Antimicrobial Stewardship Facility Resource...What can residential aged care facilities do? In order to ensure adherence to the Aged Care Quality Standards, and demonstrate activities

The Aged Care Quality Standards, under standard 8 - Organisational governance, require that aged care facilities participate in Antimicrobial Stewardship (AMS) as part of their clinical governance framework.

Antimicrobial resistance is recognised by the World Health Organization (WHO) as a global health threat. Antimicrobial Stewardship is a comprehensive set of strategies aimed to reduce antimicrobial resistance. AMS programs have been shown to reduce inappropriate antimicrobial use, improve patient outcomes, and reduce adverse effects and consequences of antimicrobial use (resistance, toxicity)

The Australian Commission on Safety and Quality in Health Care has developed the Antimicrobial Stewardship Clinical Care Standard. This is a small number of quality statements which has been developed to complement and support antimicrobial stewardship.

There are 9 quality statements which have been outlined.

Quality Statement 1

A patient with a life-threatening condition due to a suspected bacterial infection receives prompt antibiotic treatment without waiting for the results of investigations.

Quality Statement 2

A patient with a suspected bacterial infection has samples taken for microbiology testing as clinically indicated, preferably before starting antibiotic treatment.

Quality Statement 3

A patient with a suspected infection, and/or their carer, receives information on their health condition and treatment options in a format and language that they can understand.

Quality Statement 4

When a patient is prescribed antibiotics, whether empirical or directed, this is done in accordance with the current version of the Therapeutic Guidelines (or local antibiotic formulary*). This is also guided by the patient’s clinical condition and/or the results of microbiology testing.

*applicable to hospital settings

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Antimicrobial Stewardship Facility Resource



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Quality Statement 5

When a patient is prescribed antibiotics, information about when, how and for how long to take them, as well as potential side effects and a review plan, is discussed with the patient and/or their carer.

Quality Statement 6

When a patient is prescribed antibiotics, the reason, drug name, dose, route of administration, intended duration and review plan is documented in the patient’s health record.

Quality Statement 7

A patient who is treated with broad-spectrum antibiotics has the treatment reviewed and, if indicated, switched to treatment with a narrow-spectrum antibiotic. This is guided by the patient’s clinical condition and the results of microbiology tests.

Quality Statement 8

If investigations are conducted for a suspected bacterial infection, the responsible clinician reviews these results in a timely manner (within 24 hours of results being available) and antibiotic therapy is adjusted taking into account the patient’s clinical condition and investigation results.

Quality Statement 9

If a patient having surgery requires prophylactic antibiotics, the prescription is made in accordance with the current Therapeutic Guidelines (or local antibiotic formulary*), and takes into consideration the patient’s clinical condition.

*applicable to hospital settings

Definitions

It is important to be aware that antimicrobials do not only include antibiotics.

Antimicrobial - medications used to treat any infection, including bacterial fungal and viral. For example: Bactroban ointment, Hydrozole cream, Tamiflu.

Antibiotic - medication specifically aimed at treating bacterial infection.



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What can residential aged care facilities do?

In order to ensure adherence to the Aged Care Quality Standards, and demonstrate activities to promote antimicrobial stewardship are in place, the following may be considered:

1. Utilise Meditrax Resources: ▪ In-services (face to face) and/or Medi-Learn Modules:

- Antimicrobial Stewardship - UTIs - ‘Bugs, Hugs, & Drugs’ - Common Infections in the Elderly

▪ Antimicrobial Stewardship Tool (Appendix A). ▪ Essential Facts - Guide to Common Antibiotics use in Aged Care (Appendix B). ▪ Educate residents and relatives regarding Antibiotic Use. Utilise Meditrax Residents and

Relatives Newsletter - ‘Antibiotic Resistance - One of our biggest health threats’ (Appendix C).

**An editable version of the Antimicrobial Stewardship Tool can be downloaded by facility managers from Meditrax QUM Resources at https://www.meditrax.com.au/qum-members/

**Medi-Learn courses are available to facility nursing and care staff at:https://www.medilearn.meditrax.com.au/login/index.php.

For registration email: [email protected]

2. Plan for participation in the annual Aged Care National Antimicrobial Stewardship Survey (acNAPS) – one day survey of antibiotic use collected and sent for analysis with national data with feedback provided regarding areas of compliance and for improvement. See https://www.naps.org.au/Resources/acNAPS_Information_sheet_2018.pdf for further information.

3. Review antimicrobial use at your facility– either on a single day, or over a longer period such as a week. Consider making this a regular practice (eg monthly or every quarter).

