the clinical state of the patient and the microbiology results
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Pharmacists will review all prescription charts on a regular, mostly daily, basis
The antimicrobial pharmacist will coordinate the antimicrobial / microbiology ward rounds, liaise with
microbiology and the infection prevention and control team with regards most appropriate treatment of
infection and coordinate audits to assess compliance with the policy and Trust prescribing guidelines
The microbiologists will carry out regular multi-disciplinary ward rounds with pharmacy with the aim of
improving antimicrobial prescribing and providing interactive education on the wards
The microbiology laboratory will deliver a timely, accurate, appropriate and efficient service
The IPCT will work with Matrons, Clinical Directors, clinical leads, heads of specialties and infection
control link persons to improve adherence to infection prevention and control guidelines and policies
Results and actions from any audit of antimicrobial prescribing will be reported to the Director of Infection
Prevention and Control via the Infection Prevention and Control Management Committee and
Antimicrobial Management Group
All staff have a duty of care to the patients and themselves to ensure they deliver high standards of
infection control practice including antimicrobial prescribing practice at all times. Wherever there is
deficiency in their knowledge or experience this must be highlighted to the department/ward manager
who is responsible for ensuring the member of staff receives the appropriate training, education or advice
Matron, Clinical Directors, clinical leads and heads of specialties have a duty of care to ensure that staff
receive education on all aspects of infection prevention and control which relate to their workforce’s job
5. PROCESS
1. PATIENT SAFETY
Antimicrobial prescribing within PHT is prudent, appropriate and safe for both the patient and the
environment. Antimicrobials will be used wisely. Patients will not be exposed to unnecessary antimicrobial
therapy. Antibiotics must not be started in the absence of clinical evidence of bacterial infection.
2. DOCUMENTATION OF CLINICAL NEED TO PRESCRIBE ANTIMICROBIALS
The clinical indication, duration or review date, route of administration and dose all need to be clearly
documented on the prescription chart and in the medical notes
3. CORRECT DOSING AND ADMINISTRATION
Antimicrobials will be administered at the most appropriate dose for treatment of infection taking into account
modifications required for renal and/or liver dysfunction. Antibacterials must be started within one hour if a
patient is suspected as having severe sepsis or septic shock or neutropaenic sepsis. All aminoglycoside and
glycopeptide antimicrobials will be administered and monitored according to local Trust guidelines.
Antimicrobials will be administered via the most appropriate route for the clinical presentation.
4. MICROBIOLOGY SUPPORT FOR ANTIMICROBIAL PRESCRIBING
Appropriate microbiological samples will be taken prior to the commencement of antimicrobial therapy. The
results of these cultures will be used to rationalise the empirical prescription in the individual, to guide future
empirical therapy advice and for surveillance purposes. Appropriate antimicrobial sensitivity testing will be
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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carried out by the laboratory on clinical specimens received. A range of sensitivities will be released allowing
the clinician a reasonable choice of targeted antibiotic treatments.
5. REVIEW OF ANTIMICROBIAL PRESCRIPTIONS WITH CLEAR PRESCRIBING PLAN BY 48 HOURS
By 48 hours a clear antimicrobial prescribing plan should document whether antimicrobial therapy is to
continue, change, stop, switch or be delivered by OPAT, i.e. an antimicrobial prescribing decision must
be made and documented in the clinical notes by 48 hours. This plan will be guided by clinical progress and
results of investigations including blood and culture results. Intravenous to oral switch must be considered
wherever possible so avoiding the risks associated with intravenous cannulation including iatrogenic
bloodstream infection and thrombosis.
6. PREFERENTIAL USE OF NARROW SPECTRUM ANTIMICROBIALS
Antimicrobial therapy should be targeted to treat the specific infection using as narrow-spectrum an
antimicrobial agent as is possible. Certain broad spectrum or tertiary antibacterials will only be prescribed
with microbiology approval (see appendix 1; Restricted antimicrobial agents).
7. APPROPRIATE DURATION OF THERAPY
Antimicrobials will be prescribed for as short a time period as possible. The duration of antimicrobial therapy
depends on the infecting organism(s), the site of the infection, the patient’s own immune response and other
additional features such as surgical and medical interventions. Each antimicrobial prescription needs to be
assessed on a daily basis and the review documented in the clinical notes.
