About Community Hospital Guidance
Antimicrobial prescribing: NHS Forth Valley
This guideline currently only applies to Stirling Care Village Wallace Suite due to availability of suitably trained staff.
Diagnosis of Infection
This document aims to provide a safe treatment guide for patients being treated for infection within NHS Forth Valley community hospitals, who are often frail and have multiple co morbidities and may prefer treatment delivered in a local community setting. Antibiotic recommendations include once daily IV or highly bioavailable oral (i.e. equivalent to IV administration) antibiotics for treatment of more complicated/severe infections.
Where an IV antibiotic is recommended within this guidance, it is expected that it will only be administered within community hospital ward areas, by an adequately trained healthcare worker, following the Standard Operating Procedure for the specific IV antibiotic prescribed.
Within community hospitals, the initial diagnosis of infection will be on clinical grounds taking into account the symptoms and signs the patient presents with, this may or may not be supported with access to imaging where appropriate e.g. CXR.
Where possible appropriate samples e.g. MSU, will be taken prior to the commencement of antibiotic therapy and sent to the laboratory for analysis. Requests should be made electronically using OrderComms.
Ideally all patients transferred to a community hospital setting will already have a ReSPECT plan in place clarifying the plans for deterioration e.g. whether for transfer to FVRH and in what circumstances, however, up to date discussions will still need to take place in that specific clinical context.
If someone has a severe life-threatening infection or is at risk of further deterioration, clear and sensitive discussions and planning needs to take place if this has not taken place already. Admission to FVRH for acute management may not be appropriate or wanted (see community hospital SOP) and sensitive realistic conversations with the patient and/or proxy decision-maker (e.g POA, Legal Guardian) about treatments goals need to be taken forward. These discussions should include whether transfer to FVRH is appropriate for further acute hospital care, whether starting antibiotic treatment in community hospital is appropriate or a more symptomatic or palliative approach should be adopted. (Further guidance available from SAPG GPR for antibiotic prescribing towards end of life https://www.sapg.scot/media/5446/gprs-for-use-of-antibiotic-towards-eol.pdf)
Following the commencement of IV antibiotic, the switch to oral therapies should be considered after 24-48hrs of their temperature settling or once improvement is seen if afebrile.
If the oral route is no longer possible after 24-48 hrs of starting therapy then consideration will be given to whether or not intravenous therapies are required.
Broad spectrum antibiotic use in elderly and frail patients is associated with a high risk of C difficile infection, especially when multiple courses are given. This is especially true for the “4C antibiotics” – co-amoxiclav, clindamycin, cephalosporins (e.g. ceftriaxone, cefalexin), ciprofloxacin (+ levofloxacin). Where these antibiotics are recommended in this guideline it has been considered that benefit of use is greater than the risk of C. diff i.e. for severe infection or when other antibiotics are higher risk. It is advisable to discuss with A+H consultant, GP and/or microbiology consultant prior to giving multiple or extended courses of these antibiotics.
Please ensure you are familiar with penicillin allergy and cross-reactivity of other β-lactam antibiotics prior to prescribing. This is relevant to following β-lactam antibiotics mentioned in this guideline:
Amoxicillin, Flucloxacillin, Co-amoxiclav, Pivmecillinam, Cefalexin, Ceftriaxone
Further information can be found here.
If IV ceftriaxone is recommended without an alternative non β-lactam option and patient has a true immediate type I hypersensitivity reaction to penicillin – it is best to discuss treatment options with the consultant microbiologist.