▪ Obtain reports of antimicrobials prescribed from supplying Pharmacy. ▪ Analyse prescribed antimicrobials for appropriate use. The Antimicrobial Stewardship Tool

(Appendix A) can assist with this.4. Consider subscribing to Therapeutic Guidelines – Antibiotic, for access to guidelines for appropriate

medications and treatment courses for infections.5. Do not carry out routine urinalysis for all residents – investigate if there are symptoms according to

Therapeutic Guidelines.6. Review the reported antibiotic allergies/adverse reactions for residents - discuss with residents/family

members and document the reaction where known



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Treatment of common infections (as per Therapeutic Guidelines)

• The Antibiotic Therapeutic Guidelines was updated in June 2019, and contains comprehensive information about treatment approaches. Use the following information in conjunction with the Therapeutic Guidelines.

• The following information should also be used in combination with prescriber clinical judgment and the results of microbiology testing, as well as consideration of the resident’s document allergies/adverse reactions.

• Prescribers must consider harm-benefit profile of each medication, including potential drug interactions.

• Antibiotics that are known to be overused in primary care include: amoxicillin+clavulanate, cefalexin, cefaclor, roxithromycin and erythromycin.

Urinary Tract Infection (UTI) in aged care residents

Asymptomatic bacteriuria is common in aged care facility residents. Only residents with clear symptoms or history of rapid deterioration with previous UTIs are recommended to be treated.

It can be challenging to diagnose UTI in aged care residents. The Therapeutic Guidelines - Assessment and treatment of aged-care facility residents with suspected urinary tract infection (Appendix D) can be used as a general guide for initial assessment and management of suspected UTI.

• Do not screen for or treat asymptomatic bacteriuria (except in elective urological procedures)• Do not investigate or treat cloudy or malodorous urine in aged-care facility residents with no

other signs or symptoms of UTI.• Correct dehydration before starting antibiotic therapy.

For the tables the follow, a number in brackets denotes which antibiotic should be used first, and second etc. For example, (1) indicates the antibiotic is first line

therapy.

The important notes that follow each table must also be considered.



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Antibiotic Treatment of acute cystitis and acute mild pyelonephritisAntibiotic Recommended Dose

Acute Cystitis(1) trimethoprim 300 mg a Female: 1 nocte for 3 nights

Male: 1 nocte for 7 nights(2) nitrofurantoin 100 mg Female: 1 q6h for 5 days

Male: 1 q6h for 7 daysOnly if unable to tolerate the above:

cefalexin 500 mgFemale:1 q12h for 5 daysMale: 1 q12h for 7 days

If the pathogen is resistant to empirical therapy and symptoms of cystitis are not improving, use the narrowest spectrum antibiotic to which the pathogen is susceptible. If the pathogen is susceptible, suitable alternatives are: b

(1) amoxicillin 500 mg 1 q8h for 5 days(2) trimethoprim+sulfamethoxazole 160+800 mg

1 q12h for 3 days

(3) amoxicillin+clavulanate 500+125 mg 1 q12h for 5 daysIf resistance to the above and other narrow spectrum antibiotics and symptoms not improving, if pathogen is susceptible a suitable alternative is:(1) fosfomycin 3 mgor(1) norfloxacin 400 mgor(2) ciprofloxacin 250 mg

3 grams as a single dose

1 q12h for 3 days

1 q12h for 3 daysAcute Mild Pyelonephritis

(1) amoxicillin 875 mg/clavulanate 125 mg 1 q12h for 10-14 days (stop after 10 days if rapid response)For penicillin allergy:

ciprofloxacin 500 mg 1 q12h for 7 daysIf the pathogen is susceptible to any of the following narrower-spectrum antibiotics, stop the empirical regimen and switch to:(1) amoxicillin 500 mgor(1) trimethoprim 300 mg

1 q8h for 14 days

1 daily for 14 days(2) cefalexin 500 mg 1 q6h for 14 days(3) trimethoprim+sulfamethoxazole 160+800 mg

1 q12h for 14 days

If resistance to the above is confirmed or the pathogen is Pseudomonas aeruginosa use:ciprofloxacin 500 mg 1 q12h for 7 days



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Important Notes:• a.) Do not give trimethoprim if it has been used in the past 3 months, or the person has had trimethoprim-resistant

