Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
BEDFORDSHIRE COMMUNITY ANTIMICROBIAL PRESCRIBING GUIDELINES 2008 "Addressing known local sensitivities" Before you open this book ….. Do you need to prescribe an antibiotic or is it a virus? VIRUS? Symbol means that a virus is commonly involved Introduction These Guidelines are intended to assist General Practitioners in choosing appropriate first line antimicrobial agents for commonly encountered community acquired infections. Local sensitivity patterns of common pathogens have been taken into account. Bear in mind that, if the patient has recently been on an antibiotic, resistant organisms may have been selected out requiring a change of therapy if further treatment is indicated. It is very useful to take specimens for culture before starting treatment; preliminary results are usually available the following day. Treatment may need to be altered once culture and sensitivity results are available. More detailed advice on treatment options may be obtained from the Consultant Microbiologists at the respective hospitals. Doses given are for normal weight adults, unless otherwise stated. Always refer to the BNF to check paediatric doses, contra-indications and side-effects. If the patient is genuinely allergic to penicillin use erythromycin for presumed gram positive infections. THESE GUIDELINES ARE BASED ON THE BEST AVAILABLE EVIDENCE BUT THEIR APPLICATION MUST BE MODIFIED BY PROFESSIONAL JUDGEMENT Aims To assist GPs in choosing empirical antimicrobial agents for common community infections. To minimise the emergence of bacterial resistance in the community. To encourage rational and cost-effective use of antibiotics. To aim to mimimise incidence of antibiotic associated Clostridium difficile & MRSA infections To aim to minimise incidence of toxicity and other adverse effects associated with antibiotic prescribing To aim to promote the safe and appropriate use of antibiotics encouraging patient education Principles of treatment 1. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. Evidence clearly links increased risk of opportunist infections such as C. difficile with high volume prescribing of antibiotics 2. Do not prescribe an antibiotic for viral infections. 3. Limit prescribing over the telephone to really exceptional cases. 4. Consider patient compliance issues which may influence drug choice, dose frequency and length of treatment.Check ability to swallow tablets or capsules and prescribe acceptable dose form. Include patient counselling to explain reason for full compliance 5. Reduce or avoid the use of broad spectrum antibiotics, particularly cephalosporins and quinolones, as much as possible. When antibiotics are necessary and appropriate, use standard and cost effective ones. 6. Topical antibiotics have very limited indications and should be used sparingly. 7. In pregnancy avoid tetracyclines, aminoglycosides, quinolones, high dose metronidazole, trimethoprim (in the first trimester) and nitrofurantoin (in the third trimester). 8. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from the consultant microbiologists at the Luton and Dunstable Hospital (01582 497318/497319) or Bedford Hospital (01234 795913). 9. Duration of therapy depends on the nature of the infection and response to treatment. Please refer to the BNF section 5.1 if unsure. In addition, the principle of treatment duration should aim to be minimal length to achieve effect -in uncomplicated infections evidence would indicate 5 days to be adequate. 10. Samples should be sent for culture where infections are persistent or recurrent. 1 Respiratory Tract Infections In both upper and lower respiratory tract infections, excluding Pharyngitis, Streptococcus pneumoniae is the commonest pathogen, and if antibiotics are indicated, this organism must be covered. Remember, presently available quinolones (e.g. ciprofloxacin) have insufficient activity against S. pneumoniae. Antibiotics are rarely indicated for upper respiratory tract infections and an NNT value of 4000 to prevent one serious complication has been calculated. (Paterson et al BMJ 2007 335:982). Patient education is particularly important in this area in line with National programmes to reduce prescribing Pharyngitis / Tonsillitis Antibiotics should not be used to secure symptomatic relief in sore throats. The majority