All doctors, nursing staff and pharmacists. January 2019

Transcription

1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Author: Contact Name and Job Title Directorate & Speciality Guidelines for Prudent Antimicrobial Prescribing at NUH Annette Clarkson (Acting Lead Clinical Pharmacist Antimicrobials and Infection Control) Stephen Holden (Microbiology Consultant) Sarah Partridge (Antimicrobial Pharmacist) Diagnostics and Clinical Support, Microbiology Date of submission January 2016 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) All patients prescribed an antimicrobial at Nottingham University Hospitals NHS Trust. IV to PO switch guideline applicable to adult patients only. Version 4.0 Changes from previous guideline If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without randomisation 3b at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: Date: Target audience Review Date: (to be applied by the Integrated Governance Team) Examples of interventions updated to reflect new drug chart. New section added on individual roles. Ciprofloxacin added as IV-PO switch in urosepsis / pyelonephritis. Replaces guideline number Public Health England (PHE) Antimicrobial Stewardship: Start Smart Then Focus Guidance for antimicrobial stewardship in hospitals (England). Available from: al-stewardship-start-smart-then-focus (accessed: ). The Antibiotic Stop / Review Date and Indication Policy (appendix A) was originally adapted from one written by the microbiology and pharmacy departments of St Georges Hospital London. NUH Antibiotics Guidelines Committee NUH Drugs and Therapeutics Committee All doctors, nursing staff and pharmacists January 2019 A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date, however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. NUH Antimicrobial Guidelines Committee Page 1 of 17

2 Guidelines for Prudent Antimicrobial Prescribing at NUH Contents Page 1. Introduction 3 2. Start Smart Then Focus 3 Appendix A: Antimicrobial stop / review date and indication policy and prescribing on the antimicrobial section of the drug chart 5 Appendix B IV to PO switch guidelines 13 NUH Antimicrobial Guidelines Committee Page 2 of 17

3 1. Introduction Appropriate prescribing of antimicrobials is an essential part of patient care. Unnecessary use can lead to: Increased selection of resistant organisms e.g. MRSA, multi resistant Gram negative organisms. Antimicrobial treatment related illnesses e.g. Clostridium difficile infection. Unnecessary adverse effects and expenditure. Patients currently on antimicrobials require close monitoring to ensure response to therapy. In addition certain antimicrobials require blood monitoring e.g. Vancomycin or Gentamicin see Therapeutic Drug Monitoring Guidelines on the antimicrobial website. Failure to do this may lead to renal failure, ototoxicity and death. 2. Start Smart Then Focus Public Health England (PHE) in its Start Smart Then Focus campaign outlines how antimicrobials should be prescribed in secondary care: NUH Antimicrobial Guidelines Committee Page 3 of 17

4 All clinicians should ideally within one hour (or as soon as possible) - START SMART: Do not start antimicrobials in the absence of clinical evidence of bacterial infection. Positive cultures from non-sterile sites e.g. wounds and catheter urines do not necessarily warrant treatment. If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with life threatening infections. (Avoid inappropriate use of broad-spectrum antibiotics). Document on drug chart and in medical notes: clinical indication, duration or review date, route and dose (see appendix A). Antimicrobials in hospitals are often continued unnecessarily because clinicians caring for the patient do not have information indicating why the antimicrobials were initially commenced and how long they were planned to be continued. This problem is compounded where primary responsibility for patient care is frequently transferred from one clinician to another. Ensuring that all antimicrobial prescriptions are always accompanied by an indication and a clear duration or review date will help clinicians change or stop therapy when appropriate. Obtain cultures first. Knowing the identity and susceptibility of an infecting organism can help clarify the diagnosis and lead to narrowing of broad-spectrum therapy, changing therapy to effectively treat resistant pathogens and stopping antimicrobials when cultures suggest an infection is unlikely. Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have been shown to be effective. Critical to this advice is that the single dose is administered within the 60 minutes prior to surgical incision or tourniquet inflation to enable peak blood levels to be present at the start of the surgical procedure. A repeat dose of antibiotic prophylaxis is required for prolonged procedures and where there is significant blood loss. A treatment course of antibiotics may also need to be given (in addition to appropriate prophylaxis) in cases of dirty surgery or infected wounds. The appropriate use and choice of antibiotics should be discussed with Infection specialists for each case. THEN FOCUS: Review the clinical diagnosis and the continuing need for antimicrobials at hours and make a clear plan of action - the Antimicrobial Prescribing Decision Antimicrobials are generally started before a patient's full clinical picture is known. By hours, when additional information is available, including microbiology, radiographic and clinical information, it is important for clinicians to re-evaluate why the therapy was initiated in the first place and to gather evidence on whether there should be changes to the therapy. The five antimicrobial prescribing decision options are Stop, Switch, Change, Continue and OPAT: 1. Stop antimicrobials if there is no evidence of infection 2. Switch antimicrobials from intravenous to oral (see appendix B) 3. Change antimicrobials ideally to a narrower spectrum or broader if required 4. Continue and review again at 72 hours 5. Outpatient Parenteral Antibiotic Therapy (OPAT). It is essential that the review and subsequent decision is clearly documented in the medical notes / chart. NUH Antimicrobial Guidelines Committee Page 4 of 17

