Download Worcestershire Guidelines for Primary Care Antimicrobial Prescribing

Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Worcestershire Guidelines for
Primary Care Antimicrobial
Prescribing
Fifth Edition v.3 Updated Feb 2017
Review date: October 2018
Always consider if antibiotic treatment is necessary
Prescribing antibiotics for viral or mild self-limiting infections such as coughs and colds
is unlikely to improve the course of the illness, puts patients at risk of side effects and
encourages further consultations. Antibiotics should be targeted at those patients who
are most likely to benefit. The Clinical Knowledge Summaries (CKS) Library contains
many
patient
leaflets
that
support
appropriate
use
of
antibiotics
(www.cks.library.nhs.uk ). The Department of Health website gives details of the
Public Health campaign and available leaflets.
(https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/245826/
3-PC-Get-well-soon-without-antibiotics1.pdf)
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Updated February 2017v.3
INTRODUCTION
Welcome to the fifth edition of the Primary Care Guidelines for Antimicrobial Prescribing.
The review group contains representatives of the key parties concerned with this area. The guide tries to provide a balanced
picture and takes into account local sensitivity data, and its biases, likely pathogens, general practitioners (GP) clinical problems at
the interface, best prescribing practice, and evidence based medicine and cost effectiveness.
The guide includes all the infection problems that GPs commonly encounter, and many sections have two parts - the first page is a
quick reference guide to 1st and 2nd choices where appropriate, together with a few help notes [1st line = preferred drug, 2nd
line = drug choice if 1st line is ineffective or inappropriate]. The second page gives further details and helpful clinical pieces of
information. It is usually divided into 3 sections: common pathogens, clinical details, and precautions.
It is intended that the guide is used to promote best practice and equity of practice across the county of Worcestershire, and is to
be updated on a regular basis.
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Antibiotic prescribing and stewardship
UK Five Year Antimicrobial Resistance Strategy: 2013 to 2018
Department of Health and DEFRA
This document identifies the need for good antibiotic stewardship practices as a vital tool to help reduce antimicrobial resistance.
Antibiotic stewardship is actively promoted in secondary care as well as primary care. The tool used in secondary care is given
below for information.
An antimicrobial stewardship alert was issued by NICE in August 2015, reference: https://www.nice.org.uk/guidance/ng15
Optimising Prescribing in Primary Care
It is recognised that GP consultations can often be challenging, particularly when patients expect to receive antibiotics and may be
unwilling to accept that they do not need them. Antimicrobial stewardship has been identified as a key priority by the Royal College
of General Practitioners (RCGP).
There are a number of different prescribing decision aid tools currently available to guide clinicians on prudent prescribing of
antimicrobials to reduce risks associated with the inappropriate prescribing and thus also promote both cost and clinical
effectiveness.
Some of these guidance tools are applicable to primary care settings: TARGET: ‘Treat Antibiotics Responsibly, Guidance and
Education Tool’ (TARGET) and NICHE: Need (for antibiotic), Investigation (cultures for prescribing), Choice (spectrum of
antibiotic), How Long (is your prescription for), Evaluate (your patient and prescription. In secondary care a ‘Start Smart then
Focus’ approach is promoted. For the purpose of this guidance it is encouraged that clinicians in both the primary and secondary
care settings are aware of the guidance tools in both sectors and therefore acronyms and guidance tools applicable in both primary
and secondary care are covered for information and as a reference source within the content of this guidance.
TARGET
To provide support for GPs in 2012, a GP toolkit – ‘Treat Antibiotics Responsibly, Guidance and Education Tool’ (TARGET)
was developed by the then Health Protection Agency (HPA), in collaboration with several other professional bodies
www.RCGP.org.uk/TARGETantibiotics/
The ‘Antimicrobial Stewardship in Primary Care’ (ASIPC) Collaboration
The TARGET antibiotic toolkit can be found on the clinical and research pages of the RCGP website:
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx
The toolkit provides training resources, patient information leaflets and audit tools to promote optimal antimicrobial prescribing.
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Patient information leaflets facilitate none prescribing of antibiotics for situations where they are not indicated. The antibiotic
management guidance on this website is the HPA (Public Health England) guidelines for the management of infection in Primary
Care which is the major reference source for the Worcestershire guidance.
NICHE
As part of its activities to support European Antibiotic Awareness Day on 18 November 2015, BSAC (British Society for
Antimicrobial Chemotherapy) has launched its NICHE campaign – offering all prescribers 5 moments to make a difference and
prevent antibiotic resistance. NICHE is an electronic poster campaign with its acronym inviting prescribers to consider the
following: Need (for antibiotic), Investigation (cultures for prescribing), Choice (spectrum of antibiotic), How Long (is your
prescription for) Evaluate (your patient and prescription). Posters are available in pop art, info graphic and diagrammatic formats,
with the info graphic version available for both hospital and community settings. Healthcare professionals are encouraged to
download and display locally, helping ensure the messages of European Antibiotic Awareness Day reaches as many individuals as
possible. Reference: http://bsac.org.uk/news/bsac-launch-of-niche-antibiotic-prescribing-campaign/
Start Smart then Focus
National guidance for secondary care to support evidence-based antimicrobial stewardship published in 2011 and updated in 2015.
Start Smart is:
 Do not start antibiotics in the absence of clinical evidence of infection.
 If there is evidence/suspicion of bacterial infection, use local guidelines to initiate prompt effective antibiotic treatment.
 Document on drug chart AND in medical notes
o Clinical indication
o Duration or review date
o Route
o Dose.
 Obtain cultures first.
 Prescribe single dose antibiotics for surgical prophylaxis: where antibiotics have been shown to be effective.
Then Focus is:
 Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and make a clear plan of action
o The “Antimicrobial Prescribing Decision”
 The Five Antimicrobial Prescribing Decision options are:
o Stop
o Switch IV to Oral
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o Change
o Continue
o Outpatient Parenteral Antibiotic Therapy (OPAT)
General Guidance Notes When Prescribing Antibiotics:
Signs/Symptoms of infection
Does the patient have any clinical signs/symptoms of infection?
Samples
Have appropriate samples been sent off for and taken for sensitivity testing if possible? Co-amoxiclav for COPD should only be
prescribed after positive sputum sample testing result.
Microbiology
Microbiology – does the patient have any relevant previous microbiology which may impact on the antimicrobial choice?
Known MRSA, ESBL-producing coliforms, previous C.difficile infection?
Allergy
Does the patient have any relevant previous history of allergy to penicillins, if so what is the nature of the allergy? – Refer to page 6
of guideline for further detail on allergies and adverse drug reactions to antibiotics.
Is Referral needed?
Does the patient require further referral? All patients presenting with pelvic inflammatory disease and/or epididimo-orchitis and at
high risk of Sexually Transmitted Disease (STD) should be referred to the Genitourinary Medicine (GUM) clinic for further treatment
with intramuscular (IM) ceftriaxone 500mg stat (the IM injection is not administered by GP’s) resistance to quinolones is increasing
in this patient group and prompt referral is important. Refer to relevant section of guideline for further detail.
Timing of the prescription
Timing of the prescription – can it be delayed? For all acute and self-limiting lower respiratory tract infections the prescription
should be delayed and the patient advised to ‘self-treat’: refer to individual section of the guideline for further advice on ‘no’ or
‘delayed/back up’ prescription strategy.
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Dose
Is the prescribed dose of the antibiotic correct according to the patient’s renal or hepatic function?
Antibiotic durations
Information on antibiotic durations has been given in this guidance document where possible.
Adverse Drug Reactions
Always take a detailed history of any reported allergy to antibiotics so that patients with a true allergy can be identified. The
type of reaction should be documented as this has implications for antibiotic choices. Many patients who report that they are
allergic only experienced minor symptoms such as gastrointestinal (GI) disturbance. Restricting the choice of antibiotic on the
basis of an inaccurate allergy history may result in them receiving sub optimal treatment.
Penicillin allergy
Nausea, vomiting or diarrhoea do not, by themselves, constitute an allergic reaction. They are NOT a contraindication for penicillin
use.
Mild/Rash reaction to penicillin
Carbapenem antibiotics (ertapenem and meropenem) are the recommended alternatives in a number of infections when the patient
reports a rash reaction to penicillin. Cephalosporins (cephalexin, ceftriaxone etc.) can also be used.
Anaphylaxis/Angioedema to penicillin
An anaphylactic reaction related to histamine release occurs 30-60mins after previous administration of a penicillin, symptoms may
include erythema or pruritis, angioedema, hypotension or shock, urticaria, wheezing, rhinitis.
An accelerated allergic reaction occurs 1-72hours after previous administration of a penicillin: symptoms may include erythema or
pruritis, angioedema, urticaria, wheezing, rhitinitis (particular caution if symptoms include laryngeal oedema).
Unknown/uncorroborated history of penicillin allergy
For patients who are unable to give a clear history of penicillin allergy history/reaction, please try, where possible, to gain collateral
history from relatives or GP records; including antibiotic use history.
Patients who have undetermined penicillin allergy, but have previously received and tolerated a cephalosporin, can receive a
carbapenem. Only where there is a clear history of anaphylaxis or absolutely no collateral history available should cephaosporins
and carbapenems be avoided
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Antibiotic compliance, drug interactions and side effects
It is important to impress on patients who receive a prescription for an antibiotic, that they should always complete the
full course of treatment, unless they experience side effects or allergy with the agent. If adverse effects are experience
the patient should be advised stop the agent in question to return for clinical review, with change of agent if necessary.
When prescribing antibiotics consideration must be given to potential drug interactions; refer to the current edition of the BNF or
the drug’s Summary of Product Characteristics (available at www.medicines.org.uk ). Remember female patients may be receiving
oral contraceptives from another prescriber. Also always consider if a premenopausal women may be pregnant when
prescribing.
Always be aware of potential side effects of antibiotics, particularly C.difficile disease. Advice on managing this condition is
incorporated within these guidelines and further information is available in the Infection Prevention and Control Guidelines.
Clostridium difficile risk
Patients who have had repeated and /or prolonged antibiotic courses and have had recent hospital admission are recognised to be
at increased risk of developing C. difficile infection.




Particular high risk groups include;
o Elderly
o Renal, Oncology and Haematology patients
o Patients with inflammatory bowel conditions
o Those on Proton Pump Inhibitors (PPIs)
o Patients who have been treated with clindamycin, ciprofloxacin or cephalosporins.
If the patient is potentially at risk for C. difficile infection please consider using narrow spectrum agents and avoid
coamoxiclav, ciprofloxacin, cephalosporins and clindamycin unless indicated by specific organism/sensitivity
results.
Where it is not possible to avoid the above ‘high-risk’ agents, please try, where possible to prescribe as short a
course as possible.
Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and
cephalosporins) when narrow spectrum antibiotics remain effective, as they increase of C.difficile, MRSA and resistant
urinary tract infections (UTIs).
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GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
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Avoid widespread use of topical antibiotics (especially those agents also available as systemic agents, e.g. fusidic acid)
Limit prescribing over the telephone to exceptional cases.
Consider ‘no’ or ‘delayed/back up’ prescription strategy where possible for upper respiratory tract infections and
mild UTIs.
Sepsis
Management of sepsis in General Practice http://sepsistrust.org/
‘Sepsis is a medical emergency. It is responsible for 37,000 deaths annually in the United Kingdom and severe sepsis has a fivefold higher mortality than STEMI or stroke. The reliable recognition of sepsis is the responsibility of all health professionals. The
campaign in secondary care has increased awareness and helped to structure the management of sepsis once the patient reaches
hospital. However, it is essential that sepsis is recognised early for the patient to reach hospital soon enough to avoid serious
complication or death. There are significant challenges and barriers to reliable sepsis identification in a Primary Care setting.
Sepsis is a complex condition and its presentation variable. GPs will be experienced in assessing need for hospital assessment in
patients with probable self-limiting infection: it is not practicable to expect differentiation between uncomplicated viral and bacterial
illness in all cases. Patients who are obviously critically ill are likely to be identified without the need for new efforts.
However, there are some patients with severe sepsis with less immediately obvious signs of critical illness. Some of this group
might be identified earlier with greater awareness and targeted clinical assessment.’
In light of this the UK Sepsis Trust have developed a clinical tool kit in partnership with the RCGP to facilitate the reliable
identification and management of sepsis in the primary care setting.
The toolkit is compatible with international guidelines on sepsis management, with the Department of Health’s document ‘Start
Smart- then Focus’, and with guidance on infection management in primary care issued by Public Health England. The General
Practice Sepsis Screening and Action Tool is as follows:
General Practice Sepsis Screening and Action Tool is available for reference:
http://sepsistrust.org/wp-content/uploads/2015/08/1409322477GPScreening2014Final.pdf
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Fifth Edition
Review Team:
Review date:
Expiry date:
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Dr Emma Yates: Consultant Microbiologist, WAHT
Dr Thekli Gee: Consultant Microbiologist, WAHT
Dr Sumit Bhaduri: Consultant in Genito-urinary Medicine, WHC NHS Trust
Priti Patel: Medicines Commissioning Support Pharmacist, SWCCG
Carole Clive: Nurse Consultant in Infection Prevention and Control, WHC NHS Trust
October 2015. [Ratified by the Area Prescribing Committee (APC)] Electronic updates will be issued as required.
30th October 2018
Disclaimer: Whilst every effort has been made to ensure the accuracy of this document, the steering group or any associated NHS Trusts
cannot accept responsibility for any errors or omissions in the text. The text is not intended to be totally comprehensive, and the reader should
be cognisant of any appropriate drug interactions, adverse effects, contra-indications etc. for antibiotics, as indicated in texts such as the BNF
and Summaries of Product Characteristics (SPCs). The clinician is still required to exercise clinical judgement.
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GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
CONTENTS
Introduction
Urinary Tract Infections:
Urinary Tract Infection Uncomplicated
Urinary Tract Infections in Pregnancy
Higher Urinary Tract Infection or Pyelonephritis
Urinary Tract Infection in Children
Recurrent Urinary Tract Infection
Acute Prostatitis
Epididymo-Orchitis
Genito-Urinary and Gynaecological Infections:
Bacterial Infections – Genital – Bacterial Vaginosis or Trichomonas
Bacterial Infections – Genital – Pelvic Inflammatory Disease
Bacterial Infections – Genital – Chlamydia, Gonorrhoea and Non-gonococcal Urethritis
Genital Viral Infection
Genital Yeast infections
Respiratory:
Community Acquired Pneumonia
Acute cough / bronchitis
Chronic Obstructive Pulmonary Disease - Acute Exacerbations
Bronchiectasis
Whooping Cough
Bronchiolitis
Croup – Acute Laryngotracheobronchitis
Ear, Nose and Throat:
Acute Otitis Media
Acute Otitis Externa
Dental Infections – Simple Gingivitis
Dental Infections – Acute necrotising Ulcerative Gingivitis and Pericoronitis
Dental Infections – Dental Abscess
Pharyngitis
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1
12
15
16
17
18
19
20
22
23
24
25
27
28
29
29
31
32
33
34
35
37
39
40
41
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Oral Candidiasis
Sinusitis
Updated February 2017v.3
44
45
Skin and soft tissue Infections:
Animal & Human bites
Bacterial Skin Infection – Impetigo / eczema
Bacterial Skin Infection – Cellulitis and Erysipelas and Insect Bites
Cellulitis associated with lymphedema
Leg Ulcers
Mastitis
MRSA Infection
MRSA Colonisation
Acne
Fungal Infections - Skin and Nail
Parasite Infections – Scabies
Parasite Infections – Head Lice
Chicken Pox and Shingles
46
47
49
50
52
53
54
55
56
57/8
60
61
62
Intra-Abdominal Infections:
Enteric and Intra-abdominal Infections
C.difficile associated diarrhoea
Diverticulitis
Cholangitis
65
66
67
68
Miscellaneous:
Eye Infections
Splenectomy and Infection
Antibacterial Prophylaxis – Infective endocarditis / Malaria
Meningitis
Sepsis / Inoculation Incidents
Local Contact Details - TB, HIV, Meningococcal Meningitis
References and acknowledgements
69
70
71
72
73
75
76
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URINARY TRACT INFECTIONS
Drug
Dose
Duration
Uncomplicated Use nitrofurantoin first line due to general and community multiresistant. Nationally, extended-spectrum Beta-lactamase E. coli
UTI
are increasing. Trimethoprim can still be considered as a first line
N.B Consider
agent (if low risk of resistance).
‘back up’
Risk factors for increased resistance include: care home resident, recurrent
or
UTI, hospitalisation >7d in the last 6 months, unresolving urinary symptoms,
‘delayed’
recent travel to a country with increased antimicrobial resistance (outside
antibiotic
Northern Europe and Australasia) especially health related, previous known UTI
prescription
resistant to trimethoprim, cephalosporins or quinolones.
In all cases
If increased resistance risk, send culture for susceptibility testing & give safety
net advice.
Nitrofurantoin
To aid compliance:
For 3 days in
Please note MHRA advice 100mg modified-release female patients
on prescribing of
(m/r) caps BD (in line
(treat males for
nitrofurantoin
with
PHE)
7 days)
Refer to page 13 notes
reference GFR
2
<45ml/min/1.73m
Trimethoprim
OR
50mg every 6 hours
200mg BD
Penicillin
Allergy
Not
applicable
a)
b)
c)
d)
e)
f)
g)
h)
i)
For 3 days in
female patients
(treat males for
7 days)
Second Line Drug(s)
As per MSU specimen sensitivity
Multi-drug resistant ESBL E-coli are increasing: always safety net when prescribing and consider risk
factors for resistance. If only intravenous options remain available the home IV team should be
contacted [Tel number: 01905 681818]
12
j)
Refer to HPA Diagnosis of UTI Quick Reference Guide
for Primary Care April 2011 for further details.
www.hpa.org.uk
Patients over 65 are likely to have complicated UTI,
consider courses of 7 days treatment.
Women with severe/ ≥ 3 symptoms: treat.
Women with mild/ ≤ 2 symptoms: use dipstick to guide
treatment. Nitrite & blood/leucocytes has 92% PPV; -ve
nitrite, leucocytes, and blood has a 76% NPV.
Asymptomatic bacteriuria does NOT generally require
treatment; it is common in the elderly, but not
associated with increased morbidity.
For elderly, males, pregnant patients or children, or
where there is fever/loin pain always send off an MSU
sample
For treatment in pregnancy, send MSU for culture &
sensitivity and start treatment – see additional notes.
In catheterised patients, avoid treatment, unless
patient is systemically unwell. If clinically unwell,
consider co-amoxiclav, and send urine for culture.
Do not give prophylactic antibiotics for catheter
changes unless history of catheter-changeassociated UTI
Do not use trimethoprim in patients on methotrexate as
haematological toxicity can occur.
Fluid promotion and early hydration is very important in
all patient groups with urinary tract infections – ensure
adequate fluid and hydration measures are in place
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional notes: Nitrofurantoin and MHRA alert

