Download prodigy guidelines for management common infectious illness 2008

PRODIGY GUIDELINES FOR
MANAGING INFECTION
2008
SORE THROAT------------------------------------------------------------ PAGE 2
ACUTE OTITIS MEDIA ------------------------------------------------ PAGE 5
PERSISTENT ACUTE OTITIS MEDIA - ---------------------------- PAGE 9
ACUTE SINUSITIS ----------------------------------------------------- PAGE 13
SINUSITIS TREATMENT FAILURE -------------------------------- PAGE 16
RECURRENT OR CHRONIC SINUSITIS -------------------------- PAGE 19
OTITIS EXTERNA ------------------------------------------------------ PAGE 20
CYSTITIS HEALTHY WOMEN (NOT PREGNANT) ----------
PAGE 23
RECURRENT CYSTITIS (NOT PREGNANT) -------------------- PAGE 25
CYSTITIS AND BACTIURIA IN PREGNANCY ----------------
PAGE 27
CYSTITIS TREATMENT FAILURE -------------------------------
PAGE 30
1
Acute Sore Throat
-
When should I admit?
Admit immediately anyone who has:
- Stridor or respiratory difficulty:
o Respiratory distress, drooling, systemically very unwell, painful
swallowing, muffled voice: suspect acute epiglottis. Do not examine
the throat of anyone who has suspected epiglottitis.
o Upper airway obstruction.
- Dehydration or reluctance to take any fluids.
- Severe suppurative complications (e.g. peri-tonsillar abscess or
cellulitis, parapharyngeal abscess, retropharyngeal abscess, or
Lemierre syndrome) as there is a risk of airway compromise or rupture
of the abscess.
- Signs of being markedly systemically unwell and is at risk of
immunosuppression.
- Suspected Kawasaki disease.
- Diphtheria: characteristic tonsillar or pharyngeal membrane.
- Signs of being profoundly unwell and the cause is unknown or a rare
cause is suspected, for example:
o Stevens–Johnson syndrome: high fever, arthralgia, myalgia,
extensive bullae in the mouth followed by erosion and a greyish
white membrane.
o Yersinial pharyngitis: fever, prominent cervical lymphadenopathy,
abdominal pain with or without diarrhoea.
-
If the person is on chemotherapy, has known or suspected leukaemia,
asplenia, aplastic anaemia or HIV/AIDS, or is taking an
immunosuppressive drug following a transplant:
 Seek immediate specialist advice or referral.
 Meanwhile check the FBC urgently.
Refer or seek urgent specialist advice for anyone who has severe oral
mucositis.
Who should I refer for consideration of tonsillectomy?
Identify people who may need non urgent referral for consideration of
tonsillectomy:
- Confirm the diagnosis of recurrent tonsillitis by history and
examination, if possible differentiating it from pharyngitis. In practice
this may be difficult to do because people do not always consult when
they have sore throat and there may be uncertainty about whether
previous sore throats were due to acute tonsillitis or pharyngitis.
- Note whether the frequency of episodes is increasing or decreasing.
- In most children only consider referral for tonsillectomy if all of the
following criteria are met:
o The child has five or more episodes of acute sore throat per year,
documented by the parent or clinician.
o Symptoms have been occurring for at least a year.
o The episodes of sore throat have been severe enough to disrupt the
child's normal behaviour or day to day functioning.
- Refer if the child has guttate psoriasis which is exacerbated by
recurrent tonsillitis.
- Refer if the child has a history of sleep apnoea, daytime drowsiness,
and failure to thrive.
- Refer adults if they have had had five or more episodes per year of
sore throat due to tonsillitis. The episodes should have been disabling
and have prevented normal functioning.
When should I refer or seek advice?
