There is evidence to suggest that antimicrobials are associated with more prescribing errors than any other class of medicine (Lewis et al, 2009). Inappropriate antimicrobial prescribing in secondary care has resulted increased costs and patient length of stay (Dunegan et al, 1989). This is due to treatment failure, toxicity, delayed and omitted doses and adverse reactions. Narrow spectrum antibiotics are generally preferred to broad spectrum ones. However inexperienced prescribers can tend not to use these. This increases the risk of antimicrobial resistance and healthcare associated infections (Department of Health, 2003). Indeed healthcare associated infections are said to affects an estimated one in ten NHS hospital patients per year. The Department of Health has produced a guidance document for managing infections in primary care called Management of infection guidance for primary care for consultation and local adaptation (2010) which is available on the Department of Health website.. This will help you to understand the principles of treatment with antimicrobials and how to treat common infections effectively. It also provides you with links to other relevant national guidance. In secondary care, the Department of Health has produced guidelines for antimicrobial stewardship called Start smart then focus – Guidance for antimicrobial stewardship in hospitals (2011) which is also available on the Department of Health website. This sets out a clear pathway for the use of antimicrobials that Trusts are expected to adhere to. It also sets out clear responsibilities for all prescribers of antimicrobials.

Are you aware of what these are? As a prescriber, you should not start an antimicrobial unless there is clinical evidence of bacterial infection. Where antimicrobials are indicated, you should prescribe using the local guidelines. You should therefore make sure that you are familiar with your local antimicrobial prescribing policy. You should also know how to contact your local clinical microbiologist as they can provide advice on appropriate treatment options. Wherever possible you should obtain samples prior to prescribing or administering antimicrobials and ensure that cultures and sensitivities are available. When you prescribe antimicrobials you should document the indication, the course length or review date, the route and the dose clearly in the patient’s medical records and prescription chart. Treatment should then be commenced within one hour of diagnosis. It is essential that you review the clinical diagnosis and the continuing need for antibiotics within 48 hours and make a clear plan of action. Prescribing decisions include:

• Stopping the antimicrobial (the shortest duration that gives an appropriate clinical outcome should be used)
• Switching the route from IV to oral (this should happen as soon as clinically appropriate)
• Changing the antimicrobial (this should be in line with culture and sensitivity results or the clinical signs/symptoms of infection)
• Continuing the antimicrobial You need to make sure that you document this review and any subsequent decision clearly in the patient’s medical records. You must always check the allergy status of a patient before antibiotics are prescribed. Reports of patients being prescribed and administered a drug that they have a documented allergy to remains high. This is especially true with penicillin and can be fatal.

'In the UK, 80% of antibiotic prescribing occurs in primary care, with over half for respiratory tract infections. The inappropriate use of antibiotics is related to bacterial resistance, so using antimicrobials responsibly should help control it.' (RCGP 2015)

The TARGET Antibiotics Toolkit was developed to help influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers’ and patients’ responsible antibiotic use. TARGET stands for: Treat Antibiotics Responsibly, Guidance, Education, Tools

Penicillin containing antimicrobials

Have a look at this list of antimicrobials. Do you know which ones contain penicillin?

• Amoxicillin
• Magnapen
• Timentin
• Pivmecillinam
• Flucloxacillin
• Penicillin v
• Augmentin
• Benzylpenicillin
• Piperacillin
• Co-amoxiclav
• Tazocin
• Piperacillin with tazobactam
• Co-fluampicil
• Ampicillin