Nitrofurantoin is contra-indicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45ml/min/1.73m2

Nitrofurantoin should not be used to treat sepsis syndrome secondary to UTI’s or suspected UTI’s

A short course (3-7 days) may be used with caution in patients with an eGFR of 30-44ml/min/1.73m2. This should only be prescribed to
such patients to treat lower UTI with suspected or proven multi-drug resistant pathogens when the benefits of nitrofurantoin are
considered to outweigh the risks of the side effects

Consider checking the renal function when choosing to treat with nitrofurantoin, especially in the elderly

Closely monitor the patient for signs of pulmonary, hepatic, neurological, haematological and gastro-intestinal side effects of drug
treatment as previously advised in the SPC

The BNF advises to avoid nitrofurantoin at term as it may cause neonatal haemolysis
References:
1. https://www.gov.uk/drug-safety-update/nitrofurantoin-now-contraindicated-in-most-patients-with-an-estimated-glomerular-filtration-rateegfr-of-less-than-45-ml-min-1-73m2 25 September 2014
2. Drug Safety Update volume 8 issue 2, September 2014: A3
http://webarchive.nationalarchives.gov.uk/20150122075153/http:/www.mhra.gov.uk/home/groups/dsu/documents/publication/con45763
5.pdf
3. http://www.mims.co.uk/nitrofurantoin-new-advice-use-renal-impairment/genito-urinary-system/article/1316024
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Additional Notes: U.T.I.
Common Pathogens:
E.coli.
Coliform organisms
S.saprophyticus
Proteus mirabilis
Clinical Details:
1. 70-80% of isolates are sensitive to trimethoprim. Trimethoprim attains higher concentrations for longer periods than beta-lactam
antibiotics.
2. The presence of Proteus may suggest the possibility of renal or bladder calculi. S.aureus may indicate infection higher in the
urinary tract.
3. Quinolones are highly effective, but should never be used routinely, and only with microbiologist advice for complicated
infections. Quinolones and cephalosporins have been highly associated with the incidence of C difficile diarrhoea.
4. ESBL (Extended Spectrum Beta-lactamase) producing organisms are becoming increasingly prevalent in the community.
These should be treated according to sensitivity patterns. Nitrofurantoin is often effective, and some are susceptible to
trimethoprim, co-amoxiclav or ciprofloxacin. Occasionally ertapenem, a once daily parenteral agent is advised.
5. Isolates are commonly still sensitive to nitrofurantoin (65-85% sensitive), even ESBL producing strains of Gram negative
bacteria. Nausea is a common problem with this drug which can be reduced using capsules and/or the modified-release (MR)
version.
6. Group B Strep bacteriuria reported during pregnancy, treat infection and consider use of peripartum antibiotics.
7. Sterile pyuria, consider urethritis (possibly chlamydia, TB or calculi).
8. For men: consider prostatitis and send pre-treatment MSU OR if symptoms mild/non-specific, use –ve dipstick to exclude UTI.
9. Nitrofurantoin – avoid if eGFR less than 45ml/min/1.73m2. Nitrofurantoin is excreted by the kidneys meaning that impaired renal
function may lead to inadequate urine concentrations and also a risk of peripheral neuropathy. (see BNF or MHRA Drug Safety
Update, Volume 8, Issue 2, September 2014, for further details). Reference: see page 13 for further information on this.
10. In cases of severe renal impairment, please contact the consultant microbiologists for further advice. For patients currently
treated by a renal unit, please seek further advice from their consultant renal physician.
Precautions:
50% of isolates are resistant to amoxicillin, and thus it is no longer suitable for empirical treatment of a UTI.
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Infection
UTI
In pregnancy
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Nitrofurantoin
Dose
100mg m/r BD
Duration
For 7 days
Updated February 2017v.3
Penicillin
Allergy
Help Notes
a)
b)
Refer to page 13 notes
reference GFR
2
<45ml/min/1.73m
c)
d)
Second Line Drug (s)
Drug
e)
Dose
Trimethoprim – (see help 200mg BD
note d).
Duration
For 7 days
Third Line Drug (s)
Cephalosporin
i.e. Cefalexin
Cefalexin is recommended 500mg TDS
by PHE as a third line
agent if sensitivity
indicates for this
Amoxicillin (if sensitivities 500mg TDS
indicate susceptible)
For 7 days
For 7 days
15
Send MSU for culture & sensitivity and start
empirical treatment.
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 (e.g. antiepileptic treatment or proguanil)
Give folic acid if first trimester – recommended dose is
5mg OD.
BNF states to avoid nitrofurantoin at term as it may
produce neonatal haemolysis
PHE Infection Guidance in Primary Care states that shortterm use of trimethroprim or nitrofurantoin in pregnancy is
unlikely to cause problems to the foetus.
The PHE guidance quotes the National Teratology
Information Service:
Trimethroprim is a folate antagonist. In some women low
folate levels have been associated with an increased risk of
malformations. However, in women with normal folate
status, who are well nourished, therapeutic use of
trimethroprim for a short period is unlikely to induce folate
deficiency.
A number of retrospective reviews and case reports indicate
that there is no increased risk of foetal toxicity following
exposure to nitrofurantoin during pregnancy. Serious
adverse reactions e.g. peripheral neuropathy, sever hepatic
damage and pulmonary fibrosis are extremely rare.
Nitrofurantoin can cause haemolysis in patients with G6PD
deficiency. Foetal erythrocytes have little reduced
glutathione and there is a theoretical possibility that
haemolysis may occur. However, haemolytic disease of the
new born has not been reported following in utero exposure
to nitrofurantoin.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Drug
Higher UTI or Co-amoxiclav
Pyelonephritis
in Adults
See help note
h) For
definition of
symptoms
First Line Drug (s)
Dose
625mg TDS
Second Line Drug (s)
Drug
Dose
Duration
For 10-14 days
Duration
Ciprofloxacin (as per dosing for penicillin allergy)
Use with caution Clostridium difficile risk
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Penicillin
Allergy
Help Notes
Ciprofloxacin
500mg BD for 7
days
a) Always obtain an MSU for culture.
b) Avoid cefalexin - insufficient activity.
c) Admit to hospital if no response within 24 hours for
intravenous (IV) therapy or if septicaemia is suspected.
d) Do not treat catheter-associated bacteriuria, unless
patient has systemic symptoms.
e) MRSA in urine is difficult to treat - sensitivity results are
essential. Do not treat CSU infections unless prior to surgery
or as for note d
f) if there is an ESBL risk and upon microbiology advice;
consider IV antibiotics via outpatients (OPAT): Outpatient
Parenteral Antimicrobial Treatment
g) Do not use prophylactic antibiotics for catheter
changes unless there is a history catheter-change
associated UTI or trauma (NICE and SIGN guidance)
h) Definition – Symptoms of higher UTI include:
High fever, loin pain, rigors, flank pain, nausea, vomiting and
diarrhoea. Symptoms of cystitis may or may not be present.
Symptoms develop rapidly over a few hours or a day.
Use with caution
as risk of C.
difficile
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Drug
Lower U.T.I.
in children
Trimethoprim
Nitrofurantoin
First Line Drug (s)
Dose
Refer to
children’s BNF
for dose
calculation in
Paediatrics
Duration
Updated February 2017v.3
Penicillin
Allergy
Help Notes
For 3 days
a)
For 3 days
b)
c)
d)
If susceptible: Amoxicillin for 3 days
Upper UTI
In children
e)
Second Line Drug (s)
Drug
Dose
Duration
Co-amoxiclav
Refer to
children’s BNF
for dose
calculation in
Paediatrics
For 7-10 days
17
Investigation of cause is commonly needed
according to age of child. See NICE clinical
guideline and local paediatric protocols.
In babies up to 3 months, IV antibiotics are
recommended – refer immediately
For children older than 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.
Repeat samples may be useful if diagnosis is in doubt
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Drug
Recurrent
UTI
First Line Drug (s)
Dose
Duration
Long term (more than three months at a time)
prophylaxis
dosing
regimens
are
no
longer
recommended for recurrent UTI in adult patients.
Instead: Discreet ‘treatment doses’ of antibiotics are
recommended for no longer than three months duration
followed by a repeat sample for symptomatic episodes.
For patients with recurrent UTI, recommend a discrete
treatment course of either an empiric or specific agent (if
previous MSU/sensitivity results available) and repeat
sampling for further symptomatic episodes. If empiric agents
are used they should be reviewed in light of any subsequent
MSU results and treatment adjusted accordingly.
This strategy can help to prevent selection of multi-drug
resistant organisms reducing potential Clostridium difficile
infection risk and allows monitoring of organism and
resistance profiles against treatment.
Prophylaxis treatment is only needed for children: on
specialist advice
18
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a) Also consider standby antibiotics as an alternative.
b) Post-coital prophylaxis – use recommended drug choices
for UTI but as a single stat dose each time after sex (off-label
use)
c) Recurrent UTI may be due to relapse or re-infection and
may occur for a variety of different clinical reasons.
d) CKS gives very useful advice on how to manage
symptoms in a wide variety of patients.
e) Best practice (as outlined in the guidance statement)
would be to give discrete treatment courses of either empiric
or specific antibiotic agents (based on previous
MSU/sensitivity results available), with repeat sampling for
repeat episodes, rather than single agent prolonged
prophylaxis/treatment. This strategy can help to prevent
selection of antibiotic resistant organisms and reduce the
potential C.difficile infection risk.
f) For patients in whom antibiotic prophylaxis has
already been (historically) instituted, the guidelines DO
NOT recommend discontinuation of their on-going
prophylaxis. It would be clinically prudent, however, to
review the need for prophylaxis and the agent being used
(which should include some degree of repeat sampling to
assess agent effectiveness against organisms cultured).
g) For patients who are not on prophylaxis for recurrent UTI,
but for whom the clinician feels there would be benefit to
commencing an agent for prolonged treatment (i.e. not low
dose/half dose); the guidelines DO NOT prohibit their use,
but do guide that they should not be used for greater than 3
months in any given period. Certainly the clinician should
undertake sampling at 3 months (if not before) to assess ongoing effectiveness of the agent being used.
Fifth Edition
Infection
Acute Prostatitis
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Ciprofloxacin
500mg BD
Duration
For 28 days
Second Line Drug (s)
Drug
Dose
Duration
Ofloxacin
200mg BD
For 28 days
Alternative If Above Not Tolerated
Drug
Dose
Duration
Trimethoprim
200mg BD
28 days
Additional Notes
Common Pathogens:
E.coli.
Gram negative bacilli
Enterobacter spp.
Clinical Details:
1. Prostatic tissues are best penetrated by drugs with a high pKa and
high lipid solubility, such as quinolones.
2. Empiric treatment is common, but gonorrhoea and chlamydia
should be excluded.
3. Late relapse (6-12 months after treatment) is common.
19
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a) Send MSU for culture and sensitivity.
b) Consider an STD, send urine for chlamydia PCR.
c) Most infections are caused by Gram negative bacteria.
d) Chronic bacterial prostatitis may require 4-6 weeks
treatment – refer to NICE/CKS guidance
e) Refer all patients with STD’s to GUM clinic
f) NB risk of C difficile disease with quinolones. Stop
immediately if diarrhoea occurs. In patients at high risk
of, or previous, C difficile disease use an alternative
agent.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
First Line Drug (s)
Drug
Dose
EpididymoOrchitis
Doxycycline
In cases where
aetiology most
probably due to
STI e.g. chlamydia
OR
N.B. Refer high risk
gonorrhoea patients to
the GUM clinic - see
help notes f) and g)
and Refer page 21 for
contact details
Ofloxacin
100mg BD
For 10 days
200mg BD
For 14 days
N.B. Refer high risk
gonorrhoea patients to
the GUM clinic - see
help notes f) and g)
and Refer page 21 for
contact details
Help Notes
a)
b)
Relevant investigations: MSU and urine for chlamydia PCR
and urethral swab for N. gonorrhoea culture if clinically
indicated
N.B If there is suspicion of an STD – refer the patient
to the GUM clinic for treatment - see help note (h)
First Line Drug (s)
Drug
Dose
In cases where
aetiology most
probably due to
enteric organisms
Duration
Penicillin
Allergy
Ofloxacin
200mg BD
Duration
For 14 days
Relevant investigations: MSU and urine for chlamydia PCR
and urethral swab for N. gonorrhoea culture if clinically
indicated
N.B If there is suspicion of an STD – refer the patient
to the GUM clinic for treatment - see help note (h)
20
Updated February 2017v.3
c)
d)
a) In males <35 years, often caused by STI such as
Chlamydia – if suspected, advise to abstain from
intercourse until treatment finished. Suggest partner is
screened and treated.
b) In males >35 years, often caused by non-sexually
transmitted, Gram negative enteric organisms that cause
UTIs, however crossover between both groups occurs.
If N. gonorrhoea is isolated, contact GUM Clinic.
Refer to page 21 for contact details.
c) In all cases- testicular torsion should be considered
as a differential diagnosis especially in patients under 20
(although this can occur at any age) presenting with
acute onset severe pain – this requires urgent surgical
referral.
d) Consider mumps in non-immunised adults born
between 1982-1986 with history of headache, fever and
