Start Smart Then Focus
Expansion
Start Smart
- Take cultures before starting, where it will not delay treatment
- Prescribe according to local guidelines and known sensitivities
- Document the indication, drug, dose, route, and the duration or review date
- Do not start antibiotics without clinical evidence of bacterial infection
Then Focus, reviewing at 48 to 72 hours with one of five decisions:
- Stop
- Switch intravenous to oral
- Change to a narrower agent (de-escalate)
- Continue and set a review date
- Move to outpatient parenteral therapy
The four Cs drive Clostridioides difficile: co-amoxiclav, cephalosporins, ciprofloxacin and clindamycin.
Criteria for intravenous to oral switch: afebrile for 48 hours, improving clinically, falling inflammatory markers, a functioning gut, and no indication requiring the intravenous route such as endocarditis, meningitis or bone infection.
“Shorter is usually as good.” Evidence increasingly supports shorter courses in pneumonia, urinary tract infection and cellulitis, and prolonged courses add toxicity and resistance rather than cure.
Allergy delabelling matters: most recorded penicillin allergy is not genuine, and the label leads to broader, more toxic and less effective alternatives.