Download Antibiotic Policy

Primary Care Antimicrobial Policy
May 2015
Next Full Review: March 2018
1
Contents
1.
2.
3.
4.
5.
6.
7.
INTRODUCTION ................................................................................................................... 4
1.1 PRINCIPLES OF TREATMENT .................................................................................... 4
1.2 HYPERSENSITIVITY TO PENICILLIN .......................................................................... 5
1.3 PREGNANCY ............................................................................................................... 5
1.4 DRUG INTERACTIONS ................................................................................................ 5
1.4.1 Contraceptives ........................................................................................................... 5
1.4.2 Warfarin and other anticoagulants ............................................................................. 6
1.5 HEALTHCARE ASSOCIATED INFECTIONS ................................................................ 6
1.5.1 MRSA ........................................................................................................................ 6
1.5.1.1 MRSA Topical Decolonisation Regime ...................................................................... 6
1.5.2 Clostridium difficile ..................................................................................................... 6
1.6 SEXUALLY TRANSMITTED DISEASES ....................................................................... 7
1.7 MENINGOCOCCAL INFECTION .................................................................................. 8
1.7.1 Prophylaxis of Meningococcal infection.......................................................................... 8
LOWER RESPIRATORY TRACT INFECTIONS ................................................................... 9
2.1 Influenza treatment........................................................................................................ 9
2.2 Acute sore throat ........................................................................................................... 9
2.3 Acute Otitis Media ....................................................................................................... 9
2.4 Acute Otitis Externa..................................................................................................... 10
2.5 Chronic Otitis Externa ................................................................................................. 10
2.6 Acute Rhinosinusitis .................................................................................................... 10
LOWER RESPIRATORY TRACT INFECTIONS ................................................................. 11
3.1 Acute cough, bronchitis ............................................................................................... 11
3.2 Acute exacerbation of COPD ...................................................................................... 11
3.3 Community-acquired pneumonia - treatment in the community ................................... 11
URINARY TRACT INFECTIONS ......................................................................................... 12
4.1 CATHETERISED PATIENTS ...................................................................................... 12
4.2 UTI in adults (no fever or flank pain) ............................................................................ 12
4.3 Acute prostatitis ........................................................................................................... 13
4.4 UTI in pregnancy ......................................................................................................... 13
4.5 UTI in Children ............................................................................................................ 14
4.6 Acute pyelonephritis .................................................................................................... 14
4.7 Recurrent UTI in non-pregnant women ≥ 3 UTIs/year ................................................. 14
GASTRO-INTESTINAL INFECTIONS ................................................................................. 15
5.1 Eradication of helicobacter pylori ................................................................................. 15
5.2 Infectious diarrhoea ..................................................................................................... 15
5.3 Traveller’s diarrhoea.................................................................................................... 15
5.4 Giardiasis .................................................................................................................... 16
5.5 Oral Candidiasis .......................................................................................................... 16
5.6 Threadworms .............................................................................................................. 16
GENITAL TRACT INFECTIONS.......................................................................................... 17
6.1 STI screening .............................................................................................................. 17
6.2 Chlamydia trachomatis /urethritis ................................................................................ 17
6.3 Vaginal Candidiasis ..................................................................................................... 17
6.4 Bacterial vaginosis ...................................................................................................... 17
6.5 Trichomoniasis ............................................................................................................ 17
6.6 Pelvic Inflammatory Disease ....................................................................................... 18
SKIN INFECTIONS.............................................................................................................. 18
7.1 Impetigo ...................................................................................................................... 18
7.2 Eczema ....................................................................................................................... 18
7.3 Cellulitis and Erysipelas............................................................................................... 18
7.4 Leg Ulcer ..................................................................................................................... 18
7.5 Paronychia…………………………………………………………………………………… 19
7.6 PVL ............................................................................................................................. 19
7.7 Bites (human or animal) .............................................................................................. 19
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7.8 Scabies ....................................................................................................................... 19
7.9 Dermatophyte Infection – scalp ................................................................................... 19
7.10 Dermatophyte Infection – skin ..................................................................................... 19
7.11 Dermatophyte Infection – nail ...................................................................................... 20
7.12 Varicella zoster/ chicken pox Herpes zoster/ shingles ................................................ 20
7.13 Acne ............................................................................................................................ 20
7.14 Cold Sores ................................................................................................................. 20
7.15 Genital herpes ............................................................................................................. 21
8.
EYE INFECTIONS ............................................................................................................... 21
8.1 Conjunctivitis ............................................................................................................... 21
9.
DENTAL INFECTIONS ........................................................................................................ 21
10. CONTACTS ......................................................................................................................... 22
11. KEY CHANGES FROM PREVIOUS GUIDANCE AND DIFFERENCES FROM PHE
GUIDANCE .................................................................................................................................. 22
Revision history:
2013 North East Sector guidance revised & cross-referenced with PHE ‘Management of
infection guidance for primary care for consultation and local adaptation’ Oct 14.
First draft circulated for consultation / comment to: HMR CCG, Bury CCG, Oldham CCG,
PAHT & Pennine Care
Updated following advice from: Dr R Stokes, Robert Hallworth, Dr I Cartmill, Gloria
Beckett, Dr P McMaster, Catherine Jackson
Final draft circulated to NESDAT members for electronic ratification
Addition of guidance on paronychia (section 7.5)
Final version ratified electronically via NESDAT
3
J Tilstone March 15
J Tilstone March 15
J Tilstone April 15
29.4.15
2.6.15
12.6.15
1.
INTRODUCTION
This document provides guidance for health professionals regarding appropriate and cost-effective
prescribing for the treatment of infections commonly encountered in general practice. It is based
upon Public Health England’s ‘Management of infection guidance for primary care for
consultation and local adaptation’ document published in October 2014, with some local
adaptation. Local differences from the PHE document are listed in the changes table on page 22.