5 Appendix A: Antimicrobial stop / review date and indication policy and prescribing on the antimicrobial section of the drug chart Initiating Antimicrobials Correct use of antimicrobial agents requires that prescriptions are reviewed on a regular basis to ensure that the selected agent is still appropriate, continuation of therapy is still necessary and the route is still appropriate. The Antibiotic Point Prevalence Study conducted at Nottingham University Hospitals in November 2014 showed that 40% of all antimicrobial prescriptions did not have an intended stop / review date. There have been incidences where patients have received unnecessarily long and excessive treatment, as a result of therapy not being reviewed. This can have an impact on: increased selection of resistance organisms antibiotic treatment related illnesses e.g. Clostridium difficile diarrhoea increased risk of adverse effects increased expenditure The Trust has a clear mandate to reduce infections from drug resistant pathogens e.g. MRSA and Clostridium difficile (C. diff.). A major part of this battle is the reduction of unnecessary antibiotic use. A study confirmed a clear trend of the increased risk of C. diff. diarrhoea associated with longer duration for many of the commonly used antibiotic classes. In general 1-3 days caused a lower risk than 4-6 days which caused a lower risk than 7 or more days. This policy aims to prevent unintended long durations of therapy and hence reduce C. diff. risk for patients. The addition on the prescription chart of a stop / review date every time an order for an antimicrobial agent is made, has worked successfully in many hospitals. Pharmacists and nurses facilitate the policy as part of their role on the wards. The indication for an antimicrobial agent is often not clear or easy to find in the notes and makes monitoring for appropriateness by other clinicians and health professionals difficult. In many cases the prescriber initiating the antimicrobial may not be available to regularly review it (due to shift working). It would therefore be very beneficial to have the indication written on the medicine chart for all orders of antimicrobial agents. Overall, documenting the indication and intended stop date/duration on the drug card will be beneficial to all and help prevent unnecessarily extended antimicrobial courses. The Policy All prescribers must ensure that an appropriate stop / review date and indication is documented on the prescription chart for all orders of antimicrobial agents. NUH Antimicrobial Guidelines Committee Page 5 of 17

