About Hospital at Home Guidance

Diagnosis of Infection

This document aims to provide a safe treatment guide for patients being treated for infection within their own home who are frail and have multiple co-morbidities, for whom it is felt admission could be prevented.

Within the H@H Service the initial diagnosis of infection will be on clinical grounds taking into account the symptoms and signs the patient presents with.  Patients will have access to investigations thereafter, should these be felt to be indicated through the Access to Imaging SOP.

Where possible samples will be taken prior to the commencement of antibiotic therapy and sent to the laboratory for onward analysis.

Renal function and the frail elderly population

It is important to have an awareness of the significant difference of renal function between creatinine clearance (CrCl) and estimated glomerular filtration rate (eGFR). In this patient group it would be important to calculate CrCl and use this to base antibiotic dosing rather than eGFR which can overestimate renal function in extremes of body weight. Of particular note levofloxacin doses need to be reduced in CrCl <50ml/min - see Renal Drug Database for specific dosing advice in reduced renal function. 

Decision making in very unwell frail / elderly patients including end of life

Should someone have severe infection and admission to hospital is not thought to be helpful then conversations around the appropriateness of starting antibiotic therapies should be had with the patient, their power of attorney or relative/carer and a decision made around whether symptomatic care is felt to be beneficial. (Further guidance available from SAPG GPR for antibiotic prescribing towards end of life and SAPG GPR for antimicrobial use in frail older people) 

IV to Oral Switch

Following the commencement of IV antibiotics, the switch to oral therapies will be made 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.

Further guidance on IV to Oral switch can be found here.

C difficile

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, 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 or microbiology consultant prior to giving multiple or extended courses of these antibiotics.

Penicillin allergy

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 on penicillin allergy can be found here.