E.Coli during this time• b.) For acute cystitis, if urine culture and susceptibility testing show resistant pathogen, do not change if symptoms

are improving.• Do not use quinolones first-line, as their use is associated with the development of resistance, and they are the only

drugs available to treat infections caused by Pseudomonas aeruginosa and some multidrug-resistant bacteria.• Do NOT perform post-treatment urine culture to confirm resolution of infection if asymptomatic.• Post-treatment urine culture to confirm resolution of infection for asymptomatic patients should ONLY be done for

men with prostatitis.• In men, cystitis is uncommon. Although prevalence does increase with age, consider prostatitis as an alternative

diagnosis, especially with fever (38 degrees Celsius or higher), obstructive symptoms, or prostate tenderness.• For acute mild pyelonephritis, if there is no symptomatic response after 24-48 hours, and results of culture and

susceptibility testing are not available, reconsider diagnosis.• Severe pyelonephritis is treated with intravenous antibiotics.• Treat acute episode of recurrent UTI as for cystitis or pyelonephritis.

Prevention of recurrent UTIs

For women with recurrent UTIs, antibiotic prophylaxis can decrease incidence. Adverse effects and resistant micro-organisms may however occur. Antibiotic prophylaxis may be considered for women with frequent infections - 2 or more infections within 6 months, or 3 or more infections within 12 months.

Antibiotic Recommended DoseProphylaxis for recurrent UTI

(1) trimethoprim 150 mg 1 at night(2) cefalexin 250 mg 1 at night(3) nitrofurantoin 50mg 1 at night

Notes:• Continue for 6 months and then stop. If UTIs recur despite prophylaxis, refer to specialist.• Long-term use of nitrofurantoin is associated with higher risk of rare adverse effects: pulmonary toxicity,

hepatotoxicity and peripheral polyneuropathy.



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Respiratory Tract Infections

The differentiation between viral and bacterial respiratory infections, and consequently the decision about whether to prescribe antibiotic therapy, is difficult in aged care residents.

• If a viral infection is likely, and the patient is not severely ill, consider withholding antibiotic therapy until the results of investigations are available to guide treatment.

• If empirical antibiotic therapy has been started, consider stopping antibiotic therapy if the results of investigations indicate a viral cause of the patient’s clinical presentation.Pneumonia

Antibiotic Recommended DoseCommunity Acquired Pneumonia (CAP) in aged-care facility residents

amoxicillin 1 gram orally 8 hourly for 5-7 daysFor penicillin allergy:

doxycycline 100 mg orally 12 hourly for 5-7 daysIf doxycycline contra-indicated or not tolerated (e.g. bedbound resident):

cefuroxime 500 mg orally or enterally 12 hourly for 5-7 days

If not improving after 48 hours, reassess diagnosis. If pneumonia remains likely, and hospital admission and parenteral antibiotics are not in line with the patient’s goals of care, use alternative oral antibiotic:

Antibiotic Recommended Doseamoxicillin+clavulanate 875+125 mg orally 12 hourly for 5-7 daysOR if liquid is needed

amoxicillin+clavulanate 400+57 mg/5mL oral liquid 11mL orally or enterally

12 hourly for 5-7 days

Notes:• If not improving after 48 hours of antibiotics, reassess need for hospital admission, consider other diagnoses such as heart failure.



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Chronic Obstructive Pulmonary Disease (COPD) exacerbation

Exacerbations may be triggered by viral or bacterial infection, or non-infective causes (e.g. heart failure). Viruses are identified in 64% of exacerbations. Bacterial cause is more likely if:

• increased sputum volume• purulent sputum (containing pus, sputum yellow or green)• fever.

• Sputum culture is not routinely recommended, unless there is a failure to respond to treatment.

• For patients with mild to moderate exacerbations managed as outpatients, antibiotic treatment does not consistently improve outcomes and can be safely withheld in many cases. However, antibiotic therapy and oral corticosteroids improve outcomes in patients with severe exacerbations requiring hospitalisation.

• Generally, antibiotics should not be used unless the patient has clinical signs of infection.

• The aim of treatment with antibiotic therapy is to hasten recovery rather than eliminate colonising organisms.

• Antibiotics other than amoxicillin or doxycycline (eg macrolides, cephalosporins, amoxicillin+clavulanate) are not recommended because they do not have superior efficacy.

For people with COPD exacerbation and clinical features of bacterial infection if antibiotics are indicated:

Antibiotic Recommended Dose(1) amoxicillin 500 mg 8 hourly for 5 days(1) amoxicillin 1 gram 12 hourly for 5days

(1) doxycycline 100 mg 1 daily for 5 days

• For patients with severe COPD and recurrent exacerbations requiring hospitalisation despite maximal preventive therapy (including long-acting bronchodilators and inhaled corticosteroids), recent trials have found that long-term low-dose oral macrolides reduce the frequency of exacerbations.

