Good Practice in Antimicrobial Prescribing

The aim of this guidance is to promote appropriate antibiotic prescribing in order to minimise the risk of patients developing C. difficile infection and to reduce the development of multi-drug resistant bacteria, while at the same time adequately treating the infection that has been diagnosed.

This guidance is for empirical treatment.  Alternative antibiotics may be required if specific pathogens are identified or there is failure to respond.

Clostridioides difficile (formerly Clostridium difficile) infection is associated with the use of all antibiotics but most strongly with cephalosporins, co-amoxiclav, clindamycin and quinolones (ciprofloxacin, levofloxacin, moxifloxacin and ofloxacin) and it is particularly important to avoid these agents if at all possible. 

Antibiotics should be:

• used only when there is a definite indication – consider withholding therapy unless there is a clear signs of an infection          
• used for the shortest duration required to treat the infection         
• targeted at the most likely or known pathogens i.e. use as narrow a spectrum agent and rationalise as soon as microbiology results are available    
• stopped immediately if started inappropriately – i.e. a subsequent non-infectious diagnosis is made

Good Practice notes:

• Take cultures for microbiology before starting antibiotic therapy whenever possible.             
• The indication for prescribing antibiotics and the duration MUST be clearly documented in the patients’ case notes.
• Review all patients on a daily basis with a view to IV to oral switch.                                 
• The use of the ‘penicillin allergy’ option should only be used in patients with a true allergy to penicillin and this should be investigated fully.
• Doses quoted are for adults with normal renal function – separate guidance is available for children
• Before prescribing antibiotics always check for any potential drug interactions 
• Unless specifically mentioned, this guidance does not cover prescribing in pregnancy.  For appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, see BNF, BNF for Children and the Renal Drug Database (password access).
• Fluoroquinolones may be associated with increased risk of tendinitis and neurological side-effects, particularly in the elderly, patients with renal impairment or a solid organ transplant, or receiving corticosteroids. Do not prescribe ciprofloxacin for uncomplicated cystitis, or for minor or self-limiting infections, unless there is no clear alternative.

Adapted from NHS Fife with permission 7^th October 2019