Secondary Care Antimicrobial Guidance for Antimicrobial Management Teams in NHS Scotland

Aim                                                                               

Antimicrobial management teams (AMT) in NHS boards are responsible for maintaining a local antimicrobial stewardship (AMS) programme [1, 2]. Antimicrobial guidance is a core component of an AMS programme. This guidance outlines recommendations on best practice for secondary care antimicrobial guidance for both adults and children.

Other key components of an AMS programme, such as the broader organisational aspects of AMS, AMS in the laboratory, infection prevention and control (IPC), and antimicrobial resistance (AMR) surveillance are not included here. AMT’s can consider applying to the British Society for Antimicrobial Chemotherapy (BSAC) Global Antimicrobial Stewardship Assessment Scheme (GAMSAS) [3] for peer review and assurance of local board AMS programmes.

Summary of Good Practice Recommendations for secondary care antimicrobial guidance

1. Ensure guidelines are readily accessible to prescribers. Review guidelines regularly, complete a formal review at least every three years, and have a process in place to update the guidelines more frequently if the evidence changes 

2. Ensure empirical treatment guidelines include recommendations to manage common infections, avoid unnecessary antibiotic use, assess the severity of infection and minimise any unintended consequences of antimicrobial prescribing

3. Ensure guidelines give recommendations on the review of empiric treatment.This should include the criteria for review, recommendations for intravenous to oral antibiotic switch,guidance on duration of therapy,and use of antimicrobial therapy in hospital at home services including outpatient parenteral antibiotic therapy (OPAT)

4. Ensure a surgical procedural antibiotic prophylaxis guideline is in place for all specialities where interventional procedures are undertaken

5. Implement a strategy to limit prescribing of WHO Watch and Reserve antibiotics 

6. Agree a local protected or “alert” list of antimicrobials which require infection specialist approval and a system to manage the approval and supply of antimicrobials on the list

7. Monitor compliance with antimicrobial guidelines 

8. Be alert to and monitor for unintended consequences of antimicrobial guidelines with support from clinical and governance teams

9. Provide training and education on guidelines to all staff that prescribe, administer and monitor antimicrobials 

10. Ensure robust systems are in place for AMTs to communicate key issues or updates with clinical teams including prescribing alerts,guideline updates and antimicrobial supply 

Detailed recommendations

• Ensure prescribers can easily access antimicrobial guidelines eg via NHS board Right Decision Service (RDS) guidance and intranet, therapeutic handbook, posters in clinical areas including antimicrobial calculators [4] and other relevant national guidance via RDS and on the SAPG website [5].  
• Regularly review local guidelines and complete a formal update at least every three years. AMTs should do this in collaboration with relevant clinical specialties.
• AMT should be alert to practice changing evidence and have a process in place to incorporate this into guidance in a timely manner before scheduled 3-year review.
• Guideline development and review should consider the following:
  • Local and national emerging antimicrobial resistance
  • Local and national surveillance of antimicrobial use
  • Local qualitative data on prescribing (eg point prevalence surveys)
  • Rates of C. difficile 
  • Emergence and recognition of unintended consequences of guidance 
  • Emerging evidence supporting best practice

2. Ensure empirical treatment guidelines include recommendations to manage common infections, avoid unnecessary antibiotic use, assess the severity of infection and minimise any unintended consequences of antimicrobial prescribing

• Common infections in adults and children include

  • Respiratory tract infections including community acquired pneumonia, healthcare associated pneumonia, aspiration pneumonia, infective exacerbations of chronic obstructive pulmonary disease (COPD), tonsillitis and pertussis (children), suspected influenza and coronavirus disease (COVID-19) infection.

  • Skin and soft tissue infections including rapidly progressive necrotising infections, animal bites and those related to injection drug use. 

  • Urinary tract infection including lower urinary tract infection (UTI), pyelonephritis and catheter related infections. 

  • Intra-abdominal infection including gastroenteritis, acute abdomen and subacute bacterial peritonitis. 

  • Bone and joint infection including orthopaedic infections, spinal infection, septic arthritis, osteomyelitis and diabetic foot infection. 

