ALERT ANTIMICROBIAL GUIDANCE For ADULT PATIENTS

‘ALERT’ ANTIMICROBIAL GUIDANCE for ADULT PATIENTSResistance to antimicrobials is recognised nationally and internationally as a major threat to public health and patient safety. Using agents less likely to select for resistance can delay theemergence of resistant strains. It is known that a significant proportion of antimicrobial usage in hospitals is inappropriate because of excessive use or incorrect choice. All hospitals in NHSScotland must have an ‘alert’ or ‘restricted’ antimicrobial policy to meet guidance from the Scottish Antimicrobial Prescribing Group and HAI Standards.The antimicrobials in this NHS Tayside guidance have been chosen as they are considered to be those that are most frequently irrationally prescribed, increased risk of toxicity or should bereserved for occasions where there are clear microbiological indications e.g. multi resistant organisms. The NHS Tayside Antimicrobial Management Group routinely adds all newantimicrobials to this guidance.There are 3 categories: Routine use on empirical guidelines, approved use within specific treatment guidelines, use that requires approval. Any member of clinicalstaff can identify an ‘alert’ antimicrobial on a patient’s medicine chart and if not prescribed in line with guidance request that the medical team review and discuss with ID or Microbiology. Ifthe team do not seek advice they can be referred directly by clinical pharmacist to the Antimicrobial Team. Refer to MicroMan for guidance on microbiological cover usually provided by theseantimicrobials.RESTRICTEDAGENTUse withinEMPIRICAL GUIDELINESUse within SPECIFIC TREATMENTGUIDELINES‘ANTIBIOTIC MAN’GENTAMICINTreatment doseHartford regimeSevere hospital acquired or aspirationpneumoniaUse that requiresID OR MICROBIOLOGY APPROVALMany indicationsRequires approval by ID/Micro if IV gentamicin required 72 hours BEFORECONTACTING first ensure review of: microbiology results consider IVOST consider alternative e.g. aztreonamAppropriate Use of Aztreonam - As an alternative forpatients who have reduced renal function or have had 72hours of gentamicin and require further IV treatmentAll other indications must be approved by ID/MicroIntra-abdominal sepsis includingpancreatitisUrosepsisSepsis unknown sourceAZTREONAMDoes not providesame level of gramnegative cover asgentamicin. No grampositive or anaerobicor ESBL cover.MEROPENEMOveruse increasesrisk of multi drugresistant gramnegative bacteriaConsidercarbapenem sparingagentsDoes not requireadditional anaerobiccoverAdult Cystic FibrosisNeutropenic sepsis in patients with penicillin allergyUrology Surgical ProphylaxisVascular Infection GuidanceEndocarditis in native valve sepsis AND risk factors forresistant pathogensITU guidanceNeutropenic sepsisAdult Cystic FibrosisNTM (Non- tuberculous mycobacterial) infection – priordiscussion at Respiratory Complex Infection MDTALL OTHER INDICATIONS MUST beapproved by ID/MicroThere is particular concern regarding over use ofcarbapenems nationally and internationally. Locallyuse is monitored very closely and any patientsidentified on meropenem will be referred for ID/Microreview.All patients (except ITU/SHDU/Haem/Paeds/CF) shouldbe notified to Antimicrobial Team:Tay-UHB.antibioticpharm@nhs.net