- If the person may be immunosuppressed:
- If taking a disease-modifying anti-rheumatic drug (DMARD) and
immediate admission is not appropriate then:
o Take blood for a full blood count (FBC). Arrange to contact them
later with the result.
o Withhold the DMARD whilst awaiting the result and until discussed
with the hospital rheumatology service (or follow local protocols).
o Seek urgent specialist advice/referral if the person has a low white
cell count or deteriorates.
o Provide symptomatic relief.
o Consider prescribing an antibiotic taking into account potential
interactions with DMARDs.
- If the person is taking carbimazole (which can cause idiosyncratic
neutropenia) take an urgent FBC and withhold the drug until the result
is available. Seek specialist advice. Consider prescribing an antibiotic.
When should I investigate?
- Throat swabs or rapid antigen tests should not be carried out routinely
in the investigation of acute sore throat.
- If the person is at risk of immunosuppression see Referral.
- If infectious mononucleosis (glandular fever) is suspected and the
person wishes to be tested:
 In immunocompetent people over 12 years of age, the following
tests may be done:
o Full blood count, differential white cell count and blood film.
o Heterophile antibodies (Monospot): false negative results
are less likely after the second week of the illness.
2

o Liver function tests.
In children under 12 years of age, and in people who are
immunocompromised at any age, viral serology for the EpsteinBarr virus is preferred.
o
Prevent the development of rheumatic fever and acute
glomerulonephritis.
For people with sore throat where it is felt safe not to prescribe antibiotics
immediately:
What advice should I give?
- Reassure the individual that a sore throat is generally self limiting, with
most immunocompetent people recovering after 7 days with or without
antibiotic treatment.
- Advise the person to see a healthcare professional if they do not
improve. Explain that they should seek urgent medical attention if they
develop any difficulty breathing, stridor, drooling, a muffled voice,
severe pain, dysphagia, or if they are not able to swallow adequate
fluids or become systemically very unwell.
- Advise regular use of paracetamol or ibuprofen to relieve pain and
fever.
- Provide advice regarding food and drink to avoid exacerbating pain
(e.g. avoid hot drinks).
- Suggest the use of simple mouthwashes (e.g. warm salty water) at
frequent intervals until the discomfort and swelling subside.
- Discuss the role of antibiotics (see Prescribing an antibiotic).
- If the person is immunosuppressed:
o If they are taking a disease-modifying anti-rheumatic drug
(DMARD), or carbimazole tell them to stop this while waiting for
result of a full blood count (FBC). Arrange to contact them later
with the result and explain that you will seek specialist advice.
o Stress that they should seek immediate medical advice if they
become systemically unwell.
o Explain to all other people who are immunosuppressed that you
will seek urgent specialist advice. This includes people who:
- Have leukaemia, aplastic anaemia, asplenia or HIV/AIDS.
- Are on chemotherapy or who are taking an
immunosuppressive drug following a transplant. Advise them
not to stop their medication unless after your discussion with
the specialist they are advised to do so.
o
o
Use of delayed antibiotic prescriptions may be considered. Delayed
prescription may help to reduce re-attendance.
However, there is no evidence to indicate that it is different to 'no
antibiotics' in terms of symptom control, patient satisfaction and
disease complications.
Prescribe an antibiotic for:
o
o
o
o
o
o
o
Those with features of marked systemic upset.
Those at increased risk of complications. Have a low threshold for
prescribing an antibiotic in people:
With an increased risk of severe infection (e.g. diabetes or
immunocompromised).
Who are at risk of immunosuppression (e.g. on disease-modifying antirheumatic drugs [DMARDs], carbimazole).
With a history of valvular heart disease.
With a history of rheumatic fever.
People with peritonsillar abscess or peritonsillar cellulitis will receive
antibiotics in secondary care: admit immediately.
An antibiotic may be useful in:
o
o
Preventing cross-infections with group A beta-haemolytic streptococcus
(GABHS) in closed institutions such as barracks or boarding schools.
However, it should not be used routinely to prevent cross infection in
the general community.
Treating recurrent sore throat associated with GABHS.
Which antibiotic should I prescribe for sore throat?
