Download Infections - Eastbourne, Hailsham and Seaford CCG

CHAPTER 5 INFECTIONS
First line drugs
– drugs which are
recommended in both primary
and secondary care
Second line drugs
– alternatives (often in
specific conditions) in both
primary and secondary care
Specialist drugs
– Drugs where a specialist
input is needed (see
introduction for definition)
Specialist only drugs
– prescribing within
specialist service only.
Page:
5.1
5.3
East Sussex Guidelines for the Management of
Infection in Primary Care
2
East Sussex Healthcare NHS Trust Antimicrobial
Prescribing Policy for Adults and Children
16
NICE guidance
16

Cystic Fibrosis

Rifaximin for hepatic encephalopathy

Antivirals
04/13
Chapter update
06/13
02/14
02/15
5.1 (NICE guidance)
5.3 (NICE guidance)
Primary care guidelines update
04/15
07/15
09/15
02/16
07/16
5.3 (NICE guidance)
5.1 (NICE guidance)
5.3 (NICE guidance)
5.3 (NICE guidance)
Primary care guidelines update; CMO
letter 18.12.15 ‘Gonorrhoea and
Antimicrobial Resistance’
5.1 (change of status)
01/17
5.3 (NICE guidance)
First line drugs
Dr A Krause, Dr A Wilson, Dr S Umasankar, Dr R Springbett, V
Gudka, Z Badri, A Evans, R Partington, G Ells
G Ells
G Ells
Dr A Wilson, Dr S Umasankar, Dr R Springbett, Z Badri, A
Haddon, R Partington
G Ells
G Ells
G Ells
G Ells
Dr A Wilson, Dr S Umasankar, Dr S Sheehan, Dr H Patel, R
Partington.
G Ells
G Ells
Second line drugs
Specialist drugs
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Specialist only drugs
Page 1 of 18
East Sussex Guidelines for Management of Infection in Primary Care
Aims
 To promote a simple, effective, economical and empirical approach to the treatment of common
infections.
 To minimise the emergence of bacterial resistance in the community.
Principles of Treatment
1. This guidance is based on the best available evidence but professional judgement should be
used and patients should be involved in the decision.
2. It is important to initiate antibiotics as soon as possible in severe infection.
3. A dose and duration of treatment for adults is usually suggested, but may need modification for
age, weight and renal function. For childrens doses the BNF for Children should be consulted
(unless childrens doses stated here). 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
4. Lower threshold for antibiotics in immunocompromised or those with multiple morbidities;
consider culture and seek advice.
5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract
infections, and mild UTI symptoms
7. Limit prescribing over the telephone to exceptional cases.
8. 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.
9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic
preparations, e.g. fusidic acid).
10. 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 foetal problems. Trimethoprim is also unlikely to cause problems unless poor dietary
folate intake or taking another folate antagonist eg antiepileptic.
11. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice
can be obtained from consultant microbiologists via hospital switchboards.
12. 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.
UPPER RESPIRATORY TRACT INFECTIONS
ILLNESS
COMMENTS
Influenza
PHE Influenza
ADULT
DURATION OF
DOSE
TREATMENT
(unless
stated)
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults
antivirals not recommended. Treat ‘at risk’ patients, when influenza is circulating in the community
and within 48 hours of onset 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).
For current guidelines on treatment and prophylaxis of influenza see PHE Influenza and NICE
Influenza
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
DRUG
Page 2 of 18
East Sussex Guidelines for Management of Infection in Primary Care
Acute sore
throat
CKS
Acute Otitis
Media
(child doses)
CKS
Avoid antibiotics as 90% resolve in 7
days without, and pain only reduced
by 16 hours.
If Centor score 3 or 4
(Lymphadenopathy; No Cough; Fever;
Tonsillar Exudate) or FeverPAIN
score 4 or 5 (fever in past 24 hours,
pus, attendance within 3 days,
inflamed tonsils, no cough or cold
symptoms): consider 2 or 3-day
delayed or immediate antibiotics or
rapid antigen test.
RCT in <18yr olds shows 10d had
lower relapse.
Antibiotics to prevent Quinsy NNT
>4000.
Antibiotics to prevent Otitis media NNT
200.
If throat swab is positive for group A
Strep – ALWAYS treat
Optimise analgesia and target
antibiotics
OM resolves in 60% in 24h without
antibiotics, which only reduce pain at 2
days (NNT15) and does not prevent
deafness.
Consider 2 or 3-day delayed or
immediate antibiotics for pain relief if:

<2 years AND bilateral AOM
(NNT4) or bulging membrane & ≥ 4
marked symptoms

All ages with otorrhoea NNT3
Abx to prevent Mastoiditis NNT >4000
phenoxymethylpenicillin
Penicillin Allergy:
Clarithromycin
amoxicillin
Penicillin Allergy:
Clarithromycin
oral suspension
or
clarithromycin tabs for
over 12yrs (if can
swallow)
ILLNESS
Acute Otitis
Externa
CKS
COMMENTS
First use aural toilet (if available) &
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
and refer.
If no improvement after
48 hours – consider coamoxiclav
DRUG
First Line:
acetic acid 2%
Second Line:
neomycin sulphate with
corticosteroid:
- Betnesol N
- Otomize spray
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
500mg QDS
1G BD
(QDS when
severe)
10 days
250-500mg
BD
10 days
Child
doses
(all tds)
Neonate 728 days
30mg/kg
1 month1yr: 125mg
1-5 years:
250mg
5-18 years:
500mg
< 8kg
7.5mg/kg bd
8-11kg
62.5mg bd
12-19kg
125mg bd
20-29kg
187.5mg bd
30-40kg
250mg bd
See BNF /
cBNF for
dosage
ADULT
DOSE
(unless
stated)
1 spray TDS
5-7 days
(longer duration
if severe
infection)
5-7 days
(longer duration
if severe
infection
DURATION OF
TREATMENT
7 days
7 days min to
14 days max
3drops TDS
1 spray tds
Page 3 of 18
East Sussex Guidelines for Management of Infection in Primary Care
Acute
rhinosinusitis
CKS
Avoid antibiotics as 80% resolve in
14 days without, and they only offer
marginal benefit after 7 days NNT15
Use adequate analgesia
Consider 7-day delayed or immediate
antibiotic when purulent nasal
discharge NNT8
In persistent infection use an agent
with anti-anaerobic activity eg. coamoxiclav
amoxicillin
500mg TDS
1g if severe
7 days
or doxycycline
200mg
stat/100mg
OD
7 days
or
phenoxymethylpenicillin
500mg QDS
7 days
For persistent symptoms:
co-amoxiclav
625mg TDS
7 days
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 4 of 18
East Sussex Guidelines for Management of Infection in Primary Care
LOWER RESPIRATORY TRACT INFECTIONS
ILLNESS
COMMENTS
DRUG
ADULT
DURATION OF
DOSE
TREATMENT
(unless
stated)
Note: Low doses of penicillins are more likely to select out resistance , Do not use quinolone (ciprofloxacin, ofloxacin)
first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant
organisms.
Acute cough,
Antibiotic little benefit if no coamoxicillin
500mg
5 days
bronchitis
morbidity.
TDS
or
CKS
Consider 7d delayed antibiotic
NICE 69
with advice.
doxycycline
5 days
Symptom resolution can take 3
200mg
weeks.
stat/100
Consider immediate antibiotics if
mg OD
> 80yr and ONE of:
hospitalisation in past year, oral
steroids, diabetic, congestive
heart failure
OR> 65yrs with 2 of above
Acute exacerbation
Treat exacerbations promptly with Amoxicillin
500mg
5-7 days
of COPD
antibiotics if purulent sputum and
TDS
or
NICE CG101
increased shortness of breath
and/or increased sputum volume
GOLD
doxycycline
5-7 days
Risk factors for antibiotic resistant
200mg
organisms include co-morbid
stat/100
disease, severe COPD, frequent
If resistance:
mg OD
exacerbations, antibiotics in last
co-amoxiclav
5-7 days
3m
625mg
TDS
Community–
Use CRB65 score to help guide
IF CRB65=0:
acquired pneumonia and review: Each scores 1:
amoxicillin
500 mg –
CRB65=0: use 5 days.
- treatment in the
Confusion (AMT<8);
1g TDS
Review at 3 days &
community
Respiratory rate >30/min; Age
or
extend to 7-10 days if
>65;
BTS 2009 Guideline
clarithromycin
500mg BD
poor response
BP systolic <90 or diastolic ≤ 60;
or doxycycline
Score 0: consider suitability for
200mg
home treatment;
stat/100
Score 1-2: consider hospital
mg OD
assessment or admission
Score 3-4: urgent hospital
If CRB65=1,2 &
admission
AT HOME
Mycoplasma infection is rare in
amoxicillin
500mg –
7-10 days
over 65s
AND
1g TDS
clarithromycin
500 mg BD
Give immediate IM
benzylpenicillin or amoxicillin 1g
or doxycycline
200mg
7-10 days
po if delayed admission/life
alone
stat/100
threatening
mg OD
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 5 of 18
East Sussex Guidelines for Management of Infection in Primary Care
MENINGITIS (NICE fever guidelines)
ILLNESS
COMMENTS
Suspected
meningococcal
disease
PHE
Transfer all patients to hospital
immediately. IF time before
admission, and non-blanching rash,
give IV benzylpenicillin or
cefotaxime, unless definite history
of hypersensitivity ie history of
difficulty breathing, collapse, loss of
consciousness, or rash
DRUG
IV or IM
benzylpenicillin
Or
IV or IM cefotaxime
ADULT DOSE
(unless stated)
Age 10+ years:
1200mg
Children 1 - 9 yr:
600mg
Children <1 yr:
300mg
Child < 12 yrs:
50mg/kg
Age 12+ years:
1gram
DURATION
OF
