Download recommendation for the use of antibiotics for the treatment of infection

RECOMMENDATION FOR THE USE OF ANTIBIOTICS FOR THE TREATMENT OF INFECTION
Aims
to provide a simple, best guess approach to the treatment of common infections, based on known sensitivity and resistance
patterns in Cumbria
to promote the safe, effective and economic use of antibiotics
to minimise the emergence of bacterial resistance in the community



Principles of Treatment
1.
This guidance is based on the best available evidence but its application must be modified by professional judgement in the light of
co-existing diseases and other drug therapy.
2.
Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
3.
Limit prescribing over the telephone to exceptional cases.
4.
Use simple generic antibiotics first whenever possible.
5.
The use of new and more expensive antibiotics (e.g., quinolones and cephalosporins) is inappropriate when standard and less
expensive antibiotics remain effective. Antibiotics are listed in order of preference.
6.
Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
7.
In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole. Short-term use of trimethoprim
(theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretical risk of
neonatal haemolysis) is unlikely to cause problems to the foetus.
8.
Doses quoted are intended for otherwise fit adults. Doses may need to be changed in children and those with renal impairment. The
duration of therapy will vary by individual patient, disease severity and speed of resolution.
9.
Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from the Consultant
Microbiologists at:
West Cumberland Hospital
 01946 693181
Cumberland Infirmary
 01228 814641
Furness General Hospital
 01229 491022
This guidance has been produced in consultation with the consultant microbiologists and the Cumbria Medicines Management team.
Published: December 2012, Review date: November 2014
Condition
Comments
Drug and dose
(listed in order of preference)
Duration
(days)
UPPER RESPIRATORY TRACT/ENT
Delayed prescriptions are a useful strategy as most upper respiratory tract infections are viral, self-limiting and improve
without antibiotics. Regular use of analgesics such as paracetamol and ibuprofen should be encouraged.
Influenza
Tonsillitis/pharyngitis/sore
throat
Acute rhinosinusitis
Annual vaccination is essential for all those at
risk of influenza. For otherwise healthy adults
antivirals not recommended. Treat ‘at risk’ patients,
ONLY within 48 hours of onset and when influenza is
circulating in the community or in a care home where
influenza is likely. At risk:
pregnant
65 years or over
chronic respiratory disease (including COPD and
asthma)
significant cardiovascular disease (not
hypertension)
immunocompromised
diabetes mellitus
chronic neurological
renal or liver disease
AVOID ANTIBIOTICS as 90% resolve in 7 days
without and pain only reduced by 16 hours. If Centor
score 3 to 4:
lymphadenopathy
history of fever
tonsillar exudate
no cough
consider 2 or 3-day delayed antibiotics or immediate
antibiotics.
Antibiotics to prevent quinsy, NNT >4000
Antibiotics to prevent otitis media, NNT 200
AVOID ANTIBIOTICS as 80% resolve in 14 days
without, and they only offer marginal benefit after 7
days (NNT 15)
Use adequate analgesia
Consider 7-day delayed or immediate antibiotic when
purulent nasal discharge (NNT 8)
In persistent infection use an agent with anti-anaerobic
activity e.g., co-amoxiclav
OSELTAMIVIR 75mg BD or, if there
is resistance to oseltamivir
ZANAMIVIR 10mg BD (2 inhalations
by diskhaler)
5
For prophylaxis, see NICE. (NICE
Influenza). Patients under 13 years
see HPA Influenza link.
ANTIBIOTIC TREATMENT NOT
ROUTINELY RECOMMENDED
If antibiotic is required,
PHENOXYMETHYLPENICILLIN 500mg
QDS (severe), or
CLARITHROMYCIN 250-500mg BD
10
5
ANTIBIOTIC TREATMENT NOT
ROUTINELY RECOMMENDED
If antibiotic is required,
AMOXICILLIN 500mg TDS, or
DOXYCYCLINE 200mg stat, then
100mg daily, or
CLARITHROMYCIN 250mg BD
2nd line – CO-AMOXICLAV 625mg
TDS
5
5
5
5
Condition
Comments
Otitis externa (acute)
First use aural toilet and analgesia.