of sore throats are viral; however there is clinical overlap between viral and streptococcal infections. Antibiotics only shorten duration of symptoms by 8 hours. Antibiotics can prevent non-suppurative complications of -haemolytic streptococcal pharyngitis but, in developed societies, such complications are rare. NICE recommends antibiotics in the following situation, features of marked systemic upset secondary to the acute sore throat, unilateral peritonsillitis, a history of rheumatic fever or an increased risk from acute infection (such as a child with diabetes or immunodeficiency). Results of a bacterial throat swab can be available within 2 working days but a Group A streptococcal infection will be notified in 24 hours. Drug Name Dose Frequency Duration Comments Virus? Penicillin V 500mg Amoxicillin 250500mg Erythromycin * 500mg four times daily three times daily 10 days two or four times daily 10 days This is absorbed better than penV and may be used as an alternative if compliance is an issue. Maculopapular rashes commonly occur with amoxicillin but are not usually true penicillin allergy -do not use blindly or if glandular fever is a possibility. 10 days Acute Otitis Media Available evidence suggests that antibiotic treatment should NOT be routinely prescribed as 80% of cases resolve within 3 days without antibiotics. Use NSAID or paracetamol. A study of predictors of poor outcome found that in children with AOM but without fever and vomiting, antibiotic treatment had little benefit. The lack of antibiotic did not lead to a poor outcome. The simplest method to target the minority of children at higher risk of poor outcome would be to select for antibiotic treatment those children with systemic features (ie either high temperature or vomiting). Poor outcome more likely if recurrent. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness and their use is associated with increased adverse effects, such as nausea and diarrhoea. Viruses are a common cause, but if antibiotics are indicated use: Drug Name Dose Frequency Duration Comments Virus? Amoxicillin 250-500mg Erythromycin* 500mg three times daily two or four times daily 5 days (maximum) 5 days (maximum) 2 First line choice. For paediatric doses see BNF. For paediatric doses see BNF. *Clarithromycin is an acceptable alternative in those unable to tolerate erythromycin. 10 days treatment for confirmed Group A streptococcus Acute Sinusitis Usually self-limiting. Reserve treatment for severe or persistent cases of at least 7 days duration in adults and 10-14 days duration in children There is very little evidence that antimicrobials are effective in children and many infections are viral, resolving in 7 days. Drug Name Dose Amoxicillin 250-500mg Erythromycin* 500mg Frequenc y Duration Comments three times daily two to four times daily 5 days (maximum) 5 days (maximum) Virus? *Clarithromycin is an acceptable alternative in those unable to tolerate erythromycin. 10 days treatment for confirmed Group A streptococcus Acute Bronchitis Virus? Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults. Acute Exacerbations of Chronic Bronchitis Viral infections may cause acute exacerbations, but if purulent sputum is being produced, bacterial infection is possible. NB Culture of the sputum is advised prior to initiation of therapy. Drug Name Dose Frequency Duration Comments Virus? CoAmoxiclav 625mg three times daily 5 days Doxycycline 200mg once daily then 100mg once daily first day only for 4 more days May be considered as an alternative and can be used cautiously in renal impairment Erythromycin is an acceptable alternative for true penicillin allergy Uncomplicated community acquired pneumonia Patients with severe pneumonia will usually need hospital admission for nursing and intravenous therapy. Drug Name Dose Frequency Duration Amoxicillin 500mg three times daily 7 days Erythromycin* 500mg four times daily 7 days Comments Severe staphyloccocal pneumonia can occur following viral influenza- such patients require urgent referral For atypical pneumonia if no response to amoxicillin after 48 hours add in erythromycin and review again *Clarithromycin is an acceptable alternative in those unable to tolerate erythromycin. 