8. AVAILABLE GUIDANCE FOR ANTIMICROBIAL PRESCRIBING
Antimicrobials will be prescribed following referenced guidelines which are available to the prescriber at the
point of care in electronic format. These guidelines will be evidence based and written by a clinician with
expertise in the area with local epidemiological knowledge. Current guidelines available on the PHT intranet
are listed in appendix 2. Each registered prescriber will be issued with a pocket guide for empirical
antimicrobial prescribing at Trust induction or at mandatory annual Infection Prevention and Control updates,
(see appendix 3). Further advice on antimicrobial prescribing can be obtained from the British National
Formulary.
9. SUPPORT AND EDUCATION FOR MANAGEMENT OF INFECTION
Antimicrobial prescribing is supported by regular (usually weekly) antimicrobial ward rounds carried out by
microbiology in liaison with pharmacy across all acute clinical areas. Education to the junior doctors will be
provided on these ward rounds.
A regular program of infection updates is included in the F1/F2 junior doctor’s training.
Education to senior clinicians will take place via core training programs and annual infection control updates.
In addition, infection advice is available from a consultant microbiologist 24 hours a day, 7 days a week.
Requirements for fulfilment of policy
 Sufficient numbers of qualified pharmacists to allow all prescription charts to be reviewed on a regular
basis
 1.0 WTE band 8a pharmacist(s) acting as the lead antimicrobial pharmacist(s) for the Trust
 Adequately resourced microbiology laboratory with quality assurance procedures in place.
 Sufficient numbers of microbiologists or infection specialists to allow regular antimicrobial ward rounds.
Royal College of Pathologists guidance from 2001 states that for our current population (520,000) and
renal specialist services there should be 4.0 WTE consultant microbiologists. This guidance predates
the expansion of Infection Prevention targets. There are currently 3.45 WTE consultant microbiologists
 Adequately resourced infection prevention and control team to support education and surveillance on
antimicrobial resistance and nosocomial infection.
 Access for all staff in all clinical areas to computer-based and paper-based up-to-date guidelines and
current copies of the British National Formulary.
 Senior clinical support in all clinical areas to allow regular (mostly daily) review of all antimicrobial therapy
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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6. TRAINING REQUIREMENTS
 All antimicrobial prescribers need to familiarize themselves with the Antimicrobial prescribing guidelines
available on the intranet at http://pharmweb/MedicinesInformation/Guidelines/alpha.aspx
 All new medical staff will receive antimicrobial prescribing guidance from the Trust’s antimicrobial
pharmacists at induction and will be given an empirical antimicrobial prescribing guide as laminated card.
 All medical staff need to complete an annual update on infection prevention and control which includes
emphasis on appropriate antimicrobial prescribing
 There is an electronic antimicrobial prescribing update available for all prescribers and all new medical
staff.
 Anyone who fails to complete the mandatory training will be managed by their line manager in liaison
with Human Resources using the Trust Capability Policy
7. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Livermore DM. Has the era of untreatable infections arrived? J Antimicrob Chemother. 2009;64(Suppl
1):29-36
2. Hawkey, P., Jones, A. The Changing Epidemiology of Resistance. J Antimicrob Chemother. 2009;
64:Suppl 1:i3–10
3. Department of Health’s advisory committee on Antimicrobial Resistance and Healthcare associated
Infection (ARHAI), Antimicrobial stewardship “Start smart, then focus”, November 2011
4. Davey, P., E. Brown, L. Fenelon, R. Finch, I. Gould, G. Hartman, A. Holmes, C. Ramsay, E. Taylor, M.
Wilcox, and P. Wiffen. 2005. Interventions to improve antibiotic prescribing practices for hospital
inpatients. Cochrane Database Syst. Rev.19:CD003543
5. Dellit TH, Owens RC, McGowan JE et al. Infectious Diseases Society of America and the Society for
Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance
Antimicrobial Stewardship. Clin Infect Dis. 2007;44:159-77.
6. Department of Health Chief Medical Officer. Winning ways: Working together to reduce healthcare
associated infection in England. London: Department of health, 2003.
7. World Health Organisation (2001). WHO Global Strategy for containment of antimicrobial resistance.
WHO, Geneva, Switzerland.