Cure rates similar for topical acetic acid or antibiotic
steroid
Otitis media (acute) – child
doses
Antibiotics do not reduce pain in first 24 hours,
subsequent attacks or deafness. Use paracetamol or
NSAID.
Otitis media resolves in 60% of patients in 24 hours
without antibiotics. Antibiotics reduce pain at 2 days
(NNT 15)
Consider antibiotics (2 to 3 days) if:
 <2 years AND bilateral otitis media (NNT 4) or
marked otoscopic signs and ≥ 3 symptoms
 All ages with otorrhea (NNT 3)
Immediate prescribing may be appropriate for the
following groups:
 otorrhoea
 <2 years with bilateral acute otitis media
Drug and dose
(listed in order of preference)
ACETIC ACID spray (EarCalm®) 1
spray TDS, or
PREDNISOLONE + NEOMYCIN ear
drops 3 drops TDS
ANTIBIOTIC TREATMENT NOT
ROUTINELY RECOMMENDED
If antibiotic is required,
AMOXICILLIN 40-90mg/kg/day in 3
divided doses up to 1 gram TDS, or
CLARITHROMYCIN
<8kg - 7.5mg/kg BD
8-11kg – 62.5mg BD
12-19kg – 125mg BD
20-29kg – 187.5mg BD
30-40kg – 250mg BD
2nd line - CO-AMOXICLAV
1-6yrs - 156mg TDS
6-12yrs - 312mg TDS
Duration
(days)
5
5
5
5
Haemophilus is an extracellular pathogen so macrolides
(e.g., erythromycin), which concentrate intracellularly,
are less effective therapy.
LOWER RESPIRATORY TRACT
Lower respiratory tract
infection (including acute
bronchitis) in otherwise
healthy individuals
Exacerbations of COPD
Community acquired
pneumonia
Antibiotics are not routinely indicated. Consider
prescribing an antibiotic if the person has a
significantly impaired ability to fight infection (e.g.,
immunocompromised status, cancer, or physical
frailty) or if acute bronchitis is likely to significantly
worsen a pre-existing condition (e.g. heart failure,
angina, or diabetes).
Alternative antibiotics may be used on the basis of
sputum results.
Treat exacerbations promptly with antibiotics if:
purulent sputum and
increased shortness of breath and/or
increased sputum volume
Risk factors for antibiotic resistant organisms include
co-morbid disease, severe COPD, frequent
exacerbations, antibiotics in last 3 months
Assess the person's need for admission by determining
CRB65 score:
Confusion (AMT<8)
Respiratory rate > 30/minute
Age >65 years
BP systolic <90 or diastolic ≤60
Score 0, suitable for home treatment
Score 1-2, hospital assessment or admission
Score 3-4, urgent hospital admission
Bronchiectasis
Give immediate Benzylpenicillin 1.2 grams IM or
Amoxicillin 1 gram oral if delayed admission or
life-threatening
Antibiotics should be given for exacerbations that
present with an acute deterioration with worsening
symptoms (cough, increased sputum volume or
change in viscosity, increased sputum purulence with
or without increasing wheeze, breathlessness,
haemoptysis) and/or systemic upset.
Sputum samples should be taken to guide therapy.
Need long course of 10 to 14 days.
EYES
Bacterial conjunctivitis
Treat if severe, as most are viral or self-limiting.
Bacterial conjunctivitis is unilateral and also selflimiting. It is characterised by red eye with
mucopurulent, not watery discharge. 65% resolve on
placebo by day 5.
STD: unilateral inclusion conjunctivitis usually with
urethritis (causative agent: C. trachomatis).
Ocular Herpes simplex
infection
Urgent ophthalmic referral necessary.
In recurrent infection treatment may be initiated but
this must be done in consultation with
ophthalmologist.
Avoid topical steroids and remove contacts lenses.