3 Urinary Tract Infections Uncomplicated Lower Urinary Tract Infection Eg otherwise healthy women who are not pregnant Drug Name Dose Frequency Duration Trimethoprim 200mg twice daily 3 days Nitrofurantoin MR 100mg twice daily 3 days 375mg Three times a day 3 days Comments First line ONLY for patients not presenting with previous infection and treatment in last 6 months OTHERWISE: Co-amoxiclav Complicated Urinary Tract Infection E.g. treatment of men, children and pregnant women, recurrent infection, pyelonephritis, stone, tumour, etc. An MSU should be sent prior to treatment and antimicrobial choice should be reassessed when urine culture results are available Drug Name Dose Frequency Duration Nitrofurantoin MR 100mg twice daily 7 days Co-amoxiclav 625mg three times daily 7 days Cefalexin 250mg or 500mg four times daily 7 days twice daily 7 days Comments Not in third trimester Add to comments box- not to be used in treatment of upper UTIs e.g. pyelonephritis as it does not achieve adequate blood levels. Not recommended in pregnancy Can be used to treat pyelonephritis. For penicillin allergies refer to consultant microbiologist Appropriate ONLY in pregnancy Ciprofloxacin only appropriate for the treatment of confirmed pseudomonas infection Prostatitis An MSU should be sent prior to the start of treatment. Antimicrobial choice should be reassessed when urine culture results are available 4 Drug Name Ofloxacin Dose 200mg Frequency twice daily Duration 28 days Comments Acute episode- Add Doxycycline 100mg twice a day duration 4-6 weeks into treatment if Chlamydia is suspected (sexually active)- consider referral to GUM clinic In Chronic Prostatitis: Ofloxacin 200mg bd for 28 days and refer to urology. It may be necessary to seek specialist opinion. Epididymo - Orchitis Treatment depends whether the male is sexually active or not. In sexually active male, chlamydia should be considered. Drug Name Dose Frequency Duration Comments Doxycycline PLUS Cefixime 400mg Ofloxacin 100mg twice daily 14 days 500mg 400mg single dose twice daily 14 days In the sexually active male. Refer to GUM clinic. As second line when Doxycycline is unsuitable Ciprofloxacin 500mg twice daily 10-14 days Non-sexually active male Refer to GRASP surveillance programme. (Gonococcal Resistance to Antimicrobials Surveillance Programme).For non sexually active men, ciprofloxacin 500mg twice daily for 10-14 days can be given or changed according to sensitivity results Catheter Urines 1. Catheters inevitably become colonised by bacteria after a few days, and therefore there is NO VALUE in sending urine from those with longstanding catheters. Treatment may be indicated if the patient is systemically unwell. 2. Cloudiness and smell in the urine are not reasons for culturing urine. 3. Inappropriate antibiotics will not eradicate colonising bacteria, but will induce resistance. 4. Antibiotic and antiseptic bladder washouts are not recommended. 5 Genital Infections Vaginal Discharge in a Child Commonly due to Streptococcus pyogenes (Group A haemolytic streptococci), and occasionally to Haemophilus influenzae, but possibility of sexual abuse should be considered. Vulval swab should be sent for culture. Antimicrobial choice should be reassessed when results are available Drug Name Amoxicillin Dose Refer to BNF for paediatric doses. Vaginal Discharge in an Adult Common causes are chlamydia, trichomonas, candidiasis and bacterial vaginosis. Culture samples required as listed under Pelvic Inflammatory Disease. Trichomonas vaginalis Drug Name Dose Frequency Duration Metronidazole 400 mg twice daily 7 days Metronidazole 2g one dose only Comments Not in breastfeeding or pregnancy Treatment of the sexual partner may be indicated, especially if there is recurrence of the infection. Candidiasis Drug Name Dose Frequency Duration Comments Clotrimazole pessaries 500mg once at night 1 day Available OTC Fluconazole capsules 150mg once daily 1 day Available OTC. For persistent infections. Not in pregnancy. Oral fluconazole is expensive. With recurrent infections, consider treating the sexual partner. 