 Prescribe phenoxymethylpenicillin (or erythromycin if the person
is allergic to penicillin) for 10 days.
 Avoid prescribing broad-spectrum penicillins (such as amoxicillin
and ampicillin) for the blind treatment of sore throat.l summary:
Management of persistent sore throat
When should I prescribe an antibiotic for sore throat?
Do not routinely prescribe antibiotics for acute sore throat.
Antibiotics should not be prescribed to:
o Secure symptomatic relief.
o Prevent suppurative complications.
o Treat recurrent non-streptococcal sore throat.
3
How should I manage someone with persistent sore throat?
 Reconsider the initial diagnosis.
 Consider alternative diagnosis or further investigation if the
individual has not responded to a course of antibiotics.
 Consider cancer if the sore throat is persistent, especially if
there is a neck mass (cervical node metastases).
 Refer urgently anyone with:
 An unexplained persistent sore or painful throat.
Persistent would refer to a time frame of 3 to 4 weeks.
 Red, or red and white patches, or ulceration or swelling
of the oral/pharyngeal mucosa for more than 3 weeks.
 Pain on swallowing or dysphagia for more than 3 weeks.
 Suspect infectious mononucleosis if sore throat and lethargy
persist into the second week, especially if the person is 15–
25 years of age. Request a full blood count, differential white
cell count and blood film to look for mononuclear leucocytosis,
and a Monospot test to look for heterophile antibodies if the
person wishes to be tested.
 Consider non-infectious causes of sore throat (for example,
gastro-oesophageal reflux disease, chronic irritation from
cigarette smoke, alcohol, or hayfever).
Penicillin V tablets: 500mg four times a day
Age from 12 years onwards
Phenoxymethylpenicillin 250mg tablets. Take two tablets four times a
day for 10 days. Supply 80 tablets.
1st line in penicillin allergy: erythromycin for 10 days Licensed
use: yes
Patient Information: Continue to take painkillers if needed.
Erythromycin s/f suspension: 125mg four times a day
Age from 1 month to 1 year 11 months
Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free.
Take one 5ml spoonful four times a day for 10 days. Supply 200 ml.
Erythromycin s/f suspension: 250mg four times a day
Age from 2 years to 11 years 11 months
Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free.
Take one 5ml spoonful four times a day for 10 days. Supply 200 ml.
Patient Information: Continue to take painkillers if needed
Erythromycin s/f suspension: 500mg four times a day
Age from 8 years to 11 years 11 months
Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free.
Take one 5ml spoonful four times a day for 10 days. Supply 200 ml.
Penicillin V s/f solution: 62.5mg four times a day
Age from 1 month to 11 months
Phenoxymethylpenicillin 125mg/5ml oral solution sugar free. Take 2.5ml
four times a day for 10 days. Supply 100 ml.
Erythromycin e/c tablets: 500mg four times a day
Age from 12 years onwards
Erythromycin 250mg gastro-resistant tablets. Take two tablets four times
a day for 10 days. Supply 80 tablets.
1st line antibiotic: penicillin V for 10 days Licensed use: yes
Penicillin V s/f solution: 125mg four times a day
Age from 1 year to 5 years 11 months
Phenoxymethylpenicillin 125mg/5ml oral solution sugar free. Take one
5ml spoonful four times a day for 10 days. Supply 200 ml.
Penicillin V s/f solution: 250mg four times a day
Age from 6 years to 11 years 11 months
Phenoxymethylpenicillin 250mg/5ml oral solution sugar free. Take one
5ml spoonful four times a day for 10 days. Supply 200 ml.
4

ACUTE OTITIS MEDIA (AOM)
Scenario: First-line treatment
Erythromycin (use high doses) or clarithromycin (use standard doses)
are alternative antibiotics if the child has a documented allergy to
penicillin.
Practical prescribing points
 If a delayed prescription is issued, advise the parent to destroy
the script or dispose of the antibiotics if they are not used for the
current episode of acute otitis media.