6 Standard An indication and a stop / review date or intended duration should be indicated on the prescription chart at the point of prescribing any antimicrobial agent (when an order for antimicrobial therapy is made.) Audit This will be an ongoing campaign monitored by the yearly Point Prevalence Study and directorate audits. Outcome measures: % compliance, changes in antibiotic usage, changes in mean duration and savings on antimicrobial expenditure, reductions in Clostridium difficile infection. A. Antimicrobial section of the prescription chart and using stop / review dates and indications Prescribers to write the indication in the DIAGNOSIS or INDICATION box on the prescription chart for each antimicrobial agent prescribed. The indication should also be clear in the medical records. The indication should be as specific as is known at the time of prescribing e.g. sepsis? cause maybe appropriate if there really are no clinical features. This should be updated as more information is available. Rarely, for confidentiality reasons, it is not deemed appropriate for the indication of the antimicrobial to be written on the drug chart (e.g. HIV). In these cases, please ensure it is written clearly in the medical notes and add "see notes" along with the stop or review date on the drug chart. All antimicrobial prescriptions should have a valid stop / review date. Prescriptions within the antimicrobial section of the chart will have an automatic review date on day 3. Additionally prescriptions within the antimicrobial section of the chart will have an automatic stop date of 6 or 14 days. The majority of IV antimicrobials will require a review rather than stop date prior to being converted to oral. Review dates All prescriptions should be reviewed by / on day 3 and the outcome documented both in the Day 3 Review box where available and in the medical notes. Review dates prior or after 3 days may be appropriate depending on the prescription. Review doses should be targeted for lunchtime doses where possible and should avoid weekends unless the patient is due for daily consultant review. Additional antimicrobial reviews should be documented on the chart e.g. crossing through r/v and writing give plus endorsing a new appropriate review date. For some infections, e.g. empyema, it may be difficult to endorse a definite stop date until the patient s condition begins to improve. Antimicrobials in these circumstances should have review dates about twice a week (e.g. at consultant ward rounds and/or Fridays). NUH Antimicrobial Guidelines Committee Page 6 of 17

7 Please refer the IV-PO switch guideline that accompanies this document (see Appendix B). Intended duration Following an IV to PO switch. Please indicate the duration as either: days total i.e. the total required duration of IV and PO together or clearly mark a stop date on the chart The need for antimicrobials should be reviewed on the daily ward rounds with deescalation to narrower spectrum regimens or from IV to oral, in line with culture results, whenever possible. Antimicrobials should be stopped / reviewed earlier than the indicated date if clinically indicated (e.g. microbiology results suggest that infection is unlikely). Example with stop date (mostly appropriate for oral therapy) and Day 3 review box filled in: Example with early review date (mostly appropriate for initial IV therapy): Example prescription for 5 days (with Day 3 review box completed) prescription will automatically stop. NUH Antimicrobial Guidelines Committee Page 7 of 17

8 Example prescription with an IV-PO switch completed at day 3 review: If the prescription is reviewed and a total course length of more than 5 days is identified, the prescription should be re-prescribed. The ANTIMICROBIAL - Defined longer course box (last 2 on chart) should be utilised if: at point of prescribing (e.g. C.diff, pyelonephritis, severe pneumonia) a duration of more than 5 days is required. during a prescription review a further duration of more than 5 days is identified. Note - planned courses of greater than 10 days or prophylactic antimicrobials may be prescribed on the regular section of the drug chart. However, stop / review dates and indications should still be documented. NUH Antimicrobial Guidelines Committee Page 8 of 17

9 Standard total course lengths Please see current guidelines Surgical prophylaxis (standard) Single dose at induction Surgical prophylaxis (involving implant) no longer than 24 hours Low severity pneumonia (e.g. CURB65 score 0-1) 5 days Moderate severity pneumonia (e.g. CURB65 score 2) 7 days Severe pneumonia (CURB65 score 3-5) 7-10 days Non-pneumonic LRTI/ Infective exacerbation of COPD 5 days Hospital Acquired pneumonia 5 days Uncomplicated UTI 3 days Complicated UTI (including male patients) 7-10 days Wound/soft tissue infection 5-7 days Abdominal/biliary sepsis (without abscess) 5-7 days Clostridium difficile diarrhoea 10 days NB Clinical judgement is still required, some patients / minor infections will not require the full standard course length detailed above- shorter courses of antibiotics equate to a lower risk of C. difficile diarrhoea. Please note the following conditions normally require an extended course Acute Prostatitis Osteomyelitis Endocarditis Meningitis / Brain Abscess Septic Arthritis Neutropenic sepsis Empyema Staphylococcus aureus bacteraemia Tuberculosis Prophylaxis for PCP / splenectomy Necrotising soft tissue infections Infected implants / prosthesis Mediastinitis Exacerbation of CF / bronchiectasis Missed doses Antimicrobial doses may be missed for a number of reasons (e.g. no cannula, unable to swallow). Patients should be reviewed clinically and consideration given for re-prescribing additional doses if required. NUH Antimicrobial Guidelines Committee Page 9 of 17