TREATMENT
(give IM if
vein cannot
be found)
If Hx of penicillin anaphylaxis
Chloramphenicol (if
available)
25mg/kg qds IV
Prevention of secondary case of meningitis: Only prescribe following advice from Consultant in Communicable
Disease Control, Surrey and Sussex Local Health Protection, County Hall North, Chart Way, Horsham, RH12 1XA;
Tel: 0845 8942944, Fax: 01403 251006
Out of hours Tel: 08449670069
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 6 of 18
East Sussex Guidelines for Management of Infection in Primary Care
URINARY TRACT INFECTIONS – refer to PHE UTI guidance for diagnosis information
ILLNESS
COMMENTS
DRUG
ADULT
DURATION OF
DOSE
TREATMENT
(unless
stated)
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity.
Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or
pyelonephritis likely.
Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma
(NICE & SIGN guidance). Urine dipsticks are of little value in catheterised patients as positive results are common in
asymptomatic patients and are therefore of no diagnostic value.
UTI in adults
First line: nitrofurantoin if eGFR >45ml/min.
nitrofurantoin
100mg m/r
Women all ages
(no fever or flank
eGFR 30-45: only use if resistance and no
BD
3 days (for
pain)
alternative
pregnancy see
PHE URINE
trimethoprim
200mg BD
below).
Women - severe/or ≥ 3 symptoms: treat
SIGN
Men 7 days
Women - mild/or ≤ 2 symptoms AND
If organism
CKS
RCGP UTI clinical
a) Urine NOT cloudy 97% negative predictive susceptible:
module
value, do not treat unless other risk factors
amoxicillin
500mg TDS
SAPG UTI
for infection.
Second line: perform culture in all treatment
b) If cloudy urine use dipstick to guide
failures
treatment. Nitrite plus blood or leucocytes
Amoxicillin resistance is common; only use if
has 92% positive predictive value; nitrite,
susceptible
leucocytes, blood all negative 76% NPV
c) Consider a back-up / delayed antibiotic
Community multi-resistant Extended-spectrum
option
Beta-lactamase E. coli are increasing, use
nitrofurantoin first line.
Men: Consider prostatitis & send pretreatment MSU OR if symptoms mild/nonFosfomycin may be recommended by microbiology
specific, use –ve dipstick to exclude UTI.
in selected cases (3g stat in women plus 2nd 3g
dose in men 3 days later).
It should NOT be used unless advised by
microbiologist.
Acute prostatitis
BASHH
CKS
Send MSU for culture and start antibiotics.
4-wk course may prevent chronic prostatitis.
Quinolones achieve higher prostate levels.
If gonorrhoeal or chlamydial infection is
possible, send patient to GUM clinic for
assessment and treatment.
Refer any case of acute prostatitis to urology
if: inadequate response to antibiotics; preexisting urological conditions or acute urinary
retention; symptoms are post urological
intervention. All men after recovery should be
referred to urology for investigation of their
urinary tract to exclude structural
abnormality.
Chronic cases should always be managed by
urology– avoid antibiotics until appropriate
cultures have been taken.
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
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 resistance risk send culture for susceptibility
testing & give safety net advice.
ciprofloxacin
500mg BD
28 days
or ofloxacin
200mg BD
28 days
2nd line:
trimethoprim
200mg BD
28 days
Page 7 of 18
East Sussex Guidelines for Management of Infection in Primary Care
ILLNESS
UTI in pregnancy
PHE URINE
CKS
COMMENTS
Send MSU for culture and start antibiotics.
Short-term use of nitrofurantoin in pregnancy
is unlikely to cause problems to the foetus.
Avoid trimethoprim if low folate status or on
folate antagonist (eg antiepileptic or
proguanil).
DRUG
First line:
nitrofurantoin
if susceptible,
amoxicillin
Second line:
trimethoprim
Give folate if
1st trimester
UTI in children
PHE URINE
NICE
CKS
Child <3 mths: refer urgently for assessment
Child ≥ 3 months: use positive nitrite to start
antibiotics. Send pre-treatment MSU for all.
Imaging: only refer if child <6 months,
recurrent or atypical UTI
Acute
pyelonephritis
CKS
If admission not needed, send MSU for
culture & sensitivities and start antibiotics.
If no response within 24 hours, admit.
If ESBL risk, consult microbiology to discuss
appropriate treatment.
Recurrent UTI in
non-pregnant
women (≥ 3
UTIs/year)
Post-coital OR standby antibiotics may
reduce recurrence.
Nightly: reduces UTIs but adverse effects.
Cranberry products may be of benefit but
evidence is inconclusive
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