ANTIBIOTIC TREATMENT NOT
ROUTINELY RECOMMENDED
If antibiotics are required,
AMOXICILLIN 500mg TDS, or
DOXYCYCLINE 200mg stat, then
100mg daily
AMOXICILLIN 500mg TDS, or
DOXYCYCLINE 200mg stat, then
100mg daily, or
CLARITHROMYCIN 500mg BD
If CRB65=0
AMOXICILLIN 500mg TDS, or
DOXYCYCLINE 200mg stat, then
100mg daily, or
CLARITHROMYCIN 500mg BD
If CRB65=1 & AT HOME
AMOXICILLIN 500mg TDS AND
CLARITHROMYCIN 500mg BD, or
DOXYCYCLINE 200mg stat, then
100mg daily
5
5
5
5
5
5
5
5
5-7
5-7
Antibiotic choice should be based on
previous culture results. Consider
need for anti-pseudomonal cover if
not responding, or Pseudomonas
growth from the sputum. If culture
negative send sample for
Aspergillus
14
CHLORAMPHENICOL eye drops 1
drop every 2 hours for 2 days, then
4 hourly (whilst awake) for up to 1
week; eye ointment at night
7
If pregnant or history of blood
dyscrasia use FUSIDIC ACID BD
Chlamydial: DOXYCYCLINE 100mg
BD, or
AZITHROMYCIN 1 gram stat (treat
the sex partner as well)
Commence ACICLOVIR eye
ointment, applied 5 times a day
7
7
21
Condition
Corneal abrasions
ORAL
Mucosal ulceration and
inflammation
Dental abscess
Comments
If corneal ulcer - Urgent ophthalmic referral is
necessary.
Temporary pain and swelling relief can be attained with
saline mouthwash(½tsp in glass of warm water)
Advise urgent dental consultation, as repeated courses
of antibiotics for abscess are not appropriate.
Antibiotics are only recommended if there are:
signs of severe infection
systemic symptoms
high risk of complications
Otherwise, regular analgesia should be first option until
a dentist can be seen.
Oral thrush
Drug and dose
(listed in order of preference)
CHLORAMPHENICOL eye ointment
BD
Duration
(days)
5
CHLORHEXIDINE 0.2% mouthwash,
rinse mouth for 1 minute BD with
5ml diluted with equal volume of
water, or
HYDROGEN PEROXIDE 6%, 15mls in
½ glass of warm water TDS
AMOXICILLIN 500mg TDS, or
PHENOXYMETHYLPENICILLIN
500mg-1 gram QDS
Until lesion
resolves of
less pain
allows oral
hygiene
5
5
If penicillin allergic, or in severe
infection
METRONIDAZOLE 200mg TDS
5
NYSTATIN 100,000 units QDS, or
MICONAZOLE gel, 5mL QDS
7
7
(miconazole interacts with statins and
anticoagulants)
Acute necrotising ulcerative
gingivitis
Pericoronitis
Refer to dentist for scaling and oral hygiene advice,
after starting antibiotic
Refer to dentist for irrigation and debridement. If
persistent swelling or systemic symptoms, use
metronidazole
GASTRO-INTESTINAL INFECTIONS
H.pylori infection
Tetracycline 500mg four times a day may be used
instead of amoxicillin in penicillin-allergic patients.
Resistance to clarithromycin or to metronidazole is
much more common than to amoxicillin and can
develop during treatment. Do not use clarithromycin
or metronidazole if used for any infection in the past
year.
Giardiasis
Recurrence is high even with optimal treatment,
therefore follow-up with a stool sample is advised.
Threadworms
Acute gastroenteritis
Travellers diarrhoea
C.difficile infection
Treat all household contacts at the same time PLUS
advise hygiene measures for 2 weeks (hand hygiene,
pants at night, morning shower) PLUS wash
sleepwear, bed linen, dust and vacuum on day one.
Antibiotics not usually indicated. Discuss any intended
treatment with microbiologist.
