Antimicrobial Guidelines for Primary Care For use in Calderdale PCT, Kirklees PCT Wakefield District PCT
Produced February 2008 Review date February 2010
Aims < to < to < to < to
provide a simple approach to the treatment of common infections promote the safe, effective and economic use of antibiotics minimise the emergence of bacterial resistance in the community recommend antibiotics with consideration to local susceptibility
M icrobiological advice can be obtained from the M icrobiologists at the • Calderdale and Huddersfield NHS Foundation TrustRoyal Hospital • 01484-342000 ext 2427 • Microbiology Laboratory on Ext 2507 • M id Yorkshire Hospitals NHS Trust • 0844-8118110 • Consultant M icrobiologists • Dewsbury District Hospital - Dr Lucia Pareja-Cebrian - ext 83677 • Pinderfields General Hospital - Dr Aneel Sohal - ext 2655; Dr Adekola Adedeji - ext 2314 • Pontefract General Infirmary - Dr Viv Peiris - ext 6743 (M on-W eds Only) • Microbiology Laboratory - ext 2499
Prepared by a working group consisting of:< Dr Anu Rajgopal - Consultant Microbiologist - Calderdale and Huddersfield NHS Trust < Mrs Sandra M artin - Antibiotics Pharmacist - Calderdale and Huddersfield NHS Trust < Mr John Yorke - Principal Pharmacist - Medicines Information (Halifax) – Calderdale and Huddersfield NHS Trust < Consultant Microbiologists, Mid Yorkshire Hospitals NHS Trust < Calderdale PCT < Kirklees PCT < W akefield District PCT
Index Principles of Treatment ..........................
Introduction
Penicillin Allergy .....................................
Page 1
Dental Prophylaxis ..................................
Page 3
Parasitic Infections ..................................
Page 13
Eye Infections ..........................................
Page 4
Respiratory Tract Infections - Lower ....
Page 14
Gastro-Intestinal Tract Infections .........
Page 5
Respiratory Tract Infections - Upper ....
Page 19
Genital Tract Infections ..........................
Page 9
Skin/Soft Tissue Infections ......................
Page 23
M eningitis ................................................
Page 12
Urinary Tract Infections .........................
Page 27
Viral Infections ........................................
Page 33
Advice on doses Unless otherwise stated the doses recommended are for adult patients. Where a range is given the higher dose should only be prescribed for severe infections. The dose may also need to be varied according to age, weight and renal function. Further advice is given in the BNF, or from a Consultant Microbiologist.
Presentation by Medicines Inform ation Centre, The Calderdale Royal Hospital, Halifax
Principles of Treatment 1.
increase the incidence of MRSA.
General Information a. Always consult the latest BNF or Summary of Product Characteristics for full prescribing details b. This guidance is based on the best available evidence but its application must be modified by professional judgement. c. Prescribe an antibiotic only when there is likely to be a clear clinical benefit
h. High antibiotic prescribing can select for resistant bacteria, eg MRSA and extended spectrum $-lactamase producing bacteria (ESBLs) 2.
W here appropriate send samples for microbiological testing
3.
Drug Interactions Remember potential drug interactions between antibiotics and long term medication, eg oral contraceptives, theophylline, statins, warfarin etc - for further information see the BNF Appendix 1
d. Donâ&#x20AC;&#x2122;t forget the potential usefulness of delayed prescriptions for certain conditions, eg otitis media, acute sinusitis, acute infective conjunctivitis and acute bronchitis. e. Limit prescribing over the telephone to exceptional cases. f. Do not prescribe an antibiotic for viral sore throat, simple coughs and colds. g. High levels of prescribing of quinolones can
4.
W hich Antibiotics to Prescribe a. Use simple generic antibiotics first whenever possible. b. The use of new and more expensive antibiotics (eg quinolones and
cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective. c. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations - eg fusidic acid).
diet, as folate antagonist) and nitrofurantoin (at term, theoretical risk of neonatal haemolysis). b. Tetracyclines and quinolones should be avoided in breast feeding 7.
Optimal dosing of antibiotic is encouraged to hasten bacteriological (and clinical) cure, reduce relapses and shorten length of treatment. Inappropriate treatment, e.g. long term or low dose is associated with selection of resistance leading to treatment failure
8.
Course Lengths
d. Clarithromycin is an acceptable alternative in those who are unable to tolerate erythromycin because of side effects. 5.
Children a. In children avoid the use of quinolones and tetracyclines
6.
a. Keep course lengths as short as possible , eg 3 days for simple UTIs in women under 65 years of age.
Pregnancy and Lactation a. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole, trimethoprim (theoretical risk in first trimester in patients with poor
9.
This guidance is based on the best available evidence at this tim e but its application must be modified by professional judgem ent.
Penicillin Allergy 1. 2. 3. 4.