ADULT
DOSE
(unless
stated)
DURATION OF
TREATMENT
100mg m/r
BD
All for 7 days
500mg TDS
200mg BD
(off-licence)
Third line:
cefalexin
500mg BD
Lower UTI: trimethoprim or
nitrofurantoin; if susceptible,
amoxicillin
Second line: cefalexin
Lower UTI
3 days
Upper UTI: co-amoxiclav
Second line: cefalexin
Upper UTI
7-10 days
See BNF / cBNF for dosages
ciprofloxacin
500mg BD
or
co-amoxiclav
500/125 mg
if lab reports
TDS
shows
sensitive:
trimethoprim
200mg bd
Antibiotics:
nitrofurantoin
50–100mg
or
trimethoprim
100mg
7 days
7 days
14 days
Post coital
stat (off-licence)
Prophylaxis
OD at night
Page 8 of 18
East Sussex Guidelines for Management of Infection in Primary Care
GASTRO-INTESTINAL TRACT INFECTIONS
ILLNESS
COMMENTS
Oral
candidiasis
Nystatin oral
suspension
Symptomatic
relapse
Infectious
diarrhoea
CKS
DURATION OF
TREATMENT
7 days (and 48
hours after
lesions have
healed)
2.5ml qds after
food
5-7 days (and 7
days after lesions
have healed)
Fluconazole
50mg od
(100mg in
unusually
difficult
infections)
7-14 days
Fluconazole
Itraconazole
See BNF for
licensed
dosages
Treat all positives in known DU, GU
or low grade MALToma. In NonUlcer NNT is 14.
Do not offer eradication for GORD.
Do not use clarithromycin,
metronidazole or quinolone if used in
past year for any infection (may be
difficult to identify).
Always use PPI
TWICE DAILY
Penicillin allergy: use PPI plus
clarithromycin & metronidazole.
Penicillin allergy
and previous
clarithromycin:
bismuthate PLUS
metronidazole PLUS
tetracycline.
240mg BD
400mg BD
500mg QDS
Relapse & previous
metronidazole and
clarithromycin:
amoxicillin PLUS
tetracycline
OR levofloxacin
1g BD
500mg QDS
250mg BD
Antifungal agents absorbed from the
gastrointestinal tract prevent oral
candidiasis in patients receiving
treatment for cancer.
PHE H.pylori
CKS
ADULT DOSE
(unless
stated)
100,000 units
qds after food
Miconazole oral gel
For unresponsive infections, if a
topical agent cannot be used, or
immunocompromised.
Eradication of
Helicobacter
pylori
NICE dyspepsia
DRUG
In relapse see NICE.
First and second
line:
amoxicillin
PLUS either
clarithromycin
OR metronidazole
1g BD
All for
7 days
500mg BD
400mg BD
MALToma
14 days
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
Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157
infection.
Antibiotic therapy not indicated unless systemically unwell. If systemically unwell and
Campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin
250–500 mg BD for 5–7 days if treated early (within 3 days).
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 9 of 18
East Sussex Guidelines for Management of Infection in Primary Care
ILLNESS
Clostridium
difficile
DH
PHE
Traveller’s
diarrhoea
CKS
Threadworm
CKS
Giardiasis
COMMENTS
DRUG
ADULT
DOSE
(unless
stated)
DURATION OF
TREATMENT
1st / 2nd episode
Stop unnecessary antibiotics
and/or PPIs
metronidazole (MTZ)
400mg TDS
10-14 days
70% respond to MTZ in 5 days;
3rd episode/severe/type 027
92% in 14 days
If severe symptoms or signs
oral vancomycin
(below) should treat with oral
125mg QDS
10 -14 days
vancomycin, review progress
Recurrent disease:
closely and/or consider hospital
Oral vancomycin
referral.
125mg qds,
10-14 days, or
Treat ribotype 027 with
consider
taper 10 days
vancomycin
(NB fidaxomicin is NOT to
taper
Admit if severe: T >38.5; WCC
be prescribed in primary
>15, rising creatinine or
care)
signs/symptoms of severe colitis
Only consider standby antibiotics for remote areas or people at high-risk of severe illness with
travellers’ diarrhoea. If standby treatment appropriate give: ciprofloxacin 500 mg 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 (private Rx or OTC purchase)
Treat all household contacts at the >6 months age:
100mg
Stat; repeat in 2
same time PLUS advise hygiene
mebendazole (off-licence if
weeks if
measures for 2 weeks (hand
<2yrs)
infestation
hygiene, pants at night, morning
persists
shower) PLUS wash sleepwear,
< 6 months age: 6 wks
bed linen, dust, and vacuum on
hygiene measures alone
day one
Pregnant: hygiene measures
until after 1st trimester; if
treatment still required use
mebendazole as above
Metronidazole
2g od
3 days
400mg tds (if 5 days
pregnant or
2g dose not
tolerated)
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 10 of 18
East Sussex Guidelines for Management of Infection in Primary Care
GENITAL TRACT INFECTIONS Contact UKTIS for information on foetal risks if patient is pregnant.
ILLNESS
COMMENTS
DRUG
ADULT DOSE DURATION OF
(unless
TREATMENT
stated)
STI screening