10 B. Actions For Nurses The antimicrobial prescription on the prescription chart contains an automatic stop date after 6 days (14 days if defined longer course prescription utilised) unless the prescriber has re-prescribed the antimicrobial. Stop administering antimicrobials once prescription comes to an end. If you think the patient is not clinically stable or that the plan was to continue antimicrobials you MUST contact an appropriate prescriber for review and if continuation appropriate the prescriber must re-prescribe the antimicrobial and endorse a new indication / duration Example prescription for 5 days administration should stop: Example where prescriber has forgotten to re-prescribe complete course but there is a clear intention for 10 days therapy contact prescriber to review and re-prescribe. Query all prescriptions continuing beyond the review dates with the medical / surgical staff. Whilst awaiting a review, continue to administer the antimicrobial. NUH Antimicrobial Guidelines Committee Page 10 of 17

11 Examples of prescriptions that need reviewing by the prescribing team Ask doctor to review if a number of doses have been missed during the prescribed course, especially if the patient is still unwell or approaching a weekend where regular review is unlikely. All nurses should request an indication to be written in the DIAGNOSIS box on the medicine chart for all antimicrobial agents where missing. C. Action For Pharmacists All pharmacists should request an appropriate stop / review date and indication to be written in the DIAGNOSIS box on the prescription chart for all antimicrobial agents by contacting the prescriber within hours of the prescription being written. If this is not possible, write in the notes requesting the prescriber to add a stop date and / or indication for the antimicrobial agent. If the prescription is written in the presence of a pharmacist, request a stop / review date and indication as part of the prescription writing process. If a clinically appropriate stop date has been documented the pharmacist may alter the administration boxes to ensure nurses do not give a longer course than was intended. NUH Antimicrobial Guidelines Committee Page 11 of 17

12 Example of pharmacist clarifying prescription in line with prescribers intended duration. If a review date has been documented by the doctor, the pharmacist should highlight and endorse R/V around the appropriate administration box. If possible, choose a weekday lunchtime dose: Example of pharmacist clarifying prescription in line with prescribers intended review date. Pharmacists should request that antimicrobials are reviewed at Day 3 and the outcome documented in the Day 3 Review box. Pharmacists can add review dates as appropriate to improve antimicrobial stewardship e.g. add a 5 day review date if it was decided at day 3 to continue for an extended course. The antimicrobial prescription on the prescription chart contains an automatic stop date after 6 days (14 days if defined longer course prescription utilised) unless the prescriber has re-prescribed the antimicrobial. Pharmacists should ensure that if the prescribers are intending to give an antimicrobial for longer than 5 days that it is re-prescribed before the prescription runs out to ensure doses are not missed. NUH Antimicrobial Guidelines Committee Page 12 of 17

13 D. Summary of Individual Roles in Ensuring Appropriate Antimicrobial Prescribing Summary Individual roles in ensuring antimicrobials are appropriately prescribed for patients at NUH Doctor / Prescriber Ensuring there is evidence of clinical infection before initiating antimicrobial therapy. Obtaining and documenting a full allergy history from patients. Using antimicrobial guidelines, which are readily available on the antimicrobial website and mobile phone app. Obtaining relevant cultures prior to administering antimicrobials. Ensuring that the indication is clearly documented for initiating antimicrobials on the prescription chart and in the medical notes. Ensuring that a stop and review date is clearly documented for antimicrobials on the prescription chart and in the medical notes. Review the clinical diagnosis and the continuing need for antimicrobials by hours and clearly document the antimicrobial prescribing decision on the designated section of the prescription chart and in the medical notes. Reviewing antimicrobials regularly e.g. with culture results, and stopping or switching to appropriate oral agents as appropriate. Nurse Checking a patient s allergy status before any medication, including antimicrobials, is administered. Encouraging prescribers to document an indication and stop / review date for all antimicrobial prescriptions where missing. Querying all prescriptions continuing beyond their stop or review date. Stop administering antimicrobials once prescription comes to an end. Query with the prescriber if you believe the intended course should be longer or if the patient has not received intended duration due to missed doses. Highlighting situations where IV antimicrobials may be appropriately switched to oral agents. Checking and obtaining a full allergy history from patients. Ensuring that prescriptions are in line with antimicrobial guidelines/ microbiology advice. Pharmacist Making sure that all antimicrobial prescriptions have clear stop or review dates and indications documented on the prescription chart. Ensuring that antimicrobial prescriptions are regularly reviewed e.g. with culture results and the hour antimicrobial prescribing decision box is completed on the prescription chart. Highlighting situations where IV antimicrobials may be appropriately switched to oral agents. NUH Antimicrobial Guidelines Committee Page 13 of 17