Obtain an accurate allergy status from the patient Ensure that all patientsâ&#x20AC;&#x2122; allergies and adverse side effects are documented fully Always check the allergy status of the patient before prescribing, dispensing or administering a medicine Be alert to the fact that the name of a medicine itself may not indicate 100% of the time that the medicine is a penicillin or related to a penicillin.
Patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration are at risk of immediate hypersensitivity to a penicillin; these individuals should not normally receive a penicillin, a cephalosporin, imipenem/meropenem, or another $-lactam antibiotic. Signs and symptoms of immediate hypersensitivity include, dyspnoea, swelling, rash, urticaria. Individuals with a history of a minor rash (ie non-confluent restricted to a small area of the body), or a rash that occurs more than 72 hours after penicillin administration are probably not allergic and $-lactam antibiotics should not be withheld. Drug intolerance (eg gastrointestinal symptoms, feeling faint) is not an indication to avoid $-lactam antibiotics.
Antimicrobial Guidelines for Primary Care - January 2008
Page 1
Antimicrobial Guidelines for Primary Care - January 2008
Page 2
Dental Prophylaxis Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Dental prophylaxis for infective endocarditis under local or no anaesthesia
Amoxicillin
In penicillin allergy, or if penicillin has been taken more than once in the previous month Clindamycin
Antimicrobial Guidelines for Primary Care - January 2008
Dose given 1 hour before treatment Adult - 3g stat Child - 5 to 10 years - 1.5g Child - under 5 years 750mg
Dose given 1 hour before treatment Adult - 600mg stat Child - 5 to 10 years 300mg Child - under 5 years 150mg
Page 3
Eye Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Conjunctivitis
Viral infections are common. Conjunctivitis is usually a self-limiting condition. Most people experience remission after 2-5 days - consider offering a delayed prescription. Bacteria may intially present unilaterally with glued eyes, no itch, and no past history of conjunctivitis. Exclude serious causes of red eye
Chloramphenicol 0.5% drops and 1% ointment at night or Chloramphenicol ointment 1%
2 hourly reducing to QDS All for 48 hours after resolution TDS or QDS
In newborn consider the possibility of Chlamydia and Neisseria gonorrhoea Exclusion of single cases from school/nursery is not generally necessary. It may be necessary if an outbreak occurs (see HPA Website)
Antimicrobial Guidelines for Primary Care - January 2008
Page 4
Gastro-Intestinal Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Note: Helicobacter test and treatment strategies benefit patients with ulcer disease and 8% of patients with functional dyspepsia. They reduce future risk of ulcer disease and gastric cancer, and reduces the need for long term PPIs. Eradication of Helicobacter pylori
1. Confirm presence of H. pylori before starting eradication therapy 2. There is normally no need to continue proton pump inhibitors or H2-receptor antagonists unless the ulcer is complicated by haemorrhage or perforation 3. Two week triple therapy regimens offer higher eradication rates but poor compliance and adverse effects offset this. 4. There is insufficient evidence to support eradication therapy in patients who continue to take NSAIDs Eradication rate is around 93% DO NOT use dual therapy, these are much less effective, and promote resistance. Tests for Clearance To test for clearance use the 13C-Urea breath test. This should NOT be done within 4 weeks of treatment with an antibacterial, or within 2 weeks of treatment with an antisecretory drug.
Antimicrobial Guidelines for Primary Care - January 2008
High dose PPI (Omeprazole, or Lansoprazole), and Clarithromycin and Amoxicillin
(20mg 12 hourly, or 30mg 12 hourly) 500mg 12 hourly 1g 12 hourly
7 days treatment only
If Penicillin Allergic use High dose PPI (Omeprazole, or Lansoprazole) and Clarithromycin and Metronidazole
(20mg 12 hourly, or, 30 mg 12 hourly) 500 mg 12 hourly 400 mg 12 hourly
7 days treatment only
Page 5
Gastro-Intestinal Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. If eradication has failed with this treatment 1. check that the original treatment indications were valid 2. check that failure of eradication has been confirmed with C13 urea breath test 3. check that patient is strongly motivated (treatment failure is often due to poor compliance) 4. If treatment failure has still occurred despite the above - seek further advice from Gastroenterologists Gastroenteritis
Most infections are self-limiting Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days, can cause resistance, and may be associated with side effects. Initiate treatment if the patient is systemically unwell following advice from the microbiologist. Notification and advice on exclusion from environmental health (Calderdale - 01422-392329; Kirklees - 01484226456; Wakefield 0845-8506506). General holding advice is to exclude until 48 hours after cessation of symptoms where the patient may be in a position to pass on infection. For more difficult cases contact HPA - 0113-284-0606, to speak to the duty professional. Metronidazole
Giardiasis
Adults
2g od
all for 3 days
Children < 1 yr - 40mg/kg/day 1-3 yrs - 500mg od 3-7 yr - 600-800mg od 7-10 yr - 1g Cryptosporidium
This coccoidal protozoa causes diarrhoea in animals and man. Infection is common in children and young adults.