unilateral/bilateral parotid swelling 7-10 days prior to
testicular swelling. Antibiotics not indicated.
e) In all cases consider general support measures such
as scrotal elevation (good supporting underwear),
analgesia and bed rest.
f) Common risk factors for gonorrhoea are: previous
N. gonorrhoeae infection; known contact of gonorrhoea;
presence of purulent urethral discharge, men who have
sex with men and black ethnicity
g) Refer high risk gonorrhoea patients to the GUM clinic
for treatment with IM ceftriaxone 500mg stat. These high
risk patients must receive oral therapy as indicated in the
guideline AND be referred for IM ceftriaxone treatment in
the GUM clinic AS WELL. Refer to page 21 for contact
details. Clinical care pathway for management of
epidiymo-orchitis produced by BASSH is available:
Reference:
http://www.bashh.org/documents/3547.pdf
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Epididymo-orchitis
National guidelines produced by BASHH (British Association for Sexual Health and HIV) for the management of epididymo-orchitis
make the following statements regarding the aetiology of acute epididymo-orchitis in relation to patient age.
• Under 35 years - most often a sexually transmitted pathogen such as Chlamydia trachomatis and Neisseria gonorrhoeae.
• Over 35 years - most often non-sexually transmitted Gram negative enteric organisms causing urinary tract infections. Particular
risks include recent instrumentation or catheterisation.
However the guidelines also state that:
• There is crossover between these groups and complete sexual history taking is imperative.
In light of this, if there is clinical concern of an STI in a patient >35years of age presenting with symptoms of acute epididymoorchitis, they should be treated accordingly
Reference: http://www.bashh.org/documents/3546.pdf
GUM CLINIC CONTACT TELEPHONE NUMBERS
John Anthony Centre, Newtown Road, Worcester, WR5 1JF. Tel: 0300 123 1731
Arrowside, Alexandra Hospital Site, Woodrow Drive, Redditch, Worcestershire B98 7UB. Tel: 01527 516398
21
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
GENITO-URINARY AND GYNAECOLOGICAL INFECTIONS
Infection
Bacterial
Vaginosis
First Line Drug (s)
Penicillin
Allergy
Drug
Dose
Duration
Metronidazole
400mg BD
For 7 days
OR
Metronidazole
Help Notes
a)
b)
2 grams
Single dose
c)
d)
e)
Trichomonas
First Line Drug (s)
Drug
Dose
f)
Duration
Metronidazole
400mg BD
For 7 days
Metronidazole
2 grams
Single dose
In pregnancy/breastfeeding: avoid 2g stat dose. Refer to
GUM.
Consider clotrimazole 100mg pessary at night for 6
nights for symptom relief (not cure) if metronidazole
declined. Refer to GUM – page 21 contact details.
22
g)
h)
History of vaginal discharge with odour (typically fishy)
and raised pH of vaginal fluid very suggestive of
infection. Diagnosis may be based on swab or if at
low risk of STI, patients with relevant symptoms may
be treated empirically without investigation
Oral metronidazole is as effective as topical treatment
and more cost effective.
There is less relapse with 7 days treatment than 2g
stat at 4 weeks.
For those intolerant to metronidazole use clindamycin
vaginal cream.
For bacterial vaginosis in pregnancy, avoid 2g
dose, treat with oral metronidazole 400mg bd for 7
days as early as possible in the 2nd trimester. (There
is no evidence of teratogenicity in humans when used
at this dose).
Group B strep is normal flora in the vagina and when
isolated in an HVS does not require treatment,
however when isolated in pregnancy peri-partum
antibiotics should be considered. Ensure patients are
aware of risks and notes annotated accordingly, and
appropriate advice leaflet given (see RCOG website)
Trichomonas is a sexually transmitted infection,
consider contact tracing. Treat partners and refer to
GUM clinic.
Consider HIV or syphilis testing in all cases of STD.
There is evidence suggesting that the use of acetic
acid is effective for the treatment of bacterial vaginosis
as well although dosing schedules are not provided
within the scope of this guideline.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Pelvic
Inflammatory
Disease
Refer high risk
gonorrhoea patients to
the GUM clinic – see
help note f) and g)
These high risk patients
must receive oral
therapy as indicated in
the guideline AND be
referred for IM
ceftriaxone treatment in
the GUM clinic AS
WELL. Refer page 21
contact details
Chlamydia
N.B doses differ in
pregnant patients, refer
to help note c)
First Line Drug (s)
Penicillin
Allergy
Drug
Dose
Duration
Ofloxacin
400mg BD
For 14 days
400mg BD
For 14 days
Help Notes
AND
Metronidazole
h)
Azithromycin
1 gram
OR
Doxycycline (this 100mg BD
is preferred for
rectal chlamydia)
OR (Alternative regimens)
Erythromycin
500mg BD
OR
Ofloxacin
200mg BD
OR
400mg OD
Single dose
For 7 days
For 14 days
For 7 days
23
Updated February 2017v.3
a) In cases of suspected PID, always test for gonorrhoea
and Chlamydia.
b) If treatment failure in P.I.D. reassesses diagnosis and
antibiotic compliance, consider referral to Gynaecology
clinic.
c) Consider admission if systemically unwell.
d) In pregnancy, seek specialist advice.
e) Partners of index patients diagnosed with PID should
be offered anti-chlamydial treatment empirically.
f) 28% of gonorrhoea isolates now resistant to
quinolones. If gonorrhoea likely (partner has it, severe
symptoms, sex abroad) refer to GUM- avoid treatment with
ofloxacin
g) Common risk factors for gonorrhoea are: previous N.
gonorrhoeae infection; known contact of gonorrhoea;
presence of purulent urethral discharge, men who have sex
with men and black ethnicity
Refer high risk gonorrhoea patients to the GUM clinic -see
help note f) and g). Refer page 21 for contact details
a) Contact tracing and treatment is an important issue.
b) STDs often co-exist with other infections.
c) In pregnancy, azithromycin 1g stat (unlicensed use in
UK) is the most effective option or erythromycin 500mg qds
for 7 days or amoxicillin 500mg tds for 7 days should be
used. Due to low cure rate in pregnancy, test for cure 6
weeks after treatment. If treatment failure, refer to GUM
clinic.
d) Patients should be advised to avoid sexual intercourse
(including oral sex) until they and their partner(s) have
completed treatment (or wait 7 days if treated with
azithromycin)
N.B Relevant investigations in all cases:
MSU and urine for chlamydia PCR and
urethral swab for N. gonorrhoea culture if
clinically indicated
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
First Line Drug (s)
Drug
Gonorrhoea
Non-gonococcal
urethritis (NGU)
Refer high risk
gonorrhoea patients to
the GUM clinic – see
help note b) and c)
These high risk patients
must receive oral
therapy as indicated in
the guideline AND be
referred for IM
ceftriaxone treatment in
the GUM clinic AS
WELL.
Refer page 21 contact
details
Dose
Penicillin
Allergy
Duration
REFER ALL PATIENTS TO GUM CLINIC – refer to page
21 for contact details. See help note a)
Azithromycin
1 gram
Single dose
Updated February 2017v.3
Help Notes
a)
http://www.bhiva.org/documents/News/151218/D
H-CMO-CPO-letter.pdf
b)
c)
For recurrent infection:
Azithromycin
500mg stat then
250mg for the next four days
AND
Metronidazole
400mg BD for 5 days
d)
24
PLEASE NOTE: Department of Health guidance:
Gonorrhoea and Antimicrobial Resistance
Treatment for recurrent infection should include cover
for Mycoplasma genitalium and Trichomonas vaginalis
Common risk factors for gonorrhoea are: previous N.
gonorrhoeae infection; known contact of gonorrhoea;
presence of purulent urethral discharge, men who
have sex with men and black ethnicity
Refer high risk gonorrhoea patients and patients with
gonorrhoea to the GUM clinic. Refer page 21 contact
details
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Primary Herpes
simplex
(Type 1 or 2)
First Line Drug (s)
Drug
Dose
Duration
Aciclovir
200mg 5 times
daily
For 5 days
Updated February 2017v.3
Penicillin
Allergy
Help Notes
a)
b)
c)
d)
e)
f)
g)
Mild recurrences
Manage symptomatically
Infrequent severe
recurrences
Frequent severe
recurrences
(more than six
episodes a year)
Treat each occurrence with five days aciclovir as above
Aciclovir 400mg BD for 6-12 months ( review 3 monthly)
25
Depending on severity, a topical analgesic (e.g.
lidocaine 2%) can be prescribed. Discuss other
measures for pain relief - oral analgesics and daily
soaks/baths in saline solution.
Watch out for secondary bacterial infection. STDs
commonly co-exist, & therefore refer to GUM for new
presentations.
Syphilis testing should be offered in all patients with
genital ulceration.
Patients are advised to avoid sexual intercourse until
lesions have healed.
In all cases of HSV in pregnancy, seek advice for
details of management.
In difficult cases seek GUM advice.
Explanations as regards latency of infection should be
offered with GUM referral if further counselling
required.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Genital yeast
infections
Treatment for
NON-PREGNANT
PATIENTS
First Line Drug (s)
Penicillin
Allergy
Drug
Dose
Duration
PO Fluconazole
150mg
Single dose
a)
c)
d)
OR
500mg
Single application
5 grams
Single application
OR
Clotrimazole 10%
vaginal cream
Help Notes
b)
N.B DO NOT
prescribe PO
fluconazole if
pregnant or
possibly pregnant
Refer page 27
for treatment of
pregnant
patients
Clotrimazole
pessary
Updated February 2017v.3
26
If the vulva is very inflamed topical treatment may be
painful – use oral fluconazole. Avoid perfumed soap
and shower gels. Topical clotrimazole HC cream bd
may alleviate symptoms.
Recurrent vaginal infections may suggest possible
underlying pathology e.g. diabetes. Take a swab to
confirm diagnosis and assess antifungal susceptibility
of any Candida isolated. See CKS guidance for further
information on the management of vaginal discharge.
Avoid antibiotic therapy where possible as it may
precipitate candidiasis.
For penile candidiasis use 1% clotrimazole topical
cream.
Clotrimazole pessaries and cream (but not HC version)
and fluconazole capsules can be purchased from
community pharmacies.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
First Line Drug (s)
Penicillin
Allergy
Genital yeast
infections
Drug
Dose
Duration
Treatment for
PREGNANT
PATIENTS
Clotrimazole
Pessary
N.B can be
prescribed in
pregnancy
100mg pessary at
night
6 nights
pregnant patients
5g intravaginally
BD
7 days
pregnant patients
OR
Miconazole 2%
cream
N.B can be
prescribed in
pregnancy
27
Updated February 2017v.3
Help Notes
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
RESPIRATORY
Infection
Drug
Community
Acquired
Pneumonia
First Line Drug (s)
Dose
Duration
Mild infection (CRB-65 score 0)
Suitable for home treatment
Amoxicillin
500mg TDS
For 5 days
Penicillin
Allergy
Help Notes
Clarithromycin
500mg BD for
5 days
a)
b)
OR
Manage using
clinical judgment
and modified
CRB-65 score as
follows
(each scores 1):
Confusion (AMT <8)
Respiratory rate >30/min
BP systolic <90mmHg
diastolic <60
Age >65 years
Doxycycline
200mg stat
then
100mg od
for 5 days
Moderate infection (CRB-65 score 1 or 2)
Hospital Assessment or admission
Amoxicillin
500mg TDS
7 days
AND
Clarithromycin
500mg BD
7 days
OR
Doxycycline 200mg stat then 100mg OD for 7 days as a
single agent
Severe infection (CRB-65 score 3+)
Urgent Hospital admission
28
Doxycycline
200mg stat
then
100mg od
for 7 days
If pneumonia is suspected, pneumococci account for
70+% of cases.
In Worcestershire penicillin resistance in pneumococci
is extremely rare.
If an atypical pneumonia is strongly suspected, then
clarithromycin would be 1st choice.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Drug
Acute Cough /
Bronchitis
Amoxicillin
OR
Doxycycline
For all patients:
Consider 7-14 day
delayed antibiotic
with symptomatic
advice/leaflet
See help note d)
for further advice
C.O.P.D. Acute
Exacerbations
Many acute
infective
exacerbations are
viral, and do not
require antibiotics
See help notes a)
b) and c)
Drug
Amoxicllin
OR
Doxycycline
Drug
Clarithromycin
First Line Drug (s)
Dose
Duration
500mg TDS
For 5 days
200mg stat
then 100mg OD
For 5 days
First Line Drug (s)
Dose
Duration
500mg TDS
For 7 days
200mg STAT
THEN
100mg OD
For 7 days
Second Line Drug (s)
Dose
Duration
500mg BD
For 7 days
If resistance risk factors: see help note g):
Co-amoxiclav*
625mg TDS
For 7 days
*Ensure positive sputum sample result before prescribing
29
Updated February 2017v.3
Penicillin
Allergy
Help Notes
Doxycycline
200mg stat
then
100mg od
for 5 days
a)
b)
Doxycycline
200mg stat
then
100mg od
for 5-7 days
OR
Clarithromycin
500mg BD for
5-7 days
a)
Antibiotic is of little benefit if no co-morbidity.
Consider immediate antibiotics if >80 years and ONE
of: hospitalisation in the past year, oral steroids,
diabetic, congestive heart failure,
OR >65 years with 2 of the above.
c) Symptom resolution can take 3 weeks.
Most H. influenza strains are resistant to erythromycin,
therefore not advised in this condition.
d) N.B CRP levels can be used to guide treatment when
considering if antibiotic prescription is indicated or not
although definitive criteria and guidance on when to issue a
prescription or defer issue with the use of CRP testing
apparatus is not provided within the scope of this guidance.
b)
c)
d)
e)
f)
g)
Many acute infective exacerbations are viral, and
do not require antibiotics.
Patients with recurrent infections will require longer
courses, and sputum cultures should be taken.
st
Consider standby home packs of 1 line antibiotics
and oral steroids, if indicated, for appropriate patients.
COPD patients require single pneumococcal
vaccination and annual influenza vaccination.
In some circumstances more than 7 days treatment
may be needed, particularly in patients with features of
bronchiectasis.
Treat exacerbations promptly with antibiotics if
purulent sputum and increased SOB and/or increased
sputum volume.
Risk factors for antibiotic resistant organisms include:

co-morbid disease,

severe COPD,

frequent exacerbations,

antibiotics in last 3 months
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Respiratory Tract Infection
Common Pathogens:
Haemophilus influenzae
Streptococcus pneumoniae
Atypical - Mycoplasma pneumoniae, Legionella pneumophilia
Moraxella catarrhalis
Clinical Details:
1. Use of beta-lactam antibiotics - amoxicillin remains the treatment of choice in patients not allergic to penicillins, as resistance in
pneumococci is very rare locally, and most strains of H. influenzae are also sensitive. Question carefully about penicillin allergy to validate it. Coamoxiclav is active against beta-lactamase producing organisims but does not cover penicillin-resistant pneumococci .
2. Uses of macrolides - erythromycin, clarithromycin and azithromycin all have a similar spectrum of activity, and resistance to one usually indicates
resistance to all these compounds. Resistance in pneumococci is uncommon, but some H. influenzae strains are less susceptible.
3. Use of cephalosporins (e.g. cefalexin) – inappropriate as oral agents for chest infections (insufficient activity against Haemophilus sp), also
increased risk of C.difficile disease.
4. Use of quinolones – Not generally advised due to risk of C.difficile disease. Ciprofloxacin & ofloxacin are not reliably effective against
pneumococci, and should not be used to treat primary pneumonias. Quinolones penetrate into lung tissue well, and are thus useful in treating
difficult cases of COPD and bronchiectasis. They are not licensed for use in children or in pregnancy, although ciprofloxacin has been used
extensively in paediatric cystic fibrosis. Moxifloxacin is more effective against pneumococci, this may be occasionally prescribed if no suitable
alternative available.
5. Use of tetracyclines - there is little difference in activity for various tetracyclines. Most of the atypical organisms are sensitive, as are a majority of
the pneumococci and Haemophilus influenzae isolates. Tetracyclines are bacteriostatic, and as they cannot be used in children or pregnancy,
their role is limited to less severe infections in adults.
6. Consider Pneumococcal and influenza vaccines in at risk cases (see annual CMO letter and HMSO Publication Immunisations against Infectious
Diseases.
30
Fifth Edition
Infection
Acute infective
exacerbation of
Bronchiectasis
Always base
choice on results
of previous
sputum cultures
and response to
previous
treatment.
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Penicillin
Allergy
Drug
Dose
Duration
Amoxicllin
500mg TDS
For 14 days
500mg QDS
For 14 days
100mg BD
For 14 days
OR
Oxytetracycline
OR
Doxycycline
OR
Ciprofloxacin*
*(NB – risk of
C.diff disease,
prescribe with
caution in
elderly
patients)
500mg BD
For 14 days
31
Updated February 2017v.3
Help Notes
a)
High doses of amoxicillin e.g.3g bd for 14 days
are sometimes given to patients with advanced
cystic bronchiectasis to improve sputum
penetration.
b) Patients with severe impairment of lung function
or who have developed acute respiratory failure
may require IV therapy and may require
admission to hospital.
c) Patients with bronchiectasis require single
pneumococcal vaccination and annual influenza
vaccination.
d) There is little evidence to support the use of
inhaled antibacterials during exacerbations.
e) There is little evidence on whether long-term
antibacterial therapy should be given between
exacerbations. This will depend on individual
patients, for some longer courses of therapy
may be preferential, usually on advice of
respiratory team.
f) APC has approved the use of inhaled (nebulised)
colistimethate in people with non-Cystic Fibrosis
bronchiectasis under the following circumstances:

Frequent exacerbations requiring antibiotic
therapy

Evidence of P.aeruginosa infections
causing exacerbations

Previous IV antibiotic therapy required and
where, for example, resistance to
ciprofloxacin has developed, or there are
problems with venous access
 Treatment with colistimethate must be
initiated within secondary care; on-going
prescribing in primary care is supported.
®
N.B. Colistimethate sodium (Colomycin injection,
®
Promixin ) is only licensed for treating pulmonary
infections caused by Pseudomonas aeruginosa
in people with cystic fibrosis but not in non-cystic
fibrosis bronchiectasis.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Infection
Whooping Cough
Telephone Public
Health England with
any suspected or
confirmed cases. Tel:
0344 2253560 select
option 2 and then
option 3 – refer page 75
for further contact
details
Drug
First Line Drug (s)
Dose
Duration
Azithromycin
500mg OD
For 3 days
For paediatric
dosing see note f)
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a)
b)
Second Line Drug (s)
Discuss with microbiologist
Chemoprophylaxis may be recommended if:
Onset date in the index case is within the preceding
21 days AND there is a vulnerable close contact,
these are:
 Newborn infants born to symptomatic mothers
 Infants under 1 year who have received less than 3
doses of DTaP/IPV/Hib
 Unimmunised and partially immunised infants or
children up to 10 years
 Women in the last month of pregnancy
 Children/adults who attend/work in a healthcare,
social care or childcare facility
 Immunocompromised individuals (as per Green Book)
 Presence of other chronic illnesses e.g. asthma
Where both conditions are met – ALL close contacts
should be given prophylaxis. Contact HPA/microbiologist
for further details. Dose same as for treatment:
See help note f) and g) for further links and reference
32
c)
d)
e)
If strong clinical suspicion of whooping
cough, refer to microbiology for a pernasal
swab for immediate processing to improve
isolation rates of Bordetella pertussis
Although most infectious during the initial
catarrhal phase, antibiotics given in the
paroxysmal phase may decrease severity,
duration and communicability of disease.
14-day treatment prevents bacteriological
relapse.
Causative organism is Bordetella
pertussis. However the classical
symptoms of whooping cough may also
be the result of other agents, notably
parainfluenza virus.
Whooping cough is a notifiable disease.
Complete the notification and return to the
CCDC/PHE. If further information is
needed, contact CCDC/PHE or Public
Health Consultants if out of hours.
Patient advice leaflet available on
www.cks.library.nhs.uk
f)
REFERENCE: Public Health England
guidance:
https://www.gov.uk/government/uploa
ds/system/uploads/attachment_data/fi
le/541694/Guidelines_for_the_Public_
Health_Management_of_Pertussis_in
_England.pdf
g)
Pertussis GP Pack: AWAITING
UPDATE from Public Health England
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Bronchiolitis
 Bronchiolitis is an acute lower respiratory tract illness occurring during the first two years of life.
 It is viral in origin. Respiratory Syncytial Virus (RSV) causes the majority of cases, with parainfluenza
viruses being the next most commonly isolated.
 The diagnosis of bronchiolitis is made most frequently on the basis of the characteristic clinical and
epidemiological findings.
 The diagnosis may be aided by the rapid identification of the causative virus. The viruses may be
detected from nose and throat swabs sent in viral transport medium, but this would be rarely required in
primary care.
 Studies have shown that the risk of secondary bacterial infection in infants with RSV infection is low.
 As the condition is viral in origin, antibiotics are not routinely indicated. Severely ill infants
should be referred to secondary care.
33
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Croup – Acute Laryngotracheobronchitis
 Croup is an acute viral infection of the upper and lower respiratory tract that occurs in young children.
The peak incidence is in the second year of life, with most cases occurring between 3 months and 3
years of age.
 Croup is caused by a variety of viral agents and occasionally Mycoplasma pneumoniae.
Parainfluenza virus type 1 is the most common cause of croup in the U.K.
 The diagnosis of croup is usually based on the characteristic clinical picture.
The diagnosis may be aided by the rapid identification of the causative virus. The viruses may be detected
from nose and throat swabs sent in viral transport medium, but this would be rarely required in primary
care.
 Bacterial infection superimposed or occurring after croup is uncommon and administration of
antibiotics to children with croup prophylactically or without evidence of concomitant bacterial infection
is not warranted.
 Patient information leaflets are available from www.cks.library.nhs.uk
34
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
EAR NOSE AND THROAT INFECTIONS
Infection
Acute Otitis Media
60% of Acute Otitis
Media cases can
resolve without
antibiotic treatment
Pharmaco-vigilance
when prescribing
antibiotics for this
indication
First Line Drug (s)
Drug
Dose
Duration
Amoxicillin
For 5 days
500mg TDS
Second Line Drug (s)
Penicillin
Allergy
Help Notes
See second
line drugs
a)
Erythromycin
250mg QDS
For 5 days
N.B Always check the children’s BNF for calculation of
doses in children
b)
c)
d)
e)
35
In childhood, consideration
should be given to whether
antibiotic treatment is relevant.
It may be appropriate to reserve
treatment for high risk groups
e.g. children under 2 years AND
bilateral AOM, or bulging
membranes and 4 or more
marked symptoms; all ages with
otorrhoea.
Ensure adequate analgesia is
given
Consider delaying prescription for
2 days to see if condition resolves
on its own.
In penicillin allergic patients use
erythromycin.
Consider ENT referral for recurrent
episodes.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Otitis Media
Common Pathogens:
Viruses
S.pneumoniae
Moraxella catarrhalis
Haemophilus influenzae
Group A Streptococci
Clinical Details:
 Current debate lies in whether to prescribe antibiotics at all. Health Protection Agency guidelines suggest that antibiotics should be
avoided as 60% of cases are better in 24hours without: they only reduce pain at 2 days and do not prevent deafness.
 Feared complications are rare e.g. mastoiditis, meningitis
 Reduction in frequency of prescribing of antibiotics may help limit the increasing antibiotic resistance among bacteria implicated in this
type of infection.
 A strategy of watchful waiting and use of delayed prescriptions may be appropriate for many children. Paracetamol and ibuprofen can
be used for symptomatic relief of pain and fever.
 If antibiotics are prescribed, a five day course is probably adequate.
 See www.cks.library.nhs.uk for patient information leaflets.
36
Fifth Edition
Infection
Acute Otitis
Externa
Always ensure
adequate
analgesia is
given
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Topical First Line
Dose
Penicillin
Duration Allergy
Oral First Line
500mg-1g QDS
For 7 days
500mg BD
For 7 days
Oral Second Line
Clarithromycin
Help Notes
a)
Fungal:
Clotrimazole 1% solution 3 drops TDS for 4 weeks
37
A patient information leaflet can be found at:
http://patient.info/health/ear-infection-otitisexterna
First line measure: keep the ear canal clean and dry and free
of sloughy material +/- acetic acid 2%: EarCalm® spray if
pseudomonas growth in ear swab sample – refer to help note
a–f. In severe/difficult to manage cases refer to help note l.
OR
Betamethasone-neomycin
2-3 drops
For 7 days
sulphate
TDS/QDS
min to 14
- refer help note g).
days max
OR
Otomize® ear spray
1 spray
For 7 days
(Acetic acid-dexamethasoneTDS
min to 14
neomycin sulfate)
days max
- refer help note g).
OR
Sofradex® ear drops
2-3 drops
For 7 days
(dexamethasone-framycetin
QDS
min to 14
sulphate-gramicidin)
days max
- refer help note g).
Flucloxacillin
Updated February 2017v.3
b)
Clarithromycin
500mg BD for 7
days
Cleansing the area and toilet care is important and a
useful alternative to antibiotic therapy.
c) Patients should be advised to keep the ear clean and
dry, due to the risk of secondary fungal infection.
d) For mild symptoms (mild discomfort and/or pruritus;
no deafness or discharge), use acetic acid 2%
®
solution (EarCalm ), which can be purchased from
community pharmacies.
®
e) Acetic acid (EarCalm ) has been used in some
studies – lowering the pH inhibiting Pseudomonas
spp. growth and colonisation.
f) Swabs of ear discharge may guide treatment.
g) Topical treatment is usually effective - choice guided
by infection treated and manufacturer availability.
h) If the eardrum is perforated, the use of drops
containing aminoglycosides is contra-indicated (CSM
advice, see BNF).
i) Oral antibiotics are indicated if the patient is
systemically unwell or there is evidence of
spreading infection.
j) Treatment for longer than 7 days should be
avoided, as bacterial resistance will occur and
may result in fungal infection.
k) Fungal infections are difficult to treat and may require
specialist referral.
l) If condition recurrent, aural toilet may be provided by
local nurse practitioner. Consider underlying disease
such as diabetes or exfoliative skin conditions.
m) If severe (cellulitis or disease extending outside ear
canal) or recurrent episodes, start antibiotics and
refer to ENT
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Otitis Externa
1. Steroid/antibiotic drops are of secondary importance, and if used in isolation for long periods, encourage bacterial resistance, otomycosis
and local skin reactions.
2. Steroid drops are of benefit in the prodromal phase of eczematous otitis externa.
3. Furuncles, and other localised lesions, are best treated by the insertion of a soothing wick, and if symptoms are severe use systemic
antibiotics active against staphylococci. Referral to ENT should be considered.
4. Failure to respond to aural toilet may indicate inadequate treatment, or a localised reaction.
If infection progresses to involve soft
tissues, perichondrium or bone, then hospital admission for intravenous antibiotics, and further aural toilet may be required.
5. The isolation of Candida albicans or Pseudomonas spp. usually indicates colonisation after antibiotic therapy, but will occasionally
require specific antimicrobial therapy.
6. Malignant otitis externa, caused by Pseudomonas aeruginosa is a serious invasive condition, requiring aggressive intravenous
antibiotic therapy.
7. Recurrent otitis externa - consider underlying disease such as diabetes mellitus or exfoliative skin conditions.
38
Fifth Edition
Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dental Infections –
Simple Gingivitis
(Mucosal ulceration
and inflammation)
N.B. The guidance on
dental problems is
not designed to be a
definitive guide to
oral conditions. It is
intended to be advice
on the management
of acute oral
conditions pending
being seen by a
dentist or dental
specialist.
Dose
Duration
Simple Saline Mouthwash (1/2 teaspoon salt dissolved
in a glass of warm water
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a)
b)
c)
OR
Chlorhexidine mouthwash 0.12-0.2 %( Rinse mouth for 1
minute bd using 5ml diluted with 5-10ml water). In cases
where oral desquamation occurs dilution of the
mouthwash with an equal volume of tap water, freshly
mixed, will often allow continued use of the mouthwash.
Do not use within 30 minutes of toothpaste
OR
Hydrogen peroxide 6% (spit out after use)
39
d)
e)
Always spit out mouthwash after use.
Use until lesions resolve or less pain
allows oral hygiene.
Temporary pain and swelling relief can
be attained with saline mouthwash.
Use antiseptic mouthwash:
If more severe and pain limits oral
hygiene to prevent treat or prevent
secondary infection.
The primary cause for mucosal
ulceration or inflammation (aphthous
ulcers, oral lichen planus, herpes
simplex infection oral cancer) needs to
be evaluated and treated.
Fifth Edition
Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Penicillin
Allergy
Updated February 2017v.3
Help Notes
Acute Necrotising
Ulcerative Gingivitis
and Pericoronitis
Metronidazole
400mg TDS
3 days
If pain limits oral hygiene add:
Chlorhexidine or hydrogen peroxide mouthwash as per
instructions for simple gingivitis
a)
Pericoronitis
First Line Drug (s)
a)
Amoxicillin
500mg TDS
3 days
Commence metronidazole and refer to
dentist for scaling and oral hygiene
advice. Use in combination with
antiseptic mouthwash if pain limits oral
hygiene.
Use mouthwash until oral hygiene possible
b)
c)
Second Line Drug (s)
Metronidazole
400mg TDS
d)
3 days
Chlorhexidine or hydrogen peroxide mouthwash as per
instructions for simple gingivitis
40
Refer to dentist for irrigation and
debridement
If persistent swelling or systemic
symptoms use metronidazole.
Use antiseptic mouthwash if pain and
trismus limit oral hygiene.
Use mouthwash until oral hygiene
possible.
Fifth Edition
Infection
Acute Dental
Abscess
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Mild infection
Amoxicillin
500mg TDS
For up to 5
days.
Updated February 2017v.3
Penicillin
Allergy
Help Notes
Mild infection
If true penicillin
allergy:
Clarithromycin
500mg BD for up
to 5 days.
a)
b)
c)
If severe infection:
Penicillin
Allergy
Metronidazole
AND
400mg TDS
Amoxicillin
500mg TDS
For 5 days
For up to 5
days.
Severe infection
and penicillin
allergy:
Clindamycin
450mg TDS for 5
days
d)
e)
f)
g)
41
Regular analgesia should be first
option until a dentist can be seen for
urgent drainage, as repeated courses
of antibiotics for abscess are not
appropriate. Repeated 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.
The empirical use of cephalosporins,
co-amoxiclav, clarithromycin, and
clindamycin do not offer any
advantage for most dental patients
and should only be used if no
response to first line drugs when
referral is the preferred option.
If pus, drain by incision, tooth
extraction or via root canal. Send pus
for microbiology.
For true penicillin allergy, use
clarithromycin or clindamycin if severe.
If spreading infection (lymph node
involvement, or systemic signs i.e.
fever or malaise) ADD metronidazole.
Fifth Edition
Infection
Pharyngitis
Many sore
throats are viral
and do not
require
antibiotic
treatment - see
help note a) and
refer page 43 for
additional notes
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Phenoxymethylpenicillin
500mg QDS
for 10 days
Updated February 2017v.3
Penicillin
Allergy
Help Notes
See second line
agent
a)
OR: if patients find it difficult taking Phenoxymethylpenicilllin
they may find amoxicillin more palatable: Refer: help note (f)
and (i)
b)
N.B Always check the children’s BNF for calculation of
doses in children
Amoxicillin
500mg TDS
10 days
d)
c)
e)
f)
Second Line Drug (s)
Clarithromycin
250-500mg BD
for 5 days
g)
h)
i)
j)
k)
42
Remember that many sore throats
are viral, and thus you should have
a considered intention to treat for
bacterial infections e.g. Strep.
pyogenes.
In penicillin allergic patients use
clarithromycin first line.
Consider giving ‘a delayed
prescription’ i.e. ‘if you are no better in
48 hours, then take your antibiotic’.
Consider a throat swab prior to
treatment for recurrent infections.
For severe infections, consider
phenoxymethylpenicillin 1g qds for 10
days.
Amoxicillin may be used instead of
penicillin for children, because of
better taste and absorption and
tolerability
For recurrent infections, more
prolonged & aggressive therapy may
be required.
Consider diphtheria, if travel history is
appropriate.
Where there is strong clinical
suspicion of Glandular fever as part
of the differential diagnosis, do not
prescribe amoxicillin for the
patient. If antibiotics are indicated for
possible concurrent or suspected
bacterial pharyngitis, where Glandular
fever is also suspected, phenoxymethyl penicillin v should be the agent
of choice’.
Consider glandular fever within
differential diagnosis.
N.B Always check the children’s BNF
for calculation of doses in children
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Pharyngitis
Common Pathogens:
VIRUSES
Less commonly -
Streptococcus pyogenes;
Haemophilus influenzae (under 5’s)
Clinical Details:
1. The Health Protection Agency state that antibiotics should be avoided as 90% of cases resolve in 7 days without them and pain only
reduced by 16 hours. Consider giving only advice and/or advice sheet and/or a delayed prescription to be dispensed only if the condition
does not improve in 2 - 3 days along with analgesics for symptom relief.
2. If centor score 3 or 4: (Lymphadenopathy; No cough; Fever; Tonsillar Exudate) consider 2 or 3 day delayed or immediate antibiotics. The
presence of 3 or 4 of these clinical signs suggests the chance of having Group A beta-haemolytic streptococcus (GABHS) is between 40
and 60% so patient may benefit from an antibiotic.
3. Only 30% of throat infections are bacterial in origin. This may be up to 50% in the 4 -13 yrs age group. Streptococcal throat infections
are less common in infants; other organisms in infants include Haemophilus for which amoxicillin is appropriate first line therapy.
4. Viral and bacterial throat infections are indistinguishable except for Scarlet Fever (causative organism - Strep. pyogenes). However, both
are usually self-limiting. There is some evidence that recurrence and relapse may be more common in those who have had early
treatment with antibiotics and patients are more likely to return to their GP.
5. Severe pharyngitis, pronounced systemic features and scarlet fever have been suggested as diagnostic features to prompt antibiotic
treatment.