Limit prescription of antibacterial to be carried abroad
and taken if illness develops (ciprofloxacin 500mg
single dose, unlicensed indication) to people travelling
to remote areas in whom an episode of infective
diarrhoea could be dangerous.
Stop unnecessary antibiotics and/or PPIs. 70% respond
to metronidazole in 5 days, 92% in 14 days.
Admit if severe:
Temperature >38.5°C
WCC >15
Rising creatinine
Signs/symptoms of severe colitis
If immunosuppressed, consider
fluconazole 50-100mg OD for 7 to
14 days
METRONIDAZOLE 200mg TDS
3
METRONIDAZOLE 200mg TDS
3
Triple-therapy:
LANSOPRAZOLE 30mg BD plus
AMOXICILLIN 1 gram BD plus
either
CLARITHROMYCIN 500mg BD, or
METRONIDAZOLE 400mg BD
7
METRONIDAZOLE 200mg TDS for 7
days is the most tolerable and
effective doses; 400mg TDS for 5
days or 2 grams daily for 3 days
MEBENDAZOLE 100mg
(mebendazole is not licensed for
children under 2 years, use
piperazine instead)
Antibiotic treatment not routinely
recommended
Fluid replacement essential
3-7
depending
on the
doses
One dose
repeat in
two weeks
METRONIDAZOLE 400mg TDS for 1st
and 2nd episodes
VANCOMYCIN 125mg QDS for 3rd
episode/severe or type 027
10-14
10-14
URINARY TRACT
Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic
bacteriuria: it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter,
antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely.
Co-amoxiclav is alternative in patients with low GFR. Nitrofurantoin should not be used if GFR is <60mL/min/1.73m2 or trimethoprim if GFR is
<15mL/min/1.73m2.
Cystitis in women
Routine urine culture unnecessary for simple cystitis in
TRIMETHOPRIM 200mg BD, or
3
adult women.
NITROFURANTOIN MR 100mg BD
3
(Note that trimethoprim may cause a rise in
Further diagnosis should be made on basis of
serum creatinine especially in pre-existing
symptoms and dipstick analysis (see HPA guidance).
renal impairment due to competition for
renal excretion)
UTI in men
Co-amoxiclav is alternative in
patients with low GFR (see above)
TRIMETHOPRIM 200mg BD, or
NITROFURANTOIN MR 100mg BD
Co-amoxiclav is alternative in
patients with low GFR (see above)
7
7
Condition
UTI or confirmed
asymptomatic bacteriuria in
pregnant women
UTI in children
Comments
Screening requires a urine sample to be sent to
microbiology for microscopy and culture, dip stick
testing alone is not adequate
Pyelonephritis
< 3 months, immediate paediatric referral
> 3 months with acute pyelonephritis/upper UTI,
consider referral to paediatric specialist, treat with
antibiotics
> 3 months with cystitis/lower UTI, treat. If still
unwell after 24 to 48 hours, child should be
reassessed
Culture required.
Epididymo-orchitis
Screen for chlamydia.
Drug and dose
(listed in order of preference)
AMOXICILLIN 500mg TDS, or
NITROFURANTOIN MR 100mg BD,
or
CEFALEXIN 500mg TDS for 7 days,
or
TRIMETHOPRIM 200mg BD for 7
days (unless folate deficient or
taking folate antagonist [e.g.
antiepileptic or proguanil])
TRIMETHOPRIM 4mg/kg BD (max
200mg), or
CEFALEXIN
1 month-1 year - 125mg BD
1 – 5 years - 125mg TDS
5 - 12years - 250mg TDS
Duration
(days)
7
7
CO-AMOXICLAV 625mg TDS, or
CIPROFLOXACIN 500mg BD
DOXYCYCLINE 100mg BD
7-10
7
7
3 (lower)
7-10 if
upper UTI
10-14
Add IM CEFTRIAXONE 500mg stat if
there likelihood of sexually
transmitted pathogen
GENITAL SYSTEM
Vaginal candidiasis
Bacterial vaginosis
Chlamydia
Clotrimazole and fluconazole are available over-thecounter.
7 day course recommended during pregnancy.