People with risk factors should be screened for chlamydia, gonorrhoea, HIV, & syphilis. All
positive cases barring Chlamydia MUST BE REFERRED TO GUM SERVICE. Gonococcal
infection needs dual therapy including an injectable antibiotic available in GUM clinics.
Risk factors: < 25y, no condom use, recent (<12mth)/frequent change of partner, symptomatic
partner, area of high HIV.
Chlamydia
Opportunistically screen all 15-25yrs.
azithromycin
1g
stat
trachomatis /
or doxycycline
Treat partners.
100mg BD
7 days
urethritis
Refer to GUM (as injectable antibiotics
SIGN
needed if gonorrhoea also present):
BASHH
gonorrhoea suspected or
PHE
confirmed
CKS
all partners (for screening)
Pregnancy or breastfeeding:
azithromycin is the most effective option.
Due to lower cure rate in pregnancy, test
for cure 6 weeks after treatment.
Vaginal
candidiasis
BASHH
PHE
CKS
For suspected epididymitis in men over
35 years with low risk of STI (high risk –
refer to GUM)
All topical and oral azoles give 75% cure
Trichomoniasis
BASHH
PHE
CKS
1g (off-licence)
500 mg QDS
500 mg TDS
stat
7 days
7 days
200mg BD
100mg BD
500mg pess or
10% cream
14 days
14 days
stat
150mg orally
stat
clotrimazole
100mg
pessary at
night
6 nights
or miconazole 2%
cream
5g
intravaginally
BD
400mg BD
or 2g
5g
applicatorful at
night
5g
applicatorful at
night
400mg BD
or 2g
7 days
100mg
pessary at
night
6 nights
ofloxacin PLUS
doxycycline
clotrimazole
or oral
fluconazole
In pregnancy: avoid oral azoles and use
intravaginal treatment for 7 days
Bacterial
vaginosis
BASHH
PHE
CKS
Pregnant or
breastfeeding:
azithromycin
or erythromycin
or amoxicillin
Oral metronidazole (MTZ) is as effective
as topical treatment but is cheaper.
Less relapse with 7 day than 2g stat at
4 wks.
Pregnant/breastfeeding: avoid 2g stat
Treating partners does not reduce
relapse
oral MTZ
Treat partners and refer to GUM service.
In pregnancy or breastfeeding: avoid 2g
single dose MTZ. Consider clotrimazole
for symptom relief (not cure) if MTZ
declined
metronidazole
(MTZ)
or MTZ 0.75%
vag gel
or clindamycin
2% crm
clotrimazole
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
7 days
stat
5 nights
7 nights
5-7 days
stat
Page 11 of 18
East Sussex Guidelines for Management of Infection in Primary Care
ILLNESS
Pelvic
Inflammatory
Disease
BASHH
CKS
COMMENTS
Always screen for gonorrhoea &
chlamydia.
DRUG
metronidazole
PLUS
ofloxacin
ADULT DOSE
(unless
stated)
400mg BD
DURATION OF
TREATMENT
14 days
400mg BD
14 days
Refer to GUM (as injectable antibiotics
needed if gonorrhoea also present)::
- confirmed chlamydia or gonorrhoea with
pelvic pain
- if not responding to treatment
- all partners for screening
- if gonorrhoea likely (partner has it,
severe symptoms, sex abroad)
In pregnancy/breast-feeding, refer to
obs/gynae
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 12 of 18
East Sussex Guidelines for Management of Infection in Primary Care
SKIN INFECTIONS
ILLNESS
Impetigo
CKS
Eczema
CKS
Cellulitis
CKS
Leg ulcer
PHE
CKS
MRSA
PVL
PHE
Bites
(human or
animal)
CKS
Human:
Cat or dog:
COMMENTS
For extensive, severe, or bullous
impetigo, use oral antibiotics.
DRUG
oral flucloxacillin
If penicillin allergic:
oral clarithromycin
ADULT DOSE (unless
stated)
500mg QDS
DURATION
OF
TREATMENT
7 days
250-500mg BD
7 days
Reserve topical antibiotics for
topical fusidic acid
TDS
5 days
very localised lesions to reduce
the risk of resistance.
MRSA only mupirocin
TDS
5 days
Reserve mupirocin for MRSA
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
If patient afebrile and healthy
flucloxacillin
1g QDS
All for 7 days.
If penicillin allergic:
other than cellulitis, use oral
If slow
flucloxacillin alone.
clarithromycin
500mg BD
response
or clindamycin (avoid
If river or sea water exposure,
300–450mg QDS
continue for a
discuss with microbiologist.
clindamycin in elderly
further 7 days
If febrile and ill, admit for IV
i.e. >65yrs)
treatment Stop clindamycin if
diarrhoea occurs.
facial: co-amoxiclav
500/125mg TDS
N.B.If MRSA associated cellulitis,
contact micro for further advice
Ulcers always colonized.
Active infection if cellulitis/increased pain/pyrexia/purulent
Antibiotics do not improve
exudate/odour
healing unless active infection
If active infection:
If active infection, send preflucloxacillin
500mg QDS
As for cellulitis
treatment swab.
or clarithromycin
500mg BD
Review antibiotics after culture
results.
For MRSA screening and suppression, see PHE MRSA Quick Reference Guide
If active infection, MRSA confirmed by lab results, infection not
For active MRSA infection:
