Antibacterial resistance – a global threat to public ... · guidelines to ensure appropriate...

Antibacterial resistance –a global threat to public health:the role of the pharmacy team

Completing the learning experience

A CPPE distance learning programme

DLP 173September 2014

Educational solutions for the NHS pharmacy workforce

© Copyright controller HMSO 2014

Antibacterial resistance –a global threat to public health:the role of the pharmacy team


Answers and suggestions forputting your learning into practice

Acknowledgements

Lead writer for this edition

Nick Haddington, teacher practitioner, University of Bath

CPPE programme developer for this edition

Paula Higginson, lead pharmacist, learning development

Reviewer for this edition

Julia Lacey, antimicrobial pharmacist, Derby Hospitals NHS FoundationTrust

We are grateful for the contribution made by those involved in producing theoriginal edition of this programme as set out below.

Project team

Mazim Ali, community pharmacist, BirminghamKathryn Featherstone, PCT pharmacist, SouthTyneside PCTPaula Higginson, senior pharmacist, CPPEJyoti Saini, PCT advisor, East Birmingham PCTAmit Shah, community pharmacy adviser, Brent PCTSueWalton, learning and development co-ordinator, CPPE

Reviewer

Kevin Frost, antibiotic pharmacist, Airedale General Hospital

The original edition of this learning programme was piloted nationally by thefollowing pharmacists and pharmacy technicians: Adedamola Folowosele, LindaMacDonald, Julie McCann, Chinjal Patel, Seema Patel, JoanneTaylor

CPPE reviewers

Christopher Cutts, directorPaula Higginson, senior pharmacist, learning development

Production

Outset Publishing Ltd,West Sussex

Second edition published in September 2014. Original edition published inNovember 2007 by the Centre for Pharmacy Postgraduate Education, ManchesterPharmacy School, University of Manchester, Oxford Road, Manchester M13 9PT

www.cppe.ac.uk

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Having worked through the Antibacterial resistance – a global threat to public health:the role of the pharmacy team learning programme, you now have an opportunity tocompare your answers to the case studies and activities with the suggested answersprovided here. We have also included suggestions about how you can share yourlearning with your pharmacy team, as well as ideas about how to develop aprotocol for infection control in your workplace. The additional activities providedin this document will be useful for your CPD and should help you to plan a CPDentry for your records.

Aim

The aim of this learning programme is to update your knowledge about the issuesof antimicrobial resistance and healthcare-associated infections (HCAIs) so thatyou can contribute to reducing their impact.You will learn about the importantrole the pharmacy team can play in supporting healthcare professionals andpatients to optimise patient outcomes in antimicrobial therapy, while minimisingharm.You will start to recognise the significance of the application of antimicrobialguidelines to ensure appropriate antibacterial use.

This learning programme focuses on antibacterials and antibacterial resistance.However, the same principles apply to antifungals and antivirals. Each of theseimpact on the global problems presented by antimicrobial resistance.

Learning objectives

On completion of this learning programme you should be able to:

� explain why antimicrobial resistance is considered to be one of the greatestpublic health risks in the UK and globally

� apply the principles of antimicrobial stewardship to your everyday practicethrough the use of one of the national toolkits

� advise prescribers on the appropriate and inappropriate use of antibacterialstherapy and optimising prescribing practice

� support public awareness campaigns on avoiding the use of antibacterials

� design learning materials for your team and your customers on avoidingantibacterial resistance

� develop a protocol to support the introduction of infection control to your workplace.

As policies relating to antibacterials can vary widely between trusts, it is importantthat you are aware of what your local policies say. There is not always a definiteright or wrong – your own experience of pharmacy practice and your local policiesmay mean that your responses to the activities differ from the suggested answersprovided here.

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C O M P L E T I N G T H E L E A R N I N G E X P E R I E N C E

Feedback

We hope you find this learning programme useful for your practice. Please help usto assess its value and effectiveness by visiting the my CPPE page on our website:www.cppe.ac.uk/mycppe

Alternatively, please email us at: [email protected]

All web links in this document were accessed on 2 October 2014.