A fully referenced copy of the PHE guidance is available at:
https://www.gov.uk/government/publications/managing-common-infections-guidance-forprimary-care
This policy is for GUIDANCE ONLY and does not cover every eventuality; however clinicians
should aim to adhere to this guidance and be able to demonstrate this. This guidance should not
be used in isolation; it should be supported with patient information about back-up/delayed
antibiotics, infection severity and usual duration, clinical staff education, and audits. Materials are
available on the RCGP TARGET website.
Doses are stated within the clinical indications; these are mainly oral doses for adults with normal
renal and hepatic function. Full details of doses, interactions, contra-indications and sideeffects can be found in the British National Formulary and the Childrens BNF. Ideally,
bacteriological specimens should be taken before giving antibiotics, although it is appreciated that
this is not always possible in general practice.
1.1
PRINCIPLES OF TREATMENT
Antibiotic stewardship is now an essential responsibility for all clinicians and measures to avoid
and reduce inappropriate antibiotic use are at the forefront of management strategies for all
infective episodes. Educating patients about the benefits and disadvantages of antimicrobial
agents is essential. Practices can provide leaflets and / or display notices advising patients not to
expect a prescription for an antibiotic, together with the reasons why. This educational material can
be obtained from the RCGP TARGET website and the CCG Medicines Management Team.
Principles of Treatment
This guidance is based on the best available evidence but professional judgement and involve patients
in management decisions.
2. It is important to initiate antibiotics as soon as possible in severe infection.
3. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be
obtained from  0161 627 8360.
4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
5. Consider a NO, or back-up / delayed, antibiotic strategy for acute self-limiting upper respiratory tract
infections, and mild UTI symptoms.
6. Limit prescribing over the telephone to exceptional cases.
7. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (eg. co-amoxiclav,
quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk
of Clostridium difficile, MRSA and resistant UTIs.
8. A dose and duration of treatment for adults is usually suggested, but may need modification for age,
weight and renal function. Child doses are provided when appropriate and can be accessed through the
Childrens BNF. In severe or recurrent cases consider a larger dose or longer course. Please refer to
BNF for further dosing and interaction information (e.g. interaction between macrolides and statins) if
needed and please check for hypersensitivity.
9. Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider
culture and seek advice.
10. Avoid widespread use of topical antibiotics (especially those agents also available as systemic
preparations, e.g. fusidic acid).
11. In pregnancy take specimens to inform treatment; where possible avoid tetracyclines, aminoglycosides,
quinolones, high dose metronidazole (2 g) unless benefit outweighs risks. Short-term use of
nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is not expected to cause fetal problems.
Trimethoprim is also unlikely to cause problems unless poor dietary folate intake or taking another folate
antagonist eg antiepileptic.
1.
4
AVOID:
- Using longer courses than are necessary.
- Unnecessary use of combinations where a single drug would be equally effective.
- Broad-spectrum antibiotics where a narrow spectrum agent is indicated.
- Prophylactic use of antibiotics unless of proven benefit.
Please be ready to change therapy and / or course-length in the light of:
 Culture and sensitivity results
 Patient non-response / reaction
 Microbiological consultation
Topical antibiotics should be used very rarely, if at all (eye infections are an exception). For
wounds, topical antiseptics are generally more effective, if required. Topical antibiotics encourage
resistance and may lead to hypersensitivity. If considered essential select an antibiotic that is not
used systemically.
1.2
HYPERSENSITIVITY TO PENICILLIN
Penicillin-allergic patients will react to all penicillins. Up to 10% of penicillin-sensitive patients will
also be allergic to cephalosporins. If necessary a microbiologist can advise on suitable alternatives.
Penicillin-sensitivity should be clearly documented in the patient’s notes. True penicillin allergy is
defined as anaphylaxis, urticaria, angioedema or rash that occurs immediately after
penicillin administration. These patients are at risk of further immediate hypersensitivity
reactions and they should NOT receive further doses of penicillin or beta-lactam antibiotics
including cephalosporins and carbapenems due to the risk of cross-hypersensitivity. The BNF
advises that the 3rd generation of cephalosporins can be used with caution in patients with
hypersensitivity reaction to penicillins.
Patients with a history of minor rash (non-confluent & restricted to a small body area), or a rash
that occurs more than 72 hours after penicillin administration are probably not allergic to penicillin.
In these patients, penicillins or other beta-lactam related antibiotics should not be withheld for
treatment of serious infections.
Check – is patient truly penicillin allergic/sensitive, or just intolerant? Do not add ‘allergy to
penicillin’ onto patient’s medical history if patient experiences mild side-effects such as
indigestion.
1.3 PREGNANCY
The following are felt to be safe in pregnancy:
- Penicillins
- Cephalosporins
- Erythromycin
- Nitrofurantoin (not in the third trimester)
- Metronidazole (low dose regimes only i.e. not 2 gram dose)
Applicators for pessaries used to treat vaginal infections should not be used in pregnancy.
1.4 DRUG INTERACTIONS
1.4.1 Contraceptives
Latest recommendations are that no additional contraceptive precautions are required when
combined oral contraceptives, progestogen-only contraceptives, contraceptive patches, or vaginal
rings are used with antibacterials that do not induce liver enzymes, unless diarrhoea or vomiting
occur.
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Antibacterials that do induce liver enzymes are rifampicin and rifabutin.
For further guidance on these drugs and use in contraception – see section 7 of the BNF.
1.4.2 Warfarin and other anticoagulants
Experience in anticoagulant clinics suggests that the International Normalised Ratio (INR) can be
altered by a course of most antibiotics. Increased frequency of INR monitoring is advisable during
and after a course of antibiotics until the INR has stabilised again. Cephalosporins, erythromycin,
ciprofloxacin, trimethoprim and rifampicin seem to cause a particular problem. In these cases the
anticoagulant clinic should be contacted by the patient or a member of the practice team for further
advice and to ensure the necessary INR monitoring occurs.
