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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 2 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. 5 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. 6 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. 7 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