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Caitlyn MorelandFour-year-old girl with atemperature and sore throatfor three days

Eileen Roberts59-year-old female with nosignificant medical history

Keisha Shakeshaft24-year-old female withasthma

Drug Amoxicillin 250 mg/5 mL sugar-free suspension

Dose 250 mg three times a day

Course Five days

Indication Sore throat

Appropriate?

Drug Cefuroxime tablets

Dose 250 mg twice a day

Course Seven days

Indication Post-operative prophylaxis, following eye surgery

Appropriate?

Drug Ciprofloxacin tablets


Course Ten days

Indication Chest infection

Appropriate?

Tom WatsonEight-year-old boy withearache, no other symptoms

Drug Erythromycin 125 mg/5 mL sugar-free suspension

Dose 125 mg four times a day

Course Five days

Indication Otitis media

Appropriate?


Answers to exercises

At the start of this learning programme we presented a set of ten prescriptions andasked you to jot down whether you thought they were appropriate.

Work through the exercise again, without looking back at your original answers.One of the reasons for repeating this exercise is to see whether your thinking haschanged as a result of your learning so far.

Exercise 1

Here is a selection of ten prescriptions for antibacterial therapy. For each onewe have provided the drug name, together with its dose and course length.We also tell you the noted indication and additional comments which may beuseful for that person. None of the patients have a stated allergy to theprescribed medicine. Have a look at each of these and note whether you thinkthe prescription is appropriate.

1

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Esther Cohan20-year-old female withCrohn’s disease

Yanna Koslov41-year-old female with nosignificant medical history

Nicholas Swift38-year-old male withprosthetic heart valve

Rupa Akthar58-year-old female with nosignificant medical history

Bessie Arnold79-year-old female withinfection due to a catheterprophylaxis

Drug Metronidazole tablets

Dose 400 mg at eight hour intervals

Course Four doses before surgery

Indication Bowel surgery prophylaxis

Appropriate?

Drug Norfloxacin tablets


Course 14 days

Indication Urinary tract infection

Appropriate?

Drug Penicillin V tablets


Course Seven days

Indication Dental prophylaxis

Appropriate?

Drug Sodium fusidate infusion


Course Five days

Indication Cellulitis

Appropriate?

Drug Trimethoprim tablets


Course Three days


Appropriate?

George Mathers61-year-old male inpatient



Course Ten days

Indication Diarrhoea

Appropriate?

2 C O M P L E T I N G T H E L E A R N I N G E X P E R I E N C E

S E P T E M B E R 2 0 1 4

Caitlyn MorelandFour-year-old girl with atemperature and sore throatfor three days

Drug Amoxicillin 250 mg/5 mL sugar-free suspension


Course Five days

Indication Sore throat

Appropriate? NNOO

Eileen Roberts59-year-old female with nosignificant medical history

Drug Cefuroxime tablets


Course Seven days

Indication Post-operative prophylaxis, following eye surgery

Appropriate? NNOO

These are our suggested answers. How do they compare with yours? For each one,we have provided a brief explanation for our choice.

What we thought

Most sore throats are viral and self-limiting. Caitlyn has only had symptoms for two

days. She could take Paracetamol to relieve her temperature and reduce any pain. You

can use the CENTOR scoring system to determine whether antibacterials are indicated.1

If antibacterials are indicated, phenoxymethylpenicillin (penicillin V) is usually first

choice.

Bacterial sore throats are nearly always caused by streptococci. Phenoxymethylpenicillin

is a narrow spectrum agent which will cover this. The broader spectrum offered by

amoxicillin is unnecessary and contributes to the spread of resistance.

If phenoxymethylpenicillin is indicated Caitlyn shoud take it for 10 days.2

What we thought

This looks like a treatment course, not prophylaxis. Based on the current evidence

prophylaxis is indicated, but the route and choice of antibacterial may vary, depending

on the type of eye surgery that the patient is having.

Some sources recommend topical antibacterial drops for a number of doses after

surgery, with the option of subconjunctival or intracameral injections of antibacterial

agents at the time of surgery.