1.5 HEALTHCARE ASSOCIATED INFECTIONS
Concerns regarding health care-associated infections (HCAIs), particularly methicillin-resistant
Staphylococcus aureus (MRSA) and Clostridium difficile infection, have grown in recent years.
These HCAIs are associated with volume of antibiotic use.
1.5.1
MRSA
Treatment of MRSA infections is unlikely to be commenced in primary care, and should only
be commenced following discussion with a microbiologist.
It is important to distinguish MRSA colonisation from infection. Antibiotics that are active against
MRSA must not be started to treat MRSA colonisation if it is not causing an infection. The MRSA
topical eradication regime should be started in order to decolonise the MRSA loads carried by the
patients for the protection of themselves and other severely ill patients in areas that are
categorised as high-risk.
1.5.1.1
MRSA Topical Decolonisation Regime
BACTROBAN® (Mupirocin) nasal ointment THREE times daily in both nostrils.
Hibiscrub (4% Chlorhexidine) as a body wash ONCE DAILY
Chlorhexidine 0.2% mouthwash 10ml TWICE DAILY
Alternative
Treat for
Naseptin Nasal Cream QDS will be used where the strain of MRSA is
resistant to Mupirocin.
FIVE days, stop for two days and re-screen.
Restart second course only if screen positive for up to a maximum of
two courses.
For persistent positive results, contact Infection Control or
Microbiology for advice.
Further information:
www.gov.uk/government/uploads/system/uploads/attachment_data/file/330793/MRS
A_screening_and_supression_primary_care_guidance.pdf
1.5.2 Clostridium difficile
All antibiotics predispose patients to the development of Clostridium difficile gut infection. There
must be a clear indication for antibiotic use, particularly in the vulnerable elderly population. Broad
spectrum agents, prolonged / recurrent courses are associated with the greatest risk.
The antibiotics most commonly associated are clindamycin, quinolones, second and third
generation cephalosporins, and co-amoxiclav, and use of these products is actively
discouraged.
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For confirmed or clinically suspected cases of C diff – stop antibiotics if clinically possible or switch
to a low risk (narrow spectrum) alternative. Discuss with microbiologist.
All anti-motility agents should be stopped. PPIs should be stopped if possible.
If there is a strong suspicion of C diff in a primary
care patient, commence treatment after sending a
stool sample (check with microbiologist if unsure
whether empirical treatment is indicated):
Metronidazole 400mg TDS for
10 – 14 days
Review when sample result is
available
Disease Severity Assessment
If patient has ONE or more of the following markers
 Fever ≥ 38.5OC
 WCC ≥ 15 x 109/L
 Evidence of severe colitis (abdominal signs)
 Creatinine >50% increase from baseline / new oliguria
→ Severe CDI → discuss with microbiologist. Patient may require admission.
If none of these markers → Non-severe CDI → metronidazole as above
Patients require daily assessment (management of fluid loss & review of Bristol stool chart).
Symptoms not improving:
Non-severe CDI : If symptoms have not improved, or have worsened or relapsed at the
end of the course of metronidazole
DO NOT RETEST
Discuss with microbiologist: vancomycin may be indicated.
Severe CDI : If symptoms have not improved, or have worsened after 1 week of treatment
– discuss with microbiologist or Infectious Diseases.
DO NOT RETEST
1.6 SEXUALLY TRANSMITTED DISEASES
It is important that patients are REFERRED to GUM clinic for screening for other
infections, contact tracing and health promotion BEFORE starting antibiotics.
The use of antibiotics will affect the screening results of other possible infections.
If you strongly suspect patient will not attend GUM clinic – contact clinic for advice (0161 627 8753)
In order to prevent re-infection and treatment failure it is important to treat the patient and their
sexual partners, plus advice to avoid sexual relations during treatment.
Pregnant patients need follow-up to ensure successful eradication of infections - ideally by GUM
clinic.
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1.7 MENINGOCOCCAL INFECTION
Rapid admission to hospital is highest priority when meningococcal disease is
suspected. If there is time before admission, early administration of benzyl penicillin
(which all GPs should carry) while waiting for the ambulance can be life-saving in invasive
meningococcal disease. Penicillin should only be withheld if there is a history of penicillin
anaphylaxis (immediate allergic reaction after previous penicillin administration). A
simple rash or intolerance to penicillin is not a contra-indication. If there is a true history of
anaphylaxis get the patient to hospital as quickly as possible. Remember, meningism may
not be a feature of meningococcal disease and young children rarely show typical signs of
meningitis.
The likely infecting organisms in adults / older children are Pneumococcus or Meningococcus. The
incidence of Haemophilus meningitis is now low due to HIB vaccination in the childhood
vaccination programme.
Occasionally Neisseria meningitides will appear unexpectedly in throat swabs. In the absence of
invasive disease this is part of the normal flora of the throat and does not need treatment.
Meningococci from conjunctival swabs need public health action. Seek the advice of the
Consultant in Communicable Disease Control (Public Health England) if this happens.
First line
If true penicillin anaphylaxis
exists
Benzyl penicillin:
under 1year 300mg
1-9 years 600mg
10 years and over 1200mg
GPs do not need to carry an alternative antibiotic.
However, if other antibiotics are available, a 3rd
generation cephalosporin may be used.
1.7.1 Prophylaxis of Meningococcal infection
Discuss with Public Health
Prophylaxis should be given to all close / household contacts of the patient. It is important that all
family members should have prophylaxis at the same time, so that the organism can be
eradicated ‘at a stroke’. Health care workers need prophylaxis only when engaged in mouth-tomouth resuscitation of the patient. Take advice from microbiology or public health.