• However, given the potential significant adverse effects of such regimens (including cardiac toxicity, ototoxicity, diarrhoea, and the development of antibiotic resistance [which affects both the individual and the community]), expert advice is recommended before starting long-term antibiotic therapy.

Aspiration Pneumonia

• Aspiration pneumonia is common in aged care residents due to the presence of risk factors such as stroke, neuromuscular disorders or impaired consciousness, but in some cases aspiration of acidic gastric contents which are sterile causes a transient chemical pneumonitis that does not require antibiotic treatment.

• Gastric acid suppression and bowel obstruction increase the risk of developing aspiration pneumonia following aspiration pneumonitis.

• Recurrent aspiration can be particularly difficult to manage because risk factors such as neuromuscular disorders or impaired consciousness cannot be modified. Repeated courses of antibiotics can lead to serious problems, such as colonisation with increasingly resistant pathogens, or Clostridium difficile infection.

• Aspiration pneumonia should be managed as community or hospital acquired pneumonia initially. Exclude aspiration pneumonitis if there has been an aspiration event, before starting antibiotics for pneumonia.

• In patients with aspiration pneumonia, the results of cultures may enable directed therapy or de-escalation of antibiotic treatment after 48 to 72 hours.

• If the person isn’t improving on empirical antibiotic therapy for pneumonia at 48 hours, reassess diagnosis. If they have been treated with broad spectrum antibiotics, and are still not improving, seek expert advice. If they have been treated with other antibiotics for pneumonia, and infection with anaerobes is likely:

Antibiotic Recommended Doseamoxicillin 1 gram

PLUS

metronidazole 400 mg

8 hourly for 5-7 days

12 hourly for 5-7 daysIf single-drug regimen is preferred (to reduce toxicity or improve adherence)

(1) amoxicillin+clavulanate 875+125 mg 12 hourly for 5-7 days

(1) clindamycin 450 mg 8 hourly for 5-7 days

(2) moxifloxacin 400 mg 1 daily for 5-7 days

Important notes:• For penicillin allergy use clindamycin or moxifloxacin• If unable to swallow oral therapy, refer to Therapeutic Guidelines for intravenous antibiotic regimens

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Cellulitis

Important to distinguish from potential other conditions such as contact dermatitis, septic bursitis, gout, and acute lipodermatosclerosis. Rest and elevation of the affected area improves clinical response.

Antibiotic Recommended DoseFor purulent cellulitis (e.g. associated abscess) or if S. aureus is suspected

(1) dicloxacillin 500 mg 6 hourly for 5 days(1) flucloxacillin 500 mg 6 hourly for 5 daysDelayed non-severe penicillin allergy:

cefalexin 500 mg 6 hourly for 5 daysHigh risk of MRSA infection, OR immediate (non-severe or severe), or delayed severe penicillin allergy:

(1) trimethoprim+sulfamethoxazole 160+800

or

(2) clindamycin 450 mg

12 hourly for 5 days

8 hourly for 5 daysImportant Note: It is usually appropriate to stop antibiotic therapy after 5 days, even if mild signs of inflammation remain. Extend therapy if infection hasn’t improve by the end of the treatment course.

• For people with frequent recurrent cellulitis, antibiotic prophylaxis can be considered:

▪ phenoxymethylpenicillin 250 mg orally, twice daily for up to 6 months initially, then review regularly.

apfwe

PO BOX 90ANNANDALE NSW 2038Ph: (02) 9819 0600Fax: (02) 8572 [email protected]



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References

• Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. Sydney: ACSQHC, 2014.

• Antibiotic [June 2019]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2019 June.

• National antimicrobial prescribing survey Available at: https://www.naps.org.au/Default.aspx

Copyright 7th Edition © Meditrax January 2019 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole

or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.

Antimicrobial Stewardship Tool

Consumer 1 Consumer 2 Consumer 3 Consumer 4 Consumer 5

YES NO YES NO YES NO YES NO YES NO

1. Has the consumer displayed symptoms of infection (as per guidelines) in the week prior to prescribing?

2. Were the symptoms documented in the consumer’s notes?

3. If symptoms of life-threatening infection (as per guidelines) were reported, was there prompt antimicrobial treatment without waiting for the results of investigations?4. If the consumer had a suspected infection (as per guidelines), were samples taken for microbiology testing as clinically indicated, preferably before starting antimicrobial treatment?5. Were these results reviewed by the doctor in a timely manner (within 24 hours of results being available)?6. If empirical antimicrobial therapy was initiated, was antimicrobial therapy adjusted in view of the investigation results and the consumer’s condition?