In practice, you should consult your locally agreed guidelines to determine whether this

prescription is adherent. See references 3 and 4 for further information.3, 4

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Tom WatsonEight-year-old boy withearache, no other symptoms

Drug Erythromycin 125 mg/5 mL sugar-free suspension


Course Five days

Indication Otitis media

Appropriate? NNOO

George Mathers61-year-old male inpatient



Course Ten days

Indication Diarrhoea

Appropriate? NNOO

Keisha Shakeshaft24-year-old female withasthma

Drug Ciprofloxacin tablets


Course Ten days

Indication Chest infection

Appropriate? NNOO

What we thought

Ciprofloxacin would not give adequate cover, especially against Streptococcus

pneumoniae. It is an unusual choice as a sole first-line agent to treat a respiratory tract

infection.

Treatment will also depend on the type of chest infection Keisha has been diagnosed

with. ‘Chest infection’ is a broad and vague term, and encompasses a range of infective

conditions. If it is a lower respiratory tract infection (pneumonia) then antibacterials are

indicated. The NICE clinical knowledge summaries (CKS) website suggests amoxicillin or

doxycycline as first-line agents for low severity pneumonia. The Health Protection

Agency (HPA) Primary Care guideline suggests the same, with a course length of seven

days. It should be noted that for higher severity pneumonia, you should consider

different combinations of oral antibacterials or admission to hospital for intravenous

treatment. If however the ‘chest infection’ is bronchitis, then antibacterial therapy may

not be indicated at all.5, 6

If antibacterial therapy is indicated, then the HPA guideline recommends a shorter

course of five days. It should be noted that infective exacerbations of asthma tend to be

of viral and not bacterial cause, therefore the prescribing of antibacterials is

inappropriate in the absence of clear clinical signs of a bacterial infection.7

What we thought

Tom just has earache and no other symptoms. We don’t know how long he has had

symptoms for, but as there are no systemic symptoms this prescription is likely to be

inappropriate. Also, the dose is normally 250 mg four times daily for an eight-year-old.

What we thought

George should be given metronidazole three times a day. It is important to determine

the cause of the diarrhoea. If it is Clostridium difficile (C. difficile) then three times daily

dosing would be appropriate.


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Esther Cohan20-year-old female withCrohn’s disease


Dose 400 mg at eight hour intervals

Course Four doses before surgery

Indication Bowel surgery prophylaxis

Appropriate? NNOO

Yanna Koslov41-year-old female with nosignificant medical history

Drug Norfloxacin tablets


Course 14 days


Appropriate? IITT DDEEPPEENNDDSS

Nicholas Swift38-year-old male withprosthetic heart valve

Drug Penicillin V tablets


Course Seven days

Indication Dental prophylaxis

Appropriate? NNOO

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What we thought

A single dose before surgery would be the usual treatment. In addition, metronidazole

probably does not provide adequate spectrum of cover alone.3,4

Guidelines vary, but

either the addition of gentamicin, or the use of co-amoxiclav as a sole agent, may be

appropriate. Local guidelines vary significantly between hospitals.

What we thought

Is this an upper urinary tract infection (UUTI) or an uncomplicated lower urinary tract

infection (LUTI)? If it is a LUTI, trimethoprim or nitrofurantoin are more appropriate.

Amoxicillin is no longer suitable for empirical treatment of a urinary tract infection in

most areas, as resistance rates for Escherichia coli (E. coli) are in the region of 50 percent.6

Norfloxacin may be indicated in a patient with a penicillin allergy, depending on patient

factors, but as first-line empirical therapy, fluoroquinolones do not normally have a

place in practice.5, 6, 8

Also, norfloxacin is not specifically licensed for the treatment of

UUTI.9

What we thought

Based on the current evidence, prophylaxis is not indicated.10

However, some

cardiologists still recommend the use of prophylactic antibacterials in specific patient

groups at present. This remains an area of controversy. Additionally, this length of

therapy appears to be a treatment course, rather than prophylaxis.