First line
Treat for
Alternative
Treat for
Pregnancy
Ciprofloxacin:
1 month to 4 years 125mg
5 - 12 years 250mg
Adults & children over 12 years 500mg
SINGLE DOSE
Rifampicin:
Infants under 12 months 5mg/kg BD
1 – 12 years 10mg/kg BD
Adults & children over 12 years 600mg BD
TWO DAYS
Ceftriaxone IM 250mg as a single dose (dissolved
in 3.5mL of 1% lidocaine HCl.)
8
2. LOWER RESPIRATORY TRACT INFECTIONS
ILLNESS
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
2.1 Influenza
treatment
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not recommended.
2.2 Acute sore
throat
Avoid antibiotics as 90% resolve in 7 days without,
and pain only reduced by 16 hours.
Recommend analgesia.
If Centor score 3 or 4: (Lymphadenopathy; No Cough;
Fever; Tonsillar Exudate) consider 2 or 3-day delayed
or immediate antibiotics or rapid antigen test.
2.3 Acute Otitis
Media
(child doses)
Treat ‘at risk’ patients, when influenza is circulating in the community and ideally within 48 hours of onset (do not wait for lab report) or in a care
home where influenza is likely.
At risk: pregnant (including up to two weeks post partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant
cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease, morbid obesity
(BMI>=40).
Use 5 days treatment with oseltamivir 75mg bd. If resistance to oseltamivir or severe immunosuppression, use zanamivir 10mg BD (2 inhalations
by diskhaler for up to 10 days) and seek advice.
Phenoxymethylpenicillin
500mg QDS
1G BD (QDS when severe)
10 days
250-500mg BD
5 days
Penicillin Allergy:
Clarithromycin
Optimise analgesia and target antibiotics
AOM resolves in 60% in 24hrs without antibiotics, which
only reduce pain at 2 days and does not prevent
deafness
Amoxicillin
Consider 2 or 3-day delayed or immediate antibiotics
for pain relief if:
Penicillin Allergy:
Erythromycin
 <2 years AND bilateral AOM or bulging membrane
and ≥ 4 marked symptoms
 All ages with otorrhoea
OR
Clarithromycin
9
Child doses
Neonate 7-28 days
30mg/kg TDS
1 month-1 yr: 125mg TDS
1-5 years: 250mg TDS
5-18 years: 500mg TDS
<2 years: 125mg QDS
2-8 years: 250mg QDS
8-18 years: 250-500mg QDS
1 month – 12 years:
<8kg
7.5mg/kg BD
8 – 11kg
62.5mg BD
12 – 19kg 125mg BD
20 – 29kg 187.5mg BD
30 – 40kg 250mg BD
12 – 18 years – as adult dose
5 days
5 days
ILLNESS
2.4
Acute Otitis
Externa
COMMENTS
First use aural toilet (if available) and analgesia.
Cure rates similar at 7 days for topical acetic acid or
antibiotic +/- steroid
If cellulitis or disease extending outside ear canal, start
oral antibiotics (Flucloxacillin, or Clarithromycin if
penicillin allergic) and refer
2.5
Chronic Otitis
Externa
2.6
Acute
Rhinosinusitis
DRUG
First Line:
Acetic acid 2%
Second Line:
Neomycin sulphate with
corticosteroid
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
1 spray TDS
7 days
3 drops TDS
7 days min to 14 days
max
Antibacterials or antifungals are not needed. Keep ear(s) clean and dry.
Avoid antibiotics as 80% resolve in 14 days without;
they only offer marginal benefit after 7days
Amoxicillin
500mg TDS
1g TDS if severe
7 days
Use adequate analgesia
Consider 7-day delayed prescription, or immediate
antibiotic when purulent nasal discharge
or Doxycycline
or
Phenoxymethylpenicillin
200mg stat then100mg OD
7 days
500mg QDS
7 days
10
3. LOWER RESPIRATORY TRACT INFECTIONS
ILLNESS
ADULT DOSE
DURATION OF
See Childrens BNF for
TREATMENT
child doses
Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for
proven resistant organisms. Low doses of penicillins are more likely to select out resistance, 500mg of amoxicillin is recommended.
3.1
Acute cough,
bronchitis
3.2
Acute
exacerbation of
COPD
3.3
Communityacquired
pneumonia treatment in the
community
COMMENTS
Antibiotic little benefit if no co-morbidity.
Consider 7d delayed antibiotic with advice.
Symptom resolution can take 3 weeks.
Consider immediate antibiotics if > 80yr and ONE of:
hospitalisation in past year, oral steroids, diabetic,
congestive heart failure OR > 65yrs with 2 of above.
Treat exacerbations promptly with antibiotics if purulent
sputum and increased shortness of breath and/or
increased sputum volume
Risk factors for antibiotic resistant organisms include comorbid disease, severe COPD, frequent exacerbations,
antibiotics in last 3 months.
Use CRB65 score or CRP to help guide & review: Each
CRB65 parameter scores 1:
Confusion (AMT<8);
Respiratory rate >30/min;
BP systolic <90 or diastolic ≤ 60; Age >65;
Score 0: suitable for home treatment;
Score 1-2: hospital assessment or admission
Score 3-4: urgent hospital admission
Mycoplasma infection is rare in over 65s
DRUG
Amoxicillin
or
Doxycycline
500mg TDS
5 days
200mg stat then100mg OD
5 days
Amoxicillin
or Doxycycline or
Clarithromycin
If sensitivities show
resistance to amoxicillin and
doxycycline: Co-amoxiclav
IF CRB65=0:
Amoxicillin
or Clarithromycin
or Doxycycline
500mg TDS
200mg stat/100mg OD
500mg BD
5 days
5 days
5 days
625mg TDS
5 days
500mg TDS
500mg BD
200mg stat/100mg OD
7 days
7 days
7 days
500mg TDS
500mg BD
200mg stat/100mg OD
7-10 days
If CRB65=1 and AT HOME
Amoxicillin AND Clarithromycin
or Doxycycline alone
If atypical pathogens suspected, use Amoxicillin +
Clarithromycin
If staphylococcal infection suspected (e.g. post
influenza) add Flucloxacillin.