Inappropriate use of antimicrobials, including prescribing AND administration, is the KEY driver of Antimicrobial Resistance.

ANTIMICROBIAL STEWARDSHIP• A set of strategies to promote appropriate use of antimicrobials, improve consumer outcomes, reduce resistance, and reduce the spread of

infections.• Achieved by promoting the appropriate selection of antimicrobial regimen, dose, duration and route of administration.

InstructionsFacilities may use this tool at any given time, as a ‘spot check’, to assess adherence to antimicrobial stewardship clinical care standards. At the time of assessment, include any consumer prescribed an antimicrobial agent - this includes topical agents such as creams and ointments.

Any answer of ‘NO’, may indicate that a review of the facility policy, and clinical governance is warranted.

APPENDIX A

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Antimicrobial Stewardship ToolResident 1 Resident 2 Resident 3 Resident 4 Resident 5

YES NO YES NO YES NO YES NO YES NO

7. Is there ease of access to the current version of ‘Therapeutic Guidelines: Antibiotic’ at the facility?8. Did the doctor prescribe the correct medication according to current evidence-based guidelines?9. Was the reason for antimicrobial prescribing documented in the medical notes?10. Is the antimicrobial prescribed appropriate, taking into account documented allergies or adverse drug reactions?11. Did the doctor prescribe the correct dose (including adjustment for renal function) according to guidelines?12. Did the doctor prescribe the antimicrobial for the correct duration according to the guidelines?

13. Was the duration of therapy well documented?

14. Was a review plan documented in the consumer’s medical notes?

15. Did the consumer/carer receive information about their treatment, its duration, ongoing review and potential side effects? 16. Was the medication given correctly according to specific directions e.g. with specific time intervals, before or after food?

17. Did review of the efficacy of the antimicrobial occur during the course?

18. If adverse effects occured after taking the antimicrobial, were these appropriately monitored and recorded, and added to the list of adverse drug reactions for the consumer?

PO BOX 90ANNANDALE NSW 2038Ph: (02) 9819 0600Fax: (02) 8572 [email protected]

a

pfwe

Copyright 7th Edition © Meditrax January 2019 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole

or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.12

Generic Name (Brand Name) Recommended Dosage Adverse Effects Points for Consideration Indications

Ceph

alos

porin

s cefaclor (Ceclor) controlled-release tablet oral liquid: 25 mg/mL or 50 mg/mL

• 250–500 mg every 8 hours; or 375–750 mg every 12 hours using controlled release tablet

diarrhoea, nausea, vomiting, rash, headache, dizziness, allergy, Clostridium difficile-associated disease

• Be careful if there is carbapenem or penicillin allergy as cross-reactivity between penicillins, cephalosporins and carbapenems can occur

• Cephalexin may be administered with or without food• Cefaclor is best taken with food. Swallow whole (do not cut,

crush or chew them)

• Urinary Tract Infection• Respiratory Tract Infection• Staphylococcal and Streptococcal

Infections

cephalexin (Keflex)

capsule oral liquid: 25 mg/mL or 50 mg/mL

• 250–500 mg every 6 hours or 500 mg – 1 g every 6–12 hours

• If CrCl <20 mL/minute, 250–500 mg every 8–12 hours• For uncomplicated UTI - 500 mg every 12 hours for 5 days

for women, 14 days for men• For UTI prophylaxis - 250 mg at night

Mac

rolid

es

clarithromycin (Klacid)

tablet oral liquid: 50 mg/mL

• 250–500 mg twice daily• If CrCl <30 mL/minute, 250 mg once or twice daily

nausea, vomiting, diarrhoea, abdominal pain and cramps, candidal infections

clarithromycin may cause taste disturbance

• May prolong the QT interval and increase the risk of arrhythmia• Potential for drug interactions including statins, carbamazepine

and calcium channel blockers • Roxithromycin is absorbed best if you take it at least 15 minutes

before a meal. If it makes the resident feel sick then it may be taken with food

• Erythromycin capsule should be taken 1 hour before food

• Respiratory tract infections• H. pylori infection, with other agents

roxithromycin (Rulide) tablet dispersible tablet: 50 mg

• 150 mg twice daily, or 300 mg once daily• If severe hepatic impairment, 150 mg once daily