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Rupa Akthar58-year-old female with nosignificant medical history

Drug Sodium fusidate infusion


Course Five days

Indication Cellulitis

Appropriate? NNOO

Bessie Arnold79-year-old female withinfection due to a catheterprophylaxis

Drug Trimethoprim tablets


Course Three days


Appropriate? NNOO

6

What we thought

Sodium fusidate should not be administered as sole agent, as otherwise there is an

increased risk of resistance developing.9, 11

Local antimicrobial policies should provide

guidance on the choice of combined therapy. Flucloxacillin would be the usual first

choice empirical agent for cellulitis.5, 6, 11

Reasons for variations from this would include

allergy or MRSA infection.11

What we thought

Is the lady symptomatic? Patients with a catheter and asymptomatic bacteriuria should

not receive antibacterial treatment. If symptomatic, then treatment of catheter-

associated urinary tract infections should be guided by culture and sensitivity results and

the catheter may need to be replaced.

Exercise 2

Having highlighted the importance of following local guidelines, there aresometimes good clinical reasons why prescribers need to diverge fromthese. What valid clinical reasons can you think of for prescribers notfollowing guidelines when prescribing antimicrobials for a patient?

Reasons we thought of for not following local guidelines include:

� allergies to first-line options

� co-pathologies that contraindicate or caution use of certain agents

� other prescribed medicines that could interact with certain agents

� known or previous colonisation or infection with resistant organisms

� an infection that has not responded to first-line antibacterials.

Often, when these circumstances occur, it is best to seek expert input from a

microbiologist, specialist infectious diseases doctor, or specialist antimicrobial

pharmacist, in order to select the most appropriate alternative agent.


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Exercise 4

You want to expand the services you provide from your pharmacy and areconsidering a diabetes testing service.

What infection control issues do you need to consider before setting up adiabetes testing service in your pharmacy?

Staff will need training on the risks of handling body fluids and a consultation area must

be used for the testing. Staff should wear gloves when handling body fluids and all staff

involved in testing will need to be vaccinated against hepatitis B and have their blood

titre checked regularly. Standard operating procedures should be in place for needlestick

injury, spillage of bodily fluids and disposal of clinical waste and sharps.


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8

Case study answers

As you worked through the learning programme you were presented with a seriesof case studies to help you put things into context. These are our suggestedsolutions to them.

Case study 1

Danuta Tarnowski has just taken her nine-year-old son Jozef to the GP, forsome “antibiotics” to clear his chest. He has had a cold for a week and he isstill sniffling and coughing. The GP wouldn’t prescribe any “antibiotics” forJozef and Danuta has come in to complain about the situation, as she isfurious. How would you respond to her?

Some important points that should come out in the discussion with Danuta to reinforce

the GP include:

� Jozef has a viral infection that will not respond to antibacterial treatment

� coughs and runny noses can persist for two to three weeks following a cold

� coughs and colds will resolve without treatment

� Danuta can purchase a soothing cough syrup, for example, simple linctus paediatric,

as there is some evidence to show that soothing syrups may reduce the frequency of

coughing

� Jozef should get plenty of rest and drink plenty of fluid

� inappropriate antibacterial use leads to unnecessary side-effects and resistance.

� consider giving Josef and Danuta a copy of the TARGET patient antibacterial

(antibiotic) leaflet.

Case study 2

Andy Hawarden asks your advice; his five-year-old daughter, Ava, hasearache, which started this morning. On questioning him you discover thatAva has severe ear pain, especially when eating. She also has itching andhearing loss in both her ears. She swims regularly and has not had a coldrecently. What advice would you give Andy?

From the information, it would seem that Ava has otitis externa, which is five times more

common in regular swimmers. Other factors that can lead to otitis externa are chemicals

(hairspray), skin conditions and ear trauma. Otitis externa in swimmers is due to any

water remaining in the ear after swimming becoming infected. Otitis externa will need

treatment with ear drops containing an antibacterial and a corticosteroid. Andy should

take Ava to the GP. Advice should be given on keeping the ear dry while swimming

(swimming cap) or applying drops after swimming to dry the ear. The corner of a towel

should not be used to dry the ear as this can damage the ear, pushing any alien bodies

further into the ear. Painkillers, ibuprofen or paracetamol will help relieve the pain.