 Broad-spectrum antibiotics may cause gastrointestinal adverse
effects such as vomiting. A skin rash may also occur.
 Ibuprofen may occasionally cause gastrointestinal adverse effects,
such as discomfort, nausea, and diarrhoea.
Which therapy?
This guidance is primarily intended for the treatment of children with acute
otitis media (AOM). Although AOM can occur in adults, it is less common,
and there is little evidence on which to base guidelines. In the absence of
good evidence or guidelines on the treatment of AOM in adults, treatment
should be the same as in children.
Offer analgesia if pain is present. For most children, this is the
mainstay of treatment.
 Paracetamol is the preferred treatment.
 Ibuprofen is an alternative to paracetamol.
Refer?
Admission or immediate referral to an Ear, Nose, and Throat (ENT)
specialist is indicated in children with:




Antibiotics should not be routinely prescribed for uncomplicated
AOM. Discuss and reassure the individual or their parent on the benefits of
and drawbacks of using antibiotics for AOM. The Shared decision making
sections are useful resources for this.
Sudden severe hearing loss (except in simple perforation)
Sudden dizziness with nystagmus
Signs suggesting meningitis
Progression to mastoiditis
Elective referral to an ENT department is indicated in:
 Children with persistent problems with effusion, discharge, or
perforation (if not healed after 6 weeks)
 Children with frequent episodes of AOM and proven hearing loss
(four episodes or more in a period of 6 months)
 Children in whom there is persisting effusion or impaired hearing
after 3 to 6 months (see the CKS topic on Otitis media with
effusion)
 Note: have a low threshold for referral of children with serious
craniofacial abnormalities or immune deficiencies that are not
responding to primary care management, as they are at high risk
of developing head and neck complications.
However, some children may significantly benefit from antibiotics.
Consider prescribing antibiotics in the following children:
 All children aged 6 months and under
 Children aged between 6 months and 2 years where the diagnosis is
reasonably certain
 Children older than 2 years where there are severe symptoms:
o Moderate or severe ear pain (otalgia) with a fever of 39°C or
above, or systemic features such as vomiting
o Severe local signs, such as perforation with purulent discharge
o Bilateral AOM
A good compromise is to use a 'wait and see' policy by issuing a
delayed prescription to be redeemed. This is a compromise where parents
are issued with a prescription to be redeemed within 72 hours only if the
condition has not adequately improved.
Investigate?
No investigations are indicated for a first episode of acute otitis media in
primary care.
Choice of antibiotic:
 Amoxicillin is the usual first-line antibiotic. Treat for 5 days. If there
are severe symptoms present, or there has been a previous episode of
AOM within the last month, use high doses (double the standard dose).
Most people do not require follow-up. Ask the parent to arrange a
follow-up appointment if symptoms have not significantly improved after
3 days, whether the child has been given an antibiotic or not.
5

If a delayed prescription has been used, the parent should seek
advice 3 days after the antibiotic has been taken.
There is no advantage in using an antibiotic to cover beta-lactamase
resistant organisms (e.g. co-amoxiclav) in the initial treatment of AOM
Consider active follow-up in the following circumstances:
 The person is a young child (under 2 years of age).
 There are systemic symptoms such as high temperature (> 39°C)
or vomiting.
 There is discharge from the ear. Visualisation of the tympanic
membrane can be difficult when there is discharge present. Reexamine after 2 weeks to assess the integrity of the membrane and
to check for complications. If there is a perforation still present,
monitor the situation and consider referral if it has not healed after
6 weeks.
It demonstrates favourable pharmacokinetics, with high concentrations
forming in the middle ear.
Amoxicillin has a relatively narrow spectrum of microbiological activity
(compared with some other broad-spectrum antibiotics), targeting most of
the bacteria involved in AOM. Consequently, it has relatively few adverse
effects, and a lower potential for causing antibiotic resistance.