14 Appendix B IV to PO Switch Guidelines Introduction IV to oral switch is the prompt conversion of IV antimicrobial therapy to oral. Patients may be considered candidates for switching from IV to oral therapy once the patient has shown clinical improvement and is medically stable. Rationale The majority of patients with a severe infection who are adequately absorbing oral medication and initially require IV therapy can be safely switched to oral therapy within 48 hours. There are a number of advantages to support the prompt switch from IV to oral therapy these are as follows 1,2 : Reduction in the likelihood of hospital acquired bacteraemia and infected/phlebitic IV lines. Saves both medical and nursing time. Reduces discomfort for patients and enables improved mobility and the possibility of earlier hospital discharge. Potential to significantly reduce treatment costs. Patient is more likely to receive antimicrobials at the correct time. Potential reduction in the risk of adverse effects; errors in preparation are significantly higher with parenteral drugs, compared to oral formulation. Considerations for the early switch to oral therapy COMS (review at hours) C O M Clinical improvement observed Oral route is not compromised (vomiting, malabsorptive disorder, NBM, swallowing problems, unconscious, severe diarrhoea) NB: if NG/PEG feeding then please consult your pharmacist Suitable oral antibiotic option available (see flow chart) Markers showing a trend towards normal: Patient should be apyrexial for the last 24 hours (Temp>36 o C and <38 o C) and NOT have more than one of the following, heart rate>90/min, resp rate>20/min, BP unstable, WCC<4 or >12x10 9 /L. White cell count should show a trend towards normal; absence of such should not impede the switch if all other criteria are met and not neutropenic. S Specific indication/deep-seated infection (Prior to switch refer to table 1) NUH Antimicrobial Guidelines Committee Page 14 of 17

15 High risk / deep-seated infections Certain infections may appear to respond promptly to intravenous therapy, but warrant prolonged IV therapy. This is to ensure that adequate drug levels are attained at the site of infection and to optimise the response and prevent relapse. Discuss with Microbiology before switching patients with a high risk / deep seated infection to oral therapy. Table 1: Deep seated infections that may require an initial two weeks of IV therapy Liver abscess Osteomyelitis,Septic arthritis (N.B. high-dose oral Clindamycin may be appropriate once patient is stable, see memo appendix A) Empyema Cavitating pneumonia High risk infections requiring prolonged IV therapy Staphylococcus aureus bacteraemia Severe necrotising soft tissue infections Severe infections during chemotherapy related neutropenia Infected implants/prosthesis Meningitis/encephalitis Intracranial abscesses Mediastinitis Endocarditis Exacerbation of cystic fibrosis/ bronchiectasis Inadequently drained abscesses or empyema Certain multi-resistant organisms often require treatment with agents that are only available in an intravenous form, please seek advice from microbiology regarding the length of treatment. References 1. Sevinc F et al. Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital. Journal of Antimicrobial Chemotherapy : Guidance for intravenous antibiotic switch therapy North West Antibiotic Pharmacists Network Advisory Group. 3. McLaughlin C et al. Pharmacy-implemented guidelines on switching from intravenous to oral antibiotics: an intervention study. Q J Med 2005;98:745:752 NUH Antimicrobial Guidelines Committee Page 15 of 17