Fluconazole is contra-indicated in pregnancy.
Usually associated with anaerobes, recurrence is
frequent, but is not a sexually transmissible infection
(STI).
Do not retest if symptoms resolve.
In pregnancy 7 days of clindamycin gel recommended.
In pregnancy testing should be repeated after 1
month to ensure cure achieved.
Advise sexual abstinence until the infected woman and
her partner(s) have both completed the course of
treatment. If treatment with single-dose azithromycin
is given, then sexual abstinence for the following 7
days is advised.
CLOTRIMAZOLE pessaries 500mg,
or
200mg
1
FLUCONAZOLE 150mg
METRONIDAZOLE 400mg BD, or 2
grams stat, or
METRONIDAZOLE vaginal gel,
0.75% daily – apply at night
Stat dose
7
CLINDAMYCIN vaginal gel,
2% daily – apply at night
DOXYCYCLINE 100mg BD, or
AZITHROMYCIN 1 gram (not
licensed for use in pregnancy, see
comments)
7
METRONIDAZOLE 400mg BD
CEFTRIAXONE IM 500mg stat and
AZITHROMYCIN 1 gram stat
7
stat
CEFTRIAXONE IM 500mg stat
followed by DOXYCYCLINE 100mg
BD and METRONIDAZOLE 400mg
BD or
OFLOXACIN 400mg BD and
METRONIDAZOLE 400mg BD
CIPROFLOXACIN 500mg BD, or
TRIMETHOPRIM 200mg BD
ACICLOVIR 200mg five times a day
14
3
5
7
stat
(Azithromycin has been used for 20 years, during which time a
number of studies have shown that there is no increased risk of
adverse effects associated with using the drug during pregnancy. It
is significantly more effective and better tolerated than the
alternative agents (erythromycin and amoxicillin), but its use is
more limited).
Trichomoniasis
Gonorrhoea - uncomplicated
Pelvic inflammatory disease
Pregnant woman must be retested after 5 weeks after
completing therapy (6 weeks if azithromycin used).
Refer to GUM clinic for contact tracing.
Refer to GUM – may be associated with other STDs.
Increasing resistance Refer to GUM clinic for contact
tracing and screening for other sexually transmitted
diseases.
Refer to GUM.
Tests essential for gonococcus and chlamydia.
Acute prostatitis
Bartholins gland infection
Send MSU for culture and start antibiotics. 2 week
course may prevent chronic prostatitis.
Screening for low risk patients may be done in practice.
Higher risk should be referred to GUM.
May be associated with STD – consider screening.
Genital warts
Screening for co-existent STD indicated.
Genital herpes
Podophyllotoxin is contra-indicated in pregnancy.
WOUND AND SKIN INFECTION
Cellulitis
If afebrile and well other than cellulitis oral therapy is
- limb
adequate.
If febrile and unwell admit or arrange for IV antibiotics
(flucloxacillin or clarithromycin, as approved under
PCT Cellulitis pathway).
- facial
If river or seawater exposure discuss with
microbiologist.
Early referral necessary if not responding to treatment.
14
14
14
5
Antibiotics not indicated for
uncomplicated disease
PODOPHYLLOTOXIN applied twice
daily for three consecutive days,
repeated at weekly intervals if
necessary for a total of 4 to 5
courses
Liquid nitrogen if small number of
low volume warts or keratinized
FLUCLOXACILLIN 500mg QDS, or
CLARITHROMYCIN 500mg BD
5
5
CO-AMOXICLAV 625mg TDS
7
Condition
Surgical wounds, abscesses,
mastitis, wound infection
Comments
Abscesses should be drained.
If wound could be contaminated with soil, faeces or
bodily fluids or if infection area has poor vascular
supply.
Leg ulcers and pressure
sores
Herpes zoster
Animal and human bites
Tick bite
Treatment of later stages of Lyme disease - discuss
with Microbiologist.
Fungal nail infections
For extensive, severe or bullous impetigo, use oral
antibiotics
Reserve topical antibiotics for very localised lesions to
reduce the risk of resistance.