6 Bacterial Vaginosis Drug Name Dose Frequency Duration Comments Metronidazole 400mg twice daily 7 days Metronidazole 2g one dose only Clindamycin cream 2% 5g once each night Preferred regimen in pregnancy Not in breastfeeding or pregnancy If unable to tolerate metronidazole 3-7 days Specific STIs All sexually transmitted infections are becoming more common. Syphilis Serology is advisable. Patients with sexually transmitted diseases and their partners require full microbiological investigation and referral to the GUM clinic. (Bedford Hospital GUM Clinic 01234 792146 and L&D Hospital GUM Clinic 01582 497071/497070) Pelvic Inflammatory Disease (PID) A chlamydia swab of the cervix (and urethra) and bacterial swabs from both the cervix and high vagina are important to determine the correct aetiology. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens in PID. Occasionally organisms forming part of the normal vaginal flora may be implicated. Treatment, until the identity of the pathogen is known, is broad spectrum: Drug Name Dose Frequency Cefixime 400mg Single dose 100mg twice daily 14 days 400mg twice daily 14 days 400mg twice a day 14 days 400mg twice a day 14 days plus Doxycyline Plus Metronidazole Ofloxacin PLUS metronidazole Duration Comments This option for treatment should only be used after discussion with microbiologist If a high possibility of gonorrhoea, add ciprofloxacin 500 mg one dose only. If laboratory subsequently reports N. gonorrhoeae, treat with an appropriate antibiotic to which the organism is sensitive for 10 days. If urine test for Chlamydia is done, there is no need for swabs. When swabs are taken however, tests for Gonorrhoea can be done which is of value in follow up and partner notification. 7 Chlamydia trachomatis Drug Name Dose Frequency Duration Comments Azithromycin** 1g one dose only Doxycycline 100mg twice daily 7 days four times daily 7 days contraindicated in pregnancy Use in pregnancy “Test of Cure” necessary after 3-4 weeks Erythromycin* 500mg Neisseria gonorrhoeae, uncomplicated Drug Name Dose Frequency Comments Cefixime 400mg 400mg One dose only 1st choice in Bedford locality (unlicensed indication). Can be used in pregnancy. Ciprofloxacin 500mg One dose only 1st line choice in Luton When treating for Gonorrhoea, GUM recommend that treatment for Chlamydia is included in regimen Herpes Simplex (Genital Infection) Drug Name Dose Frequency Duration Aciclovir 200mg five times per day 5 days 8 Comments Skin/Soft Tissue Infections Impetigo Oral therapy is preferred. You are advised not to use mupirocin (Bactroban) as this should be reserved for the treatment of MRSA. Drug Name Dose Frequency Duration Flucloxacillin 250-500mg 7 days Erythromycin* 500mg Topical Sodium Fusidate One application four times daily two or four times daily three to four times daily Comments 7 days 5 days ONLY for small and localised cases. Topical use promotes resistance and should be avoided in most cases Cellulitis Group A haemolytic streptococci (Streptococcus pyogenes) and Staphylococcus aureus are often both involved. Treat until there has been good clinical response. Drug Name Amoxicillin Plus Flucloxacillin Dose 500mg Co-fluampicil 1-2 caps Erythromycin* 500mg 250-500mg Frequency three times daily four times daily four times daily Duration 10 days four times daily 10 days 10 days 10 days Comments Amoxicillin and flucloxacillin given together Only one prescription charge For genuine penicillin allergy Wound Infections It is often useful to send a swab, with the site and nature of the wound specified, especially from a post-operative wound. Commonly due to Staphylococcus aureus. Drug Name Flucloxacillin Dose 250-500mg Erythromycin* 250-500mg Frequency four times daily four times daily Duration 5 days Comments 5 days *Clarithromycin is an acceptable alternative in those unable to tolerate erythromycin. Contaminated wounds Lacerations that have become infected and were originally contaminated with soil, manure, or faeces; puncture wounds; or lacerations that have a significant degree of devitalized tissue. Ensure wound is appropriately cleansed and current check tetanus status. Drug Name Dose Frequency Duration 9 Comments Co-Amoxiclav* 375-625mg Erythromycin plus 250-500mg Metronidazole 400mg three times a day four times daily 5 days 5 days three times a day 5 days Alternative regime for genuine penicillin allergy *If contamination is due to soil/faeces, consider adding in metronidazole 400mg 8 hourly Leg Ulcers and Pressure Sores These inevitably become colonised by bacteria. Routine swabs are not indicated. Antibiotic treatment should be reserved for patients with cellulitis, from whom a wound swab should be taken and treatment commenced as for cellulitis. Do not treat leg