11
7-10 days
4. URINARY TRACT INFECTIONS
ILLNESS
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Refer to PHE UTI guidance for diagnosis information
As E. coli bacteraemia in the community is increasing ALWAYS safety net and consider risks for resistance.
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity.
4.1 CATHETERISED PATIENTS
General advice:
-
4.2
UTI in adults
(no fever or
flank pain)
Most patients with catheters develop bacteriuria. Catheterised patients with asymptomatic bacteruria should not receive antibiotic treatment.
Only treat if systemically unwell or pyelonephritis likely. Culture & sensitivities are needed to inform treatment.
Seek advice from specialist continence nurse.
 Bladder washouts with antiseptics, e.g. chlorhexidine, are rarely indicated. Saline bladder washouts are available as an alternative.
 Change long term indwelling catheters before starting antibiotic treatment for symptomatic UTI (SIGN guidance July 12).
 Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma.
Treat women with severe/or ≥ 3 symptoms
First line: Nitrofurantoin if
100mg m/r BD
GFR over 45ml/min
Women: mild/or ≤ 2 symptoms AND
Women all ages 3
a) Urine NOT cloudy - 97% negative predictive value, do Second line:
days
not treat unless other risk factors for infection.
Trimethoprim OR
200mg BD
b) If cloudy urine use dipstick to guide treatment: Nitrite
Pivmecillinam
400mg STAT then 200mg
Men 7 days
plus blood or leucocytes has 92% positive predictive
TDS
value; nitrite, leucocytes, blood all negative 76% negative
If organism susceptible
predictive value
Amoxicillin
500mg TDS
Consider a back-up / delayed antibiotic option
Men: Consider prostatitis and send pre-treatment MSU
OR if symptoms mild/non-specific, use negative dipstick
to exclude UTI.
Always safety net.
If GFR<45 ml/min or
elderly: consider
Pivmecillinam or
Fosfomycin – only on
advice of Consultant
Microbiologist
12
3g stat in women plus 2nd 3g
dose in men 3 days later
ILLNESS
COMMENTS
In treatment failure: always perform culture
Extended-spectrum Beta-lactamase E. coli are
increasing.
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
500mg BD
28 days
28 days
GFR 30-45: only use
nitrofurantoin if
resistance & no
alternative
Risk factors for increased resistance include: care
home resident, recurrent UTI, hospitalisation >7d in the
last 6 months, unresolving urinary symptoms, recent
travel to a country with increased antimicrobial resistance
(outside Northern Europe and Australasia) especially
health related, previous known UTI resistant to
trimethoprim, cephalosporins or quinolones.
If increased resistance risk, send culture for
susceptibility testing & give safety net advice.
4.3
Acute
prostatitis
Send MSU for culture and start antibiotics.
Ciprofloxacin
4-wk course may prevent chronic prostatitis
Quinolones achieve higher prostate levels.
2 line: Trimethoprim
200mg BD
First line: Nitrofurantoin
Avoid at term
if susceptible: Amoxicillin
100mg m/r BD
Second line: Trimethoprim
Avoid in 1st trimester
200mg BD
Third line: Cefalexin
500mg BD
nd
Refer if recurrent, or diagnosis is unclear.
Provide pain relief (regular paracetamol +/- ibuprofen).
4.4
UTI in
pregnancy
Send MSU for culture and start antibiotics.
Short-term use of nitrofurantoin in pregnancy is unlikely
to cause problems to the foetus, but avoid at term.
Avoid trimethoprim in first trimester and if low folate
status or on folate antagonist (eg antiepileptic or
proguanil)
13
500mg TDS
All for 7 days
ILLNESS
4.5
UTI in Children
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
General advice:
Infants and children presenting with unexplained fever of 38°C or higher should have a urine sample tested after 24 hours at the latest.
Infants and children between 3 months and 3 years with symptoms and signs suggestive of UTI should have a clean catch urine sample sent
for urgent microscopy and culture. If urgent microscopy is not available, send a urine sample for microscopy and culture, and start antibiotic
treatment.
Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI.
Child <3 mths: refer urgently for assessment
Lower UTI:
Lower UTI 3 days
Child ≥ 3 mths: use positive nitrite to guide
If susceptible: Trimethoprim 4mg/kg BD (but local
Start antibiotics, also send pre-treatment MSU.
resistance rates around 40% so ONLY use if sensitive) or
Imaging: only refer if child <6 months, or recurrent or
Amoxicillin (again only if sensitive)
atypical UTI
Nitrofurantoin 750mcg/kg QDS (>3months old only) or
Second line: Cefalexin 1 month–1 year 125 mg twice daily
1–5 years 125 mg 3 times daily
5–12 years 250 mg 3 times daily
12–18 years 500 mg 2–3 times daily
Upper UTI:
Co-amoxiclav Second line: Cefalexin
Upper UTI 7-10 days
Nitrofurantoin liquid is VERY expensive. If child needs liquid formulation and is
not sensitive to trimethoprim or amoxicillin – use cefalexin.
4.6
Acute
pyelonephritis
4.7
Recurrent UTI
in nonpregnant
women ≥ 3
UTIs/year
If admission not needed, send MSU for culture &
susceptibility and start antibiotics.
If no response within 24 hours, admit.
If ESBL risk and with microbiology advice consider IV
antibiotic via outpatients (OPAT)/ Community IV service.
Follow up patient to ascertain why infection occurred.
To reduce recurrence, first advise simple measures
including hydration, cranberry products.