16 Guideline for the intravenous to oral switch of antimicrobial therapy Does intravenous therapy need to continue? (see COMS, Box 2) YES NO Continue with IV antimicrobials Continue to monitor closely Review need for IV therapy again after 24 hours (mark new review date on chart) Switch to oral therapy (see Box 1), add indication and intended stop date (see stop/review date policy) Check for any interactions/allergies If in doubt seek advice from a pharmacist/microbiology BOX 1- recommended empiric oral alternatives in adults N.B. Always Check for allergy/interactions/microbiology results, use narrowspectrum agents where indicated: IV Oral Amoxicillin Benzylpenicillin Piperacillin/tazobactam for abdo- or biliary sepsis Piperacillin/tazobactam for urosepsis, Piperacillin/tazobactam for HAP Cefuroxime +/- metronidazole for chest infections Cefuroxime plus metronidazole for Abdoor biliary sepsis Cefuroxime plus metronidazole (Other indications) Cefuroxime (Urosepsis) Clarithromycin Flucloxacillin Clindamycin Ciprofloxacin Co-amoxiclav Meropenem, vancomycin Piperacillin/tazobactam for other indications Amoxicillin 500mg-1g tds Amoxicillin 500mg-1g tds Co-amoxiclav 625mg tds (unless resistant organism or C.diff +ve then D/W micro.) Ciprofloxacin 500mg bd (unless resistant organism or C.diff / MRSA +ve then D/W micro.) Doxycycline 100mg bd See specific chest infection guidance (e.g. HAP, CAP, Aspiration pneumonia) penicillin allergy: Ciprofloxacin 500mg bd plus Metronidazole 400mg tds Co-amoxiclav 625mg tds If penicillin allergy(rash only): Cefalexin 500mg tds + Metronidazole penicillin allergy (rash only): Ciprofloxacin 500mg bd Clarithromycin 500mg bd Flucloxacillin 500mg-1g qds Clindamycin 450mg-600mg qds (see appendix C) Ciprofloxacin 500mg bd (750mg bd recommended for Pseudomonas sp.) Co-amoxiclav 625mg tds Seek advice from microbiology od = once daily, bd= twice daily, tds= 3 times/day, qds =4 times/day Monitor patient s progress following switch to oral therapy Considerations for IV to oral switch COMS C Clinical improvement O Oral route not compromised -Vomiting -NBM -Unconscious -Mechanical swallowing disorder -Malabsorptive disorder NB: if NG/PEG feeding then please consult your pharmacist Suitable oral antibiotic option available M S BOX 2 Markers showing a trend towards normal Apyrexial: Temp>36 and <38 o C Plus not more than one of -HR >90 beats/min -Resp rate >20 breaths/min -BP stable -WCC <4 OR >12 (if abnormal, a trend towards the normal range and without neutropenia is acceptable) Specific indication / deep-seated infection (eg meningitis/encephalitis, endocarditis, mediastinitis, deep seated abscess/empyema, bone/joint infection, Staph. aureus bacteraemia/cf/bronchiectasis, implant/prosthesis infection, necrotising soft tissue infections) NUH Antimicrobial Guidelines Committee Page 16 of 17

17 Equality Impact Assessment Report 1. Name of Policy or Service Response to external best practice policy 2. Responsible Manager Tim Hills - Lead pharmacist antimicrobials and infection control 3. Name of person Completing EIA Annette Clarkson Acting Lead pharmacist antimicrobials and infection control 4. Date EIA Completed 26/01/ Description and Aims of Policy/Service This guideline outlines how antimicrobials should be prescribed including clear documentation, timely review of choice and route. 6. Brief Summary of Research and Relevant Data See information within evidence base on front page 7. Methods and Outcome of Consultation Consultations have been carried out with the following: Antibiotic Guidelines Committee Comments from the above consultations have been received and incorporated where appropriate. 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation Assessment of Impact 9. Decisions and/or Recommendations (including supporting rationale) From the information contained in the procedure, and following the initial screening, it is my decision that a full assessment is not required at the present time. 10. Equality Action Plan (if required) - not applicable. 11. Monitoring and Review Arrangements NUH Antimicrobial Guidelines Committee Page 17 of 17