6. Complications such as abscess (quinsy), rheumatic fever and kidney problems are rare, and outcomes are not affected by a short delay
in treatment.
7. Penicillin is the drug of choice for treating Strep. pyogenes infection, but children may prefer the taste of amoxicillin syrup.
Precautions:
Avoid amoxicillin or ampicillin if there is a possibility of glandular fever, since the combination nearly always produces a rash. Clarithromycin
would be a suitable alternative.
43
Fifth Edition
Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Penicillin
Allergy
(Topical treatment)
Oral Candidiasis
Drug
Dose
Duration
Miconazole oral gel
2.5ml QDS
Continue treatment
48 hours after lesions
have resolved.
See BNFc for
paediatric doses
Updated February 2017v.3
Help Notes
a)
b)
NB : MHRA Drug safety alert: topical miconazole including oral gel
reminder of potential for serious interactions with warfarin
Second line drug(s) If miconazole unsuitable consider
nystatin but be aware of increased volume needing to be
prescribed/course and associated 7-fold cost increase if higher
dose prescribed in line with new dosing as per BNF /Nystan®
licensing
Nystatin suspension
4-6ml QDS from
Continue treatment
100,000 units/ml
the age of 2 years 48 hours after lesions
have resolved.
See BNFc for
paediatric doses
NB: Generic nystatin products still licensed at 1ml QDS for
adults and PHE still recommend this dose as current guidance
not currently updated. Please note sufficient suspension is
required to coat the entirety of the mouth as nystatin is only effective
where it is in physical contact.
Extensive or severe infection (Systemic treatment)
Fluconazole
50mg/day
for 7-14 day
44
c)
d)
e)
f)
g)
h)
Oral candidiasis is unusual in
immunocompetent individuals without clear
predisposing factors; e.g. recent antibiotics or
steroid treatment.
In neonates, miconazole oral gel may be
preferential.- NB – off licence
Data extrapolated from trial in infants &
immunosuppressed people suggest nystatin
is not as effective as topical miconazole &
therefore not proposed as first line treatment
Oral candidiasis is a common opportunistic
infection, caused by the overgrowth of
Candida spp., most commonly Candida
albicans.
Predisposing factors include antibiotic or
cytotoxic drug therapy, dentures, smoking,
diabetes mellitus, high carbohydrate diet,
malignancies and immunosuppressive
conditions (including HIV), oral and inhaled
steroids.
The management of individual patients will
depend on the underlying predisposing
condition. Symptoms may resolve simply on
withdrawal of antibiotic or cytotoxic therapy.
Prophylactic antifungal treatment may be
necessary in some groups of patients.
For patients on current cytotoxic therapy,
seek advice from oncology team.
Inhaled corticosteroid users should be given
oral hygiene advice and encouraged to use a
spacer (when appropriate to the device).
Immunocompetent children should only
receive topical treatment.
Fifth Edition
Infection
Acute
sinusitis
Many cases will
be viral, therefore
will not require
antibiotics – see
help note a)
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Amoxicillin
For 7 days
500mg TDS
Second line drug (s)
Oxytetracycline
OR
250mg QDS
Doxycycline
200mg stat, then
100mg od
Updated February 2017v.3
Penicillin
Allergy
Help Notes
See second line
agents
a) Many cases will be viral,
For 7 days
b)
For 7 days
c)
Chronic
Sinusitis
First Line Drug (s)
Co-amoxiclav
625mg TDS
For 7 days
d)
e)
f)
g)
45
therefore will not require
antibiotics. Only 30-40%
will have bacterial infection.
Antibiotics should be used
when there is systemic
illness, or several severe
signs and symptoms that last
longer than 7-10 days, or
worsen after 5-7days.
If infection severe, consider
increasing amoxicillin dose to
1g tds for 7 days (off licence
use).
Consider 7 day delayed or
immediate antibiotic when
purulent nasal discharge.
Ensure appropriate
analgesics are given.
Symptoms may persist for 23 weeks regardless of
antibiotics.
For persistent infection
(frequently relapsing)
sinusitis, consider referral,
and/or consider co-amoxiclav
625mg for 7 days.
In penicillin allergic patients
use oxytetracycline or
doxycycline.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
SKIN AND SOFT TISSUE INFECTIONS
Infection
Animal and Human
Bites
Insect Bites:
N.B For antibiotic
management of
insect bites please
refer to section of
guidelines on
‘Bacterial skin
infection treatment
cellulitis and
Erysipelas’
Reference page 49
First Line Drug (s)
Drug
Dose
Duration
Co-amoxiclav
For 7 days
625mg TDS
The blood borne contamination incident policy can be
found on the Worcestershire Health Services website:
www.worcestershirehealth.nhs.uk / Infection Control
Services / policies and procedures / Blood borne
contamination incident policy- Appendix i
Penicillin
Allergy
Help Notes
If ‘high risk’ i.e.
severe bite i.e.
deep penetration of
bite, cat or dog bite,
delayed
presentation:
a)
c)
d)
Ciprofloxacin
500mg BD
AND
Clindamycin 450mg
QDS for 7 days
(N.B prescribe
with caution in
elderly patients
due to C.difficile
risk)
If not ‘high risk’ or
severe bite:
Doxycycline 100mg
BD
AND
Metronidazole
400mg TDS for
7 days
46
b)
e)
f)
g)
Superficial bites where the skin is not
broken require local treatment only.
Puncture wounds/penetrating bites
should always be treated with
antibiotics.
In children, use co-amoxiclav, but in
cases of penicillin allergy seek
microbiology advice.
For human bites consider bloodborne viruses. Follow the blood borne
contamination incident policy.
Consider rabies immunisation if bitten
abroad. Contact Microbiologist oncall / CCDC.
Pasteurella multocida (dog and cat
bites) is mostly sensitive to penicillin,
but local treatment such as cleaning,
irrigation or debridement is also
helpful.
Check tetanus status.
Fifth Edition
Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Penicillin Allergy Help Notes
Duration
Bacterial skin
Infections
Impetigo:
For non-serious
/non spreading
Fusidic Acid
Topical
QDS
Updated February 2017v.3
For 5 days
a)
DO NOT use on extensive areas, reserve
use for very localised lesions only to reduce
risk of resistance, NOT for repeated use
b)
Topical mupirocin MUST be reserved for
known MRSA infection or PVL toxin
associated staphylococcal colonisation.
Topical antimicrobial / antiseptic liquids and
soaps are effective in reducing bacterial
colonisation. (e.g. Octenisan®) available on
FP10 / chlorhexidine or suitable available
alternatives as recommended by Infection
Control
c)
For recurrent,
extensive, severe or
bullous impetigo
Flucloxacillin
Oral
500mg QDS
For 7 days
Eczema
In eczema with visible signs of infection, use
treatment as in impetigo (as above)
47
Clarithromycin 500mg
BD for 7 days.
If no visible signs of infection in eczema, use of
antibiotics (alone or with steroids) encourages
resistance and does not improve healing
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
PVL Staphylococcus aureus
Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and is a virulence factor in some
strains of Staphylococcus aureus. Strains of PVL-SA producing a new pattern of disease have emerged in the UK
and worldwide. In the UK the genes encoding for PVL are carried by < 2% of clinical isolates of S.aureus
submitted to the national Reference Laboratory, whether methicillin sensitive (MSSA) or methicillin-resistant
(MRSA).
Like other S.aureus strains, PVL-SA predominantly cause skin and soft tissue infections (SSTI), but can also cause
invasive infections. The most serious of these is a necrotising haemorrhagic pneumonia with a high mortality,
which often follows a ‘flu-like’ illness, and may affect otherwise healthy young people in the community.
Diagnosis and Management of PVL-Staphylococcus aureus infections: Quick Reference Guide for Primary
care:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/391168/PVL_guidance_in_primary_c
are_quick_reference_guide.pdf
For guidance on local decolonisation please refer to MRSA colonisation eradication of carriage guidance
on page 55
48
Fifth Edition
Infection
Bacterial Skin
Infections Cellulitis and
Erysipelas
Insect Bites:
N.B Same treatment
protocol above for
the management of
bacterial skin
infections applies for
the management of
insect bites aswell
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Flucloxacillin
For 7 days.
500mg QDS
If slow response
continue for a
further 7 days
N.B Home IV therapy may be considered for cases
that fail to respond.
Before starting IV therapy, consider optimising oral
therapy by increasing dose of oral flucloxacillin to 1g
QDS.
Oral clindamycin 450mg QDS may also be added.
Refer to Worcestershire guidelines for IV antimicrobial
therapy at home for adults
If there is treatment failure at 7 days - refer to IV team
Reference: (www.hacw.nhs.uk WHCT clinical
policies)
49
Updated February 2017v.3
Penicillin
Allergy
Help Notes
Clarithromycin
500mg BD for 7
days
OR
Clindamycin
450mg QDS for
7 days
a)
b)
c)
d)
e)
f)
g)
h)
i)
In rapidly spreading cellulitis, consider
parenteral antibiotics - potential medical
emergency.
Diabetic patients are a special subgroup &
require a different approach - see additional
notes page 51.
For recurrent cellulitis of lower limb, exclude
fungal foot infections e.g. infected in-growing
toe nails.
Beware puncture wounds – consult
microbiologist.
For penicillin allergy, discuss with microbiology
for difficult cases. Stop clindamycin if diarrhoea
occurs.
For unusual circumstances e.g. after travel
abroad, unusual exposure to salt or fresh water,
refer to microbiologists.
For orbital cellulitis, use co-amoxiclav 625mg
tds for 7-14 days. This condition often requires
hospital referral.
For facial cellulitis, use co-amoxiclav 625mg tds
for 7-14 days.
If a patient is known to be colonised with MRSA
Please check reported sensitivities: oral
doxycycline can be used on an empirical
prescription
Fifth Edition
Infection
Cellulitis
Associated with
Lymphodema
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Flucloxacillin
500mg QDS
Updated February 2017v.3
Help Notes
Duration
Penicillin
Allergy
a)
For no less
than 14 days.
Clarithromycin
500mg BD For no
less than 14 days
b)
If there is no response after 48 hours:
c)
Recurrent
Cellulitis
Clindamycin
450mg QDS
For no less
than 14 days
Phenoxymethylpenicillin
500mg daily (1
gram if weight
greater than
75kg)
Then after
one
successful
year reduce
to 250mg
daily, then
after another
successful
year stop.
50
d)
Clarithromycin
250mg daily for
two years if
successful, then
stop
e)
f)
Refer to full lymphodema guidelines for the
management of these patients. The
management of this group of patients is
multifactorial of which antibiotic treatment is
only a part.
It may take as long as 1-2 months of treatment
to achieve complete resolution.
If diarrhoea develops, stop antibiotics and
consult microbiologists.
If patient is known to be colonised with MRSA,
consider doxycycline. A second agent may
need to be added e.g. fusidic acid or rifampicin
for optimal tissue penetration. Seek further
advice from a consultant microbiologist.
The risk of further attacks is high, so consider a
two week home supply.
Prophylaxis may need to be life-long if relapse
occurs when antibiotics are discontinued after a
two-year period of successful prophylaxis.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Bacterial Skin Infections - Cellulitis
Common Pathogens:
S aureus (including MRSA)
Pyogenic Streptococci (A,C,G)
PVL S.aureus
Deep ulcers – anaerobes
1.
2.
3.
4.
5.
6.
Less common pathogens
Coliforms (commensal - rarely pathogenic)
Pseudomonas aeruginosa (can be a commensal)
Klebsiella spp.
Enterobacter spp.
Clinical Details:
Cellulitis: (also refer to local dressings, leg ulcer policies and lymphodema guidelines)
All cases of cellulitis should be treated promptly, to reduce the risk of development of septicaemia. In most cases the causative agent is
the group A beta-haemolytic streptococcus. Secondary infection with Staph. aureus is relatively common, especially in diabetic patients.
Cellulitis in special groups such as immunocompromised patients and diabetics may be due to other less common pathogens as well.
H. influenzae cellulitis is occasionally seen in children, often orbital. Treatment here should be co-amoxiclav (IV cefotaxime may be
necessary). Cellulitis can develop into necrotising infections e.g. anaerobic cellulitis and gas gangrene. Like rapidly spreading cellulitis,
these are regarded as medical emergencies, and need urgent referral.
Diabetic patients: Whilst staphylococcal skin infections are common in diabetics, other organisms can often be present. Coliforms
(including E. coli & Klebsiella spp.) and group B streptococci can cause infection in diabetics in areas of ischaemia, trauma or abdominal
surgery. Pseudomonas is also an opportunistic pathogen in diabetic skin infections.
For Diabetic foot infections: start treatment but refer to podiatry to establish and manage the underlying cause. Consider taking
swabs, but start treatment with antibiotics. Signs of active clinical infection such as increasing pain, spreading cellulitis, exudates and
pus should be treated with co-amoxiclav 625mg tds for 7 days. Review after one week and consider a further supply and/or send swab
to microbiology. If patient allergic to penicillin or any queries relating to choice of antibiotic – discuss with microbiology. Refer to local
guidelines on referral of patients with diabetes to podiatry and NICE guidelines on diabetic foot problems.
If necrotic tissue present may require early debridement and high dose intravenous antibiotics – close review is essential.
Flucloxacillin oral solution may be poorly tolerated by some individuals, thereby comprising compliance; in such situations co-amoxiclav
may be substituted. Cases should be considered on an individual basis.
Furunculosis and folliculitis:
Oral antibiotic treatment is rarely necessary, and topical chlorhexidine may be helpful in reducing recurrent episodes. Flucloxacillin
should be used if there is a facial abscess.
51
Fifth Edition
Infection
Leg Ulcers
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Flucloxacillin
500mg QDS
Duration
For 7 days. If
slow response
continue for a
further 7 days.
Updated February 2017v.3
Penicillin
Allergy
Help Notes
Clarithromycin
500mg BD for 7
days.
a) Ulcers are always colonized. Antibiotics
do not improve healing unless active
infection. Active infection is present if
cellulitis / increased pain / pyrexia / purulent
exudate / odour.
b) If active infection present, send pretreatment swab. Review antibiotic
choice after culture results.
Reference: leaflets for further
information and guidance:
http://cks.nice.org.uk/leg-ulcer-venous
If slow response
continue for a
further 7 days.
c) Refer to ‘Guidelines for the assessment
of the patient with leg ulceration’ January
2013, available on the Worcestershire
Health and Care Trust website
(www.hacw.nhs.uk – WHCT clinical policies)
Consider use of topical antimicrobial wound
dressings if patient presents with evidence
of critical colonisation or infection.
52
Fifth Edition
Infection
Mastitis
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Flucloxacillin
for 7 days
500mg to 1g QDS
N.B It is anecdotally
reported that
flucloxacillin can cause
a change in the taste of
breast milk which can
affect the tolerability of
this antibiotic in breast
feeding mothers
Penicillin
Allergy
Help Notes
Clarithromycin
500mg BD for 7
days
a)
OR 2nd line
Clindamycin
450mg QDS for 7
days
Second Line Drug (s)
Co-amoxiclav
Updated February 2017v.3
b)
c)
d)
625mg TDS
for 7 days
e)
f)
53
Mastitis usually caused by
Staphylococcus aureus (in all age
groups). Less frequent causes include
streptococci, atypical mycobacteria
(especially around breast prosthetic
implants) and Gram negative bacteria.
Occasionally tuberculosis may need to
be considered.
When fluctuance present, consider
aspiration, or referral for surgical
drainage.
Fungi and candida are rare causes of
mastitis. There is very little evidence
to support the concept of candida as a
cause of deep breast pain in lactation.
Avoid drying/cracking of nipples during
lactation. See www.cks.library.nhs.uk
for patient information leaflets.
Other measures include breast
support, ice packs and analgesics.
Breast feeding may continue unless
an abscess develops.
Fifth Edition
Infection
MRSA Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Skin Lesions (small)
Mupirocin
TDS
cream/ointment
Duration
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a)
for 7-10 days
Mild to moderate infection requiring systemic
treatment: Treat empirically
b)
c)
Doxycycline 100mg BD for 5-7 days
ALL CASES: SEND SAMPLE FOR SENSITIVITY TO
GUIDE TREATMENT
If culture and sensitivity results available prior to
commencing therapy recommend select agents as per
reports sensitivities of isolate.
See Wound Management guidelines for the treatment of
infected wounds
N.B. Please note the dual combination of sodium fusidate
and rifampicin together for treatment of infection is not
advised; it is ineffective and can encourage further
resistance.
Evidence of systemic or invasive infection: please give
consideration to contacting the Home IV team for
treatment with IV agents. Tel: 01905 681818 and enter the
options as indicated for the relevant locality
54
d)
e)
Infected/Colonised wounds can
be dressed with antimicrobial
product e.g. iodine, silver or
honey based preparation as
indicated in wound management
formulary. Where possible
wounds should be accluded with
povidone iodine or chlorhexidine
dressing.
Avoid prolonged or repeated
treatments.
Mupirocin ointment must not be
applied to large wounds (risk of
nephrotoxicity with polyethylene
glycol base)
Mupirocin ointment may also