The macrolides are suitable alternatives to amoxicillin in people allergic
to penicillin. They are active against most of the bacterial pathogens
involved in otitis media, although resistance to them is increasing,
especially in H. influenzae.
Paracetamol and ibuprofen are the mainstays of treatment for most
people with AOM. They are effective and relatively safe antipyretics and
analgesics in both children and adults
Shared decision making
Erythromycin is a commonly used option, but requires frequent dosing
and may cause adverse effects.
Most bouts of ear infection clear on their own within a few days.
Clarithromycin is generally better tolerated than erythromycin, and is a
suitable alternative if erythromycin is poorly tolerated. It also has a more
convenient dosing regimen
Painkillers such as paracetamol or ibuprofen are the main treatment.
Use regularly until the pain eases.
These will also lower a raised temperature.
Antibiotics are not advised in most cases. They are an option if the
infection is severe, or if it does not ease after 2–3 days:
Amoxicillin is the common antibiotic used for ear infections.
Erythromycin or clarithromycin are alternatives for people allergic to
penicillin.
1st-line: low dose amoxicillin
Licensed use: yes Patient Information: Continue to take painkillers if needed.
Discard any remaining medicine safely.
Amoxicillin s/f suspension: 62.5mg three times a day
Age from 1 month to 11 months
Amoxicillin 125mg/5ml s/f susp. Take 2.5ml three times a day for 5 days. Supply
100 ml.
Antibiotics may cause side-effects such as diarrhoea or feeling sick.
Antibiotics
Prescribe amoxicillin first-line, if an antibiotic is required. There is
evidence from randomized controlled trials (RCTs) that it is more effective
than placebo and as effective as other antibiotics in the treatment of acute
otitis media (AOM). The following factors also favour its use]:
Amoxicillin s/f suspension: 125mg three times a day
Age from 1 year to 4 years 11 months
Amoxicillin 125mg/5ml s/f susp. Take one 5ml spoonful three times a day for 5
days. Supply 100 ml.
Amoxicillin s/f suspension: 250mg three times a day
Age from 4 years 11 months to 11 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take one 5ml spoonful three times a day for 5
days. Supply 100 ml.
Amoxicillin provides coverage against most of the bacteria involved in
AOM, including penicillin-intermediate Streptococcus pneumoniae (bacteria
in an intermediate stage of developing full penicillin resistance) when used
at adequate doses.
Amoxicillin capsules: 500mg three times a day
6
Age from 12 years onwards
Amoxicillin 500mg capsules. Take one capsule three times a day for 5 days.
Supply 15 capsules.
Erythromycin s/f suspension: 250mg four times a day
Age from 1 month to 1 year 11 months
Erythromycin 250mg/5ml sf susp. Take one 5ml spoonful four times a day for 5
days. Supply 100 ml.
1st-line: high dose amoxicillin
Amoxicillin s/f suspension: 125mg three times a day
Age from 1 month to 11 months
Amoxicillin 125mg/5ml s/f susp. Take one 5ml spoonful three times a day for 5
days. Supply 100 ml.
Erythromycin s/f suspension: 500mg four times a day
Age from 2 years to 11 years 11 months
Erythromycin 500mg/5ml sf susp. Take one 5ml spoonful four times a day for 5
days. Supply 100 ml.
Erythromycin e/c tablets: 500mg four times a day
Age from 12 years onwards
Erythromycin 250mg e/c tablets. Take two tablets four times a day for 5 days.
Supply 40 tablets.
Amoxicillin s/f suspension: 250mg three times a day
Age from 1 year to 4 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take one 5ml spoonful three times a day for 5
days. Supply 100 ml.
1st line pen allergy: clarithromycin
Amoxicillin s/f suspension: 500mg three times a day
Age from 5 years to 11 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take two 5ml spoonfuls three times a day for 5
days. Supply 200 ml.
