antibiotics guidelines: obstetric anti infective

Obstetric Anti Infective Prescribing Guidelines Antibiotic Guidelines Reference Number: 144TD(C)25(J2) Version Number: 4 Issue Date: 11/12/2018 of 15

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Antibiotics Guidelines: Obstetric Anti-Infective

Prescribing Guidelines

Lead Author: Antibiotic Steering Committee

Additional author(s) Andrea Marrosu

Division/ Department:: DCSS & Tertiary Medicine

Applies to: Salford Royal Care Organisation

Date approved: 15/10/2018

Expiry date: October 2021

Contents

Contents

Section Page 1 What is the Guideline about? 3

2 Where will this document be used? 3

3 Why is this document important? 4

4 What is new in this version? 4

5 What is the Guideline?

5.1 Key Practice points 5

5.2 Empiric treatment for unknown source of maternal sepsis 5

5.3 Maternal sepsis – septic shock or failure to respond to 1st line treatment 6

5.4 Maternal sepsis (unknown origin) - Empiric oral step down 6

5.5 Maternal sepsis in group B strep colonised patient with penicillin allergy 6

5.6 Treatment of a secondary postpartum haemorrhage due to retained products

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5.7 Intra-abdominal infections – first line 7

5.8 Intra-abdominal infections – non response to first line treatment 7

5.9 Intra-abdominal infections – non response to first or second line treatment 8

5.10 Intra-abdominal infections – oral stepdown 8

5.11 Intra-abdominal infections – in group B strep colonised patient with penicillin allergy

8

5.12 Urinary Tract Infections 8

5.13 Post op wound infection – post delivery Clean-contaminated/contaminated-dirty surgery

8

5.14 Post op wound infection – post delivery Contaminated-dirty surgery or no response to 1st line

9

5.15 MRSA skin colonisation 9

5.16 Mastitis/breast abscess 1st line 9

5.17 Mastitis/breast abscess 2nd line 9

5.18 Gentamicin in pregnancy 10

6 Roles and responsibilities

7 Monitoring document effectiveness

8 Abbreviations and definitions

9 References and Supporting Documents

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)



10 Document Control Information

11 Equality Impact Assessment (EqIA) screening tool



1. What is this Guideline about? 1.1 This policy recommends antibiotic options for infections in obstetric patients. If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Where will this document be used?

2.1 This policy applies to all clinical staff involved in the prescribing of antimicrobials. NB – These guidelines are based on the Manchester University Foundation Trust (MFT) ‘Obstetrics anti-infective Prescribing guideline’ and are for patients receiving care at Salford Royal NHS Foundation Trust (inpatient or emergency department). If the patient is on the midwife-led unit then they should be managed according to Central Manchester antibiotic guidelines. 2.2 This document provides treatment guidelines for the most common situations in which antibiotic treatment is required. The products and regimens listed here have been selected by the Trust's Medicines Management Group on the basis of published evidence. Doses assume a weight of 60-80kg with normal renal and hepatic function. Adjustments may be needed for the treatment of some patients.

This document provides treatment guidelines for the appropriate use of antibiotics. The recommendations that follow are for empirical therapy and do not cover all clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20% of cases. Alternative recommendations will be made by the microbiologist in consultation with the clinical team. This document refers to the treatment of adult patients (unless otherwise stated). Refer to up to date BNF/SPC for information on interactions, side effects, cautions and contraindications for individual drugs.

In the case where an antibiotic prescription is necessary, probiotic therapy should be considered in order to reduce the risk of C. difficile infection

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)

http://intranet/policies-resources/trust-policy-documents/topics/antibiotic/antibiotic-prescribing-principles/144tdc25a4/



3. Why is this document important?

3.1 Antimicrobial agents are among the most commonly prescribed drugs and account for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to individual patients are compromised by the development of bacterial drug resistance. Resistance is a natural and inevitable result of exposing bacteria to antimicrobials. Good antimicrobial prescribing will help to reduce the rate at which antibiotic resistance emerges and spreads. It will also minimise the many side effects associated with antibiotic prescribing, such as Clostridium difficile infection. It should be borne in mind that antibiotics are not needed for simple coughs and colds. In some clinical situations, where infection is one of several possibilities and the patient is not showing signs of systemic sepsis, a wait and see approach to antibiotic prescribing is often justified while relevant cultures are performed. 3.2 Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use NICE guideline [NG15]

4. What is new in this version?

4.1 Choices for maternal and intra-abdominal sepsis updated in line with MFT guidelines:

Stat gentamicin dose added to all regimes (previously was only ‘considered’)

Once daily gentamicin added to IV clindamycin (previously only a stat dose) and metronidazole removed.

Options for oral step down in penicillin allergy removed and replaced with advice to contact microbiology as there are no ideal oral options.

Advice for penicillin allergic patients colonised with Strep B added. Flucloxacillin as option for post-operative wound infection in clean-contaminated surgery removed in line with MFT. Co-amoxiclav now recommended for both clean-contaminated and contaminated-dirty. Guidance for Genitourinary tract infections previously referred to the Trust’s Treatment Management Protocols for Sexually Transmitted Infections however this document no longer exists as the service has moved to Bolton NHS Foundation Trust, therefore the link to this has been removed and no treatment options are given.



