How to develop antibiotic guidelines and policies

The terms antibiotic policy and guidelines are often used interchangeably and may be confusing to many healthcare providers.

An antibiotic policy is a set of principles to guide implementation of prudent and rational antimicrobial prescribing in the hospital.

While antibiotic guidelines are specific recommendations for antibiotic treatment or prophylaxis for particular infections, diseases or syndromes. In the following papers evidence for the benefits of guidelines and policies includes:

1. WHO “Step-by-step approach for development and implementation of hospital antibiotic policy and standard treatment guidelines. 2011”

2. “Guidelines for antibiotic usage in hospitals.” Brown, J. Antimicrob. Chemother. 2002; 49:587 – 92.

An antibiotic policy can:

• help reduce morbidity and mortality due to antimicrobial-resistant infections

• reduce the emergence and spread of multiple antibiotic-resistant bacteria

• preserve the effectiveness of antibiotics for treatment and prevention of diseases.

An antibiotic guideline can:

• help to improve patient outcomes

• reduce the cost of patient care

• enhance cost savings

• improve quality of care

• reduce variations in antibiotic prescription amongst physicians

• may be an effective means of changing behaviour in antimicrobial prescribing.

In many health care settings in Africa, antibiotic policies and guidelines may not be available due to limited experience with evidence based guideline development and inadequate availability of locally applicable high level evidence. Therefore it is important to know how to develop them.

It will take substantial time, effort and resources to develop antibiotic policies and guidelines from the scratch in this situation. It is advisable to look at other guidelines that are relevant to the local situation in the healthcare setting or country and adapt accordingly.

A multidisciplinary antibiotic management team can be set up to write the antibiotic guideline and policy.

This team will include physicians, surgeons, paediatricians, clinical microbiologists and pharmacists.

The team will identify available evidence based policies and guidelines, update to fit local situation and write the first draft. They may also write from scratch based on their own identified basic background information and challenges. This will entail identifying literature according to an explicit search strategy and conducting a systematic review of relevant literature. The team must have information on the local antibiotic formulary of the hospital or country; the antibiotics that are available locally; antibiotic consumption data and the local antibiogram.

After the first draft is written, input should be sought from all stakeholders including trainees to ensure ownership of the document. The draft is reviewed based on feedback from the stakeholders and a pilot testing of second draft can be tried in a selected unit or department. This is monitored and reviewed for the final version to be implemented. It is important that antibiotic guidelines are written by those who will eventually use them to ensure that they take ownership and responsibility for implementation and adherence to the guidelines.

The policy should contain antibiotics for general use, reserved and restricted antibiotics; recommendations for principles of antimicrobial stewardship, alternatives for antibiotic use in case of allergy, guidance for intravenous to oral switch etc. The treatment guideline should provide information on the syndrome/diseased e.g pneumonia; type of clinical setting – Outpatient clinics, Inpatient units, ICU setting; when to switch from IV to oral and criteria for the diagnosis of infection/syndrome. The guideline and policy should be simple, clear, relevant to local clinical conditions, applicable to day to day practice and available in acceptable formats.

The antibiotic policy and guidelines are living documents and therefore should be reviewed at regular intervals. They should be updated according to current medical knowledge, clinical practice and local circumstances.

Here is an example of an antibiotic policy from the UK:

East Cheshire NHS Trust Antibiotic Policy (Paediatric)

It provides guidance on prudent prescribing of antibiotics. It gives details on principles of antimicrobial stewardship, protected antibiotics, treatment guidelines, surgical and medical prophylaxis. Within the treatment guidelines are the different infections or diseases; specimens to collect, likely organisms and antibiotic, dose, frequency, route of administration and duration.

This document, “A pocket guide to antibiotic prescribing for adults in South Africa, 2015”, contain principles for rational antibiotic prescribing, interpreting laboratory test result, sample collection methods and guideline for treatment of different infections/disease. The guideline contains the diagnostic criteria for infections, likely pathogens, diagnostic tests, antibiotic, dose, frequency, route of administration and duration.

You may find these useful templates to refer to when developing your own policies and guidelines.