• Respiratory tract infections• Pneumonia• Skin infections

azithromycin (Zedd, Zithromax) tablet oral liquid: 40mg/mL

• 250mg-500mg single daily dose, for 3 days up to 3 weeks depending on indication

erythromycin (Eryc, E-Mycin) tablet capsule oral liquid: 40mg/mL

• 400mg-800mg every 6 hours (tablets)• 250mg every 6 hours or 500mg every 12 hours (capsule)

Oth

ers

trimethoprim (Triprim, Alprim)

tablet

• For uncomplicated UTI, 300 mg at night for 3 days in women OR for 14 days in men

• For recurrent UTI, 300 mg at night for 10–14 days• For UTI prophylaxis, 150 mg at night• For prostatitis, 300 mg at night for 4 weeks• If CrCl 15–30 mL/minute, usual dose for 3 days, then halve

dose• If CrCl 10–15 mL/minute, halve dose

fever, itch, rash, nausea, vomiting, hyperkalaemia

• May be taken with or without food• Trimethoprim is best taken at night so that the antibiotic

concentrates in the urine

• Urinary tract infections• Prostatitis (acute or chronic)

trimethoprim with sulfamethoxazole (Bactrim) tablet oral liquid: trimethoprim 8 mg/mL, sulfamethoxazole 40 mg/mL

• 80/400–160/800 mg every 12 hours• If CrCl 25–50 mL/minute, oral/IV 160/800 mg every 12

hours for 14 days, then 160/800 mg every 24 hours

fever, nausea, vomiting, diarrhoea, anorexia, rash, itch, sore mouth, hyperkalaemia, thrombocytopenia

• Take this medicine with food to reduce GI upset• Avoid sun exposure, wear protective clothing and use sunscreen

to reduce risk of rash from the sun• Maintain hydration (for those without fluid restriction) to avoid

crystalluria

• Urinary tract infections• Bronchitis• Pneumonia

hexamine hippurate (Hiprex)

tablet

• 1 g every 12 hours nausea, vomiting, diarrhoea, rash, dysuria

• Avoid taking medications like sodium bicarbonate, Ural®, Citralite® or Citravescent® as they make hexamine less effective

• Ineffective in renal impairment• Requires urinary pH <5.5 for activity, consider administration

with ascorbic acid

• Prophylaxis of chronic or recurrent UTIs

nitrofurantoin (Macrodantin)

capsule

• For uncomplicated UTI, 50-100 mg qid for 3 days in women OR 7-14 days in men

• For UTI prophylaxis, 50-100 mg at bedtime

nausea and vomiting, anorexia, diarrhoea, abdominal pain, allergic skin reactions, headache, pulmonary toxicity, peripheral polyneuropathy

• Take with food or milk to reduce nausea and to improve absorption

• May cause urine to become browinish colour • Contraindicated if eGFR < 45 as it may increase the risk of

adverse effects including peripheral polyneuropathy

• Urinary tract infections

Copyright © Meditrax October 2018: Version 3 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.

GUIDE TO COMMON ANTIBIOTICS USED IN AGED CARECopyright © Meditrax October 2018: Version 3

APPENDIX B

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Generic Name (Brand Name) Recommended Dosage Adverse Effects Points for Consideration Indications

Peni

cilli

ns

amoxycillin (Amoxil)

tablet, capsule oral liquid: 25 mg/mL or 50 mg/mL

• 250–500 mg every 8 hours or 1 g tablet twice a day. Doses of 1 g every 8 hours may be used in severe infections, eg pneumonia

diarrhoea, nausea, superinfection (including candidiasis) especially during prolonged treatment with broad-spectrum penicillins, allergy

Dicloxacillin and flucloxacillin may cause transient increases in liver enzymes and bilirubin

• May be taken with or without food• Exacerbation of chronic bronchitis• Pneumonia• Ear infections, sinusitis• Prostatitis• Urinary tract infections

amoxycillin with clavulanic acid tablet oral liquid: amoxycillin 25 mg/mL, clavulanic acid 6.25 mg mL or amoxycillin 80 mg/mL, clavulanic acid 11.4 mg/mL

• 500–875 mg every 12 hours for 5–10 days or longer, depending on the infection • Suspension is best taken with the first mouthful of food

dicloxacillin

capsule

• 250–500 mg every 6 hours• If CrCl <10 mL/minute, oral 250–500 mg every 6–8 hours • Dicloxacillin and flucloxacillin are absorbed best if the capsules

are taken on an empty stomach at least half an hour before food or 2 hours after food