No effective specific treatment. Symptomatic treatment only. Symptoms may last for 1-3 weeks in healthy individuals, and resolves slowly and spontaneously.
Antimicrobial Guidelines for Primary Care - January 2008
Page 6
Gastro-Intestinal Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Clostridium difficile
Clostridium difficile is implicated in 20% -30% of patients with antibiotic-associated diarrhoea, in 50% to 75% of those with antibiotic- associated colitis and in >90% of those with antibiotic-associated pseudomembranous colitis. Risk factors for C.difficile associated disease (CDAD) include treatment with antibiotics (commonly broad-spectrum penicillins, cephalosporins, clindamycin), advanced age, hospitalisation, exposure to other cases, ulcer-healing drugs, recent chemotherapy. Clinical diagnosis Diarrhoea in patients (profuse +/- blood), particularly if >65years of age who are currently on antibiotic(s) or received antibiotic(s) over preceding 4 weeks should have stools sent for C.difficile toxin (CDT). CDT should be looked for routinely in patients with an exacerbation of inflammatory bowel disease. It is less frequent in a community setting but should be considered in those patients who have received antibiotics. Infection Control measures (if Patient in Nursing or Residential Home etc) • Isolate the patient and start contact isolation precautions as per the infection control manual. • Maximise hand hygiene after contact with cases; hand washing in addition to alcohol gel decontamination is required as alcohol gel alone is not adequate for the inactivation of C.difficile spores • Inform the PCT infection control team Investigations FBC, Stool for C. difficile toxin For severe cases refer to hospital
Antimicrobial Guidelines for Primary Care - January 2008
Stop/review antibiotics (switch to narrow spectrum antibiotics) if possible and consider other causes of diarrhoea e.g. antacids, tube feeds Do not prescribe antimotility agents, or laxatives, and consider discontinuing proton pump inhibitors.
Page 7
Gastro-Intestinal Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Definition of severe C. cifficile. Any patient with CDAD and fever, raised WCC, abdominal pain/tenderness, acute rise in serum creatinine (more than 50% of baseline) may have severe disease, and the case should be discussed with microbiology and referred urgently to the hospital Recurrence of symptoms following initial improvement after a 10 day course is likely to be due to re-infection by another C.difficile strain, further antibacterial treatment or relapse due to germination of residual C.difficile spores within the colon. Send repeat investigations as above and treat.
Mild disease - (< 4 stools/day, patient not unwell) - Supportive therapy initially. Treat as below if toxin positive and diarrhoea persists. Moderate disease - (>4 stools/day, pt well) Metronidazole
400 mg PO tds
10 days
Severe disease refer to hospital Recurrence of symptoms - Metronidazole If > 1 recurrence or severe disease, contact Microbiology
Review - If no improvement within 3 days or clinical deterioration, contact Microbiology NB Clearance stools are not required for C.difficile infection. Repeat stool specimens for C.difficile toxin on previous positive patients should only be sent if; Symptoms persist despite treatment when a further test may be undertaken after 4 weeks. Symptoms resolve and then recur, which may be due to re-infection or relapse Salmonella
Most cases are mild and self-limiting. Seek Microbiological advice if treatment considered
Antimicrobial Guidelines for Primary Care - January 2008
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Genital Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. NOTE:- certain vaginal preparations may effect latex condoms and diaphragms - see BNF for details Vaginal Candidiasis
Bacterial vaginosis
All topical and oral azoles give 80-95% cure. In pregnancy avoid oral azole. If treatment failure send swab for culture A 7 day course of oral metronidazole is slightly more effective than 2 g stat. Avoid 2g stat dose in pregnancy
Clotrimazole 10% or Clotrimazole or Fluconazole
5g vaginal cream
stat
500mg pessary
stat
150mg orally
stat
Metronidazole
400mg BD or 2g (if compliance is an issue)
7 days
5g applicatorful at night
5 days
5g applicatorful at night
7 days
or if unable to tolerate oral treatment, or if woman prefers topical therapy Metronidazole 0.75% vag gel or Clindamycin 2% cream
Antimicrobial Guidelines for Primary Care - January 2008
stat
Page 9
Genital Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. NOTE:- certain vaginal preparations may effect latex condoms and diaphragms - see BNF for details Chlamydia trachomatis
Genital chlamydia most common in sexually active population â&#x20AC;&#x201C; women aged 16-19yr and men aged 20-24yr. 70% of infection is asymptomatic in women. Pending the introduction of a funded screening programme testing should be done on Women and Men with signs and symptoms attributable to chlamydia; Women (especially those <25yr): vaginal discharge, post coital/intermenstrual bleeding, inflamed/friable cervix, urethritis, PID, and lower abdominal pain or reactive arthritis in the sexually active. Men: Urethral discharge, dysuria, urethritis, and epididymo-orchitis or reactive arthritis in the sexually active. In addition testing should be offered to all women with risk factors undergoing uterine instrumentation; all patients with another sexually transmitted infection, sexual partners of those with C. trachomatis infection and mothers of infants with chlamydial conjunctivitis. Treat partners Refer contacts to GUM Note: Suggest referral of patients with STDs (including trichomoniasis) to Department of Genitourinary Medicine for contact tracing.
