Guidance

Recommendations

Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See how we develop NICE guidelines for more details.

This guideline should be read in conjunction with NICE's guideline on antimicrobial stewardship: changing risk-related behaviours in the general population and the NICE guidance on managing common infections.

Terms used in this guideline

Antimicrobial stewardship

The term 'antimicrobial stewardship' is defined as 'an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness'.

Antimicrobial resistance

The term 'antimicrobial resistance' is defined as the 'loss of effectiveness of any anti‑infective medicine, including antiviral, antifungal, antibacterial and antiparasitic medicines'.

Antimicrobials and antimicrobial medicines

The term 'antimicrobials' and 'antimicrobial medicines' includes all anti‑infective therapies, (antiviral, antifungal, antibacterial and antiparasitic medicines) and all formulations (oral, parenteral and topical agents).

Organisations

The term 'organisations' (also known as the 'service') is used to include all commissioners (clinical commissioning groups and local authorities) and providers (hospitals, GPs, out‑of‑hours services, dentists and social enterprises) of health or social care services, unless specified otherwise. Occasionally, in order to make a recommendation more specific to the intended care setting, the setting is specified; for example, the recommendation will state 'hospital'.

Health and social care practitioners

The term 'health and social care practitioners' is used to define the wider care team, including but not limited to, case managers, care coordinators, GPs, hospital doctors, microbiologists, pharmacists, nurses and social workers.

1.1 All antimicrobials

Recommendations for organisations (commissioners and providers)

Antimicrobial stewardship programmes
1.1.1

Commissioners should ensure that antimicrobial stewardship operates across all care settings as part of an antimicrobial stewardship programme.

1.1.2

Establish an antimicrobial stewardship programme, taking account of the resources needed to support antimicrobial stewardship across all care settings.

1.1.3

Consider including the following in an antimicrobial stewardship programme:

  • monitoring and evaluating antimicrobial prescribing and how this relates to local resistance patterns

  • providing regular feedback to individual prescribers in all care settings about:

    • their antimicrobial prescribing, for example, by using professional regulatory numbers for prescribing as well as prescriber (cost centre) codes

    • patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable life‑threatening infections, infections with Clostridium difficile or adverse drug reactions such as anaphylaxis

  • providing education and training to health and social care practitioners about antimicrobial stewardship and antimicrobial resistance

  • integrating audit into existing quality improvement programmes.

1.1.4

Ensure that roles, responsibilities and accountabilities are clearly defined within an antimicrobial stewardship programme.

1.1.5

Involve lead health and social care practitioners in establishing processes for developing, reviewing, updating and implementing local antimicrobial guidelines in line with national guidance and informed by local prescribing data and resistance patterns.

1.1.6

Consider developing systems and processes for providing regular updates (at least every year) to individual prescribers and prescribing leads on:

  • individual prescribing benchmarked against local and national antimicrobial prescribing rates and trends

  • local and national antimicrobial resistance rates and trends

  • patient safety incidents related to antimicrobial use, including hospital admissions for potentially avoidable life‑threatening infections, infections with C. difficile or adverse drug reactions such as anaphylaxis.

1.1.7

Consider developing systems and processes for identifying and reviewing whether hospital admissions are linked to previous prescribing decisions in patients with potentially avoidable infections (for example, Escherichia coli bacteraemias, mastoiditis, pyelonephritis, empyema, quinsy or brain abscess).

Antimicrobial stewardship teams
1.1.8

Organisations establishing antimicrobial stewardship teams should ensure that the team has core members (including an antimicrobial pharmacist and a medical microbiologist) and can co-opt additional members depending on the care setting and the antimicrobial issue being considered.

1.1.9

Support antimicrobial stewardship teams, by developing processes that promote antimicrobial stewardship or by allocating resources, to:

  • review prescribing and resistance data and identify ways of feeding this information back to prescribers in all care settings

  • promote education for prescribers in all care settings

  • assist the local formulary decision‑making group with recommendations about new antimicrobials

  • update local formulary and prescribing guidance

  • work with prescribers to explore the reasons for very high, increasing or very low volumes of antimicrobial prescribing, or use of antimicrobials not recommended in local (where available) or national guidelines

  • provide feedback and advice to prescribers who prescribe antimicrobials outside of local guidelines when it is not justified.

Antimicrobial stewardship interventions

1.1.10

Consider using the following antimicrobial stewardship interventions:

  • review of prescribing by antimicrobial stewardship teams to explore the reasons for increasing, very high or very low volumes of antimicrobial prescribing, or use of antimicrobials not recommended in local (where available) or national guidelines

  • promotion of antimicrobials recommended in local (where available) or national guidelines

  • IT or decision support systems

  • education‑based programmes for health and social care practitioners, (for example, academic detailing, clinical education or educational outreach).