• Skin infections• Pneumonia• Osteomyelitis, septic arthritisflucloxacillin

capsule oral liquid 25 mg/mL or 50 mg/mL

• 250–500 mg every 6 hours• If CrCl <10 mL/minute, oral/IV 250–500 mg every 6–8 hours

Qui

nolo

nes

ciprofloxacin

tablet

• 250–500 mg twice daily• For bone and joint infections, 750 mg twice daily• If CrCl <30 mL/minute, halve normal dose

rash, itch, nausea, vomiting, diarrhoea, abdominal pain, dyspepsia

• Quinolones are typically used for UTIs caused by resistant organisms, or when other agents are contraindicated

• Stop the medicine if tendon soreness or inflammation, numbness or tingling in fingers or toes develop

• Norfloxacin is best taken 1 hour before, or 2 hours after, meals for best absorption; drink plenty of fluids while taking it

• Dairy products, antacids, iron, zinc or calcium supplements may reduce the absorption of norfloxacin and moxifloxacin; do not take them within 2 hours of a norfloxacin dose; administer moxifloxacin >2 hours before or >4 hours after these agents

• Avoid sun exposure, wear protective clothing and use sunscreen while taking norfloxacin

• Complicated UTIs• Bone or joint infections• Prostatitis

norfloxacin

tablet

• For uncomplicated UTI, 400 mg every 12 hours for 3 days• For recurrent UTI, 400 mg every 12 hours for 10–14 days• If CrCl <30 mL/minute, 400 mg once daily

• Uncomplicated UTIs caused by organisms resistant to other antibacterials

• Prostatitis (acute and chronic)

moxifloxacin

tablet

• 400mg daily for 5 days for bronchitis, 10 days for sinusitis and pneumonia, and 7-21 days for skin infection

• Respiratory tract infections• Skin infections

Tetr

acyc

lines

doxycycline

tablet, capsule

• 200 mg on day 1 (as a single dose or 100 mg twice daily), then 100 mg once daily

• For rosacea, 50 mg once daily

nausea, vomiting, diarrhoea, epigastric burning, photosensitivity

• Take doxycycline as a single daily dose in the morning rather than at night

• Take doxycycline and minocycline with food or milk to reduce stomach upset

• Take with a large glass of water, and remain upright (do not lie down) for an hour after taking a tetracycline to avoid damaging throat lining

• Do not take antacids, iron, calcium or zinc supplements within 2 hours of a tetracycline as they may interfere with its absorption

• Avoid sun exposure, wear protective clothing and use sunscreen while taking this medicine

• Rosacea (severe cases or failure of topical treatment)

• Pneumonia• Exacerbation of chronic bronchitis• Acute bacterial sinusitis• Chronic prostatitis

minocycline

tablet • initial dose 200 mg, then 100 mg twice daily. Maximum 400 mg daily

• Infections due to susceptible bacteria• Bullous pemphigoid

Copyright © Meditrax October 2018: Version 3

Copyright © Meditrax October 2018: Version 3 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.

GUIDE TO COMMON ANTIBIOTICS USED IN AGED CARE

14

WHO IS MEDITRAX?

Meditrax is a group of accredited pharmacists who specialise in medication management. We regularly visit aged care facilities and provide a range of services aimed to optimise medicine management and outcomes for residents.

BACTERIA

Bacteria are organisms which can be found on the inside and outside of our whole body. Many are not harmful, and can be helpful to us. However, some can cause diseases and infections. Some examples of bacterial infections include urinary tract infections, cellulitis and bacterial pneumonia.

ANTIBIOTICS

Antibiotics are medicines used to treat and prevent bacterial infections. The first antibiotic discovered was penicillin. It was discovered in 1928 by Alexander Fleming, a Scottish researcher. There are now numerous different classes of antibiotics. Unfortunately however, a new class hasn’t been discovered since 1987.

ANTIBIOTIC RESISTANCE

Antibiotic resistance occurs when bacteria change in response to using antibiotics, making them less effective or ineffective. This increases the risk of people not recovering from infections treated with antibiotics. Resistance occurs on a small scale naturally, however, increase significantly with incorrect use of antibiotics.

Incorrect antibiotic use includes:

• Using antibiotics when not required – that is, when there is no bacterial infection. Antibiotics are not effective against viruses. Most upper respiratory infections are caused by viruses. They are usually self-limiting, that is they resolve over time.

