netFormulary NHS
Pan Mersey
Area Prescribing Committee
 Search
 Formulary Chapter 27: Antimicrobial guide - Full Chapter
Notes:

Coronavirus guidance

Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.

The list of resources will be updated as new material becomes available so please check back regularly for updates.

The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.

Antimicrobial guide

Self-care

Treatments marked as [OTC] are available to buy from pharmacies. Patients can be advised to purchase them as self-care where appropriate.

 

 Details...
27.17  Expand sub section  Treatment of Splenectomy Patients
 note 

Treatment of Splenectomy Patients

Patients who suffer from asplenia or hyposplenia are at increased risk of overwhelming bacterial infection. Infection is most commonly pneumococcal (Streptococcus pneumoniae) but other organisms such as Haemophilus influenzae type b (Hib) and Neisseria meningitidis may be involved. This risk is greatest in the first two years following splenectomy and is greater amongst children but persists into adult life.

Please check online for most up to date information PHE Green book Chapter 7

Practical schedule for immunising individuals with asplenia, splenic dysfunction or complement disorders (including those receiving complement inhibitor therapy*).

First diagnosed under 1 year of age

Children should be fully immunised according to the national schedule, and should also receive:

  • two doses of MenACWY vaccine at least one month apart during infancy;
  • one additional dose of PCV13* and one dose of MenACWY conjugate vaccine two months after the 12-month vaccinations; and
  • one additional dose of Hib/MenC and one dose of PPV231 after the second birthday.

First diagnosed at 12-23 months of age

If not yet administered, give the routine 12-month vaccines: Hib/MenC, PCV13, MMR and MenB, plus:

  • one additional dose of PCV13* and one dose of MenACWY conjugate vaccine two months after the 12-month vaccinations; and
  • one additional dose of Hib/MenC and one dose of PPV23*,† after the second birthday.

If not already received, two primary doses of MenB vaccine should be given two months apart at the same visit as the other vaccinations.

First diagnosed from two years to under ten years of age

Ensure children are immunised according to the national schedule, and they should also receive:

  • one additional dose of Hib/MenC and one dose of PPV23*; followed by:
  • one dose of MenACWY conjugate vaccine two months later

If not already received, two primary doses of MenB vaccine should be given two months apart at the same visit as the other vaccinations.

First diagnosed at age ten years onwards

Older children and adults, regardless of previous vaccination, should receive:

  • one dose of Hib/MenC and one dose of PPV23*; followed by:
  • one dose of MenACWY conjugate vaccine one month later.

If not already received, two primary doses of MenB vaccine should be given one month apart at the same visit as the other vaccinations.

All patients

Annual influenza vaccine each season

* Patients on Eculizumab (Soliris®) therapy are not at increased risk of pneumococcal disease and do not require PPV23 or additional doses of PCV13
† Patients with splenic dysfunction should receive boosters of PPV at five yearly intervals.

Prophylactic antibiotics should be offered to all patients.

Lifelong antibiotic prophylaxis is appropriate for high-risk groups including those individuals

  • aged less than 16 years or greater than 50 years
  • with inadequate serological response to pneumococcal vaccination,
  • a history of previous invasive pneumococcal disease,
  • splenectomy for underlying haematological malignancy, particularly in the context of on-going immunosuppression.

Low-risk patients should be counselled as to the risks and benefits of prophylaxis, particularly where adherence is an issue.

Lifelong compliance with prophylactic antibiotics is problematic. If the patient does not continue to be at high risk as per the criteria above, the patient must have antibiotic prophylaxis until at least 2 years after splenectomy.

If compliance is a problem, the patient must be advised to have an emergency supply of Amoxicillin or Erythromycin to take in the event of fever as well plus be advised to seek medical attention urgently.

Phenoxymethylpenicillin is preferred unless the cover is also needed against Haemophilus influenza for a child in which case, give Amoxicillin; or if the patient is allergic to penicillin, give Erythromycin.

Phenoxymethylpenicillin Child 1 – 11 months 62.5 mg bd
  Child 1 – 4 years 125 mg bd
  Child 5 – 17 years 250 mg bd
Amoxicillin Child 1 month – 4 years 125 mg bd
  Child 5 -11 years 250 mg bd
  Child 12 – 17 years 500 mg bd
Erythromycin Child 1 month – 1 year 125 mg bd
  Child 2 – 7 years 250 mg bd
  Child 8 – 17 years 500 mg bd

Adapted from BNF for children and PHE guidelines

Other measures to reduce risk include:

  • Patients should be asked to consult if they have a febrile illness and may be given a stock of antibiotics to start treatment by themselves. They should carry a card or Medic-Alert bracelet or necklace, or both.
  • When travelling abroad patients should obtain advice from a reputable travel advice centre (e.g. Liverpool School of Tropical Medicine) to ensure precautions are adequate and up to date.
  • Patients should avoid malaria (which is more severe in asplenic patients) by avoiding malaria areas or, if going to such areas, adhere scrupulously to antimalarial prophylaxis and anti-mosquito precautions.
  • Avoid tick bites as there is a risk of Babesiosis and Lyme disease.
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection. †Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

netFormulary