damage PEG sites and other
plastic devices e.g. central
venous lines.
Send specimens for sensitivity
testing to guide appropriate
combination therapy.
Fifth Edition
Infection
MRSA
COLONISATION:
Eradication of MRSA
Carriage
Nasal Carriage
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Penicillin Allergy
Dose
Help Notes
Duration
a)
Mupirocin nasal ointment
TDS
N.B For strains resistant to
mupirocin use Naseptin®
nasal cream QDS for 10
days. Do not use in
known peanut and/or soya
allergy.
Skin Carriage
Updated February 2017v.3
Octenisan® antimicrobial
wash lotion
AND
Chlorhexidine acetate 1%
dusting powder (CX
antiseptic dusting
powder®)
use
daily
For 5 days. Use
only if known to
be sensitive and
for 2 courses
only.
b)
c)
For 5 days.
d)
e)
Applied For 5 days to
daily
intact axillary or
groin areas.
N.B If patient has isolated PVL S.aureus and needs
decolonisation then use above regime for treatment refer to section on PVL
S.aureus infections for further detail within the guidelines – Refer page 48
55
Many laboratory reports of
MRSA indicate colonisation not
clinical infection.
The decision to treat MRSA
carriage will depend on the
clinical setting – please see local
infection control policy or discuss
with the microbiologist/infection
control team
®
Octenisan wash lotion should
be used like a shower gel daily,
with a contact time of 1 minute
on the skin. It also should be
used 2 out of the 5 days like a
shampoo on the hair. (Available
on FP10).
Advice can be sought from the
community IPC Team to
enhance the effectiveness of
decolonisation regime.
Throat carriage : significance
is unclear discuss all cases
with a microbiologist
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Penicillin Allergy
Updated February 2017v.3
Infection
First Line Drug (s)
Topical treatment
Drug
Dose
Help Notes
Acne
Benzoyl peroxide 5%
a)
Second line drug (s)
Topical treatment
b)
Benzoyl peroxide 5% + clindamycin 1% topical
solution e.g. Duac® once daily
c)
Duration
Third line drug (s)
Oral treatment
d)
Oxytetracycline
500mg BD
Continue for at
least 4-6 months
OR
Lymecycline
408mg daily
Continue for at
least 4-6 months
OR
Doxycycline
100mg daily
Continue for at
least 4-6 months
e)
f)
56
Resistance of P.acnes to both
topical and oral antibiotics is
rapidly developing. Topical
antibiotics should not be used as
monotherapy.
For comedonal acne topical
retinoids are the treatment of
choice. Avoid using in pregnancy.
Mild infection can be treated with
topical antibiotics or benzoyl
peroxide (NB: Peroxides are
generally cheaper).
All tetracyclines are probably
equally effective, but are contraindicated for use in children under
12 years, pregnant and breastfeeding women. With the
exception of doxycycline, the
tetracyclines may exacerbate
renal failure and should not be
given to patients with kidney
disease. They should be used
with caution in patients with
hepatic impairment or those
receiving potentially hepatotoxic
drugs.
Tetracyclines may cause
photosensitivity.
Avoid minocycline due to risk of
heptatotoxicty
Fifth Edition
Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Fungal Skin
Infections
Dose
Penicillin Allergy
Updated February 2017v.3
Help Notes
Duration
Topical agents (also available without prescription)
e.g. Imidazole creams,
Terbinafine 1%,
Undecanoic acid
Ketoconazole shampoo (for pityriasis versicolor)
Terbinafine oral
250mg OD
for 2-4 weeks
Itraconazole
200mg OD
for 7 days
(pitiriasis
versicolor)
57
a) Take scrapings for culture
b) Use topical creams if mild disease
c) For extensive athlete’s foot, oral
terbinafine for 2 weeks should be
considered. If imidazole creams are
used (e.g. clotrimazole, econazole,
miconazole) 4-6 weeks therapy may
be required (i.e. continue 1-2 weeks
after healing.
®
d) Mycota is an undecanoate
preparation licensed for use in
children.
Terbinafine is not licensed for use in
children.
e) For patients on current cytotoxic
therapy, seek advice from
oncology team.
Fifth Edition
Infection
Fungal Nail
Infections
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Penicillin Allergy
Updated February 2017v.3
Help Notes
Duration
Amorolfine 5%
nail lacquer
1-2 times
weekly
6 months
(fingers)
12 months (toes)
Terbinafine
Oral 250mg OD
6-12 weeks
(fingers)
3-6 months
(toes)
Itraconazole
Oral pulsed
courses of
200mg bd
7 days, repeated
after a 21 day
interval (finger
nails generally
require 2
courses, toenails
3 courses)
58
a) Consider whether
investigation/treatment is appropriate.
b) Take clippings for culture.
c) Topical treatment is expensive and
only appropriate where infection is
limited to distal end of nails.
d) Nail infections are usually trivial in
most cases, but treatment actively
recommended in diabetic, elderly
patients or peripheral vascular disease
to prevent a portal of entry for more
severe infection.
e) Monitor liver function according to
manufacturer’s guidance.
f) For patients on current cytotoxic
therapy, seek advice from oncology
team.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Fungal Infections
Common Pathogens:
Nail infection - Dermatophytes
Athlete’s Foot, Ringworm - Tinea
Clinical Details:
1. Oral itraconazole is an alternative first line treatment for nail infection in people unable to tolerate terbinafine. Oral itraconazole has
not demonstrated cure rates that are as good as those for terbinafine, but it may be useful in people with severe immunosuppression
who have suspected counter infection with yeasts.
2. Non-dermatophyte fungal nail disease (onychomycosis), use itraconazole or topical amorolfine (mild distal disease only), in dosing
schedules as previously specified.
3. Tinea capitis (scalp ringworm). The association of inflammation in the scalp with loss of hair and broken hairs should
make one suspicious of scalp ringworm. Pluck hairs for mycology and do not rely on scraping alone. Topical treatments for scalp
ringworm are not effective. Do not rely on Wood’s Light to make the diagnosis. Many fungi that cause scalp ringworm are Wood’s
Light negative. Treatment - oral griseofulvin 10mg /kg/day or terbinafine for 6 to 8 weeks. Discuss with specialist.
4. Tinea corporis/cruris - use topical terbinafine cream 1% twice daily for 2 -4 weeks, or oral terbinafine 250mg daily for 2 weeks if
severe.
5. For treatment in children, seek specialist advice.
Precautions:
Use topical treatments in pregnancy.
59
Fifth Edition
Infection
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Parasite Infections
- Including
scabies
Detailed advice is given in
the Parasite policy,
produced by the Public
Health England.
https://www.gov.uk/search
?o=PARASITE+INFECTIO
N+GUIDELINES&q=parasit
es+infection+guidelines&st
art=100
Additional sources for help
and advice are the
Infection Control Policies &
Procedures produced by
the Worcestershire Acute
Hospitals NHS Trust.
Penicillin
Allergy
Dose
Updated February 2017v.3
Help Notes
Duration
®
For both preparations, apply 2 applications, one
week apart (see patient leaflet for further details).
Ensure sufficient quantity is prescribed to cover body
size.
Permethrin dermal cream 5% (Lyclear )
OR ( if allergy to above)
Malathion 0.5% in aqueous base (Derbac M liquid®)
1.
2.
Brief treatment guidelines
for Head Lice infections are
as follows on the next
page, page 61:
3.
4.
5.
6.
60
Since symptoms take several weeks to
appear, it is easy for close contacts to
become infected before the disease is
suspected. Therefore, all close (body)
contacts (whether symptomatic or not)
should be treated at same time as the index
case. Non-compliance by just one
individual may make the difference between
a success or failure of a planned treatment.
The manufacturer’s instructions must be
followed carefully.
Treat all home and sexual contacts with 24
hours treatment course or according to the
manufacturer’s recommendations. Treat
whole body from ear/chin downwards and
under nails. If under 2 or elderly, also treat
face and scalp.
®
Do not use Lyclear dermal cream in
pregnant or breast feeding women, nor in
®
very small children. Derbac M liquid may
be used with caution in pregnancy.
For crusted scabies, seek advice from
Health Protection Team.
Outbreaks of scabies in care homes must
be reported to Public Health England.
Specialist advice will be given for treatment
of residents and staff.
Bedding and clothing may be washed in the
normal manner. No special precautions are
necessary.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Infection
First Line Drug (s)
Help Notes
Head lice
There are 3 treatment options:
All products can be purchased from a
community pharmacy.
a) Treatment without parasiticidal liquid
The combing method is an option for those reluctant to use chemicals; however it
requires a substantial time commitment to ensure all hair is combed through, and
may fail if not done correctly.
The combing method uses a detection comb to physically remove lice from hair.
It must be undertaken every 3 days for at least 2 weeks (longer in severe cases).
The hair is washed in normal way, and towel dried. Application of conditioner
helps the comb to slide through the hair more easily; it has no inherent
parasiticidal properties, and is therefore not a treatment - it is used only as an aid
to combing. Head lice devices are now available on prescription, see Drug Tariff
for details.
b) Treatment with other products
Dimeticone 4% lotion (Hedrin®) has a physical rather than chemical mode of
action and so has potential benefits as an alternative to conventional chemical
insecticides as no resistance towards it has been documented.
When covered by dimeticone in its silicone solvent, lice become immobilised,
from which they never recover. Dimeticone is not absorbed transdermally.
c) Treatment with a parasiticidal liquid
Malathion (e.g. Derbac M liquid®) is a parasiticidal liquid. One product should be
used for a course of treatment (2 applications, 7 days apart); if this fails, then
another product with a different active ingredient should be tried.
Check if treatment failure is due to using the product incorrectly. There is no
effective preventative therapy for head lice and parasiticidal preparations used to
treat head lice have no residual effect.
61
Fifth Edition
Infection
Shingles
Severe Shingles
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Aciclovir
for 7 days
800mg 5 times
a day
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a)
b)
Treatment should be
considered for adults >50
years of age and within
72 hours of rash (PHN
rare if <50 years), and
adults of any age who:
- present with severe
acute pain + extensive
rash
- have ophthalmic
involvement (requires
urgent referral to
ophthalmology)
- immunocompromised
- have Ramsay Hunt
syndrome
- have atopic eczema
- have contacts with
very young infants,
immunocompromised
people or pregnant
women.
c)
d)
e)
62
Start as early as practicable, and
within 72 hours of start of symptoms.
Reduces pain & post herpetic
neuralgia. Predictive factors for postherpetic neuralgia are: elderly;
extensive rash within 72 hours;
severe/prolonged prodromal pain.
See APC guidelines for treatment of
neuropathic pain.
Consider underlying
immunosuppression secondary to HIV.
N.B for pregnant patients,
immunocompromised and neonates
seek urgent and specialist advice
Fifth Edition
Infection
Chickenpox
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Aciclovir
for 7 days
800mg 5 times
a day
Penicillin Allergy
Treatment should be
considered:
If started <24hours of
rash and >14 years
of age or
severe pain or
dense/oral rash or
secondary household
case or steroids or
smoker.
Updated February 2017v.3
Help Notes
a)
b)
c)
d)
63
Consider treatment in any adult
seen within 24 hours of onset of
disease.
Severely affected individuals may
need hospital admission.
Treatment is not generally
indicated for immunocompetent
children, where the disease is
usually milder. Chickenpox is
occasionally lethal in adults.
Secondary bacterial skin infections
may occur.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Additional Notes: Chickenpox and Shingles
Pathogens:
Chickenpox – Varicella zoster
Shingles – Herpes Zoster
Clinical details:
Pregnant women or immunosuppressed individuals in contact with chicken pox or shingles:
 Ask about history of chickenpox or shingles.
 Reassure those with definite clinical history of previous chickenpox that they are immune and are not at risk of re-infection.
 Those without a definite clinical history should be screened for immunity (10ml clotted blood to microbiology). For pregnant women,
this test can be performed on stored ‘booking’ blood sample. Please contact microbiology. Note: approximately 50% of patients who
do not have a history of chickenpox are in fact, immune. If found to be non-immune, then Varicella-zoster Immunoglobulin (VZIG) may
be issued to reduce risk of severe infection providing the last contact was within 7-10 days. Advice will be given by a microbiologist,
and then VZIG issue arranged.
 In pregnancy, VZIG may currently (depending on availability of supplies) be administered at any gestation.
 Neonates (first 7 days of life) born to non-immune mothers, and exposed to chicken pox should receive VZIG.
 Systemic therapy with aciclovir should be considered in patients who develop chickenpox despite VZIG, or present too late for
VZIG treatment to be appropriate.
Cold Sores:
Cold sores resolve after 7 – 10 days without treatment. Topical antivirals applied prodomally reduce duration by 12-24 hours.
64
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
ENTERIC AND INTRA-ABDOMINAL INFECTIONS
Infection
First Line Drug (s)
Drug
Dose
Salmonella/Shigella
Ciprofloxacin
500mg BD
Antibiotics are rarely
Required
Penicillin Allergy
Duration
For 3 days (see
help note b)
NB : remember
oral rehydration
Help Notes
a)
b)
c)
d)
Campylobacter
Giardia Infection
Clarithromycin
Metronidazole
250-500mg BD
2g OD
For 5-7 days if
treated early.
See help note (g)
For 3 days
Antibiotic Associated
Stop offending antibiotic and / or PPI where possible –
Diarrhoea
see separate guidance on following page.
(If laboratory has
confirmed this is
caused by Clostridium
difficile then refer to
guideline on page 66
for treatment guidance)
NOTE:
e)
For Helicobacter pylori eradication: see BNF and NICE Dyspepsia guidelines.
NICE guidelines on website, reference: http://www.mims.co.uk/combinationregimens-eradication-h-pylori-nice-guidance/gi-tract/article/882106
The vast majority of enteric and intra-abdominal infections are self-limiting
and do not require systemic treatment **Antibiotics are rarely required**
65
f)
g)
In acute food poisoning, avoid
antibiotics.
Only treat with ciprofloxacin, where
the patient is very systemically
unwell, particularly the
elderly/debilitated.
Food poisoning cases are
notifiable to CCDC in Health
Protection Unit.
Take stool cultures. This is
particularly important for young
children, patients who have been
abroad, or have bloody diarrhoea.
Enteric fevers
(Typhoid/Paratyphoid): longer
treatments are required as guided
by microbiologists.
Cryptosporidium is a selflimiting infection with no proven
treatment. Duration of diarrhoea
may be longer than with other
gut infections.
It is recognised that
ciprofloxacin is not as effective
as other antibiotics for treatment
of campylobacter due to high
levels of resistance, therefore
this is treated with
Clarithromycin
Fifth Edition
Infection
Clostridium
difficile associated
diarrhoea
Most commonly follows
antibiotic use, and
although often associated
with hospital admission,
may also follow antibiotic
therapy in the community.
Stop offending antibiotic
where possible and /or PPI
– this may be sufficient to
relieve symptoms in mild
cases.
DO NOT USE antidiarrhoeal agents (e.g.
loperamide)
Admit if severe:
T>38.5; WCC >15,
rising creatinine or
signs/symptoms of
severe colitis
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Mild/moderate cases:
1st / 2nd episodes
(N.B DO NOT delay treatment pending stool testing if strong
suspicion- relapse common if treatment stopped prematurely)
Metronidazole
400mg TDS
If responding,
continue for 14 days
If no improvement with above regimen within 3-5 days
change to oral vancomycin as below:
Vancomycin orally
125mg QDS
If responding,
continue for 14
days.
3rd episode
Vancomycin orally
125mg QDS
for 14 days
If not responding to above regimen within 3-5 days
increase dose to 250mg QDS and complete 14 days on
this increased dose.
Further relapses
Vancomycin 250mg QDS for 14 days,
then gradually reduce: as a tapering course as below
125mg QDS for 1 week, then
125mg TDS for 1 week, then
125mg BD for 1 week, then
125mg OD for 1 week, then
125mg alternate days for 2 weeks, then
125mg every 3rd day for 2 weeks. Admit if severe: T>38.5; WCC
>15, rising creatinine or signs/symptoms of severe colitis
66
Penicillin
Allergy
Updated February 2017v.3
Help Notes
a) Send stool specimen whenever
C.difficile suspected (recent hospital
admission, antibiotic use, blood/mucus
in stools)
b) Whenever possible, avoid antibiotics
in patients known to have had C.difficile
disease. Ask for microbiology advice if
antibiotics are necessary.
c) Avoid use of cephalosporins,
quinolones and clindamycin.
d) PPIs increase risk of C.difficile.
e) Observe good infection control
practice, particularly in community
hospital and care home settings (refer
to infection control policy)
f) If patient requires hospital
admission, inform admitting team if
known or suspected to have C.difficile
disease.
g) Use of oral vancomycin does not
require therapeutic drug monitoring.
h) The use of probiotics as part of a
balanced diet may be useful in
relapsing disease.
N.B: If at any point the patient
deteriorates refer to microbiology or