First Line Azithromycin
1g stat dose
Second Line Seek advice from GUM Clinic If pregnant or breast feeding
Refer to GUM Clinic for treatment
Antimicrobial Guidelines for Primary Care - January 2008
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Genital Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. NOTE:- certain vaginal preparations may effect latex condoms and diaphragms - see BNF for details Trichomoniasis
Treat partners simultaneously Avoid high dose metronidazole in pregnancy or use clotrimazole for SYMPTOMATIC relief and treat post-natally.
Metronidazole
or Clotrimazole pessary
400mg BD or 2g
7 days
100mg daily
6 days
100mg BD
14 days
400 mg BD
14 days
stat
Note: Suggest referral of patients with STDs (including trichomoniasis) to Department of Genitourinary Medicine for contact tracing. Pelvic Inflammatory Disease (PID)
It is essential to test for Chlamydia and N. gonorrhoea as antibiotic resistance is increasing. Refer patients to GUM for contact tracing and follow up.
First Line Doxycycline plus Metronidazole
Note: Suggest referral of patients with STDs (including trichomoniasis) to Department of Genitourinary Medicine for contact tracing.
Antimicrobial Guidelines for Primary Care - January 2008
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Meningitis Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Suspected meningococcal disease
Transfer all patients to hospital IV or IM Benzylpenicillin immediately. Administer benzylpenicillin prior to admission, unless history of anaphylaxis, NOT allergy. Ideally IV but IM if a vein cannot be found. (Chloramphenicol is an alternative in patients with immediate hypersensitivity reactions to beta-lactam antibiotics - it would not be expected that GPs routinely carry chloramphenicol).
Adults and children 10 years and over: 1200 mg Children 1 - 9 year: 600 mg Children <1 year: 300 mg
Prevention of secondary case of meningitis
• Prophylaxis for prevention of secondary infection should only be prescribed in line with local policy as recommended by the HPA (version 2007). • Copies have been widely circulated, and are available from the HPA. • This will involve close family contacts, and will usually be managed from the admitting ward. • If in doubt seek advice from the Health Protection Agency duty professional 0113 284 0606. Out of hours discuss with Public Health doctor on call, available through the switch boards at :• Huddersfield Royal Infirmary - 01484 342000, or • Pinderfields General Hospital - 0844-8118110.
Antimicrobial Guidelines for Primary Care - January 2008
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Parasitic Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Threadworm
Treat household contacts.
Mebendazole (for all over 2 years of age)
Use Pripsen in children under 2.
or
Pripsen
Antimicrobial Guidelines for Primary Care - January 2008
100mg
stat (if reinfection occurs, second dose may be needed after 2 weeks)
3 months -1 yr 1 level 2.5ml spoonful
Repeat after 14 days
1 - 2yrs 1 level 5ml spoonful
Repeat after 14 days
Page 13
Lower Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. 1. Start antibiotics immediately 2. Microbiological investigations not recommended routinely for those managed in the community - consider if no response to empirical therapy after 48 hours 3. Examination for Mycobacterium tuberculosis should be considered for patients with a persistent productive cough, especially if malaise, weight loss, or night sweats, or if other risk factors exist. Severity 4. Serological investigations should be considered during outbreaks (eg legionella, mycoplasma) or when there are assessment particular or epidemological reasons. chart from 5. BTS guidelines include oral co-amoxiclav. Local advice is for amoxicillin to be used instead, resistance is not BTS guidelines problematic. Co-amoxiclav may cause cholestatic jaundice (CSM 1993, 1997). on page 14 6. Amoxicillin 250mg tds is insufficient to treat, prescribe 500mg to 1g tds Community acquired pneumonia (CAP)
Amoxicillin
500mg - 1g tds
7 days
or if immediate type penicillin allergy Erythromycin
500mg qds
7 days
500mg bd
7 days
or Clarithromycin (if gastrointestinal intolerance to erythromycin)
Antimicrobial Guidelines for Primary Care - January 2008
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Lower Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Review of patients • Review of patients recommended after 48 hours or earlier if clinically indicated. Core and additional adverse prognostic features should be assessed as part of the clinical review. • If no response after 48 hours antibiotics consider adding erythromycin if only on amoxicillin to cover Legionella or Mycoplasma (rare in those >65yr) Additionally consider for hospital admission, chest radiography, microbiological and serological investigations. Patients to be transferred to hospital • Consider starting antibiotic therapy in those severely ill if there is likely to be a delay in admssion to hospital of over 2 hours.
Antimicrobial Guidelines for Primary Care - January 2008
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Lower Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation.