  • Central nervous system infections including encephalitis and bacterial meningitis. 

  • Sepsis syndrome including sepsis of unknown source differentiating by age (neonate, child, adult) and between community and healthcare associated sepsis. [6] 

  • Fever in the immunocompromised host or neutropenic sepsis. 

  • Suspected infective endocarditis. 

  • Specific healthcare associated infections such as S. aureus bacteraemia (SABs), C. difficile [7] and candidaemia. 

• Include or take into account the core principles of AMS:
  • Highlight the importance of prudent prescribing and limit antibiotics prescribing to patients with clear symptoms of, or suspected bacterial infection. 
  • Highlight circumstances where antibiotics are not, or are unlikely to be beneficial eg self-limiting bacterial or viral infections (eg COVID-19), colonisation and infections where the source has not been removed or controlled. 
  • Restrict antibiotics that increase the risks of C. difficile  infection eg 2nd, 3rd and 4th generation cephalosporins, quinolones, clindamycin, co-amoxiclav, piperacillin/tazobactam and carbapenems [8]. Restricted antimicrobials may differ in neonates and children, so account for this in local protected antimicrobial policies. 
  • Promote use of WHO Access antibiotics and limit ‘Watch and Reserve’ antibiotics to preserve their future use and minimise resistance (see section 5). 

• Guide optimal pre-treatment clinical assessment of infection
  • Promote early identification and prompt management of sepsis based on Academy of Medical Royal Colleges Statement on the initial antimicrobial treatment of sepsis and on careful clinical assessment of severity and likelihood of bacterial infection. [6] 
  • Include details of severity of infection assessments where applicable eg community acquired pneumonia (CURB-65), C. difficile infection and neutropenic sepsis risk stratification. [9] 
  • Promote and optimise relevant microbiological sampling (particularly blood cultures), point of care testing and use of non-culture investigations prior to initiating therapy.  
  • Promote review of previous microbiological investigations (when available) before commencing therapy (eg methicillin resistant staphylococcus aureus (MRSA) status, gentamicin resistant E. coli, recent extended spectrum beta lactamase (ESBL) infection, multidrug resistant organism carriage, recurrent pseudomonal exacerbations in bronchiectasis or cystic fibrosis).

• Guide optimal selection and duration of antimicrobial therapy
  • Choose effective antimicrobials to reduce the risk of treatment failure. Consider spectrum of activity, dose, route, schedule and duration of treatment.
  • If a penicillin allergy label is on record, determine penicillin allergy status (refer to SAPG’s penicillin allergy delabelling resources) and provide alternative treatment options if penicillin allergy is suspected or confirmed. [10]
  • Highlight important antimicrobial–drug interactions (eg multiple drug interactions with clarithromycin, reduction of doxycycline and quinolone absorption by cations such as iron and calcium) and those that prolong QT interval.
  • Minimise duration of antibiotic therapy to the shortest possible based on the available evidence. [11, 12]

• Guide the safe use and monitoring of complex antimicrobials
  • Use nationally approved guidance and antimicrobial calculators for the safe use of gentamicin and vancomycin and ensure these are readily available to prescribers. These provide information on dosage, monitoring requirements and duration of treatment.  Guidance can be accessed via local NHS board intranet,  RDS and SAPG website. [4,5]  
  • Refer to guidance when prescribing other complex antimicrobials eg fluoroquinolones for their safe use and monitoring.
  • Include patients in decision making. Discuss risks and monitoring plan with the aid of Patient Information Leaflets where required. 

• Guide the safe prescribing of antimicrobials  
  • Prescribe all intravenous antimicrobials, including initial stat doses, on the hospital electronic prescribing and medicines administration (HEPMA) system (when available).   
  • Prescribe all gentamicin and vancomycin doses on HEPMA (when available). 
  • Promote and use prescribing alerts within HEPMA (when available). 

• Promote good documentation of diagnosis and management plan, including 
  • Infection diagnosis (ie indication) and management plan at the time of initiating antibiotic in the medical record. 
  • Indication for antibiotic on HEPMA (when available) or prescription chart. 
  • Duration or stop date of oral antibiotics on written or electronic prescription.  
  • Review of IV antimicrobials using ReCORD mnemonic. 
  • Duration or stop date of IV antibiotics when known on written or electronic prescription. 
  • Patient communication and consent for complex off license antimicrobials.