Then standby or post-coital antibiotics,
Ciprofloxacin
Second line:
Co-amoxiclav
If lab report shows
sensitive: trimethoprim
Antibiotics:
Nitrofurantoin
or
Trimethoprim
Nightly prophylaxis reduces UTIs but adverse effects and
long term compliance poor.
14
500mg BD
7 days
500/125mg TDS
7 days
200mg BD
14 days
Post coital stat (offlabel)
50–100mg
100mg
Prophylaxis OD at night
Review at 6 months,
and continue regular
review.
5. GASTRO-INTESTINAL INFECTIONS
ILLNESS
5.1
Eradication of
helicobacter
pylori
5.2
Infectious
diarrhoea
5.3
Traveller’s
diarrhoea
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Always use PPI
TWICE DAILY
First and second line
All for
7 days
PPI WITH amoxicillin
1g BD
PLUS either
clarithromycin
500mg BD
except
OR metronidazole
400mg BD
Penicillin allergy &
previous metronidazole +
MALToma
clarthromycin: PPI WITH
240mg BD
®
14 days
bismuthate (De-nol tab )
400mg BD
PLUS
metronidazole PLUS
500mg QDS
tetracycline hydrochloride
Relapse & previous
metronidazole +
clarithromycin: PPI WITH
amoxicillin PLUS
1g BD
tetracycline hydrochloride 500mg QDS
OR levofloxacin
250mg BD
Obtain at least 2 faecal samples at different times for cultures.
Report previous antibiotic use or travel history.
Enteric precaution might be indicated – discuss with Infection Control team.
Antibiotic therapy usually not indicated unless systemically unwell. Discuss with microbiologist.
 Fluid replacement is the mainstay of therapy.
 Antibiotics are contraindicated if Escherichia coli 0157 is a possibility.
 Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection.
 If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin 250–500mg BD for
5–7 days if treated early (within 3 days). Again - discuss with microbiologist.
Antibiotic not usually indicated. Contact microbiologist if in doubt.
Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers’ diarrhoea.
If standby treatment appropriate give: ciprofloxacin 500mg twice a day for 3 days (private Rx). If quinolone resistance high (eg south Asia): consider
bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment.
Treat all positives in known DU, GU or low grade
MALToma.
Do not offer eradication for GORD
Do not use clarithromycin, metronidazole or quinolone if
used in past year for any infection
Penicillin allergy: use PPI plus clarithromycin &
metronidazole;
If previous clarithromycin use PPI + bismuthate +
metronidazole + tetracycline. In relapse see NICE
Relapse and previous metronidazole &
clarithromycin: use PPI PLUS amoxicillin, PLUS either
tetracycline or levofloxacin
Retest for H. pylori post DU/GU or relapse after second
line therapy: using breath or stool test OR consider
endoscopy for culture and susceptibility
15
ILLNESS
5.4
Giardiasis
5.5
Oral
Candidiasis
5.6
Threadworms
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Liaise with Infectious Diseases at NMGH.
It can take two to three specimens to confirm giardiasis.
It is one of the few GI infections for which antimicrobial
treatment is generally of benefit.
Metronidazole
400mg TDS
5 days
Miconazole oral gel
Babies >4 months & infants:
advise 1.25ml put on finger &
smeared around gums QDS
Children over 2 years and
adults: 2.5ml QDS
Continue for 7 days
after symptoms have
gone
Adults & Babies >1month: 1ml
dropped into mouth QDS
Continue for 48 hours
after symptoms have
gone.
Or
If oral lesions do not respond to topical treatment – swab
to confirm diagnosis, then consider
Fluconazole 50mg OD for 7 – 14 days (longer courses
may be needed in the severely immunocompromised).
Nystatin oral suspension
All products are available over the counter: encourage patients to self-care by referring to a pharmacy.
16
6. GENITAL TRACT INFECTIONS
ILLNESS
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Contact UKTIS (www.uktis.org) for information on foetal risks if patient is pregnant
6.1
STI screening
6.2
Chlamydia
trachomatis
/urethritis
6.3
Vaginal
Candidiasis
6.4
Bacterial
vaginosis
6.5
Trichomoniasis
People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to GUM service (0161 627
8753)
Risk factors: <25yr, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner, area of high HIV.
Single dose
Refer to GUM Clinic for confirmation of diagnosis,
Azithromycin
1g
treatment, and partner notification.
Second line:
Pregnancy or breastfeeding: azithromycin is the most
Doxycycline
effective option
7 days
100mg BD
Due to lower cure rate in pregnancy, test for cure
Pregnant or
6 weeks after treatment.
breastfeeding:
Azithromycin
Stat
1g (off-label use)
or erythromycin
7 days
500mg QDS
or amoxicillin
7 days
500mg TDS
For suspected epididymitis in men over 35 years with low Epididymitis: low STI risk:
risk of STI (High risk, refer GUM)
Ofloxacin
14 days
200mg BD
or doxycycline
14 days
100mg BD
All products are available over the counter:
Single dose
Clotrimazole
500mg pess or 10% cream
encourage patients to self-care by visiting a
or oral fluconazole
Single dose
150mg orally
pharmacy.
All topical and oral azoles give 75% cure.
Pregnant: clotrimazole
6 nights
100mg pessary at night
or miconazole 2% cream
7 days
5g intravaginally BD
In pregnancy: avoid oral azoles and use intravaginal
treatment for 7 days
7 days
Oral metronidazole is as effective as topical treatment but
Oral metronidazole
400mg BD
or 2grams
Single dose
is cheaper.
or
Less relapse with 7 day than 2g stat at 4 wks.
5 nights
5g applicatorful at night
Metronidazole 0.75%
Pregnant/breastfeeding: avoid 2g stat.
vaginal gel
Treating partners does not reduce relapse
or Clindamycin 2% crm
7 nights
5g applicatorful at night
Refer to GUM Clinic for confirmation of diagnosis,
Metronidazole
400mg BD
5-7 days
treatment, and partner notification.
or 2g
Single dose
In pregnancy or breastfeeding: avoid 2g single dose of
metronidazole.
