Antimicrobial Utilisation Committee, Guidelines for Approval of Antimicrobial Guidelines


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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.


This document aims to set out the processes involved in the preparation and ratification of therapeutic guidelines and protocols involving antimicrobial medicines intended for use by healthcare professionals within NHS Greater Glasgow and Clyde (GGC).

Approval of Therapeutic Guidelines and Protocols

In most situations, the NHSGGC Antimicrobial Management Team (AMT) will lead the production of antimicrobial guidelines or protocols in order to define the appropriate choice for individual indications.

Antimicrobial guidelines which meet specific criteria (appendix 1) will be reviewed by the Antimicrobial Utilisation (AUC) Subcommittee which will have devolved responsibility to approve these on behalf of the Area Drugs and Therapeutics Committee. On occasion, the AUC may request that guidelines which meet specific criteria (appendix 1) are taken to ADTC for final ratification.

The purpose of the AUC review is:

  • To confirm that all appropriate stakeholders have been fully consulted
  • To ensure that any implications for service delivery have been considered.
  • To ensure that any significant impact on prescribing and workload in Primary Care or Secondary care has been considered.
  • To ensure that any potentially significant cost or service implications are highlighted to the Prescribing Management Group.
  • To facilitate the publication of the policy or protocol on to the ADTC website as appropriate.
  • To endorse the use of specific disease management guidelines for use in NHSGGC

Principles set down by the ADTC which the AUC should follow:

  1. Guidelines and protocols should conform to the GGC Clinical Guideline Framework.
  2. There should be a clear description of the process for development of the guideline, the membership of the group involved and those consulted, together with any relevant ‘declarations of interest’.
  3. Guideline development groups should ensure that they have included a pharmacist and representation from all other relevant healthcare professionals groups including representation from primary and secondary care as appropriate.
  4. All appropriate stakeholders must be fully consulted.
  5. Consultation should take place throughout GGC, where appropriate to ensure that the guideline is applicable across the Health Board area.
  6. Consideration should be given to the involvement of patients or their support groups where appropriate.
  7. All medicines included in NHSGGC therapeutic guidelines and protocols must already be included in the GGC Formulary. There may be exceptions to this in the case of guidelines or protocols that incorporate the use of unlicensed medicines. Unlicensed medicines are not currently included in the Formulary.
  8. The authors (AMT or clinical specialist team) of the guideline or protocol will be responsible for ensuring that the content is accurate and up-to-date and is based on current published evidence or best practice.
  9. The guideline must give full details of the individuals involved in its production
  10. The guideline must contain a date of preparation and a date of review.
  11. Existing guidelines that have been approved by AUC should be reviewed by the authors and an updated version submitted to the AMT via the AUC secretariat within 90 days before expiry.
  12. Consideration should be given on how best to facilitate access to the guideline e.g. posters, posting on the appropriate section of the Staff Intranet.

Inclusion of Guidelines or Protocols in the GGC Therapeutics Handbook

It will be appropriate to consider including guidance on the majority of indications (relating to hospital practice) in the NHSGGC Therapeutics Handbook (GGC Medicines - Adult Therapeutics Handbook). The Handbook is intended to be a reference source for prescribers in Acute Hospitals within GGC. It is intended for use by prescribers requiring prescribing advice in the acute clinical situation. The AMT should make recommendations on what information to consider for inclusion in the handbook and this must then be agreed by the AUC. The Handbook Editorial Group will review and approve any AUC guideline recommendations.

Submitting a New / Updated Guideline or Protocol for Approval by AUC

The “checklist for clinical guideline development, review, approval and posting on intranet” form (appendix 2) should be submitted to AUC with all protocols or guidelines. The purpose of this form is to ensure that all information required for the AUC to make an informed decision about the protocol is available. The form includes a section requesting declarations of interest to be completed by the chair of the guideline development group. This is essential in order to ensure that the process is transparent and not open to challenge about bias. All guidelines for AUC review should be submitted to the AUC secretariat at the address in appendix 3.

Appendx 1: Therapeutic Protocols / Guidelines: Authority for Approval


􀀀. The AMT will screen protocols/ guidelines containing advice on antimicrobial use. Protocols or guidelines (for use within acute or primary care or both) which incorporate antimicrobials in line with existing AUC-approved guidance and for the same patient group, do not require referral for further approval. In these circumstances reference should be made to the appropriate AUC guidance. AMT can give advice if required.

􀀀. Protocols/ guidelines (for use within acute or primary care or both) which do not mirror an existing AUC approved guideline and which contain advice (no matter how brief) on antimicrobial choice, dose or duration for treatment or prophylaxis should be referred to the Antimicrobial Management Team (AMT) for consideration

􀀀. Any protocol/ guidance advising on the use of an antimicrobial agent for non antimicrobial effects (eg anti-inflammatory or immune-modulatory effects) likewise should be referred to the AMT for consideration.


Those protocols / guidelines where antimicrobials are the main focus and which fulfil one or more of the following criteria will be referred to the AUC for review:
􀀀. The guideline or protocol has clinical implications for multiple directorates within acute or for acute and primary care.
􀀀. There are significant new cost implications beyond a single directorate or speciality.
􀀀. There are significant new service implications beyond a single directorate or speciality.
􀀀. The protocol or guideline includes non-Formulary medicines or medicines out with their formulary restrictions
􀀀. The protocol or guideline includes unlicensed / off-label medicines
􀀀. Any protocol or guideline the AMT consider requires AUC review
􀀀. If the guideline or protocol is not being referred to the AUC, the AMT will review the content and reply directly to the guideline authors


Protocols/ guidelines containing advice on antimicrobial choice and fulfilling one or more of the following criteria should
be referred by AUC for review by ADTC.
1. The protocol or guideline includes non-Formulary medicines or medicines out with their formulary restrictions.
2. The protocol or guideline includes unlicensed medicines.
3. Any protocol or guideline the AMT and AUC consider requires ADTC review
4. Any protocol or guideline with significant cost implications

Where there is uncertainty about whether the protocol or guideline fits the above criteria the guideline group may contact the Lead Pharmacist, Medicines Information or the Chair of AUC for specific advice.



Appendix 2: Checklist for clinical guideline development, review, approval and posting on intranet

Appendix 3: Contact Details

Chair of AUC
Dr Beth White
Email: [email protected]

Lead Pharmacist for Medicines Policy and Guidance
Roy Foot
Lead Pharmacist, Medicines Policy and Guidance
Glasgow Royal Infirmary
Email: [email protected]

Chair of Therapeutics Handbook Editorial Group
Mairi-Anne McLean
Central prescribing team
Email: [email protected]

AUC Secretariat
Karen Carberry
West House
Tel: 0141 201 4824
Email: [email protected]

Last reviewed: 19 May 2021

Next review: 31 May 2024

Author(s): Ysobel Gourlay

Version: 3

Author Email(s): [email protected]

Approved By: Antimicrobial Utilisation Committee

Document Id: 554