Acetic acid spray would be a suitable treatment also, but is not available over-the-

counter for children under 12 years.


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Acute otitis media, on the other hand, is a self-limiting infection in 80 percent of cases.12

Antibacterials are usually only required for children under two years old, with bilateral

infection, when there is discharge from the ear, the patient is systemically unwell, or has

recurrent infections. Acute otitis media is often associated with a recent cold and can be

managed initially with ibuprofen or paracetamol. If the child does not improve after two

to three days, or is systemically unwell, referral to the GP would be advisable.

Case study 3

Hari Kapoor has had a cold and now has a headache, nasal discharge andfacial pain. Hari has had these symptoms for three days now and has justvisited his GP who has issued him a prescription for amoxicillin 500 mg,three times daily for seven days, and told him to get it dispensed in a week ifhis symptoms do not improve, or at any time if the symptoms get worse.Hari said he’s going to take it now as he wants to feel better sooner ratherthan later. What advice would you give?

Sinusitis is usually caused by a virus. Antibacterials are unlikely to help and may cause

adverse effects. Antibacterials might be considered for patients with systemic illness, or

those who have several severe signs and symptoms that have lasted longer than three

days, or worsen within three days. For more information, refer to the NICE clinical

knowledge summaries on sinusitis: http://cks.nice.org.uk/

You could give Hari a copy of the TARGET patient antibacterial (antibiotic) leaflet.

Case study 4

Ellen Schofield, a 34-year-old mother of two, has had a cold for four days and is coughing up green phlegm. She comes to see you to ask if she needs an “antibiotic”. What advice would you give?

Nasty as it is, coughing up sputum (even if it is green) is often an indication the cold is

coming to an end (although antibacterials would not have helped Ellen’s cold). She

should, however, see her GP if the cough persists over three or four weeks, if she

becomes short of breath, develops chest pains, or if she already has an existing chest

condition.

On the other hand, older patients with chronic obstructive pulmonary disease should

take antibacterials when they have a chest infection and start to cough up purulent

sputum (green and lumpy, with streaks of brown/blood) as they are at a higher risk of

developing bacterial infections.


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10

Case study 5

Arthur Jones is a 78-year-old patient who has been in hospital for threeweeks, following a stroke. He has recently been prescribedpiperacillin/tazobactam for hospital-acquired pneumonia, but on yourward visit two days later you find that this has been changed to intravenousmeropenem, due to poor response to treatment. What would your concernsbe and what action would you take?

Carbapenems, such as meropenem, are restricted antibacterials in most hospitals, and

are only used in accordance with guidelines or on the recommendation of a clinical

microbiologist. They are the mainstay of treatment for serious gram negative infections

due to extended spectrum beta lactamase (ESBL) producing organisms, so widespread

use for other infections should be kept to a minimum, in order to preserve their

effectiveness. In this case you would need to find out if the change is based on culture

and sensitivity results. If not, and if the use is outside of your trust guidelines, you

should advise the medical team to discuss the situation with a clinical microbiologist

who will recommend further investigations and other possible treatment options.

Case study 6

Aaron Crossley, a local care assistant, asks your advice regarding one of hisresidents. One of the ladies has just returned to the care home from hospitaland she is having ‘eradication therapy’ for MRSA. Aaron wants to know ifthe other residents are at risk and if any special precautions are needed.

You should start by consulting the local infection control standards. You should also

contact your local infection control nurse to ascertain what these are in your area.

Usually the same infection control standards should be used for this lady as the other

residents of the care home. If good basic infection control measures are followed, MRSA

carriers are not a risk to other residents, staff, visitors or family members. The lady can

still share a room with another resident as long as the person they are sharing with does

not have open wounds or invasive devices. She can sit in the communal areas, provided

open wounds are covered by an impermeable dressing. She can still visit family and

friends outside the home.