1.1.11

Consider providing IT or decision support systems that prescribers can use to decide:

  • whether to prescribe an antimicrobial or not, particularly when antimicrobials are frequently prescribed for a condition but may not be the best option

  • whether alternatives to immediate antimicrobial prescribing may be appropriate (for example, back‑up [delayed] prescribing or early review if concerns arise).

1.1.12

Consider developing systems and processes to ensure that the following information is provided when a patient's care is transferred to another care setting:

  • information about current or recent antimicrobial use

  • information about when a current antimicrobial course should be reviewed

  • information about who a patient should contact, and when, if they have concerns about infection.

1.1.13

Consider prioritising the monitoring of antimicrobial resistance, to support antimicrobial stewardship across all care settings, taking into account the resources and programmes needed.

1.1.14

Consider supplying antimicrobials in pack sizes that correspond to local (where available) and national guidelines on course lengths.

1.1.15

Consider evaluating the effectiveness of antimicrobial stewardship interventions by reviewing rates and trends of antimicrobial prescribing and resistance.

Communication

1.1.16

Encourage and support prescribers only to prescribe antimicrobials when this is clinically appropriate.

1.1.17

Encourage health and social care practitioners across all care settings to work together to support antimicrobial stewardship by:

  • communicating and sharing consistent messages about antimicrobial use

  • sharing learning and experiences about antimicrobial resistance and stewardship

  • referring appropriately between services without raising expectations that antimicrobials will subsequently be prescribed.

1.1.18

Consider developing local networks across all care settings to communicate information and share learning on:

  • antimicrobial prescribing

  • antimicrobial resistance

  • patient safety incidents.

1.1.19

Consider developing local systems and processes for peer review of prescribing. Encourage an open and transparent culture that allows health professionals to question antimicrobial prescribing practices of colleagues when these are not in line with local (where available) or national guidelines and no reason is documented.

1.1.20

Encourage senior health professionals to promote antimicrobial stewardship within their teams, recognising the influence that senior prescribers can have on prescribing practices of colleagues.

1.1.21

Raise awareness of current local guidelines on antimicrobial prescribing among all prescribers, providing updates if the guidelines change.

Laboratory testing

1.1.22

Ensure that laboratory testing and the order in which the susceptibility of organisms to antimicrobials is reported is in line with:

  • national and local treatment guidelines

  • the choice of antimicrobial in the local formulary

  • the priorities of medicines management and antimicrobial stewardship teams.

Recommendations for prescribers and other health and social care practitioners

Antimicrobial guidelines
1.1.23

Health and social care practitioners should support the implementation of local antimicrobial guidelines and recognise their importance for antimicrobial stewardship.

Recommendations for prescribers

Antimicrobial prescribing
1.1.24

When prescribing antimicrobials, prescribers should follow local (where available) or national guidelines on:

  • prescribing the shortest effective course

  • the most appropriate dose

  • route of administration.

1.1.25

When deciding whether or not to prescribe an antimicrobial, take into account the risk of antimicrobial resistance for individual patients and the population as a whole.

1.1.26

When prescribing any antimicrobial, undertake a clinical assessment and document the clinical diagnosis (including symptoms) in the patient's record and clinical management plan.

1.1.27

For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available.

1.1.28

For patients in primary care who have recurrent or persistent infections, consider taking microbiological samples when prescribing an antimicrobial and review the prescription when the results are available.

1.1.29

For patients who have non‑severe infections, consider taking microbiological samples before making a decision about prescribing an antimicrobial, providing it is safe to withhold treatment until the results are available.

1.1.31

Prescribers should take time to discuss with the patient and/or their family members or carers (as appropriate):

  • the likely nature of the condition

  • why prescribing an antimicrobial may not be the best option

  • alternative options to prescribing an antimicrobial

  • their views on antimicrobials, taking into account their priorities or concerns for their current illness and whether they want or expect an antimicrobial

  • the benefits and harms of immediate antimicrobial prescribing

  • what they should do if their condition deteriorates (safety netting advice) or they have problems as a result of treatment

  • whether they need any written information about their medicines and any possible outcomes.

1.1.32

When an antimicrobial is a treatment option, document in the patient's records (electronically wherever possible):

  • the reason for prescribing, or not prescribing, an antimicrobial

  • the plan of care as discussed with the patient, their family member or carer (as appropriate), including the planned duration of any treatment.

1.1.33

Do not issue an immediate prescription for an antimicrobial to a patient who is likely to have a self‑limiting condition.

