Appropriate and prudent use of antimicrobials is important. Antibiotics are overused and not without risk, 1 in 5 courses are associated with adverse events including Clostridium difficile infection, antibiotic resistance (e.g. MRSA, Meticillin Resistant Staphylococcus aureus), drug interactions, drug toxicity, device related infections, Staphylococcus aureus bacteraemia (SAB). Misuse of these agents is also associated with treatment failure and increasing cost to NHSGGC. The following guidelines and policy documents aim to ensure appropriate, prompt and prudent use of antimicrobials within NHSGGC:
These guidelines are reviewed and updated at regular intervals. The most up to date information can be found on the NHSGGC Clinical Guidelines Directory / Adult Infection Management section. There are separate guidelines for infection management in primary care and in paediatrics.
Antibiotics are overused, particularly in elderly patients, those with urinary catheters/bacteria in their urine but no signs or symptoms of urinary tract infection and patients with viral or non-infective exacerbations of COPD.
To ensure appropriate and prudent antimicrobial prescribing follow the steps below:
The definition of sepsis can be found here. Early recognition and management is key to improving outcomes for patients. Patients with infection and evidence of organ dysfunction have sepsis which has 10% hospital mortality. These patients are therefore at high risk of acute deterioration and death and consideration should be given to managing these patients in a high dependency / critical care setting. The Quick Sequential Organ Failure Assessment (qSOFA) score (see figure 1) is a simple bedside clinical score using 3 criteria to rapidly identify patients with suspected infection who are more likely to have poor outcomes typical of sepsis. Always consider COVID-19 as a differential diagnosis in a febrile patient. In patients with sepsis, or severe infection, aim to complete the "Sepsis 6" (see figure 2) within 1 hour.
HIV testing is advisable in:
Prescribe IV only for those with severe / deep seated infections, sepsis syndrome (see Severe Systemic Infections) or if the oral route is unavailable. Review IV antibiotics daily and switch to oral when appropriate (see IV-Oral Antibiotic Switch Therapy (IVOST). See here for indications for initial IV route of antibiotics.
Clostridium difficile infection (CDI) is an important healthcare associated infection in Scottish hospitals. It is life-threatening (reported mortality rate 10-30%) and has the potential for person to person spread within healthcare settings. Particularly at risk are patients who are aged >65 years, frail, immunocompromised or who have chronic obstructive pulmonary disease or cardiovascular disease.
Antibiotic therapy disturbs the normal gastrointestinal flora, depleting organisms which are protective against CDI. Any antibiotic may be associated; those associated most commonly are listed below. Other broad spectrum agents (particularly the carbapenems) are also likely to show an association as prescribing increases. Overall antibiotic exposure, including excessive duration of therapy is also a risk factor for CDI as is surgical prophylaxis (with cephalosporins and quinolones). Proton pump inhibitors and H2 antagonists also increase gastric pH which is associated with an increase in the risk of Clostridium difficile acquisition.
The GG&C antimicrobial guidelines are designed to reduce the risk of CDI by limiting overall antibiotic exposure (reduced prescriptions and duration of therapy) and by limiting those agents which have the strongest association.
Guideline reviewed June 2021
Page updated March 2022