Antimicrobial stewardship and allergy documentation

Why this matters on day one

Every unnecessary antibiotic day contributes to resistance and to C. difficile. And a vague "penicillin allergy" on a chart, unchallenged, pushes patients onto broader, less effective, more toxic alternatives for the rest of their lives.

The sequence

1. 1Start smart. Take cultures before starting where possible. Prescribe according to local policy — not the last thing you saw work. Document indication, route, dose and a STOP or review date on the chart.
2. 2Then focus. Review at 48–72 hours against the culture and the clinical response: stop, switch to oral (IVOS), narrow the spectrum, or continue with a documented reason. This review is usually the FY1's job and it is usually skipped.
3. 3Document allergy properly. Record the DRUG, the REACTION and the TIMING. "Rash as a child" is not the same as "laryngeal oedema in 2019". Genuine penicillin allergy is far less common than recorded allergy, and true anaphylaxis rarer still.
4. 4Interpret cross-reactivity. Non-severe penicillin allergy: most cephalosporins (especially later generations) are acceptable on specialist advice. Severe or anaphylactic penicillin allergy: avoid all beta-lactams unless allergy-tested. Intolerance (nausea, diarrhoea) is NOT an allergy — record it as intolerance so it does not narrow future options.
5. 5Protect against C. difficile. Higher risk with broad-spectrum agents, especially in the elderly. New diarrhoea on antibiotics: isolate, send stool, stop the offending antibiotic if possible, and avoid antimotility drugs.

What goes wrong

• No indication and no stop date — the two omissions that make an antibiotic indefinite.
• Never doing the 48-hour review.
• Recording "allergic to lots of things" without detail, permanently restricting the options.
• Treating asymptomatic bacteriuria, especially in catheterised or older patients.
• Reaching for a broad-spectrum agent because the patient is unwell, without a source or a policy.