Good Practice in Antimicrobial Prescribing

The aim of this guidance is to promote appropriate antibiotic prescribing in order to minimise the risk of patients developing C. difficile infection and to reduce the development of multi-drug resistant bacteria, while at the same time adequately treating the infection that has been diagnosed.

This guidance is for empirical treatment.  Alternative antibiotics may be required if specific pathogens are identified or there is failure to respond.

Clostridioides difficile (formerly Clostridium difficile) infection is associated with the use of all antibiotics but most strongly with cephalosporins, co-amoxiclav, clindamycin and quinolones (ciprofloxacin, levofloxacin, moxifloxacin and ofloxacin) and it is particularly important to avoid these agents if at all possible. 

In January 2024, MHRA strengthened warnings to only use fluoroquinolone antibiotics (FQs – cipfofloxacin, levofloxacin, moxifloxacin and ofloxacin) if no other agents were suitable due to disabling and potentially long lasting or irreversible side effects.  See updated MHRA warnings on fluoroquinolone use.  TAM guidance will be reviewed to ensure alternatives to these agents are recommended wherever possible. 

A separate patient information leaflet has been developed to aid patient counselling when prescribing these drugs and supplied with each prescription dispensed.

MHRA Patient information leaflet - Fluoroquinolone antibiotics (-oxacins): what you need to know about tendons, muscles, joints, nervous system, and psychological side effects

Prescribers should avoid using these drugs for minor or self-limiting conditions unless there is no clear alternative.

This class of antibiotics is associated with numerous adverse drug reactions affecting a wide variety of body systems including musculoskeletal (tendinitis, muscle pain), CNS (seizures), psychiatric (suicidal thoughts and behaviours, depression) and cardiovascular (valvular heart disease, aortic dissection, QTc prolongation).  Prominent warnings are listed in the BNF entry for each drug and on the MHRA website.  A separate patient information leaflet has been developed to aid patient counselling when prescribing these drugs and supplied with each prescription dispensed.

Prescribers should avoid using these drugs for minor or self-limiting conditions unless there is no clear alternative.

Antibiotics should be:

• used only when there is a definite indication – consider withholding therapy unless there is a clear signs of an infection          
• used for the shortest duration required to treat the infection         
• targeted at the most likely or known pathogens i.e. use as narrow a spectrum agent and rationalise as soon as microbiology results are available    
• stopped immediately if started inappropriately – i.e. a subsequent non-infectious diagnosis is made

Good Practice notes:

• Take cultures for microbiology before starting antibiotic therapy whenever possible.             
• The indication for prescribing antibiotics and the duration MUST be clearly documented in the patients’ case notes.
• Review all patients on intravenous antibiotics on a daily basis with a view to IV to oral switch.
• The use of the ‘penicillin allergy’ option should only be used in patients with a true allergy to penicillin and this should be investigated fully.
• Doses quoted are for adults with normal renal function – separate guidance is available for children
• Before prescribing antibiotics always check for any potential drug interactions 
• Unless specifically mentioned, this guidance does not cover prescribing in pregnancy.  For appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, see BNF, BNF for Children and the Renal Drug Database (password access).

Adapted from NHS Fife with permission 7^th October 2019