Oral penicillin: children’s dosage recommendations
January 26, 2012 by admin
How many of the 5 million children in England who receive oral penicillins each year really need them, and what are the effective doses? It is time to replace the rule of thumb used for dosing with up-to-date evidence, according to a paper published on behalf of the improving Children’s Antibiotic Prescribing UK Research Network (iCAP).
The authors used a literature and formulary search to find out where the current, sometimes confusing, recommendations come from. It appears that, ‘a general recommendation to use age banding for all antibiotics in children, irrespective of the type of penicillin or disease indication, was published in the BMJ in 1963…Critically, these recommendations have remained unchallenged and unchanged to this day’.
Does a big child = half an adult? The BNF recommendations to halve doses between successive age bands for children have remained unchanged, for penicillin V, flucloxacillin and amoxicillin since they first appeared in it in the 1960s and 1970s. Adult penicillin doses have increased substantially but those for children have not. The mg/kg doses may also now be even lower than they were, because of an increase in average children’s weights. When the authors analysed the actual doses that would be received today, they found that at the older age/weight ranges, the doses are ’strikingly low’. Many of the older children’s medicines do have a limited evidence base, but these authors were surprised at how little recent evidence supports the current recommendations.
They warn of the risks of low dosing - for antimicrobial resistance, severe complications and need for retreatment, and conclude that work is needed to determine the effective doses for children of all weights and ages, and also to, ‘establish more clearly which children really need antibiotics in the era of pneumococcal conjugate (PCV 13), Haemophilus influenzae B, and meningitis C vaccines’.
Ahmed U et al. Dosing of oral penicillins in children: is big child=half an adult, small child=half a big child, baby=half a small child still the best we can do? BMJ 2011;343:d7803
http://dx.doi.org/10.1136/bmj.d7803
RCN indemnity changes - further reactions
January 26, 2012 by admin
The RCN has said that it is ‘unacceptable’ for GP employers to insist that nurses buy indemnity cover, or cover any costs to the practice. In a briefing issued in December (see here for the RCN briefing and here for news of the announcement and initial reactions), the RCN has hit back, saying that this is poor employment practice, that it is commonly accepted that the costs of running a business should be carried by the employing organisation, and that it will help its members resist the move. It also claims that many GPs do not know about the benefits of RCN membership and that it is important they understand that the RCN provides legal support and advice to its members for any case before the NMC - this is separate from the indemnity scheme.
As for independent prescribers, the statement stresses that the employer is vicariously liable for the actions of employed nurses, and that independent prescribers are not required to have personal cover either professionally or legally: if the GP or the medical defence organisation that covers them wishes it, then that is the employer’s responsibility.
The Medical Defence Union (MDU) has now met with the RCN and says that it believes there are implications for practice nurses who were indemnified by the RCN, because their role is changing (see here.) It claims that increased responsibilities come with greater accountability, and that although employed nurses could choose to rely on the indemnity provided by their employers’ vicarious liability, ‘many may be concerned that as professionals in their own right a claim or complaint may be brought directly against them in person, and so decide they need to join a medical defence organisation themselves for their own peace of mind.’
No news is bad news on CD changes
January 26, 2012 by admin
After hopes were raised in the autumn (see here), the Home Office said on 9 January that it is still unable to provide a date for the long-awaited amendments to the Misuse of Drugs Act about independent prescribers and controlled drugs. The statement was made in correspondence with pharmacist prescriber Mark Hutton, who specialises in the management of chronic pain, in the East Midlands, and who has been pursuing the Home Office since 2008 about these amendments. He said,’It is ridiculous that I cannot prescribe a drug such as co-codamol yet a patient can purchase it in a pharmacy, and that as a qualified independent prescriber, I have to use supplementary prescribing to prescribe controlled drugs for patients. There is a shortage of pain consultants compared with the number of people with chronic pain, and the Home Office has given no reason for the delays in allowing non-medical prescribers to provide a better service to patients in pain.’