Antibiotics should only be used severe and admission not required; only to be prescribed on advice
on advice of microbiologist.
of microbiologist.
If no response to monotherapy
If active infection
after 24-48 hours, seek further
confirmed
advice from microbiologist on
doxycycline alone OR
100mg BD
Both for 7
combination therapy.
trimethoprim
200mg bd
days
Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus. Can rarely cause severe
invasive infections in healthy people. Send swabs if recurrent boils/abscesses. At risk: close contact in
communities or sport; poor hygiene
Prophylaxis or
Thorough irrigation is important.
treatment:
Assess risk of tetanus, HIV,
hepatitis B&C.
co-amoxiclav
375-625mg TDS
If penicillin allergic:
Antibiotic prophylaxis is advised.
All for 7 days
Assess risk of tetanus and rabies. metronidazole PLUS
400mg TDS
Give prophylaxis if cat
doxycycline
100mg BD
bite/puncture wound; bite to hand, (cat/dog/man)
foot, face, joint, tendon, ligament;
immunocompromised /diabetic /
AND review at
asplenic /cirrhotic/presence of
24&48hrs
prosthetic valve or prosthetic joint.
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 13 of 18
East Sussex Guidelines for Management of Infection in Primary Care
ILLNESS
Scabies
CKS
Dermatoph
yte
infection –
skin
CKS
Dermatoph
yte
infection –
nail
CKS
Varicella
zoster /
chicken
pox
CKS
Herpes
zoster /
shingles
CKS
Acne
Cold sores
COMMENTS
Treat all home & sexual
contacts within 24h.
Treat whole body from
ear/chin downwards and
under nails. If under
2/elderly, also face/scalp
Terbinafine is fungicidal,
so treatment time
shorter than with
fungistatic imidazoles.
If candida possible, use
imidazole.
If intractable: send skin
scrapings. If infection
confirmed, use oral
terbinafine/itraconazole
Scalp: discuss with
specialist.
Only treat if clinical need
e.g. diabetic,
immunosuppressed; use
oral treatment.
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 nondermatophyte infection
confirmed, use oral
itraconazole.
For children, seek
specialist advice.
Pregnant/immunocompr
omised/neonate: seek
urgent specialist advice.
Chicken pox: IF onset
of rash <24h & >14y or
severe pain or
dense/oral rash or 2o
household case or
steroids or smoker
consider aciclovir.
DRUG
ADULT DOSE (unless
stated)
permethrin
If allergy:
malathion
5% cream
Topical terbinafine
or topical imidazole
or (athlete’s foot only):
topical undecanoates (Mycota)
BD
BD
DURATION
OF
TREATMENT
2 applications
1 week apart
0.5% aqueous liquid
1-2 weeks
for 1-2 wks
after healing
(i.e. 4-6wks)
BD
Topical treatments are used
where there is only a cosmetic
indication for treatment – these
should be purchased OTC and
not prescribed.
First line: terbinafine
250mg OD
Second line: itraconazole
200mg BD
fingers
toes
fingers
toes
6 – 12 weeks
3 – 6 months
7 days
monthly:
2 courses
3 courses
If indicated:
aciclovir
800mg five times a day
7 days
Second line for shingles if
compliance a problem, as ten
times cost
valaciclovir
1g TDS
7 days
Shingles: treat if >50
yrs and within 72 hrs of
rash (PHN rare if
<50yrs); or if active
ophthalmic or Ramsey
Hunt or eczema.
Use topical treatments
(Oxy)tetracycline
500mg BD
3/12
for most cases of mild to OR
moderate acne.
Doxycycline
100mg OD
Cold sores resolve after 7–10d without treatment. Topical antivirals applied prodromally reduce duration
by 12-24hrs
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 14 of 18
East Sussex Guidelines for Management of Infection in Primary Care
EYE INFECTIONS
ILLNESS
Conjunctivitis
CKS
COMMENTS
Treat 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 no
Gram-negative activity
DRUG
If severe:
chloramphenicol 0.5% drop
and 1% ointment
Second line:
Gentamicin 0.3% drops
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
ADULT DOSE (unless
stated)
2 hourly for 2 days then
4 hourly (whilst awake)
at night
DURATION
OF
TREATMENT
All for 48
hours after
resolution
2 hourly for 2 days then
4 hourly (whilst awake)
Page 15 of 18
East Sussex Guidelines for Management of Infection in Primary Care
DENTAL INFECTIONS – derived from the Scottish Dental Clinical Effectiveness Programme 2011
SDCEP Guidelines
ILLNESS
COMMENTS
DRUG
ADULT DOSE (unless
DURATION OF
stated)
TREATMENT
This guidance is not designed to be a definitive guide to oral conditions. It is for GPs for the management of
acute oral conditions pending being seen by a dentist or dental specialist. 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.
Mucosal
Simple saline
½ tsp salt dissolved in
Always spit out after