1.1.34

If immediate antimicrobial prescribing is not the most appropriate option, discuss with the patient and/or their family members or carers (as appropriate) other options such as:

  • self‑care with over‑the‑counter preparations

  • back‑up (delayed) prescribing

  • other non‑pharmacological interventions, for example, draining the site of infection.

1.1.35

When a decision to prescribe an antimicrobial has been made, take into account the benefits and harms for an individual patient associated with the particular antimicrobial, including:

  • possible interactions with other medicines or any food and drink

  • the patient's other illnesses, for example, the need for dose adjustment in a patient with renal impairment

  • any drug allergies (see the NICE guideline on drug allergy; these should be documented in the patient's record)

  • the risk of selection for organisms causing healthcare‑associated infections, for example, C. difficile.

1.1.36

When prescribing is outside local (where available) or national guidelines, document in the patient's records the reasons for the decision.

1.1.37

Do not issue repeat prescriptions for antimicrobials unless needed for a particular clinical condition or indication. Avoid issuing repeat prescriptions for longer than 6 months without review and ensure adequate monitoring for individual patients to reduce adverse drug reactions and to check whether continuing an antimicrobial is really needed.

Prescribing intravenous antimicrobials
1.1.38

Use an intravenous antimicrobial from the agreed local formulary and in line with local (where available) or national guidelines for a patient who needs an empirical intravenous antimicrobial for a suspected infection but has no confirmed diagnosis.

1.1.39

Consider reviewing intravenous antimicrobial prescriptions at 48–72 hours in all health and care settings (including community and outpatient services). Include response to treatment and microbiological results in any review, to determine if the antimicrobial needs to be continued and, if so, whether it can be switched to an oral antimicrobial.

1.2 New antimicrobials

Recommendations for organisations (commissioners and providers)

1.2.1

Consider establishing processes for reviewing national horizon scanning to plan for the release of new antimicrobials.

1.2.2

Consider using an existing local decision‑making group (for example, a drug and therapeutics committee, area prescribing committee or local formulary decision‑making group) to consider the introduction of new antimicrobials locally. The group should include representatives from different care settings and other local organisations to minimise the time to approval.

1.2.3

Consider using multiple approaches to support the introduction of a new antimicrobial, including:

  • electronic alerts to notify prescribers about the antimicrobial

  • prescribing guidance about when and where to use the antimicrobial in practice

  • issuing new or updated formulary guidelines and antimicrobial prescribing guidelines

  • peer advocacy and advice from other prescribers

  • providing education or informal teaching on ward rounds

  • shared risk management strategies for antimicrobials that are potentially useful but may be associated with patient safety incidents.

1.2.4

Once a new antimicrobial has been approved for local use, organisations should consider ongoing monitoring by:

  • conducting an antimicrobial use review (reviewing whether prescribing is appropriate and in line with the diagnosis and local [where available] and national guidelines)

  • costing the use of the new antimicrobial

  • reviewing the use of non‑formulary antimicrobial prescribing

  • evaluating local prescribing and resistance patterns

  • reviewing clinical outcomes such as response to treatment, treatment rates, emerging safety issues, tolerability and length of hospital stay.

Recommendations for local decision-making groups

1.2.5

Consider co‑opting members with appropriate expertise in antimicrobial stewardship when considering whether to approve the introduction of a new antimicrobial locally; this may include those involved in the antimicrobial stewardship team (see also recommendation 1.1.8).

1.2.6

Ensure that local formularies, prescribing guidelines and care pathways are updated when new antimicrobials are approved for use.

1.2.7

When evaluating a new antimicrobial for local use and for inclusion in the local formulary, take into account:

  • the need for the new antimicrobial

  • its clinical effectiveness

  • the population in which it will be used

  • the specific organisms or conditions for which it will be used

  • dose, dose frequency, formulation and route of administration

  • likely tolerability and adherence

  • any drug interactions, contraindications or cautions

  • local rates and trends of resistance

  • whether use should be restricted and, if so, how use will be monitored

  • any additional monitoring needed

  • any urgent clinical need for the new antimicrobial

  • any plans for introducing the new antimicrobial.

1.2.8

Local decision‑making groups should assess the benefits and risks of restricting access to a new antimicrobial.

1.2.9

If access to a new antimicrobial is restricted:

  • document the rationale for and the nature of the restriction, and ensure that this information is publicly available

  • review the restriction regularly to determine that it is still appropriate.

1.2.10

Ensure that there is a plan for the timely introduction, adoption and diffusion of a new antimicrobial when this has been recommended for use.

1.2.11

Discuss with commissioners early in the approval process if funding concerns for a new antimicrobial are likely to cause delay in its introduction, adoption and diffusion.