Matt Griffiths, visiting professor of prescribing and medicines management at the University of the West of England, who has also been urging the Home Office to act and highlighting the consequence of delay for some years, had this to say:
‘We have been promised these changes since 2008. As well as non-medical prescribers and their patients, this also affects nurses who want to mix medicines that include a controlled drug, as these amendments will be made at the same time. There are daily restrictions on my practice, where legislation has not kept up with the needs of the modern day health service. I can work as a visiting clinician on a daily basis. I can prescribe certain controlled drugs for palliative care patients, but I can’t carry them out to their homes unless it is on a named patient basis. Despite correspondence with Lord Henley, the Home Office minister responsible, and earlier promises from the Home Office, no date has been given, and the reasons behind the delays of nearly four years do not justify them. I believe that Secretary of State for Health Andrew Lansley, or Prime Minister David Cameron need to intervene as patient care is being affected on a daily basis’.
The statutory instrument was most recently promised for the end of October 2011 (see here) and will allow nurse and pharmacist prescribers to prescribe controlled drugs, within their competence, as well as making the promised changes on mixing medicines, where one or more is a controlled drug (see here).
ANP Chair Barbara Stuttle, who wrote to David Cameron about this issue last year, points out the anomaly involved in this long delay: ‘We keep being told about the £20 billion that needs to be saved in the NHS but something that could so easily address some efficiency concerns - but relies on Ministers - is constantly delayed! All the relevant bodies agree about these legislative changes: all it needs is the statutory instrument. If the government is serious about supporting clinicians to work efficiently and effectively, then I urge the Home Office to make these legislative changes urgently. This will enable nurses to do their job and look after patients by providing the right care at the right time.’
Where is the evidence base: NMP in primary care?
January 3, 2012 by admin
A review of the literature on non-medical prescribing (NMP) in primary care that looked for evidence of patient outcomes has found that most such studies were undertaken in the UK, and that there are ’substantial gaps’ in the knowledge base that could inform evidence-based policy making.
The authors identified 17 empirical studies providing patient outcome evidence of NMP in primary care, with only two looking at clinical outcomes. Some papers were surveys, had qualitative designs, few participants, or reported on prescribing from limited formularies, and the authors comment that, ‘the strength of evidence they provide on the whole is limited’.
NMP in primary care does seem to improve: ‘patients’ understanding of treatment, condition and self-care and provides a better level of care’, was well accepted by patients and professionals, and improved access to medicines and healthcare professionals. Other indicators of effectiveness such as clinical outcomes or patient safety had very limited evidence, and papers on health economics and efficiency were also lacking.
Bhanbhro S et al. Assessing the contribution of prescribing in primary care by nurses and professionals allied to medicine: a systematic review of literature. BMC Health Services Research 2011; 11:330.
http://dx.doi.org/10.1186/1472-6963-11-330
Medicines for Children website launched
January 3, 2012 by admin
Medicines for Children, a website for parents and carers with lots of information about specific medicines, has been developed by a partnership of the Royal College of Paediatrics and Child Health (RCPCH), Neonatal and Paediatric Pharmacists (NPPG) and WellChild. The leaflets about individual medicines contain detailed advice about missed doses, administration and side effects and there are also leaflets about different formulations and administration methods.
NRLS to transfer to NHS Trust
January 3, 2012 by admin
The day-to-day operation of the National Reporting and Learning System, said to be the largest source of patient safety incident data in the world, looks set to transfer to Imperial College Healthcare NHS Trust for a period of two years (see here). The National Patient Safety Agency is being abolished and its patient safety function will go to the new NHS Commissioning Board, which will provide oversight of the NRLS.
Categories
Recent Posts
- Why aren’t mental health nurse prescribers prescribing?
- Prescribing in prisons
- Evidence into practice: key therapeutic topics
- MHRA still working on unlicensed medicines review
- Oral penicillin: children’s dosage recommendations
- RCN indemnity changes - further reactions
- No news is bad news on CD changes
- Where is the evidence base: NMP in primary care?
- Medicines for Children website launched
- NRLS to transfer to NHS Trust
Tags
- ANP ANP conference Carey N CD children CKS Clinical Knowledge Summaries consultation controlled drugs COPD cosmetic treatments Courtenay Courtenay M CPD dermatology DH diabetes district nurse prescriber generic substitution Home Office independent prescribers Matt Griffiths mental health MeReC MHRA Misuse of Drugs mixing medicines National Prescribing Centre NICE NMC non-medical prescribing NPC NPF NPSA Nurse prescribing Patient Group Directions PGD PGDs Prescribing RCN Royal Pharmaceutical Society Stenner Stenner K supplementary prescribers unlicensed medicines