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Case study 7

While visiting one of your regular wards, you come across a new patient in aside room. You establish the patient has C. difficile infection. You need toenter the side room to assess the patient’s own medication and take a drughistory. What infection control issues should you be aware of?

An infection control isolation notice should be posted on the entrance to the side room

indicating the infection and measures needed to take before entering, which should

then be followed.

Generally, before entering you should use alcoholic hand gel and put on an apron and

gloves. On exiting the room the apron and gloves need to be discarded in the

appropriate clinical waste bin. Afterwards, wash hands with soap and water, as alcohol

gel does not kill C. difficile spores.


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The final two activities in this resource will help you to assess if you have met thelearning outcomes for this programme.

Two of the learning objectives of the programme were to equip you with theknowledge to:

� design learning materials for your team and customers on avoiding antibacterialresistance, and

� develop a protocol to support the introduction of infection control to yourworkplace.

Let’s look at how we have helped you meet those objectives.

Designing learning materials for your team and customers

We think that the key messages you need to put across in any learning materialsabout avoiding antibacterial resistance are relevant to both your team and yourcustomers. The messages, or information, can be grouped under the followingheadings:

� why avoiding antibacterial resistance is important

� what is being done in your area

� how to recognise those occasions when antibacterials are needed.

Using these as headings, jot down the messages or information that you are goingto pass on to help your team and customers learn about avoiding antibacterialresistance.

Why avoiding antibacterial resistance is important.


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13

What is being done in your area?

How do you recognise when antibacterials are needed?

Now make a note of when you plan to run through these issues with yourteam.


S E P T E M B E R 2 0 1 4


Think about the way you would like them to approach your customers to passthe information on to them, and make a note of it here.

Consider what checks you may need to put in place to be sure that the relevantinformation is being passed on to customers.

Remember that you can also offer your team an opportunity to work through theAntibacterial resistance – a global threat to public health: the role of the pharmacy teamlearning programme.

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15

Developing a protocol for infection control in your workplace

In Section 3 of the Antibacterial resistance – a global threat to public health: the role ofthe pharmacy team learning programme, we provided the information that youneed to develop an infection control protocol.

Jot down the activities that you undertake in your workplace which involve anybodily fluids (these could include needle and syringe exchange, urine testing,blood testing or other types of testing).

Use each of these activities as a separate heading and note the infection controlmeasures that your staff need to take. This will include considering where theactivity should take place, whether gloves need to be worn and what action needsto be taken if anything goes wrong.

Your protocol is likely to address:

� hand hygiene

� the use of protective equipment

� handling sharps

� the disposal of chemical waste

� other areas specific to your own sector of practice.

Reflective questions revisited

Having completed your learning on Antibacterial resistance – a globalthreat to public health: the role of the pharmacy team, take a moment to goback to your reasons for starting it.

Have you met your personal objective(s)?


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What methods did you use to do that?

How can you show that you have met your objective(s)?

Make a note of three things that you will do differently in your practice,as a result of your learning on Antibacterial resistance – a global threat topublic health: the role of the pharmacy team.

1.

2.

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C O M P L E T I N G T H E L E A R N I N G E X P E R I E N C E 17

3.

You can transfer your answers to these questions to your CPD record.

You have now completed our learning programme on Antibacterial resistance – aglobal threat to public health: the role of the pharmacy team and you will also have hadan opportunity to share your learning with your pharmacy team.

Intended outcomes

By now you should be able to: Can you?

explain why antimicrobial resistance is considered to be one of the greatest public health risks in the UK and globally

apply the principles of antimicrobial stewardship to your everyday practice through the use of one of the national toolkits

advise prescribers on the appropriate and inappropriate use of antibacterial therapy and optimise prescribing practice

support public awareness campaigns on avoiding the use of antibacterials

design learning materials for your team and your customers on avoiding antibacterial resistance

develop a protocol to support the introduction of infection control to your workplace.