Reserve mupirocin (local) for MRSA infections.
Take nail clippings.
Treatment must only be commenced after mycological
confirmation of infection.
Topical amorolfine should only be used where infection
is confined to the distal edge of the nail in the very
early stages of distal and lateral subungual
onychomycosis or in superficial white onychomycosis.
Fungal skin infections
- dermatophyte (ringworm)
- candida
Terbinafine not licensed in children but listed in BNFc.
Clotrimazole is an alternative.
Varicella zoster/chickenpox
Pregnant/immunocompromised/neonate, seek urgent
specialist advice
Chicken pox: If started < 24 hours of rash and > 14
years or severe pain or dense/oral rash or 2 household
case or smoker
Shingles: treat if > 50 years and within 72 hours of
rash or if active ophthalmic or Ramsey Hunt or
eczema.
CENTRAL NERVOUS SYSTEM
Meningitis
Duration
(days)
5
5
5
5
5
Bacteria will always be present. Antibiotics do not improve healing, unless active infection. Culture swabs and
antibiotics are only indicated if diabetic or there is evidence of clinical infection such as
inflammation/redness/cellulitis, increased pain, purulent exudate, rapid deterioration of ulcer or pyrexia.
ACICLOVIR 800mg five times a day,
5
started within 72 hours of onset of
rash
Human bites should generally be treated with
CO-AMOXICLAV 625mg TDS
5
antibiotics if the skin is broken, and consideration
given to tetanus, hepatitis B and HIV prophylaxis. If
2nd line
the skin is broken following an animal bite, consider
Cat, dog and human bites 5
antibiotics if puncture wound, bite to hand, foot, face,
DOXYCYCLINE 100mg BD and
joint, tendon, ligament or immunocompromised,
METRONIDAZOLE 400mg TDS
diabetic, asplenic or cirrhotic. Cat bites carry a high
Human bites - CLARITHROMYCIN
5
risk of infection and should be treated.
250-500mg BD and
Consider tetanus, and, if the bite occurred abroad,
METRONIDAZOLE 400mg TDS
rabies.
Lyme disease prophylaxis is indicated if tick is likely to
DOXYCYCLINE 200mg
single dose
have been attached for >24 hours, or it is obviously
engorged.
Prophylaxis not indicated if the bite occurred more than
72 hours ago, or if the patient is continually exposed
to ticks.
Treatment of localised erythema migrans:
Impetigo
Drug and dose
(listed in order of preference)
FLUCLOXACILLIN 500mg QDS, or
CLARITHROMYCIN 500mg BD
CO-AMOXICLAV 625mg TDS, or
CLARITHROMYCIN 500mg BD and
METRONIDAZOLE 400mg TDS, or
CLINDAMYCIN 300mg QDS
Urgent hospital transfer is primary consideration. Only
contra-indication to benzylpenicillin if true penicillin
anaphylaxis; use of alternate antibiotics is not
recommended.
DOXYCYCLINE 100mg BD, or
AMOXICILLIN 500mg TDS; children
<8 years Amoxicillin 50mg/kg/day
in divided doses for 2 weeks or
Erythromycin
FLUCLOXACILLIN 500mg QDS, or
CLARITHROMYCIN 250mg to 500mg
BD
FUSIDIC ACID, topical TDS
14
MUPIROCIN, topical TDS
TERBINAFINE 250mg daily;
fingernails,
5
toenails,
ITRACONAZOLE 200mg BD
fingernails, (2 courses)
toenails, (3 courses)
5
5
5
6 to 12
weeks;
3 to 6
months
7 days
monthly
TERBINAFINE cream twice a day
CLOTRIMAZOLE cream BD/TDS,
10-14
Continue 12 weeks
after
affected
area has
healed
ACICLOVIR 800mg five times day
7
BENZYLPENICILLIN, preferably IV,
but IM if access difficult
Over 10 years, 1.2 grams
1 to 9 years, 600mg
Under 1 year, 300mg
stat