5. Guideline

5.1 Key Practice Points

The recommendations below consider safety during pregnancy. For women who have given birth, the general Trust antibiotic guidelines may be followed, with consideration on safety in breast feeding if applicable. When considering treatment with antibacterial agents during pregnancy, the following factors should be considered: the severity of the maternal infection, the effects of any fever present on the pregnancy, the effects of failing to treat the mother, and the potential fetotoxicity of the medicines to be used. Where possible, the results of culture and sensitivity tests should be available before making a treatment choice, however treatment should NOT be delayed in patients who are unwell or septic. Administration of intravenous broad spectrum antibiotics is recommended within one hour of suspicion of severe sepsis, with or without septic shock. If genital tract sepsis is suspected, prompt early treatment with a combination of high-dose broad spectrum intravenous antibiotics may be lifesaving.

5.2 Empiric treatment for unknown source of maternal sepsis

Antibiotics Duration

1st line Co-amoxiclav IV 1.2g tds plus metronidazole IV 500mg tds (if intra-abdominal collection suspected) plus gentamicin stat

Review at 48 hours. If no improvement consider if collections present Total course length 7 - 10 days

Penicillin allergy

Delayed Non severe

Cefuroxime IV 1.5g tds plus metronidazole IV 500mg tds plus IV gentamicin stat

Delayed severe/ Type 1/ Unable to classify

Clindamycin IV 900mg tds plus gentamicin IV once daily (Can substitute ciprofloxacin for gentamicin post-delivery. This combination is associated with a high risk of C.difficile.)



5.3 Maternal sepsis – septic shock or failure to respond to 1st line treatment


1st line Piperacillin/ tazobactam IV 4.5g tds plus gentamicin stat

Review at 48 hours. If no improvement consider if collections present Total course length 7 - 10 days

Penicillin allergy

Delayed Non severe

Meropenem 1g tds plus gentamicin IV stat


Clindamycin IV 900mg tds plus gentamicin IV once daily plus Vancomycin IV see Trust dosing guideline

5.4 Maternal sepsis (unknown origin) - Empiric oral step down


1st line Co-amoxiclav 625mg tds plus metronidazole 400mg tds if intra-abdominal collection suspected

Total course length 7 - 10 days Penicillin allergy

Contact microbiology

5.5 Maternal sepsis in group B strep colonised patient with penicillin allergy

For clindamycin / erythromycin / clarithromycin resistant Group B streptococcus add vancomycin IV



5.6 Treatment of a secondary postpartum haemorrhage due to retained products Refer to empiric treatment for unknown source of maternal infection / sepsis.

5.7 Intra-abdominal infections – first line


1st line Co-amoxiclav IV 1.2g tds plus metronidazole IV 500mg tds if intra-abdominal collection suspected If septic, add gentamicin stat

5-10 days Extend treatment if abscess present

Penicillin allergy

Delayed Non severe

Cefuroxime IV 1.5g tds plus metronidazole 500mg tds If septic, add gentamicin IV stat


Clindamycin IV 900mg tds or po 450mg qds plus gentamicin IV daily (Can substitute ciprofloxacin for gentamicin post-delivery. This combination is associated with a high risk of c difficile.)

5.8 Intra-abdominal infections – non response to first line treatment


2nd line Piperacillin / tazobactam IV 4.5g tds If septic, add gentamicin IV stat


Penicillin allergy

Discuss with microbiology



5.9 Intra-abdominal infections – non response to first or second line treatment


3rd line Meropenem IV 1g tds Requires microbiology approval


Penicillin allergy


5.10 Intra-abdominal infections – oral stepdown


Oral stepdown

Co-amoxiclav 625mg po tds plus metronidazole 400mg po tds if collection present

5 days Extend treatment if abscess present

Penicillin allergy


5.11 Intra-abdominal infections – in group B strep colonised patient with penicillin allergy

For clindamycin / erythromycin / clarithromycin resistant Group B streptococcus add vancomycin IV

5.12 Urinary Tract Infections

For the treatment of Urinary Tract Infections, refer to trust policy. The policy includes a specific section for the treatment of urinary tract infections in pregnancy.

5.13 Post op wound infection – post delivery Clean-contaminated/contaminated-dirty surgery


1st line Co-amoxiclav IV 1.2g tds or po 625mg tds

According to response 7-14 days

Penicillin allergy

Delayed Non severe

Cefuroxime 1.5g tds plus metronidazole 500mg tds


Clindamycin 450mg IV/po qds plus ciprofloxacin 500mg po bd This combination is associated with a high risk of C.difficile

http://intranet/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25j1/



5.14 Post op wound infection – post delivery Contaminated-dirty surgery or no response to 1st line


2nd line Piperacillin/tazobactam IV 4.5g tds

According to response 7-14 days Penicillin allergy

Delayed Non severe

Meropenem IV 1g tds


Clindamycin 450mg IV/po qds plus ciprofloxacin 500mg po bd This combination is associated with a high risk of C.difficile.