3. Ensure guidelines give recommendations on the review of empiric treatment.

This should include: 

• Emphasise the importance of clinical review of the patient and the diagnosis. 
• Review of microbiological and radiological results to inform rationalisation of antibiotic therapy. 
• Daily review of intravenous therapy to optimise timely intravenous to oral switch therapy (IVOST). 
• Specific criteria for IVOST and details of oral switch options (where applicable) for key clinical indications. 
• Total duration of therapy (IV and oral) for each indication. 
• Support for early hospital discharge or admission avoidance in suitable patients either through timely IVOST or, in selected patient groups, through OPAT programmes. [13] 
• Ensure that OPAT and Hospital at Home programmes implement AMS principles and are governed in accordance with national good practice recommendations. [14] 
• Clear documentation of clinical decisions made to review and discontinue antimicrobial therapy. 

4. Surgical and procedural antibiotic prophylaxis guideline must be in place for all specialities where interventional procedures are undertaken

• Examples of specialities include all surgical specialities and others who undertake endoscopy or implant cardiac devices and those who perform interventional radiology. 

5. Implement a strategy to limit prescribing of WHO Watch and Reserve antibiotics 

• Specifically, carbapenems should only be prescribed on the recommendation of an infection specialist or as a part of a specialist infections policy authorised by the AMT. 
• Ensure alternatives to carbapenems are available to support this strategy eg aztreonam, temocillin, fosfomycin, tigecycline. 

6. Agree a local protected or “alert” list of antimicrobials which require infection specialist approval and a system to manage the approval and supply of antimicrobials on the list: 

• Antimicrobial “Alert lists” should include newly licensed antimicrobials following advice from the Scottish Medicines Consortium (SMC).  
• Put in place a local authorisation process to limit unauthorised supply or dispensing of protected or alert antimicrobials. 
• Use of protected or alert agents should be monitored and subject to review by the AMT. 

7. Monitor compliance with antimicrobial guidelines: 

• As a minimum, implement a system to record compliance with prescribing indicators agreed by SAPG. This can be achieved via targeted prescribing review, point prevalence surveys or utilisation of HEPMA data sets. Where data is collected by non-AMT members, AMTs should validate the data.  
• Undertake local surveillance of hospital antimicrobial use following SAPG guidance. [15] 

8. Be alert to and monitor for unintended consequences of antimicrobial guidelines with support from clinical and governance teams  

• Consider the unintended consequences of antibiotics through communication with and collaboration between the AMT and other clinical specialists and hospital governance bodies including infection prevention and control teams (IPCTs) and Area Drug and Therapeutics Committee (ADTC). 
• Examples of known potential unintended consequences include renal and oto-toxicity related to aminoglycosides, surgical site infections related to inadequate surgical antibiotic prophylaxis. 
• AMTs should be aware of and consider contingency plans (antimicrobial substitution) for acute shortages of key antimicrobials.  
• Consider early warning system or signals where appropriate. 

9. Antimicrobial guidelines should be supported by education and training for all staff that prescribe, administer and monitor antimicrobials. 

• Education and training can be delivered as part of new staff induction, at in-person targeted training events, and as self-directed learning modules.
• Training should include behaviour change strategies.

10. Ensure robust systems are in place for AMTs to communicate key issues or updates with clinical teams including prescribing alerts, guideline updates and antimicrobial supply  

• AMTs should discuss and review proposed actions if  
  • compliance with guidelines is suboptimal 
  • trends in usage suggest a change in prescribing habits 
  • unintended consequences of guidance is identified, or  
  • if there is acute shortages of key antimicrobials
• Establish clear lines of communication between the AMT, health board, medical, pharmacy and nursing management and ADTC. This will facilitate rapid communication of actions for prescribers and other healthcare professionals when required.

References 

Table of abbreviations

Scottish Antimicrobial Prescribing Group (SAPG) | August 2025 for review August 2028

Content updated: March 2026