Hospital immediately
Fifth Edition
Infection
Diverticulitis
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Co-amoxiclav
For at least 7 days
625mg TDS
Updated February 2017v.3
Penicillin
Allergy
Help Notes
Ciprofloxacin 500mg
BD
a)
AND
Second Line Drug (s)
Ciprofloxacin 500mg BD
Metronidazole
400mg TDS
AND
b)
c)
For at least 7 days
Metronidazole 400mg TDS
for at least 7 days
d)
e)
67
Prescribe paracetamol for pain –
nonsteroidal anti-inflammatory
drugs (NSAIDS) and opioid
analgesics have been identified as
risk factors for diverticular
perforation
Recommend clear fluids only.
Gradually reintroduce solid food as
symptoms improve over 2-3 days.
Always review patients within 48
hours or sooner if symptoms
deteriorate. Arrange hospital
admission if symptoms persist or
deteriorate.
When patients require admission,
give appropriate IM analgesia for
moderate to severe pain.
Be aware of possible risk of
C.difficile disease in patients
taking antibiotics, particularly with
the use of ciprofloxacin. Stop all
antibiotics if diarrhoea develops
Fifth Edition
Infection
Cholangitis
.
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
First Line Drug (s)
Drug
Dose
Duration
Co-amoxiclav
for 5 days
625mg TDS
Updated February 2017v.3
Penicillin Allergy
Help Notes
See second line drugs
a)
b)
Second Line Drug (s)
Ciprofloxacin 500mg BD for 5 days
c)
d)
68
If at any point a patient
deteriorates, then they should be
referred immediately to hospital.
Acute cholecystitis or cholangitis
are potentially medical
emergencies, and unwell patients
should be urgently referred to
hospital for confirmation of
diagnosis, monitoring, surgical
assessment, and intravenous
fluids, antibiotics and analgesia.
Patients who are not unwell, or
who have mild intermittent
symptoms, may be considered for
routine referral to hospital for outpatient assessment and further
investigation. Whilst awaiting this
referral, it may be appropriate to
offer analgesia and oral antibiotics.
The commonest organisms
causing biliary infection within the
UK are Klebsiella spp., E.coli, and
streptococci (including
enterococci). If antibiotic treatment
is required, then appropriate
choices are as stated
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Miscellaneous
Infection
First Line Drug(s)
Topical
Drug
Eye Infections
(If severe):
N.B: Many
conjunctiva
infections are selflimiting (64%
resolve on placebo
by day five) and
therefore do not
require treatment
Dose
Duration
Penicillin
Allergy
Help Notes
a)
Chloramphenicol
0.5% eye drops
2 hourly
AND
At night (if drops
Chloramphenicol 1% used during the
ointment
day)
Sole use : Apply
TDS-QDS
For 2 days, then 4
hourly (whilst
awake)
b)
c)
All for 48 hours
after resolution
d)
e)
If treatment failure - (see help notes c).
f)
g)
Chlamydia Eye
Infection
Systemic macrolide usually preferred for chlamydia eye
infection, but seek microbiological advice for details of drug
choice and dose.
69
Many conjunctival infections are selflimiting (64% resolve on placebo by day
five).
Evidence for blood dyscrasias due to
topical chloramphenicol is sparse and is
disputed.
If the response is poor and symptoms
>3 weeks, take a swab specimen.
Always take a swab specimen (using
appropriate swab) from neonates up to
4 weeks old. Chlamydia may be the
causative organism.
If chlamydia or gonococci are detected,
remember to treat the mother, and
undertake contact tracing. Refer to
GUM clinic for further assessment.
Contact lens users with frequent
infections should be referred to
ophthalmologists. Cleaning routine
should be checked.
Advise patients who pay for their
prescriptions that chloramphenicol eye
drops are cheaper to buy over the
counter if they prefer to.
Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Splenectomy and Infection
Patients without spleens are at increased risk of some types of infection, notably pneumococcal infection, and
disease caused by Haemophilus influenzae type b and Neisseria meningitidis. They are also at increased risk
from some tropical diseases including malaria.
Summary of advice
Vaccination:
All patients without spleens should be offered pneumococcal, Hib, MenB and MenC vaccines and
Meningococcal ACWY conjugate vaccine. Booster doses of pneumococcal vaccine are required every 5 years
without checking titres. Annual influenza vaccine should also be offered. Refer to green book: Immunisation of
individuals with underlying conditions for further information and links to full age related vaccination advice
Reference:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/309218/Green_Book_Chapter_7_
v1_3.pdf
Antibiotic prophylaxis:
Children < 5 years:
phenoxymethylpenicillin 125mg bd
Children 5-12 years:
phenoxymethylpenicillin 250 mg bd
Adults:
amoxicillin 250mg daily
Erythromycin may be given to penicillin allergic patients: < 2years 125mg/day
2-8 years 250mg/day
> 8 years 250 – 500mg/day.
The risk of infection is greatest in childhood, and in the first 2 years post-splenectomy. However the risk is
lifelong, and high enough to justify taking prophylaxis daily for life.
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Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Antimicrobial Prophylaxis
INFECTIVE ENDOCARDITIS
Antibacterial prophylaxis and chlorhexidine mouthwash are NOT recommended for the prevention of endocarditis in patients
undergoing dental procedures.
Antibacterial prophylaxis is NOT recommended for the prevention of endocarditis in patients undergoing procedures of the:
 Upper and lower respiratory tract (including ear, nose, and throat procedures and bronchoscopy
 Gentio-urinary tract (including urological, gynaecological, and obstetric procedures)
 Upper and lower gastro-intestinal tract.
See BNF and NICE Clinical Guideline for further details.
MALARIA
Malaria prophylaxis should not be prescribed on an NHS prescription form. Patients should be advised to purchase their medicines
from a pharmacy. Mefloquine, doxycycline and malarone are ‘prescription only medicines’ which should be provided on private
prescription for malaria prophylaxis. GPs may charge patients for the prescribing or providing of drugs for malaria prophylaxis for
travel abroad.
 Local community pharmacists have access to up to date advice about appropriate regimes and can advise travellers
accordingly.
 Regular GP literature also provides updated advice on the choice of antimalarials for different regions of the world. Clinical
Knowledge Summaries gives detailed practical advice on malaria prophylaxis. www.cks.nhs.uk
 The updated Guidelines for malaria prevention also available on
o www.nathnac.org
or
www.travax.scot.nhs.uk (subscription needed)
 Alternatively the following telephone advice lines may be used:
o Consultant in Infectious Diseases, Worcestershire Royal Hospital (see useful contact numbers on page 75)
o Liverpool School of Tropical Medicine – 0151 708 9393 www.liv.ac.uk/lstm
o Hospital for Tropical Diseases – 0845 1555 000 www.thehtd.org
o Birmingham Heartlands Hospital – Malaria Helpline – 0121 424 2000
In any case of suspected malaria in a returning traveller: take 3 thick blood films, send EDTA blood sample to haematology for
malaria screening. Contact Consultant in Infectious Diseases, Worcestershire Royal Hospital
Prophylactic medicines do not provide absolute protection against malaria. Personal protection against being bitten using
mosquito nets, insect repellents (containing DEET) and appropriate clothing is also important.
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Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Meningitis
For all suspected and confirmed cases: Consult Public Health England for advice and recommendations on dose
– Refer page 75 of guideline for contact numbers
Transfer all patients to hospital immediately. If time before admission, give IV benzylpenicillin or cefotaxime, unless
hypersensitive i.e. history of difficulty breathing, collapse, loss of consciousness, or rash. Risk benefit assessment may
allow cefotaxime to be given even with a history of penicillin allergy and certainly with a history of rash alone. Give IM if vein
cannot be found.
Benzylpenicillin:
Age 10+ years
Children aged 1-9 years
Children less than 1 year
Cefotaxime:
Age 12+ years
Child<12 years
1.2g stat IV/IM
600mg stat IV/IM
300mg stat IV/IM
1gram IV/IM
50mg/kg IV/IM
Chemoprophylaxis for close contacts (only when advised by PHE) – see help notes for further information
Ciprofloxacin – recommended for use in all age groups
Adults and children over 12 years
500mg by mouth as a single dose
Children 5 to 12 years
250mg by mouth as a single dose
Children 1 month to 4 years
125mg by mouth as a single dose
Rifampicin – recommended for use in all age groups
Adults and children over 12 years
600mg by mouth every twelve hours for 2 days
Children 1 to 12 years
10mg /kg (max 600mg) by mouth every twelve hours for 2 days
Children less than 1 year
5mg/kg by mouth every twelve hours for 2 days
In pregnancy and breastfeeding: Specific advice will be given by Public Health England
Common Pathogen
Bacterial Meningitis: Neisseria meningitidis is the commonest. Others include Haemophilus influenzae,
Streptococcus pneumoniae.
Viral Meningitis: Herpes simplex virus, enterovirus, adenovirus
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Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Meningitis
Help Notes
1. The most important course of action a GP can take in the event of a suspected case of meningococcal infection is to arrange an
emergency hospital admission by ambulance. Parenteral preadmission antibiotics may also be indicated.
2. Meningococcal meningitis and septicaemia are statutorily notifiable diseases: suspected cases are to be reported to the local on
call CCDC or CPHM.
3. Identification of contacts will be carried out by Public Health England, although the supply of chemoprophylaxis may be through
GPs or hospital clinicians following advice from the CCDC/CPHM.
4. Ciprofloxacin has a number of advantages over rifampicin because it is given as a single dose, does not interact with oral
contraceptives, and is more readily available in community pharmacies. Ciprofloxacin is licensed in children over 1 year of age
for specific indications, although not for meningitis prophylaxis in any age group. However, national guidance now advocates its
use in all ages for this indication.
5. Contact tracing should only include those individuals who have had prolonged close contact with the patient within the seven
days preceding the onset of infection, regardless of immunisation status. These include anyone staying overnight in the same
household as the patient within a week of the onset of symptoms, students sharing a kitchen within a hall of residence, pupils
sharing a dormitory, and kissing contacts of the patient.
6. If two confirmed or suspected cases occur within the same play group / school / university within a four week period, the CCDC
should be informed immediately, as more extensive contact tracing and treatment with antibiotic prophylaxis may be required.
7. Discuss with Public Health England regarding future vaccinations of index cases and contacts.
Clinical details
1. N. meningitidis is a normal commensal nasopharyngeal bacterium, with a carriage prevalence of approximately 25% within the
15-19 year old age group.
2. Annual rates of invasive disease leading to meningitis and/or septicaemia are approximately 2-6/100,000, with a mortality rate of
10%.
3. Factors associated with an increased risk of invasive disease include; young age (the highest rates are in infants and young
children, with a secondary peak in adolescence and early adulthood); passive smoking; overcrowded living conditions; recent
infection with influenza A
4. For further advice, see the Public Health England website, Reference:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322008/Guidance_for_management_of_meningo
coccal_disease_pdf.pdf
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Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Sepsis
A medical emergency – refer to Medical Admissions Unit and inform admitting team.
Refer to section on sepsis management in General Practice and to the UK sepsis Trust screen and action tool for
General Practice: Refer to page 8 of guidance for further information and link to references
Inoculation incidents
Refer to the Infection Control Policy for full protocol and supporting documentation available on the Worcestershire
Health Services Website www.worcestershirehealth.nhs.uk/ infection control services / policies and procedures / blood
borne contamination incident policy – appendix i.
1. First aid to wound – encourage bleeding of puncture site under running water.
2. Make risk assessment. (e.g. greater risk if hollow bore needle containing blood, from source at high risk of blood
borne virus infection)
3. If at all possible, obtain blood from source, and consent for testing for Hepatitis B & C, and HIV.
4. Take blood from victim for storage.
5. If high risk of HIV infection, contact medical microbiologist urgently to discuss post-exposure prophylaxis.
6. Ascertain Hepatitis B immune status of the victim. Most health care workers will have been immunised, and should be
aware of their status.
7. If not previously vaccinated, give first dose of Hepatitis B vaccine promptly, with arrangement made to give follow-up
doses.
Refer to ‘Immunisation against infectious disease’ for further details of accelerated schedules.
(https://www.gov.uk/government/organisations/public-health-england/series/immunisation-against-infectious-diseasethe-green-book). If incident high risk for Hepatitis B acquisition, arrange to administer Hepatitis B immunoglobulin.
8. If vaccine non-responder, and high risk of Hepatitis B, contact microbiologist for advice regarding Hepatitis B specific
immunoglobulin.
9. If source blood unknown, or known to be Hepatitis C positive, ensure victim understands that they need to return for
hepatitis C PCR testing at 6 weeks post-incident and follow-up serology at 3 months.
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Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Useful Contact Numbers
Tuberculosis:
Meningococcal Meningitis &
Whooping Cough
Dr M Roberts, Clinical lead for TB on 01562 513072 or ext. 53436 or via pager at WRH
switchboard.
Dr S O’Hickey, Dr S Deacon WRH 01905 760240 WRH switchboard ext. 33989 (Dr Deacon)
Dr S Vathenan / Dr D Brocklebank Alexandra Hospital, Redditch 01527 503881 Bleep via
switchboard
Public Health England (formerly the Health Protection Agency) 0344 2253560 – select option
2 and then option 3
Pharmacy department
Alexander Hospital, Redditch : 01527 503030, extension 44804
Worcestershire Royal Hospital, Worcestershire: 01905 763 333, extension 39221
HIV /AIDS, blood borne
viruses and Malaria:
Dr M. Roberts, Consultant in Infectious Diseases, 01562 8513072 or WRH ext. 53436 or via
pager at WRH switchboard
Dr M Ling, Consultant in Infectious Diseases, Worcestershire Royal Hospital via bleep
Microbiological Advice and
Needle-stick injury :
Dr T Gee
Dr M Ashcroft
Dr E Yates
Dr C Catchpole
Dr Hugh Morton
Alexander Hospital, Redditch: 01527 503030
Worcestershire Royal Hospital: 01905 763333 ext. 39206
Current Parasite Policy:
Public Health England (formerly the Health Protection Agency) 0344 2253560 – select option
2 and then option 3
Infection Prevention &
Control (Primary Care):
Public Health England
Based at Evesham Community Hospital. 01386 502552:
Public Health England (formerly the Health Protection Agency) 0344 2253560 – select option
2 and then option 3
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Fifth Edition
GUIDELINES FOR PRIMARY CARE ANTIMICROBIAL PRESCRIBING
Updated February 2017v.3
Location of HIV prophylaxis packs:
A&E Department and Emergency Drug Cupboard at Worcester Royal Hospital
John Anthony Centre, Worcester
Malvern Community Hospital
A&E Department and the Arrowside Unit, Alexandra Hospital, Redditch
Minor Injuries Units at the following Community Hospitals: Evesham, Kidderminster, Tenbury and Princess of Wales Hospital, Bromsgrove
Location of Meningitis chemoprophylaxis packs (ciprofloxacin tablets and rifampicin syrup):
A&E department and Emergency Drug Cupboard, Worcester Royal Hospital
Emergency Cupboard, Alexandra Hospital, Redditch
REFERENCES
The following publications were used in the preparation of this document:
British National Formulary (BNF) issue 69 March 2015 www.bnf.org : BNF for Children 2014-5: Scottish Intercollegiate Guidelines Network
(SIGN) www.sign.ac.uk : MeReC www.npc.co.uk : Prodigy www.cks.library.nhs.uk : National Institute for Health and Clinical Excellence
www.nice.org.uk : Summary of Product Characteristics www.medicines.org.uk : Immunisation against Infectious Disease
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/266583/The_Green_book_front_cover_and_contents_page_Dec
ember_2013.pdf British Association for Sexual Health and HIV (BASHH) www.bashh.org : Management of infection guidance for primary care,
HPA July 2010
ACKNOWLEDGEMENTS
The group thanks the following individuals for their very helpful contributions:
Dr Emma Yates: Consultant Microbiologist, WAHT
Dr Thekli Gee: Consultant Microbiologist, WAHT
Dr Chris Catchpole: Consultant Microbiologist, WAHT
Dr Sumit Bhaduri, Consultant, Arrowside unit
Priti Patel: Commissioning Support Pharmacist, South Worcestershire Clinical Commissioning Group
Danielle Clark: Medicines Assurance Pharmacist, South Worcestershire Clinical Commissioning Group
Carole Clive, Nurse Consultant in Infection Prevention and Control, WHC NHS Trust
Dr David Farmer, GP Clinical Lead; South Worcestershire Clinical Commissioning Group
76