ulcers unless there is clinical evidence of an infection. Animal and Human Bites Pasteurella multocida (animal only) and anaerobes may well be involved. A swab should be sent. For animal bites, assess rabies risk. For human bites, assess HIV / Hepatitis B risk. Drug Name Dose Frequency Duration Comments Co-amoxiclav 625mg three times daily 5 - 7 days In severe cases, consider IV route for the first dose. If the patient is genuinely allergic to or intolerant of co-amoxiclav, alternative treatments are doxycycline plus metronidazole or consult microbiologist. Consider Rabies prophylaxis for bites from animals in endemic countries and assess risk of blood borne viruses. Otitis Externa Antibiotics are often not appropriate and good local hygiene may solve the problem. Repeated use of topical antibiotics can result in the selection of antibiotic-resistant organisms including fungi. Culture of any discharge is valuable at first presentation to guide rational prescribing. Scabies Treat all family members of the household, close contacts and sexual contacts simultaneously Permethrin 5% dermal cream Available OTC from pharmacies If the patient is in a residential/nursing home, inform the CCDC on telephone number 01525 636841. 10 Headlice Treatment is not necessary unless a live louse is found. There is currently no local policy for the rotation of pesticides. There are two treatment strategies that can be used: Insecticides: two applications of an insecticide are used 7 days apart (Note: this is different to the packaging information, which states that a single application is sufficient). Success is checked by detection combing 2-3 days after the final application. If treatment fails or re-infestation occurs, a course of a different insecticide is used. Wet combing: this must be undertaken meticulously to be successful. It must be undertaken every 4 days for at least 2 weeks. If lice are found on the second, third, or fourth session, it should be continued until no lice have been seen for three consecutive sessions. Families using this method must be well motivated because of the time involved. Dermatophyte Infections These are chronic infections often requiring prolonged treatment. It is therefore very important to send appropriate specimens and confirm the diagnosis microbiologically. Should a case fail to respond to first line therapy, dermatological opinion should be sought. Do not change to another topical antifungal as they all have the same spectrum of activity. Scalp (Tinea Capitis) Take scalp scrapings including hair root. Refer to a dermatologist. Topical imidazole creams are ineffective. Drug Name Dose Frequency Duration Comments Griseofulvin 0.5-1.0g once daily minimum 6-12 weeks Avoid pregnancy during and for 1 month after treatment. Men should not father children within 6 months of treatment. (In children 10mg/kg) Body/Groin/Feet (Tinea Corporis/Cruris/Pedis) Take skin scrapings. Drug Name Dose Frequency Duration Clotrimazole 1 % cream two to three times daily Terbinafine 1 % cream twice daily Topical undecenoic acid (e.g. Mycota) See BNF for preparations once or twice daily Until 1-2 week after clinical cure 1 to 2 weeks 4 to 6 weeks 11 Comments For Tinea Pedis. Administer for 14 days after symptomatic resolution. Nail (Tinea Unguium) Many people have long standing fungal infections of their toenails, but many have no symptoms apart for the change in appearance of the nail. In these instances it may be entirely appropriate to give no treatment, so as to avoid complications associated with systemic therapy. Take nail clippings. Treatment should be started only when results of mycological examination are available because it is easy to misdiagnose fungal nail infections and the choice of treatment may be affected by the results. Drug Name Dose Frequency Duration Comments Terbinafine 250mg once daily Not yet recommended for children Griseofulvin 0.5g – 1.0g once daily 6 weeks (fingernails) or 3 months (toenails) 6 months (fingernails) or 12 months (toenails) Children 10mg/kg Avoid pregnancy during and for 1 month after treatment; men should not father children within 6 months of treatment. If there is no response, review the diagnosis or seek specialist help. Herpes zoster / Chicken Pox and Varicella zoster / Shingles Oral antivirals are not indicated in young (less than 60 years) healthy adults, as