8. Surviving Sepsis Campaign: International Guidelines for the Management of Severe Sepsis and Septic
Shock 2012. Dellinger RP et al. and the surviving sepsis campaign guideline committee including the
paediatric subgroup. Critical Care Medicine 2013; 41(2): 580-637
8. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
PROCEDURAL DOCUMENTS
A minimum of 2 antimicrobial prescribing audits will be carried out each year under the supervision of the
antibiotic pharmacist and the Consultant Microbiologists. Results of these audits will be reported to the
Trust via the Infection Prevention and Control Management Committee and the Antimicrobial Management
Group. An annual Trust wide point prevalence audit will be carried out by microbiology and pharmacy.
Suggested audit targets are outlined below.
 90-100% of antimicrobials prescribed are clinically warranted
 90-100% of antimicrobial use is documented in the patient’s notes
 90-100% of antimicrobial prescribing is in accordance with local guidelines
 90-100% of antimicrobials prescribed are prescribed at the correct dose
 90-100% of antimicrobials prescribed are prescribed via the most appropriate route with intravenous to
oral switch following local guidance
 90-100% of antimicrobials prescribed which require blood levels are monitored appropriately
 0-10% of antimicrobials are prescribed for longer than is necessary
 90-100% of patients and their prescription charts are reviewed daily by the clinical team
 90-100% of health care workers have an annual infection control update including antimicrobial
prescribing
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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Appendix 1:
Antimicrobial agents restricted for consultant physician approval (within 24 hours)
Ciprofloxacin (intravenous or oral)
Ertapenem
Meropenem
Antimicrobial agents restricted for consultant microbiologist approval only
Daptomycin
Linezolid
Temocillin
Tigecycline
Voriconazole
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Appendix 2:
Current (2013) Portsmouth Hospitals NHS Trust antimicrobial therapy guidelines available on the
intranet
Antibiotic prophylaxis in surgery
Antimicrobial guidance for the Intensive Care Unit
Cellulitis and erysipelas
Clostridium difficile management guideline
Diabetic foot infection guidance
Head and neck empirical antimicrobial guidelines for adults
Infective endocarditis treatment in adults
Intravenous vancomycin
IV to oral switch
Metronidazole compatibility with other IV antibiotics
Neutropaenic sepsis in adults
Once daily gentamicin administration in adults
Pneumonia, community acquired
Pneumonia, hospital acquired
Pregnancy sepsis screening tool
Prevention of sepsis in asplenic and hyposplenic adult patients
Treatment of cellulitis
Urinary tract infections
Appendix 3:
PHT empirical antimicrobial prescribing guide for adults admitted to general medical and surgical
wards
PHT empirical antimicrobial prescribing guideline for adults
UTI Trimethoprim 200mg bd po (add once daily gentamicin if septic)
Inf exac COPD Doxycycline 200mg od (2nd line amox 500mg tds po)
CAP (mild-moderate) Amoxicillin 500mg-1g tds po OR Clarithromycin 500mg bd po
CAP (severe, CURB-65 3) Benpen 2.4g stat then 1.2-2.4g qds iv + Doxycycline 200mg stat then od po/
ng OR Benpen 2.4g stat then 1.2-2.4g qds iv + iv Clarithromycin 500mg bd
If penicillin allergic: Chloramphenicol iv 12.5mg/kg qds iv (max 1g qds) for 5/7
HAP (severe) Piperacillin/taz 4.5g tds iv OR Chloramphenicol*12.5mg/kg qds iv (max 1g qds) for 5/7
Cellulitis (severe) Fluclox 1g qds iv, (clindamycin* 300mg qds) Vancomycin if known MRSA +ve
Bone / joint Flucloxacillin 2g qds iv OR (cefuroxime 1.5g tds iv)*
GI / biliary sepsis Co-amoxiclav po/iv OR (cefuroxime 750mg tds iv +/- metronidazole 500mg tds*) iv
C difficile Severe - vancomycin 125mg qds po. Non severe - metronidazole 400mg tds po
Neutropenic sepsis Piperacillin/tazobactam 4.5g tds iv (Ceftazidime 1-2g tds iv*)
Meningitis Ceftriaxone* 2g bd iv (+ aciclovir 10mg/kg tds iv if HSV encephalitis)
SBP Piperacillin/taz 4.5g tds iv, (if pen allergic* use Cefotaxime 2g tds iv)
*recommended for penicillin allergic patients, if severe or anaphylactic response contact micro.
Portsmouth Hospitals NHS Trust Antimicrobial Prescribing Policy Version 6 Issue Date 4 March 2013
Review Date 1st January 2015
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