100mg pessary at night
6 nights
Consider clotrimazole for symptom relief (not cure) if
Clotrimazole
17
ILLNESS
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Metronidazole PLUS
ofloxacin
400mg BD
400mg BD
14 days
14 days
If high risk of gonorrhoea
Ceftriaxone PLUS
Metronidazole PLUS
doxycycline
500mg IM
400mg BD
100mg BD
Stat
14 days
14 days
metronidazole declined.
6.6
Pelvic
Inflammatory
Disease
Refer ALL women and contacts to GUM service.
Always culture for gonorrhoea and chlamydia.
.
28% of gonorrhoea isolates now resistant to quinolones
If gonorrhoea likely (partner has it, severe symptoms, sex
abroad) refer to GUM.
7. SKIN INFECTIONS
ILLNESS
7.1
Impetigo
7.2
Eczema
7.3
Cellulitis and
Erysipelas
7.4
Leg Ulcer
COMMENTS
For extensive, severe, or bullous impetigo, use oral
antibiotics.
Reserve topical antibiotics for very localised lesions to
reduce the risk of resistance.
Reserve mupirocin for MRSA.
Children can be allowed back into school or nursery 48
hours after treatment has commenced.
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Oral Flucloxacillin
If penicillin allergic:
Oral Clarithromycin
500mg QDS
7 days
250-500mg BD
7 days
Topical fusidic acid
MRSA only mupirocin
TDS
TDS
5 days
5 days
If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing.
In eczema with visible signs of infection, use treatment as in impetigo.
All for 7 days.
If slow response
continue for a further 7
days
If patient afebrile and healthy other than cellulitis, use oral
flucloxacillin alone.
If river or sea water exposure, discuss with microbiologist.
Flucloxacillin
If penicillin allergic:
Clarithromycin
500mg QDS
If febrile and ill, refer to Community IV service
If facial: Co-amoxiclav
500/125mg TDS
Ulcers always colonised. Antibiotics do not improve
healing unless active infection
If active infection, send pre-treatment swab.
Review antibiotics after culture results.
Active infection if cellulitis/increased pain/pyrexia/purulent exudate/odour
If active infection:
Flucloxacillin
500mg QDS
As for cellulitis
or Clarithromycin
500mg BD
18
500mg BD
ILLNESS
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
7.5
Paronychia
Refer to Podiatrist.
Consider prescribing a 7-day course of antibiotics ONLY if incision and drainage:
o Is not required (because the lesion is non-fluctuant).
o Was performed, but the person has signs of cellulitis or fever, or has other comorbidities (such as diabetes or immunosuppression).
Further information, see: http://cks.nice.org.uk/paronychia-acute#!scenario
7.6 PVL
Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from boils/abscesses. This bacteria can rarely cause severe invasive
infections in healthy people; if found suppression therapy should be given.
Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene.
Prophylaxis or treatment:
Thorough irrigation is important.
7.7
Bites (human
or animal)
Human: Assess risk of tetanus, HIV, hepatitis B&C
Antibiotic prophylaxis is advised.
Co-amoxiclav
All for 7 days
If penicillin allergic:
Metronidazole PLUS
Doxycycline
Give prophylaxis if cat bite/puncture wound; bite to hand, (cat/dog/man)
foot, face, joint, tendon, ligament;
immunocompromised/diabetic/asplenic/cirrhotic/ presence or Metronidazole PLUS
of prosthetic valve or prosthetic joint.
Clarithromycin (human
bite)
Animal: Assess risk of tetanus and rabies
7.8
Scabies
Treat whole body from ear/chin downwards and under
nails. If under 2/elderly, also face/scalp.
Treat all home and sexual contacts within 24hr
7.9
Dermatophyte
Infection –
scalp
7.10
Dermatophyte
Infection –
skin
Discuss with specialist, oral therapy indicated.
Further information, see: http://cks.nice.org.uk/fungalskin-infection-scalp#!topicsummary
375-625mg TDS
Permethrin
If allergy:
Malathion
400mg TDS
100mg BD
AND review at 24 &
48hrs
200-400mg TDS
250-500mg BD
5% cream
0.5% aqueous liquid
2 applications 1 week
apart
Choice of drug should be
as advised by specialist.
Terbinafine is fungicidal, so treatment time shorter than
with fungistatic imidazoles
If candida possible, use imidazole.
Topical terbinafine
If intractable: send skin scrapings and if infection
confirmed, use oral terbinafine/itraconazole.
or (athlete’s foot only):
topical undecanoates
®
(Mycota )
BD
1-2 weeks
BD
for 1-2 wks after healing
(i.e. 4-6wks)
or topical imidazole
19
BD
ILLNESS
7.10
Dermatophyte
Infection – nail
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
Take nail clippings: start therapy only if infection is
confirmed by laboratory.
Terbinafine is more effective than azoles.
Liver reactions rare with oral antifungals.
If candida or non-dermatophyte infection confirmed, use
oral itraconazole.
Superficial only
Amorolfine 5% nail
lacquer
1-2x/weekly
fingers
toes
6 months
12 months
First line: terbinafine
250mg OD
fingers
toes
6 – 12 weeks
3 – 6 months
For children, seek specialist advice.
Second line: Itraconazole
200mg BD
fingers
7 days, repeat after 21
days i.e. 2 courses
Total of 3 courses
Pregnant/immunocompromised/neonate: seek urgent
specialist advice
Chicken pox: IF onset of rash <24hrs & >14 years or
o
severe pain or dense/oral rash or 2 household case or
steroids or smoker consider acyclovir.