Severity assessment chart for Community Acquired Pneumonia (CAP) Severity assessment used to determine the management of CAP in patients in the community. *The social circumstances and wishes of the patient should also be considered.
Antimicrobial Guidelines for Primary Care - January 2008
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Lower Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Acute bronchitis
Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults. Offer a delayed prescription
first line No antibiotics needed in otherwise healthy adults with no underlying lung disease. Consider use in the elderly, co-morbidity (eg heart failure, diabetes) or if deteriorating clinically. second line Amoxicillin or Oxytetracycline or Doxycycline
Antimicrobial Guidelines for Primary Care - January 2008
500mg TDS
5 days
250â&#x20AC;&#x201C;500mg QDS
5 days
200mg stat/100mg OD
5 days
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Lower Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Acute exacerbation of COPD
Many cases are viral. Antibiotics are not indicated in absence of purulent/ mucopurulent sputum. Recommended if any two of the following:• increased sputum secretion • increased sputum purulence • increased dyspnoea If there is no clinical benefit after the first antibiotic consider using an alternative first line option.
first line Amoxicillin or Erythromycin or Oxytetracycline or Doxycycline
500mg TDS 250mg - 500mg QDS 250-500mg QDS 200mg stat/100mg OD
second line Try an alternative first line agent third line Ciprofloxacin - use in proven pseudomonal infections (quinolones have poor activity against Pneumococci).
c - Antibiotics should be given until clinical improvement review after 5 days - upto 10 days treatment may be required
500-750mg BD
If patients fail to respond - discuss the case with a Microbiologist Note:
Avoid tetracyclines in pregnancy and when breast feeding. The quinolones ciprofloxacin and ofloxacin have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections.
Antimicrobial Guidelines for Primary Care - January 2008
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Upper Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Influenzae
Annual vaccination is essential for all those at high risk of influenza. For otherwise healthy adults the use of antivirals is not recommended. Treat symptomatic ‘at risk’ patients only when influenza is circulating in the community, within 48 hours of the start of symptoms, i.e. those aged 65years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus and chronic renal disease. See Green Book - www.dh.gov.uk Patients over 12 years use oseltamivir 75mg oral capsule BD.
Pharyngitis / sore throat / tonsillitis
The majority of sore throats are viral; most patients do not benefit from antibiotics. There is clinical overlap between viral and streptococcal infections. Patients with more severe symptoms (3 of 4 of history of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from antibiotics. Antibiotics only shorten duration of symptoms by 8 hours. Antibiotics can prevent non-suppurative complications of betahaemolytic streptococcal pharyngitis but, in developed societies, such complications are rare. You need to treat 30 children or 145 adults to prevent one case of otitis media. Recent evidence indicates that penicillin for 7 days is more effective than 3 days.
first line No antibiotics
10 days treatment required to eliminate carriage second line Phenoxymethylpenicillin
or
Antimicrobial Guidelines for Primary Care - January 2008
NB:- antibiotics recommended if one or more of the following:- history of rheumatic fever, scarlet fever, pronounced systemic infection, immunosuppression.
Adult - 500mg QDS < 1 year - 62.5mg QDS 1-5 years - 125mg QDS 6-12 years - 250mg QDS
7-10 days 7-10 days 7-10 days 7-10 days
Page 19
Upper Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. if allergic to penicillin Erythromycin
Otitis media (child doses)
Adult - 500mg BD or 250mg QDS (QDS less side-effects) < 2 years - 125mg QDS 2-8 years - 250mg QDS
7-10 days 7-10 days 7-10 days
Many are viral. Resolves in 80% without antibiotics. Poor outcome unlikely if no vomiting or temp <38.5<C. Use ibuprofen or paracetamol. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness. Need to treat 20 children >2yr and seven 6-24 month old to get pain relief in one at 2-7 days.
first line No antibiotics - â&#x20AC;&#x153;Wait and seeâ&#x20AC;? recommended for 72 hours
Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults.
or
Consider antibiotics in those at risk of poor outcome eg, under 2 years of age, bilateral acute otitis media, vomiting and high fever.
Offer a delayed prescription. second line Amoxicillin
if allergic to penicillin Erythromycin
<2 yrs :125 mg TDS 2-10 yrs :250mg TDS >10 yrs 500mg TDS
5-7 days * 5-7 days * 5-7 days *
<2 yrs 125mg QDS 2-8 yrs 250mg QDS Other: 250-500mg QDS
5-7 days * 5-7 days *
Antimicrobial Guidelines for Primary Care - January 2008
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Upper Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Otitis externa
Otitis externa can be localised or diffuse; acute or chronic and can be caused by infection, allergy, irritants or inflammatory conditions. Of the infectious causes localized otitis externa (furunculosis) is normally caused by S. aureus. Acute diffuse otitis externa by Pseudomonas aeruginosa or S. aureus. Fungal infection is less common but may result from candida and dermatophyte infection.
