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Protected Antibiotic Policy - Royal Hospital for Children (RHC)

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Objectives

This purpose of this policy is to promote antimicrobial stewardship by reserving the use of specific antimicrobials for special circumstances (e.g resistant organisms), in line with WHO AWaRe recommendations and local epidemiology. The aim is to reduce the development of resistance and preserve the efficacy of these valuable agents for now and in the future.

Scope

The policy is for use within all clinical areas at the Royal Hospital for Children, NHS Greater Glasgow & Clyde. Protected antimicrobials may only be used following approval from a Microbiologist or Infectious Diseases Consultant unless used in line with approved local guidelines as outlined below.

BACKGROUND: In 2019 the World Health Organisation published the antibiotic AWaRE classification database following recommendations from the WHO Expert Committee on Selection and Use of Essential Medicines. AWaRE classifies antibiotics in to three stewardship groups:

  • ACCESS – This group includes antibiotics that have activity against a wide range of commonly encountered susceptible pathogens while also showing lower resistance potential than antibiotics in the other groups.

  • WATCH - This group includes antibiotics that have higher resistance potential. Antibiotics in Watch group should be prioritized as key targets of stewardship programs and monitoring. Some Watch antibiotics are included as first- or second -choice empiric treatment options for specified infectious syndromes.

  • RESERVE - This group includes antibiotics and antibiotic classes that should be reserved for treatment of confirmed or suspected infections due to multi-drug-resistant organisms. ‘Reserve’ agents should be accessible, but their use should be tailored to highly specific patients and settings, when all alternatives have failed or are not suitable.
CLASSIFICATION AND PRESCRIBING OF PROTECTED ANTIBIOTICS

Antimicrobials MUST be prescribed:

  • In accordance with locally approved guidelines
  • In response to culture and sensitivity reports
  • On the advice of an infection specialist (Microbiology/Infectious Disease)

For all antimicrobial prescribing the following must be recorded in the patient’s medical notes AND on the drug Kardex:

  • Indication for use
  • Intended duration
  • Review/stop date

For PROTECTED antimicrobials (WATCH Abx outside of approved use; all RESERVE antibiotics) the following also applies:

  • Record the name and designation of the Infectious Disease Consultant or Microbiologist granting approval for use in the medical notes.
  • A ‘Protected Antimicrobial Form’ should be completed by the requesting clinician where indicated (see below).

*Note: Where a protected antimicrobial is commenced out of standard Pharmacy operating hours, a limited supply will be available. Pharmacy must be contacted early the following working day to obtain further supply and avoid delay in treatment.

The information collected within the ‘Protected Antimicrobial Use Form’ will be used to aid surveillance of antimicrobial use and facilitate the identification of areas where increased support with antimicrobial stewardship can be targeted.

Notes:

  • NHS GGC local policy has re-classified some antibiotics under local treatment policy to further preserve use/allow access to approved patient groups.

  • ‘Protected’ status have been presented in a ‘red-amber-green’ classification. Please note that this does NOT correlate to penicillin-allergy status.

  • ‘Reserve’ antibiotics, with the exception of Meropenem, are not routinely stocked on all wards in RHC. Some ‘watch’ antibiotics are also not kept as ward stock. When a protected antimicrobial is prescribed please alert nursing staff IMMEDIATELY so that a supply can be obtained from Pharmacy. For out-of-hours access please check the Emergency Drug Cupboard (QEUH) in the first instance.

PROTECTED ANTIBIOTICS: RESERVE

Aztreonam (IV)
Linezolid
Ceftazidime/avibactam
Colomycin (IV)
Daptomycin
Fosfomycin
Meropenem*
Temocillin
Tigecycline

RESTRICTED: RECOMMENDATION/ APPROVAL required from Microbiology or Infectious Disease Consultant prior to initiating therapy*

‘Protected Antimicrobial Use’ form mandatory for all meropenem and nitrofurantoin (liquid)

*Micro/ID approval not required where meropenem is used as second line therapy for Haematology/oncology patients in line with approved NHS GGC guidelines. A PAU form is still required for surveillance purposes.


PROTECTED ANTIBIOTICS: WATCH

Amikacin
Cefotaxime
Cefuroxime
Ceftriaxone
Clarithromycin
Ceftazidime
Ciprofloxacin
Colomycin (neb)
Daptomycin
Levofloxacin
Nitrofurantoin (liquid)
Piperacillin/Tazobactam
Rifampicin
Sodium Fusidate
Teicoplanin
Tobramycin
Vancomycin

RESTRICTED: Must be used in accordance with approved NHS GGC guidelines.

RECOMMENDATION/ APPROVAL required from Microbiology or Infectious Disease Consultant prior to initiating therapy outside of NHS GGC approved guidelines

‘Protected Antimicrobial Use’ form not required


ACCESS ANTIBIOTICS: ADDITIONAL RESTRICTIONS NOT APPLICABLE

Amoxicilin
Azithromycin
Benzylpenicillin
Cefalexin
Clindamycin
Co-amoxiclav
Co-trimoxazole
Flucloxacillin
Gentamicin
Metronidazole
Nitrofurantoin (tablets)
Phenoxymethylpenicillin
Trimethorprim

NOT RESTRICTED: Recommended for use in accordance with NHS GGC guidelines.

No approval/ ‘Protected Antimicrobial Use’ form required

PROTECTED ANTIMICROBIAL USE FORM – ROYAL HOSPITAL FOR CHILDREN
Editorial Information

Last reviewed: 23 February 2021

Next review: 28 February 2024

Author(s): Susan Kafka, Advanced Pharmacist Paediatric Antimicrobials and Medicine

Approved By: Antimicrobial Utilisation Committee