Temporary
ulceration and pain and swelling
mouthwash
glass warm water
use.
inflammation
relief can be
(simple
Use until lesions
attained with saline
gingivitis)
resolve or less pain
mouthwash
Chlorhexidine
Rinse mouth for 1 minute
allows oral hygiene

Use
0.12-0.2% (Do
BD with 5 ml diluted with
antiseptic
not use within
5-10 ml water.
mouthwash
30 mins of

If more
severe & pain limits toothpaste)
oral hygiene to treat
Hydrogen
Rinse mouth for 2 mins
or prevent
peroxide
6%
TDS with 15ml diluted in
secondary infection.
(spit
out
after
½ glass warm water

The primary
use)
cause for mucosal
ulceration or
inflammation
(aphthous ulcers,
oral lichen planus,
herpes simplex
infection, oral
cancer) needs to be
evaluated and
treated.
Acute
Commence
Metronidazole
400mg TDS
3 days
necrotising
metronidazole and
ulcerative
refer to dentist for
Chlorhexidine
see above dosing in
Until oral hygiene
gingivitis
scaling and oral
or hydrogen
mucosal ulceration
possible
hygiene advice.
peroxide
Use in combination
with antiseptic
mouthwash if pain
limits oral hygiene
Pericoronitis
Refer to dentist for
Amoxicillin
500mg TDS
3 days
irrigation &
debridement.
Metronidazole
400mg TDS
3 days
If persistent
swelling or systemic Chlorhexidine
see above dosing in
Until oral hygiene
symptoms use
or hydrogen
mucosal ulceration
possible
metronidazole.
peroxide
Use antiseptic
mouthwash if pain
and trismus limit
oral hygiene.
Dental

Regular analgesia should be first option until a dentist can be seen for urgent
abscess
drainage. Antibiotics alone, without drainage are ineffective in preventing spread of infection.