Acute localized otitis externa
Symptomatic treatment with analgesia and application of local heat (eg warm flannel) often adequate
Antimicrobial Guidelines for Primary Care - January 2008
When necessary Flucloxacillin (only if severe infection or if person at risk of severe infection (poorly controlled diabetes mellitus or immunocompromised) or if allergic Erythromycin
500mg QDS
5-7 days
250mg - 500mg QDS
5-7 days
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Upper Respiratory Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Acute diffuse otitis externa (Bacterial)
Exclude the possibility of underlying Gentamicin/Neomycin According to otiti media. and steroid drops ((several manufacturers instructions. Effective ear toilet is most important. â&#x20AC;&#x201C; preparations available) clean canal of debris and discharge. Topical treatment usually effective. Contact sensitivity may occur with topically applied ear drops usually due to the antibiotic if present. Preparations formulated with aminogylcosides should not be used if there is tympanic perforation.
Acute Sinusitis
Many are viral. Symptomatic benefit of antibiotics is small. 69% resolve without & 84% with antibiotics. Reserve for severe profuse purulent nasal discharge, facial pain, systemic symptoms) or persistent (>10 days) symptoms.
No more than 7 days.
first Line No antibiotic - offer a delayed prescription second line Amoxicillin or Erythromycin
500mg TDS
5-7 days *
250mg - 500mg QDS
5-7 days *
* Standing Medical Advisory Committee guidelines suggest 3 days but longer courses of 5-7 days may be needed to prevent relapse. Relapse at 10 days is higher with a 3 day course in otitis media, but long-term outcome is similar.
Antimicrobial Guidelines for Primary Care - January 2008
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Skin/Soft Tissue Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Impetigo
Topical use should be minimised to reduce development of resistance.
Flucloxacillin or Erythromycin
For minor infections only
Hydrogen Peroxide 2-3 times daily Cream 1% (Crystacide) or second line Mupirocin or Fusidic acid topically QDS
(Caution with the topical use of fusidic acid as there may be local resitance) Cellulitis
500mg QDS 500mg QDS
7 days 7 days upto 3 weeks
5 days
Class 1: patients have no signs or symptoms of systemic toxicity and have no uncontrolled co-morbidities and are managed on an outpatient basis with oral antibiotics. Class 2: patients are either systemically ill, without any unstable co-morbidities, or are systemically well, but have one or more co-morbidities. Require initial parenteral antibiotic therapy which may be delivered from home if home parenteral antibiotic services available. Class 3: patients may appear toxic, or have at least one unstable co-morbidity, or a limb-threatening infection. Require admission to hospital for parenteral antibiotic therapy. Class 4: refer to hospital immediately Manage underlying pre-disposing conditions if any (eg tinea pedis, ulcers, lymphoedema). Consider urgent hospital admission for intravenous antibiotic treatment in severe, or rapidly worsening infection; suspected orbital, or periorbital cellulitis; facial cellulitis in a child - maintain a low threshold for hospital admission; immunocompromised; diabetes mellitus - admission may not be necessary if diabetes is stable, but maintain a low threshold for hospital admission; significant co-morbidity (eg heart failure, renal failure); neonate or child under 1 year: Recurrent cellulitis - treat underlying pre-disposing conditions if any (eg tinea pedis, ulcers, lymphoedema). For more than 2 episodes of cellulitis at the same site, long term prophylaxis may be appropriate - seek specialist advice from dermatology.
Antimicrobial Guidelines for Primary Care - January 2008
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Skin/Soft Tissue Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Facial cellulitis consider co-amoxiclav 625mg TDS or add metronidazole.
Flucloxacillin
500mg QDS
7 – 14 days
500mg QDS
7 – 14 days
or
If no significant improvement occurs in 5 Erythromycin days - IV therapy may be necessary.
Durations depend on response
Serious infections - refer to hospital Leg ulcers
Bacteria will always be present. Antibiotics do not improve healing. Culture swabs and antibiotics are only indicated when there is evidence of clinical infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid deterioration of ulcer or pyrexia. Sampling for culture requires cleaning then vigorous curettage and aspiration.
Diabetic foot ulcer infections
Comments: Samples should not be taken routinely. Repeat samples are not required unless worsening infection. Bone/ joint involvement has to be excluded clinically and radiologically. Investigations CRP, Swabs C&S. Need to be deep, ideally tissue biopsies/ pus aspirates. Superficial swabs should be avoided.
