In an ideal world!

Considering who should be involved in prescribing decisions for patients depends on the staff available.

In an ideal world one might argue that an infection doctor should be involved in the prescribing decision for John in Step 2.10, and indeed, if there is any doubt amongst the clinical team about the most appropriate therapy then an infection doctor should be consulted urgently.

However, in many organisations, due to limited resources, it may be unrealistic to expect this. It is also important to remember that John has evidence of severe infection (his blood pressure is low in the context of a systematic inflammatory response) and any delay, due to the seeking of infection advice, in the prescribing and administering of the first dose of antibiotic therapy may impact on his subsequent outcome.

Easily accessible antimicrobial guidelines (e.g. poster on the ward and/or hospital intranet and/or smartphone application) can play a vital role here. Infection expertise could be sought following the administration of the first dose if there is doubt.

The ward nurse is critically important in administering antibiotic therapy and potentially has an important antibiotic stewardship role, for example:

• contributing to team decisions about IV to oral switch or the stopping of therapy

• communication between the prescribing team and the administering nurse team is vital to ensure antibiotic therapy is administered in a timely manner (within one hour in severe infection).

There is considerable over-lap in the role of the ward’s doctor (or other antibiotic prescribers) and pharmacist (when available) in prescribing, but both have specific skill sets and most importantly should work together to optimise prescribing.

The role of the pharmacy-doctor team includes:

• Assessing the patient diagnostically and ensuring appropriate infection tests are performed prior to timely antibiotic therapy
• Making an initial prescribing decision that accounts for allergies and pharmaco-kinetic/dynamic factors, including any kidney injury and drug-drug interactions
• Undertaking therapeutic drug monitoring as appropriate
• Deciding on an optimal duration or review date
• Adequate documentation of the prescribing decision
• Monitoring the response to antibiotic therapy and making ongoing prescribing decisions based on response and any positive tests
• Ensuring adherence to local or national guidelines
• Accounting for any prevailing epidemiological issues (such as resistance, as in the scenario).

Do you have an easily accessible antibiotic guideline in place to help the prescribing decision for John in your organisation?

If so, what does it recommend and would you follow this recommendation?

If not, or if there is no such guidance, what do you think should be recommended for this scenario and why?

Think how you might monitor adherence to any guidance where you work.