Antibiotics are recommended if there are signs of severe infection, systemic
symptoms or high risk of complications

Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in
swallowing, impending airway obstruction, Ludwigs angina. Refer urgently for admission to
protect airway, achieve surgical drainage and IV antibiotics
Issue date: April 2016
Adapted from HPA ‘Management of Infection Guidance for Primary Care’, June 2015
Page 16 of 18
East Sussex Healthcare NHS Trust Antimicrobial Prescribing Policy for Adults and
Children (Jan 2013) sets out antimicrobial prescribing policy in the hospital setting
and can be viewed here by those with access to an NHS networked computer.
5.1
Antibacterial drugs
5.1.4 & Inhaled treatments for Pseudomonas aeruginosa infection in
5.1.8
cystic fibrosis
 Nebuliser solution 75mg in 1ml
Tobramycin


(Bramitob®) 4ml nebs
Nebuliser solution 60mg in 1ml
( Tobi®) 5ml nebs
Dry powder for inhalation
28mg per capsule (Tobi
Podhaler®)
For use with Podhaler device

Injection, powder for
reconstitution 1mu, 2mu vial
 Dry powder for inhalation
For use with the Turbospin device
125mg per capsule
(Colobreathe®)
Nebulised and inhaled antibiotic treatments should be used in accordance with NICE TA 276 (March 2013)
Colistimethate
sodium
5.1.8
Rifaximin for hepatic encephalopathy
Rifaximin is an option for preventing overt episodes of hepatic encephalopathy (HE) and should be used in
accordance with NICE TA 337 (March 2015). Rifaximin should only be initiated by either a hepatologist or
gastroenterologist who will be responsible for prescribing the first 6 months of treatment. After 6 months,
treatment should only be continued if there has been an improvement in quality of life. For further information
on selection of appropriate patients and the arrangements for shared care, see the shared care guideline which
can be searched for at http://nww.esht.nhs.uk/corporate/document-search/ .
Rifaximin
5.3
5.3.3
5.3.3.1
 Targaxan® tablets, 550mg
Antivirals
Viral Hepatitis
Chronic Hepatitis B
Entecavir▼

Tenofovir▼

Baraclude® f/c tablets
500micrograms, 1mg,
oral solution 50micrograms per
ml
Viread® f/c tablets 245mg
NICE TA 153 (Aug 2008)
NICE TA 173 (Jul 2009)
For guidance on the treatment of chronic Hepatitis B see NICE CG 165 (June 2013)
5.3.3.2
Chronic Hepatitis C
Ribavirin

Tablets 200mg, 400mg,
Capsules 200mg,
Oral solution 200mg in 5ml
In combination with peginterferon alfa
for mild chronic Hep C
TA 106 (Aug 2006)
TA 200 (Sept 2010)
In combination with peginterferon alfa
for moderate to severe chronic Hep C
TA 75 (Jan 2004)
TA 200 (Sept 2010)
In combination with peginterferon alfa
for chronic Hep C (children & young
people)
TA 300 (Nov 2013)
First line drugs
Second line drugs
Specialist drugs
Hospital only drugs
Page 17 of 18
Boceprevir▼

Victrelis® capsules 200mg
In combination with peginterferon alfa
and ribavirin
TA 253 (Apr 2012)
Daclatasvir▼

Daklinza® tablets 30mg, 60mg
TA 364 (Nov 2015)
Dasabuvir▼

Exviera® tablets 250mg
TA 365 (Nov 2015)
Elbasvir–
grazoprevir▼

Zepatier® tablets 50 mg/100
mg
TA 413 (Oct 2016)
Ledipasvir sofosbuvir▼

Harvoni® tablets 400mg/90mg
TA 363 (Nov 2015)
Ombitasvir–
paritaprevir–
ritonavir ▼

Viekirax® tablets
12.5mg/75mg/50mg
with or without dasabuvir
TA 365 (Nov 2015)
Simeprevir▼

Olysio® capsules 150mg
In combination with peginterferon alfa
and ribavirin
TA 331 (Feb 2015)
Sofosbuvir▼

Sovaldi® f/c tablets 400mg
In combination with peginterferon alfa
and ribavirin or ribavirin alone
TA 330 (Feb 2015)
Telaprevir▼

Incivo® f/c tablets 200mg
In combination with peginterferon alfa
and ribavirin
TA 252 (Apr 2012)
First line drugs
Second line drugs
Specialist drugs
Hospital only drugs
Page 18 of 18