Non-limb threatening infection Flucloxacillin +/Amoxicillin (Clindamycin if penicillin allergic) Deep infections including osteomyelitis Clindamycin and Ciprofloxacin
500mg QDS PO
1-2 weeks
500mg TDS PO 300mg QDS PO
450mg QDS PO 500mg BD PO
2-4 weeks (4-6 weeks if Osteomyelitis)
Modify antibiotic treatment on the basis of sensitivities and/or clinical response
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Skin/Soft Tissue Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Animal bite
Human bite
Surgical toilet most important. Assess tetanus and rabies risk. Antibiotic prophylaxis advised for – puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic, primary closure, and prosthetic valves or joints Antibiotic prophylaxis advised. Assess HIV/hepatitis B & C risk
First line animal or human Co-amoxiclav If penicillin allergic: Metronidazole with either Oxytetracycline, or Erythromycin
625mg TDS
7 days
400mg TDS
7 days
250-500mg QDS
7 days
250-500mg QDS
7 days
* - Post exposure prophylaxis should be offered if bite is from someone known or strongly suspected to be HIV positive - patients should attend the A & E departments in the local hospital.
Dermatophyte infection of the proximal fingernail or toenail (Adults) For children seek advice
Fungal nail infections are common affecting 4.7% of those >55y. Many patients do not seek medical advice and the only symptoms are frequently cosmetic changes in the appearance of the nail. Therapy should be considered ONLY if all of the following apply and not for cosmetic reasons alone; 1. The patient has poor or diminished circulation (diabetes or peripheral vascular disease) 2. The results of mycological examination confirm the diagnosis (Nail clippings required) 3. The patient can and will comply with the long courses of treatment necessary. Take nail clippings; start therapy only if infection is confirmed by microbiology
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Skin/Soft Tissue Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. NB terbinafine is not active against candida
Terbinafine
fingers 6 – 12 weeks toes 3 – 6 months Children - < 12 years, obtain advice from Dermatologist
Itraconazole (caution when prescribing in patients at high risk of heart failure)
200mg BD -
Idiosyncratic liver reactions occur rarely with terbinafine.
250mg OD -
Nail infections may still respond after a treatment course Pulsed itraconazole monthly is recommended for infections with yeasts and non-dermatophyte moulds.
Candida
Take nail clippings; start therapy only if infection is confirmed by microbiology
Dermatophyte infection of the skin
Administer for 14 days after symptomatic resolution. If intractable consider oral itraconazole following microbiological report
fingers
7 days monthly 2 courses
toes
7 days monthly 3 courses
Children - < 12 years, obtain advice from Dermatologist Topical Clotrimazole 1%
BD
4 – 6 weeks
If failure: Topical Terbinafine 1% following results of skin scrapings
BD
1 week
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Urinary Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Note:1. UTI can only be proven bacteriologically in 50% of women with symptoms of UTI, others have inflammation of the urethra – the ‘so called’ urethral syndrome.1 Antibiotics will not hasten clinical response in urethral syndrome. 2. Asymptomatic bacteruria occurs in 25% of women and 10% of men >65 years and is not associated with increased morbidity and does not require antibiotic therapy. 3. Urine culture is always indicated in men, children, pregnant women, those with complicated infection or where empirical treatment has failed 4. In adult women with uncomplicated UTI (ie no fever or loin pain) it is reasonable to start empirical treatment with no culture if dipstick positive for nitrite or leucocyte esterase. Negative nitrite and leucocyte esterase have a 95% negative predictive value. (See below) 5. In sexually active young men and women with urinary symptoms consider Chlamydia trachomatis. 6. Tests of cure in uncomplicated resolved UTIs are unnecessary. 7. Patients with long-term catheters usually have bacteruria. Antibiotics and CSU tests are only indicated if there is evidence of systemic infection and will not eradicate bacteria from the urinary tract.. Raised urinary WCC may result solely from the presence of the catheter.
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Urinary Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation.
Uncomplicated UTI, ie no fever or flank pain in adult females <65 yr old without underlying disease
Avoid trimethoprim in first trimester of pregnancy and nitrofurantoin at term +ve nitrites or leucocyte esterase on morning urine increases likelihood of UTI
Trimethoprim or Nitrofurantoin
200mg BD
3 days
50-100mg QDS
3 days
nd
2 line - depends on sensitivity of organism isolated e.g.Cefalexin 500mg BD for 3 days, Norfloxacin 400mg BD for 3 days
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Urinary Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. UTI in men, women >65yr, recurrent infections in both sexes, and failure of therapy
MSU required to confirm diagnosis and susceptibility testing
Trimethoprim or Nitrofurantoin or Cefalexin
200mg BD
7 days
50 - 100mg QDS
7 days
500mg BD
7 days
Amoxicillin
500mg TDS
7 days
Amoxicillin or Cefalexin
500mg TDS
7 days
500mg BD
7 days
Amoxicillin if strain susceptible UTI in pregnancy MSU required to confirm diagnosis and susceptibility testing Avoid trimethoprim in first trimester and nitrofurantoin at term. UTI in children
Prophylactic antibiotics Should be considered to cover the period whilst waiting for imaging or specialist assessment. In those <1yr of age, or where other complications exist. Send MSU for culture and susceptibility. Waiting 24 hrs for results is not detrimental to outcome.