Clarithromycin suspension: 62.5mg twice a day
Age from 1 year to 2 years 11 months
Clarithromycin 125mg/5ml susp. Take 2.5ml twice a day for 7 days. Supply 70
ml.
Amoxicillin capsules: 1g three times a day
Age from 12 years onwards
Amoxicillin 500mg capsules. Take two capsules three times a day for 5 days.
Supply 30 capsules.
Clarithromycin suspension: 125mg twice a day
Age from 3 years to 6 years 11 months
Clarithromycin 125mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
1st-line pen allerg: low dose erythromcyin
Clarithromycin suspension: 187.5mg twice a day
Age from 7 years to 9 years 11 months
Clarithromycin 125mg/5ml susp. Take 7.5ml twice a day for 7 days. Supply 140
ml.
Erythromycin s/f suspension: 125mg four times a day
Age from 1 month to 1 year 11 months
Erythromycin 125mg/5ml sf susp. Take one 5ml spoonful four times a day for 5
days. Supply 100 ml.
Clarithromycin suspension: 250mg twice a day
Age from 10 years to 11 years 11 months
Clarithromycin 250mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Erythromycin s/f suspension: 250mg four times a day
Age from 2 years to 11 years 11 months
Erythromycin 250mg/5ml sf susp. Take one 5ml spoonful four times a day for 5
days. Supply 100 ml.
Clarithromycin tablets: 250mg twice a day
Age from 12 years onwards
Clarithromycin 250mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Erythromycin e/c tablets: 250mg four times a day
Age from 12 years onwards
Erythromycin 250mg e/c tablets. Take one tablet four times a day for 5 days.
Supply 20 tablets.
1st line pen allerg: high dose erythromcyin
7
Drugs not included
Antihistamines or decongestants are not recommended for use in
AOM, as they are not effective and have adverse effects
Antibiotics
© NHS Institute for Innovation and Improvement
Broad-spectrum penicillin-derived antibiotics (other than amoxicillin)
do not offer any advantages compared with amoxicillin. In general, there
is less evidence from randomized controlled trials to support the use of
alternative broad-spectrum antibiotics, and in addition:
Ampicillin has to be taken more frequently than amoxicillin
Phenoxymethylpenicillin is effective against Streptococcus pneumoniae,
but lacks efficacy against Haemophilus influenzae
Co-amoxiclav is not necessary in the initial treatment of AOM It is a
suitable second-line treatment if initial treatment is unsuccessful
Cephalosporins are not usually recommended in the first-line treatment
of AOM. Although recent RCTs have confirmed the efficacy of ceftriaxone,
it is taken as an intramuscular injection, which is inconvenient for use in
primary care. In addition, cephalosporins are not suitable for people with
allergies to penicillin, who may be cross-sensitive to cephalosporins
Quinolones are contraindicated in children under 16 years of age. In
addition, they should only be used in adults when the organism sensitivity
to them is known, as there are growing concerns about the development
of resistance to these drugs in the community. If used, a quinolone with
enhanced anti-pneumococcal activity should be selected (e.g.
moxifloxacin)
Trimethoprim and co-trimoxazole are not recommended, owing to
safety and resistance issues.
Analgesia and other drugs
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), other
than ibuprofen, are excluded because of their relatively extensive
adverse-effect profiles. In addition, aspirin should not be used in children
under the age of 16 years
8
Refer?
Admission or immediate referral to an Ear, Nose, and Throat (ENT)
specialist is indicated in children with:
Persistent acute otitis media/ treatment failure
Which therapy?




This guidance is primarily intended for the treatment of children with acute
otitis media (AOM). Although AOM can occur in adults, it is less common,
and there is little evidence on which to base guidelines. In the absence of
good evidence or guidelines on the treatment of AOM in adults, treatment
should be the same as in children.
If an antibiotic has not been given previously, prescribe a first-line
antibiotic.
Amoxicillin is the usual first-line antibiotic. Treat for 5 days with high
doses (double the standard dose).