RESTRICTEDAGENTPIPERACILLIN/TAZOBACTAMOveruse increasesrisk of multi drugresistant gramnegative bacteriaUse withinEMPIRICAL GUIDELINES‘ANTIBIOTIC MAN’Spontaneous bacterial peritonitisUse within SPECIFIC TREATMENT GUIDELINESENT guidance for skull base osteomyelitisNeutropenic sepsisITU guidanceAdult Cystic FibrosisCellulitis – for Fournier’s gangreneMaternal sepsisVascular Infection GuidanceBronchiectasis – sputum culture positive for PseudomonasUse that requiresID OR MICROBIOLOGY APPROVALALL OTHER INDICATIONS MUST be approved byID/MicroDoes not requireadditional anaerobiccoverERTAPENEMNot active againstPseudomonasCan ONLY be used if approved by ID/MicroAMIKACINNTM (Non- tuberculous mycobacterial) infection – priordiscussion at Respiratory Complex Infection MDTCan ONLY be used if approved by ID/MicroCIPROFLOXACINORAL/IVAdult Cystic FibrosisOral: Bronchiectasis exacerbation and sputum culturepositive for PseudomonasOral: COPD exacerbation and sputum culture positive forPseudomonasOral step down for specific infections – severe penicillinallergy AND renal impairmentEpidymo-orchitisAcute Bacterial ProstatitisLower UTI in CKD 4/5Post renal transplant stent removalUrology Surgical ProphylaxisITU guidanceENT guidance for skull base osteomyelitis step down to oralfollowing prolonged IV therapyNeutropenic sepsis in patients with penicillin allergyHaematology/Oncology – prophylaxis for specificchemotherapy regimensOrthopaedic Prophylaxis – Revision surgery first doseProsthetic Joint InfectionShunt associated or post op meningitis/ventriculitisMeningococcal contact prophylaxis – single doseMaternal sepsisALL OTHER INDICATIONS MUST be approved byID/MicroIncreased risk of CDIFQ warningsOral formulation hashigh bioavailability

RESTRICTEDAGENTLEVOFLOXACINIVIncreased risk of CDIFQ warningsUse withinEMPIRICAL GUIDELINES‘ANTIBIOTIC MAN’Use within SPECIFIC TREATMENT GUIDELINESSevere community acquiredpneumonia in penicillin allergy or travelabroad (legionella pneumonia)LEVOFLOXACINORAL Increased riskUse that requiresID OR MICROBIOLOGY APPROVALALL OTHER INDICATIONS MUST be approved byID/MicroH pylori infection in specific patients with penicillin allergyAND macrolide or quinolone exposureALL OTHER INDICATIONS MUST be approved byID/MicroTuberculosis/Non tuberculous mycobacterial infections(ID/Respiratory recommendation only)Can ONLY be used if approved by ID/MicroPelvic Inflammatory DiseaseEpidymo-orchitis/Acute Bacterial ProstatitisALL OTHER INDICATIONS MUST be approved byID/MicroOrbital Cellulitis/Skullbase OsteomyelitisPelvic Inflammatory DiseasePregnancy severe UTI if penicillin allergicOHPAT ServiceBrain AbscessAdult Cystic Fibrosis GuidancePD peritonitisPost operative/Post trauma/Shunt associated meningitisBronchiectasis – sputum culture positive for PseudomonasALL OTHER INDICATIONS MUST be approved byID/Microof CDI FQ warningsOral formulation hashigh bioavailabilityMOXIFLOXACINORAL/IVIncreased risk of CDIFQ warningsOral formulation hashigh bioavailabilityOFLOXACINORAL/IVIncreased risk of CDIFQ warningsOral formulation hashigh bioavailabilityCEFTRIAXONECEFTAZIDIMEEmpirical treatment of MeningitisEpiglottitis/SupraglottitisALL OTHER INDICATIONS MUST be approved byID/Micro

RESTRICTEDAGENTTEMOCILLINActive against ESBLsbut notPseudomonas spp.No gram positive oranaerobic cover.Use withinEMPIRICAL GUIDELINES‘ANTIBIOTIC MAN’Use within SPECIFIC TREATMENT GUIDELINESITU guidanceEmpirical Infection in Renal PatientsAdult Cystic Fibrosis GuidanceDAPTOMYCINDALBAVANCINLINEZOLIDVascular Infection GuidanceVentilator Associated PneumoniaOral formulation hashigh bioavailabilityUse that requiresID OR MICROBIOLOGY APPROVALALL OTHER INDICATIONS MUST be approved byID/MicroCan ONLY be used if approved by ID/Micro- refer to prescribing guidanceCan ONLY be used if approved by ID/MicroALL OTHER INDICATIONS MUST be approved byID/Micro – refer to prescribing guidance There is no longera requirement to complete a Mandatory Order Form.TEDIZOLIDCan ONLY be used if approved by ID/MicroNot routinely kept inNHS TaysideTIGECYCLINENTM (Non- tuberculous mycobacterial) infection – priordiscussion at Respiratory Complex Infection MDTCan ONLY be used if approved by ID/Micro- note FDA warningTEICOPLANINNeutropenic sepsisOHPAT ServiceAdult Cystic Fibrosis GuidanceProsthetic Joint InfectionGroup B Strep prophylaxis in pregnancyALL OTHER INDICATIONS MUST be approved byID/MicroFOSFOMYCIN IVFIDAXOMICINCan ONLY be used if approved by ID/Micro includingtreatment of Cystic Fibrosis patientsCan ONLY be used if approved by ID/Micro- refer to recurrent CDI guidance