S E P T E M B E R 2 0 1 4

18 References

1. Centor R, Witherspoon J, Dalton H, et al. The diagnosis of strep throat inadults in the emergency room. Medical Decision Making 1981;1: 239–46.http://mdm.sagepub.com/content/1/3/239.full.pdf+html?ijkey=79065ae6b3a7922b8e99953ab406b22002b555b3&keytype2=tf_ipsecsha

2. ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, GaleoneC, Esposito S, Huovinen P, Little P, Verheij T. Guideline for the management ofacute sore throat. Clinical Microbiology and Infection 2012 Apr;18 (1):1-28.doi: 10.1111/j.1469-0691.2012.03766.x.www.ncbi.nlm.nih.gov/pubmed/22432746

3. Scottish Intercollegiate Guidelines Network. SIGN 104: Antibiotic prophylaxisin surgery: a national clinical guideline. July 2008 (updated April 2014).Edinburgh: SIGN; 2008. www.sign.ac.uk/pdf/sign104.pdf

4. Bratzler DW, Patchen Dellinger E, Olsen KM, Perl TM, Auwaerter PG, BolonMK, Fish DN, Napolitano LM, Swayer RG, Slain D, Steinberg JP, WeinsteinRA. Clinical practice guidelines for antimicrobial prophylaxis in surgery:American Society of Health-System Pharmacists Report. American Journal ofHealth-System Pharmacists 2013; 70: 195-283.

5. National Institute for Health and Care Excellence clinical knowledgesummaries. http://cks.nice.org.uk/

6. Health Protection Agency. Primary care guidance: diagnosing and managinginfections. London: Public Health England; 2013.www.gov.uk/government/collections/primary-care-guidance-diagnosing-and-managing-infections

7. Scottish Intercollegiate Guidelines Network and the British Thoracic Society.SIGN 101: British guideline on the management of asthma: a national clinicalguideline (revised January 2012). Edinburgh and London: SIGN and BTS;2012. www.sign.ac.uk/pdf/sign101.pdf

8. Scottish Intercollegiate Guidelines Network. SIGN 88: Management ofsuspected bacterial urinary tract infection in adults: a national clinical guideline.(updated July 2012). Edinburgh: SIGN; 2012.www.sign.ac.uk/pdf/sign88.pdf

9. British Medical Association and the Royal Pharmaceutical Society of GreatBritain. British national formulary. 67th edition. London: BMJ Group & RPSPublishing, London, 2009. www.bnf.org/bnf/index.htm

10. National Institute for Health and Care Excellence. Clinical guideline 64:Prophylaxis against infective endocarditis: antimicrobial prophylaxis againstinfective endocarditis in adults and children undergoing interventional procedures.March 2008. London: NICE; 2008. www.nice.org.uk/guidance/cg64

11. Nathwani D, Morgan M, Masterton RG, Dryden M, Cookson BD, French, GLewis D. Guidelines for UK practice for the diagnosis and management ofmethicillin-resistant Staphylococcus aureus (MRSA) infections presenting in thecommunity. Journal of Antimicrobial Chemotherapy 2008; 61: 976-994.

12. National Prescribing Centre. MeReC bulletin volume 17: number 3. Acuteotitis media.www.npc.nhs.uk/merec/infect/commonintro/resources/merec_bulletin_vol17_no3_acute_otitis_media.pdf

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http://mdm.sagepub.com/content/1/3/239.full.pdf+html?ijkey=79065ae6b3a7922b8e99953ab406b22002b555b3&keytype2=tf_ipsecsha

www.npc.nhs.uk/merec/infect/commonintro/resources/merec_bulletin_vol17_no3_acute_otis_media.pdf

Contacting CPPEFor information on your orders or bookings, or any generalenquiries, please contact us by email, telephone or post.A member of our customer services team will be happy tohelp you with your enquiry.

[email protected]

Telephone0161 778 4000

By postCentre for Pharmacy Postgraduate Education (CPPE)Manchester Pharmacy School1st Floor, Stopford BuildingThe University of ManchesterOxford RoadManchester M13 9PT

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