5.15 MRSA skin colonisation

Add IV teicoplanin as per guideline

5.16 Mastitis/breast abscess 1st line


1st line Flucloxacillin IV 1g or 2g qds or po 500mg qds

Up to 2 weeks if abscess present or as clinically indicated Penicillin allergy

Clarithromycin IV or po 500mg bd

5.17 Mastitis/breast abscess 2nd line


2nd line Co-amoxiclav IV 1.2g tds or po 625mg tds

Up to 2 weeks if abscess present or as clinically indicated

Penicillin allergy

Clarithromycin IV or po 500mg bd Plus metronidazole 500mg IV / 400mg po tds

Obstetric Anti Infective Prescribing Guidelines Antibiotic Guidelines Reference Number: 144TD(C)25(J2) Version Number: 4 Issue Date: 11/12/2018 of

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5.18 Gentamicin in pregnancy

Neonatal ototoxicity has not been observed with use of gentamicin in pregnancy however it has been seen with other aminoglycosides, therefore gentamicin should be used with caution in pregnancy. Where possible use only a stat dose or the shortest effective course. For guidance on dosing gentamicin, please refer to the Trust policy on Once Daily Gentamicin Dosing. Monitoring Pre-dose level must be checked and be below 1mg/L before a second dose is given. Take the sample 4 hours before the second dose is due to allow for the level to be reported. Subsequent levels and renal function must be checked 2-3 times a week. Check renal function 2-3 times a week. In pre-eclampsia gentamicin clearance is reduced and levels should be checked daily.

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25h2/

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25h2/


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6. Roles and responsibilities

6.1 All clinical staff involved in the prescribing of antimicrobials to adhere to this policy including full documentation on EPMAR as detailed.

7. Monitoring document effectiveness

7.1

Key standards:

Document the Indication/rationale for antimicrobial therapy.

Review and document the patient’s allergy status.

Ensure the choice of antibiotic complies with the antibiotic guidelines.

Prescribe single dose antibiotics for surgical prophylaxis, unless policy states otherwise.

Administer antibiotic prophylaxis within 60 minutes prior to surgical incision (administration must be complete before the incision, and before inflation of the tourniquet when used)

Method(s): Audits of compliance with the guideline will be conducted on a regular basis as part of the Antibiotic stewardship monthly audit. . Team responsible for monitoring: Ward Pharmacists Frequency of monitoring: Once every three years. Process for reviewing results and ensuring improvements in performance: Monthly compliance dashboards will be shared with the divisional leads, Antibiotic Steering Group and Infection Control Committee.

8. Abbreviations and definitions

Not applicable

9. References and Supporting Documents

9.1 References Manchester University Foundation Trust Obstetric Anti-infective Prescribing Guideline June 2018


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9.2 Related SRFT/PAT documents Trusts Medicines Policy. Restricted Use Antibiotics Policy - Antibiotic Guidelines (SRFT) 144TD(C)25(A3) Antimicrobial Stop/Review Date and Indication Policy - Antibiotic Guidelines (SRFT) 144TD(C)25(A1) Antibiotic IV to oral switch Guidelines – Antibiotic Guidelines (SRFT) 144TD(C)25(A2) (SRFT)

9.3 Acknowledgement of sources These guidelines are based on the Manchester University Foundation Trust ‘Obstetrics anti-infective Prescribing guideline’


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10. Document Control Information

It is the author’s responsibility to ensure that all sections below are completed in relation to this version of

the document prior to submission for upload.

Nominated Lead author:

Antibiotic Steering Committee

Role

Lead author contact details:

0161 2065819 [email protected]

Lead Author’s Manager:

Andrea Marrosu Medicines Management Lead

Applies to:

Salford CO

X

Document developed in consultation with :

Microbiology and obstetric team at Manchester Foundation Trust.

Keywords/ phrases:

Antibiotics, Infection

Communication plan:

The guideline will form part of the Trust Antibiotic Policy and thus can be accessed via the Antibiotic and Infection Control hotlinks area on the front page of Synapse. Information about the policy will be sent to all ward managers, medical staff and pharmacists. In addition, adherence to the policy will be encouraged through FY1 and FY2 teaching sessions. The policy will be implemented in all areas with electronic prescribing.

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: Medicines Management Committee – Dr Richard Cooper

Insert full approval date: 15/10/2018

Antibiotic Steering Group – Dr Eamonn Trainor

17/08/2018

How approved: Chair’s actions Formal Committee decision X


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11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

Yes/no Email distribution to consultant staff for comments. Discussions at Antibiotic Steering Group and Medicines Management Group. Discussion at ENT directorate meeting.

1b) Have any amendments been made as a result? If yes, specify what.

Yes-see changes to policy section

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?)

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?)

Race (e.g. any specific needs identified for certain groups such as dress,

diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.)

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?)

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?)

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?)

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?)

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?)

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?)

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing


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and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer. Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? Alternative choices recommended for some patients with allergy (to avoid harm) and for pregnant patients (to protect the baby). 4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? N/A Will this policy require a full impact assessment? Yes / No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Christine Khan Date: 16/08/18 Sign off from Equality Champion: Date:

mailto:[email protected]