RESTRICTEDAGENTUse withinEMPIRICAL GUIDELINES‘ANTIBIOTIC MAN’Use within SPECIFIC TREATMENT GUIDELINESUse that requiresID OR MICROBIOLOGY APPROVALCEFAZOLINCan ONLY be used if approved by ID/MicroNo activity againstMRSA/Enterococcus/Anaerobes/Pseudomonas sppStock kept in hospital pharmacyCEFEPIMECan ONLY be used if approved by ID/MicroActive against grampositive and gramnegative bacteriaincludingPseudomonas spp.but not reliable forESBLs.Limited activityagainst MRSA/Enterococcus/Anaerobes.CEFTOBIPROLEActive against MRSAand gram negativebacteria includingPseudomonas spp.CEFTAZIDIME/AVIBACTAM(ZAVICEFTA)Active against gramnegative bacteriaincludingPseudomonas sppand ESBLsCEFTOLAZONE/TAZOBACTAM(ZEBAXA)NOT routinely stocked in hospital pharmacy – requires to beordered.Can ONLY be used if approved by ID/Micro- only approved locally for hospital acquired pneumonia (notventilator associated or community acquired) in patient withmultiple allergies/intolerances where all other antimicrobials havebeen considered and activity against MRSA and gram negativebacteria are required.NOT routinely stocked in hospital pharmacy – requires to beordered.Can ONLY be used if approved by ID/Micro- non submission to SMC so not approved nationally. Approvedlocally for ID/Micro use only for patients with multi drug resistantgram negative infections. Licensed for IA/UTI/HAP/VAP infections.No gram positive or anaerobic cover.Small quantity kept in stock in hospital pharmacy.Can ONLY be used if approved by ID/Micro- not recommended by SMC so not approved nationally. Approvedlocally for ID/Micro use only for patients with multi drug resistant

Active against gramnegative bacteriaincludingPseudomonas sppand ESBLsgram negative infections. Licensed for IA/UTIinfections.MEROPENEM/VABORBACTAM(VABOREM)Can ONLY be used if approved by ID/MicroNOT kept as stock in hospital pharmacy.Licensed for IA/UTI/HAP/VAP infections.Active against certainKPC producingcarbapenemresistantEnterobacteriaceaeNOT kept as stock in hospital pharmacy.CEFOXITINNTM (Non- tuberculous mycobacterial) infection – priordiscussion at Respiratory Complex Infection MDTCan ONLY be used if approved by ID/MicroIMIPENEM/CILASTATINNTM (Non- tuberculous mycobacterial) infection – priordiscussion at Respiratory Complex Infection MDTCan ONLY be used if approved by AZOLEPOSACONAZOLEISAVUCONAZOLEAMPHOTERICINCan ONLY be used if approved by ID/MicroHaematology Antifungal GuidanceAntifungal Guidance – invasive infections in nonhaematology/oncology patientsALL OTHER INDICATIONS MUST be approved byID/Micro – refer to guidanceRespiratory Aspergillosis Guidance (ABPA/CPA) – guidanceunder developmentUpdated: June 2019Review: June 2022Amended: Aug 2020 (Cefoxitin/Imipenem added)Amended: Oct 2020 (Cefazolin/Vaborem added)Amended: Feb 2021 (Cefepime/Colistin added)

Neutropenic sepsis in patients with penicillin allergy Haematology/Oncology – prophylaxis for specific chemotherapy regimens Orthopaedic Prophylaxis – Revision surgery first dose Prosthetic Joint Infection Shunt associated or post op meningitis/ventriculitis Meningococcal contact prophylaxis – single dose Maternal sepsis