Antimicrobial Guidelines for Primary Care - January 2008
Trimethoprim or Nitrofurantoin or Cefalexin or Amoxicillin
see BNF for childrens doses
7 days
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Urinary Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Patients with a urinary catheter
Diagnostic Criteria • Raised white cell count may occur solely due to the presence of the catheter. Growth of <105 orgs per ml may be significant in the symptomatic patient. Mixed growths in a CSU may not indicate contamination especially with long term catheterisation. Aetiology • Varies with duration of catheterisation and antibiotic use. E. coli, Enterococci, Proteus sp, Pseudomonas sp, Candida sp. Notes • Bacteriuria is common; duration of catheterisation is the most important risk factor, daily increase in prevalence is 310% • Up to 30% of short term (2-4 days) catheterisations develop bacteriuria; bacteriuria invariable in catheter placed >30days. • Bacteriuria asymptomatic in the majority of cases and antibiotics are NOT indicated. Elimination of bacteriuria unlikely or of short duration, does not reduce morbidity and increases the incidence of resistant bacteria. • A clearly marked CSU and blood cultures should always be obtained prior to the administration of antibiotics when the patient has systemic symptoms (fever, rigors etc.) • Routine CSU for cultures and sensitivitities not indicated Antibiotics should be chosen on the basis of susceptibility tests whenever possible When possible the catheter should be removed, especially when yeasts (discuss with Microbiologist) are present. Nitrofurantoin and Nalidixic acid should not be prescribed as they only achieve therapeutic concentrations in urine.
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Urinary Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. • Asymptomatic bacturia in a patient with a long-term indwelling urinary catheter should not be treated. • Symptomatic lower UTI in a patient with a long-term indwelling urinary catheter • if symptoms are severe, admit to hospital (may need parenteral treatment) • review catheter care and function. Check that the catheter is correctly positioned and not blocked. • send urine for culture (collect sample from the catheter tubing and not the bag) before commencing antibiotics. Urine dipstick tests are not likely to be helpful in people with long-term urinary catheters. • Consider antibiotic treatment, taking into account the severity of the presentation and any co-morbidity. • If symptoms are mild, consider withholding antibiotics until the result of urine culture is available to guide choice of antibiotic • If there is fever and flank, loin, back pain or tenderness - treat as for upper UTI • If immediate treatment for lower UTI is required, treat empirically with trimethoprim 200mg bd or nitrofurantoin 50mg qds for 7 days • take into account previous treatments and culture results when choosing an antibiotic for empirical treatment • if urine has been cultured recently, the sensitivity report may suggest an appropriate antibiotic • Review choice of antibiotic with progress and culture results Acute pyelonephritis
MSU required to confirm diagnosis and susceptibility testing.
Ciprofloxacin
If no response within 48 hours consider referral.
If sensitive Trimethoprim
500mg BD
7 days
200mg BD
14 days
500mg TDS
14 days
or
or Cefalexin
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Urinary Tract Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Acute prostatitis
4 weeks treatment may prevent chronic infection Quinolones are more effective. Exclude infections with Chlamydia trachomatis and Neisseria gonorrhoea
Ciprofloxacin or Trimethoprim
500mg BD
28 days
200mg BD
28 days
Seek expert advice
Chronic prostatitis
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Viral Infections Illness
Comments
Drug
Dose
Duration of Tx
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further inform ation. Chicken pox & shingles (Varicella zoster)
Chicken pox: Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND treatment started <24h of onset of rash.
Aciclovir
800mg 5x/day
7 days
Child â&#x20AC;&#x201C; see BNF
Shingles: Treatment indicated if: ophthalmic or predictors of post-herpetic neuralgia: >50 yr, severe pain, severe skin rash, prolonged prodomal pain AND <72h of onset of rash. If pregnant - VZIG (varicella zoster immunoglobulin) should be offered to all non-immune pregnant patients following serological confirmation Determine the date and nature of contact, and discuss with Microbiologist
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Viral Infections Illness
Comments
Drug
Dose
Duration of Tx
Shingles • Antivirals are recommended for adults aged 50 years and over • Antiviral drugs are recommended in adults of any age who: • present with severe acute pain or extensive rash • have ophthalmic involvement • are immunocompromised • have Ramsey Hunt Syndrome • have atopic eczema • have contact with very young infants, immunocompromised individuals, or pregnant women • Adults under the age of 50 years: expert opinion is divided as to whether antivirals should routinely be offered to people under the age of 50 years who are not in the category above. • the incidence of post-herpetic neuralgia is low in people under the age of 50 years, so antivirals will only have minimal impact on reducing the risk of the progression to post-herpetic neuralgia in this age group • however, the rash may not have fully developed at the time of presentation. Antivirals may therefore provide benefit for those people who would otherwise have gone on to develop a sever rash or extensive rash • until more evidence becomes available, CKS recommends offering antivirals to all adults under the age of 50 years, after discussing these issues with each individual
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