such individuals are unlikely to have severe symptoms and are at very low risk of developing postherpetic neuralgia. However, oral antiviral treatment should be offered to people presenting within 72 hours of the shingles rash who are at high risk, e.g. 60 years or older, have ophthalmic shingles, or are immunocompromised Ophthalmic zoster -treatment is always indicated with urgent referral to the eye clinic. Drug Name Dose Frequency Duration Aciclovir 800mg five times daily 7 days Valaciclovir 1g three times daily 7 days 12 Comments Licensed for herpes zoster and for herpes simplex infections of the skin and mucous membranes. Meningococcal Disease If Meningococcal septicaemia or meningitis is suspected give benzylpenicillin as a stat dose immediately whilst admission to hospital is arranged. Benzylpenicillin 1.2g IV or IM; In children aged 1 - 9 years 600mg In children aged < 1 year 300mg If there is a history of penicillin anaphylaxis, give: Chloramphenicol or Cefotaxime 1g IV (aged > 12 years); In children aged < 12 years 20mg/kg 2g IV or IM (adults); In children 100mg/kg (max 2g) IV or IM If there is a history of penicillin anaphylaxis and chloramphenicol or cefotaxime are unavailable, transfer to hospital immediately. All forms of meningitis particularly meningococcal meningitis or septicaemia should be notified on suspicion to the CCDC at the Bedfordshire Health Protection Agency on 01525 636841. Outside normal working hours contact the Bedford Hospital switchboard Tel: (01234) 355122. Prophylaxis in Meningococcal Disease Prophylaxis should only be initiated after discussion with the CCDC or Consultant in Public Health Medicine. Prophylaxis is given to those who had ongoing and continuous contact with the index case, such as household contacts, to eradicate any carriage. Staff who gave mouth-to-mouth resuscitation should be given prophylaxis. Please note that the prophylaxis does not offer protection against the disease. CCDC will decide on the wider public health control measures where these are required. Drug Name Dose Frequency Ciprofloxacin 500mg Single dose Ceftriaxone IM 250mg Single dose Rifampicin 10mg/kg (under 1 year 5mg/kg) Twice daily Duration Comments 2 days 1st choice for adults Not licensed for this indication 1st choice in pregnancy Not licensed for this indication 1st choice for children 13 Gastro-intestinal Infections Virus? Please note food poisoning is a statutorily notifiable to the CCDC. Stool specimens should be sent for microbiological examination, which helps in the surveillance of the diseases. Viral Viral infections are self-limiting and common. Bacterial The commonest bacterial causes are campylobacter, salmonella and shigella spp. Most infections are self-limiting and do not require antibacterial therapy. Parasitic The commonest parasitic causes are giardia sp and cryptosporidium sp. There is no specific therapy for cryptosporidial diarrhoea. Giardiasis Drug Name Dose Frequency Duration Metronidazole 2g once daily 3 days 14 Comments Infestations Threadworms Diagnosis can be confirmed by a sellotape slide. Drug Name Dose Frequency Mebendazole 100 mg Piperazine/ Sennosides oral powder 2.5 ml one dose only one dose only Repeat after 3 months to 1 year 14 days Piperazine/ Sennosides oral powder 5 ml one dose only Repeat after 1 year to 2 years 14 days Duration Comments For aged > 2 years The whole family should be treated and they should be advised to keep fingernails short, bath each morning and change bed linen. Do not treat worms during pregnancy. Washing hands and scrubbing nails before each meal and after each visit to the toilet is essential. drug treatments Eye Infections Most acute superficial infections (conjunctivitis and blepharitis) are often caused by staphylococci and can be treated topically. Endophthalmitis and keratitis may be bacterial, viral or fungal and require URGENT referral for specialist management Drug Name Dose Frequency & Duration Comments Chloramphenicol eye drops One drop Every three hours for 2 days and then four times a day for 5 days Chloramphenicol Ointment Apply small amount One drop Four times a day for 2 days and then twice a day for 5 days Twice daily for 7 days Now available to purchase from pharmacies. Avoid using for more than 5 days Ointment preferred for blepharitis Alternative to chloramphenicol Fucithalmic eye drops 15