If indicated:
Aciclovir
800mg five times a day
Topical Benzoyl Peroxide
Apply OD – BD
toes
7.11
Varicella
zoster/ chicken
pox
Herpes zoster/
shingles
7.12
Acne
Shingles: treat if >50 years and within 72 hrs of rash
(PHN rare if <50 years); or if active ophthalmic or
Ramsey Hunt or eczema.
Note: Acne is generally NOT infected.
Oral antibiotics should only be used in cases where
topical preparations have proved inadequate
Tetracyclines only for use in 12+ yrs
Minocycline should NOT be used for treatment of
acne.
7.13
Cold Sores
DURATION OF
TREATMENT
ADD
Oxytetracycline
or
Lymecycline
or
Doxycycline
If there has been no
response after 2–3
months seek specialist
advice regarding
changing the antibiotic.
Second line:
Trimethoprim
500mg BD
408mg OD
If no further response, refer to dermatologist for
100mg OD
retinoid therapy.
NB It is important to check LFTs and fasting lipids prereferral
®
In women, consider prescribing co-cyprindiol (Dianette ).
However, co-cyprindiol is not licensed for the sole
purpose of contraception and should be discontinued
three to four menstrual cycles after the woman's acne
300mg BD (unlicensed)
has resolved.
Cold sores resolve after 7–10d without treatment. Topical antivirals applied prodromally reduce duration by 12-24hrs.
Aciclovir 5% cream is available over the counter: encourage patients to self-care by visiting a pharmacy.
20
7 days
Review after 6-8 weeks.
Inadequate response:
check adherence to
treatment.
If there has been some
response, continue
treatment for up to 6
months.
DO NOT add antibiotics
to repeat therapy!
ILLNESS
7.14 Genital
herpes
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
DURATION OF
TREATMENT
Refer to GUM Clinic
8. EYE INFECTIONS
ILLNESS
8.1 Conjunctivitis
COMMENTS
DRUG
ADULT DOSE
See Childrens BNF for
child doses
Treat only if severe, as most viral or self-limiting.
Bacterial conjunctivitis is usually unilateral and also
self-limiting; it is characterised by red eye with
mucopurulent, not watery, discharge.
65% resolve on placebo by day five.
Fusidic acid has less Gram-negative activity
If severe:
Chloramphenicol 0.5%
drop
2 hourly for 2 days then
4 hourly (whilst awake)
and 1% ointment
Second line:
Fusidic acid 1% gel
at night
DURATION OF
TREATMENT
All for 48 hours after
resolution
TWICE a day
9. DENTAL INFECTIONS
Most dental infections are quickly resolved by early establishment of drainage & removal of cause, so patients should be referred to a dentist for
assessment and appropriate treatment.
GPs should not routinely be involved in dental treatment and, if possible, advice should be sought from the patient’s dentist, who should have an
answer-phone message with details of how to access treatment out-of-hours, or telephone 111 (NHS 111 service in England).
Consider antibiotics in patients only if a dentist is unavailable under the following circumstances:
- signs of systemic involvement (temperature / swelling)
- immunocompromised patients
- patients with diabetes or Paget’s disease
First line
If allergic to penicillin OR as an additional agent for severe abscesses
21
Amoxicillin 500mg tds for 5 days
Metronidazole 400mg tds for 5 days
10.
CONTACTS
Microbiology
Royal Oldham Hospital
11.
0161 627 8360
Medicines Management Teams
Bury
Heywood Middleton & Rochdale
Oldham
North Manchester
0161 762 3110
01706 652844
0161 622 6522
0161 219 9417
KEY CHANGES FROM PREVIOUS GUIDANCE AND DIFFERENCES FROM PHE GUIDANCE
All sections
Section 1.7 Meningococcal
infection
Section 3 Acute exacerbation
of COPD
Section 4 UTI
Section 4 UTI in pregnancy
Section 4 UTI in Children
Section 5 Infectious diarrhoea
Section 5 GI infections
Section 5 GI infections
Section 5 GI infections
Section 7 Skin: Cellulitis &
Erysipelas
Section 7 Skin: MRSA
Section 7 Skin: Acne
Section 7 Skin: addition of
paronychia
Section 9 Dental infections
Strengthening of antimicrobial stewardship messages
Updated with PHE instead of HPA. Prophylaxis dose for rifampicin changed in under 4s (Ref:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322008/Guidance_for_management_of_mening
ococcal_disease_pdf.pdf)
Co-amoxiclav added as third line only if resistance following amoxicillin and doxycycline.
Change to dose of amoxicillin.
New section on prophylaxis & changes to drugs.
BNF states that nitrofurantoin should be avoided at term & trimethoprim ‘avoided in first trimester’ therefore this advice has been
included.
Guidance differs significantly from previous policy:
Nitrofurantoin liquid has become very expensive, hence the pragmatic advice to use cephalexin liquid if child cannot take nitrofurantoin
caps.
PHE advise cefixime for upper UTI, local advice (Paediatric Infectious Diseases PAHT) is to use cefalexin.
Additional guidance has been retained from previous policy.
Giardia infection has been retained from previous policy
Oral candidiasis not included in PHE guidance but has been retained & updated from previous policy.
PHE guidance does not include diverticulitis, this has therefore not been included. (CKS states evidence on the use of antibiotics for
the treatment of uncomplicated diverticulitis is sparse, of low quality, and conflicting).
Previous policy had separate section on Erysipelas. Due to difficulty in distinguishing from cellulitis, this has been included in cellulitis
section.
Duration of therapy reduced.
PHE section on MRSA treatment not included as unlikely to be commenced in primary care.
NOT included in PHE guidance but retained (& updated) from previous policy.
Wasn’t in previous policy not in PHE guidance. Added to highlight advice to refer to podiatrist first line rather than prescribe
PHE section on treatment of dental infections has not been included.
Brief advice on treating dental abscess has been retained.
22