• Not using the correct antibiotic, or correct dose to treat an infection.

• Missing doses of an antibiotic.

WHY ARE WE CONCERNED?

According to the World Health Organization (WHO), antibiotic resistance is one of the biggest health threats to humans.

It can affect anybody, anywhere, at any time. The people at greatest risk are the very young, elderly, and those with poor immune system function.

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trademark of Manrex Pty Ltd t/as Meditrax.

RESIDENTS AND RELATIVES NEWSLETTERIssue 12, July 2019

‘Antibiotic Resistance - one of our biggest health threats’

APPENDIX C

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As we age, our immune function declines. This can be made worse if we take certain medications and have certain medical conditions. Therefore, we are at higher risk of infection, and it takes longer to recover.

Antibiotic resistance has led to the formation of ‘superbugs’ – bacteria which are resistant to all available antibiotics.

If antibiotic resistance continues at a rapid rate, there is a risk that many infectious diseases will become uncontrollable.

In the last 50 years, there has only been ONE antibiotic that works in a new way discovered for human use. Antibiotic resistance is growing quickly, and even if new antibiotics are discovered, resistance will still be a concern if we don’t change the way we use antibiotics.

WHAT CAN WE DO?

There is a misconception that this is a problem which we have no control over, and that individual action therefore makes no difference. However, this isn’t correct, and we are all responsible for helping to reduce inappropriate antibiotic use.

The following can help:

• Only use antibiotics when prescribed by a health professional – do not self-treat with left-over previous supplies or share medicines with others.

• Do not demand antibiotics if a professional says they are not necessary.

• ‘Green phlegm’ or coloured mucus doesn’t necessarily mean you have a bacterial infection. While some people may have bacterial infections and will need antibiotics, many will not. Sometimes the safest thing to do is ‘wait and see’, under doctor and staff supervision.

• Follow staff advice about how antibiotics should be taken (whether this is on an empty stomach, or away from other medicines).

• Help with preventing infections spreading by regularly washing hands, avoiding contact with others if you are sick, and having vaccinations regularly.

• Be aware that antibiotics do NOT treat viral infections, like cold and flu.

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URINARY TRACT INFECTIONS

As we age, urinary tract infections can become more common, especially in women. There are several common physical signs and symptoms of urinary tract infection:

• Pain or burning on urination• Increased urge to urinate, and

feeling unable to empty the bladder completely

• Fever• Lower back pain

While all these symptoms may not occur in all older people with an infection, investigation may be needed if some of these symptoms develop. Cloudy or smelly urine isn’t usually sign of an infection.

PENICILLIN ALLERGY

Penicillin allergy is very commonly reported, in about 10% of people. However, research has shown that more than 90% of people with listed penicillin allergy, do not have a true allergy and can take penicillins.

Penicillins are often the first line of defence for many infections. If someone has a penicillin allergy listed incorrectly, this limits treatment choices. It can mean we need to use antibiotics which are ‘broad spectrum’ - these are antibiotics which can lead to resistance and super bugs, or antibiotics which are usually reserved for more serious infections which may lead to a greater risk of resistance developing to these.

It can also mean that the infection may

get worse, if penicillin is the only antibiotic effective for that particular infection.

Are you sure it is an allergy?

Do you remember what happened when you had penicillin?

It is ok if you cannot remember, however if you can, this can be very useful information for your doctor.

Adverse effects are common with antibiotics, and include nausea, vomiting, diarrhoea, stomach pain. These are not however signs of allergy.

Often adverse effects are misinterpreted as penicillin allergy. It is a good idea to discuss this further with your doctor.

For more information, contact Meditrax, your doctor, or aged care staff.

More reading is also available at www.nps.org.au/consumers/antibiotic-resistance-the-facts.

PO BOX 90ANNANDALE NSW 2038

Ph: (02) 9819 0600Fax: (02) 8572 9248

[email protected]

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ANTIBIOTICBACTERIARESISTANCEINFECTION

PENICILLINPHLEGMTHREATVIRUS

Meditrax Word Search

APPENDIX D

Assessment and treatment of aged-care facility residents with suspected urinary tract infection (Figure 2.13); Antibiotic [June 2019]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2019 June.

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Copyright © Meditrax 2019 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan

has expired, the material is to be returned to Meditrax.” Meditrax is a registered trademark of Manrex Pty Ltd t/as Meditrax.

Documents

Antimicrobial Stewardship Facility Resource...What can residential aged care facilities do? In order to ensure adherence to the Aged Care Quality Standards, and demonstrate activities