Erythromycin or clarithromycin are alternative antibiotics if the child
has a documented allergy to penicillin (treat with high doses of
erythromycin or standard doses of clarithromycin for 5 days).
If an antibiotic has been prescribed previously and symptoms have
not resolved, check compliance. If this was unsatisfactory, consider represcribing a first-line antibiotic (this may also be an option if symptoms
have improved but not cleared completely). If compliance was
satisfactory, prescribe a second-line antibiotic.
Co-amoxiclav is the preferred antibiotic. Prescribe a high dose (double
standard dose) for 5 days.
If the child is allergic to penicillin and has already taken erythromycin or
clarithromycin, seek specialist advice from a microbiologist.
Continue analgesia if pain is present.
Paracetamol is the preferred treatment.
Ibuprofen is an alternative to paracetamol.
Sudden severe hearing loss (except in simple perforation)
Sudden dizziness with nystagmus
Signs suggesting meningitis
Progression to mastoiditis
Elective referral to an ENT department is indicated in:



Children with persistent problems with effusion, discharge, or
perforation (if not healed after 6 weeks)
Children with frequent episodes of acute otitis media and proven
hearing loss (four episodes or more in a period of 6 months)
Children in whom there is persisting effusion or impaired hearing after
3 to 6 months (see the CKS topic on Otitis media with effusion).
Seek specialist advice if acute symptoms of otitis media persist despite
the use of a second-line antibiotic.
Note: have a low threshold for referral of children with serious craniofacial
abnormalities or immune deficiencies that are not responding to primary
care management, as they are at high risk of developing head and neck
complications.
Investigate?
Consider sending a swab for culture and microbial sensitivity
testing if there is perforation of the tympanic membrane that allows for
a sample to be taken. This may be especially useful if first-line antibiotic
treatment has failed.
Practical prescribing points
Broad-spectrum antibiotics may cause gastrointestinal adverse effects
such as vomiting. A skin rash may also occur.
Ibuprofen may occasionally cause gastrointestinal adverse effects, such
as discomfort, nausea, and diarrhoea.
Co-amoxiclav: the Committee on Safety of Medicines has advised that
the incidence of cholestatic jaundice with co-amoxiclav is about six times
greater than with amoxicillin alone. Older people (over 65 years) are at
greatest risk, and cases in children are rare. The condition is usually selflimiting and very rarely fatal.
Ask the parent to arrange a follow-up appointment if symptoms
have not significantly improved after 3 days. Check for complications.


If a first-line antibiotic has been used, consider trying a second-line
antibiotic.
If a second-line antibiotic has been used, seek specialist advice.
Consider active follow-up in the following circumstances:
9



The person is a young child (under 2 years of age).
There are systemic symptoms such as high temperature (> 39°C)
or vomiting.
There is discharge from the ear. Visualisation of the tympanic
membrane can be difficult when there is discharge present. Reexamine after 2 weeks to assess the integrity of the membrane and
to check for complications. If there is a perforation still present,
monitor the situation and consider referral if it has not healed after
6 weeks.
Erythromycin e/c tablets: 500mg four times a day
Age from 12 years onwards
Erythromycin 250mg e/c tablets. Take two tablets four times a day for 5 days.
Supply 40 tablets.
1st line pen allergy: clarithromycin
Clarithromycin suspension: 62.5mg twice a day
Age from 1 year to 2 years 11 monthsClarithromycin 125mg/5ml susp. Take
2.5ml twice a day for 7 days. Supply 70 ml.
Clarithromycin suspension: 125mg twice a day
Age from 3 years to 6 years 11 months
Clarithromycin 125mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
1st-line: amoxicillin
Licensed use: yes Patient Information: Continue to take painkillers if needed.
Discard any remaining medicine safely.
Clarithromycin suspension: 187.5mg twice a day
Age from 7 years to 9 years 11 months
Clarithromycin 125mg/5ml susp. Take 7.5ml twice a day for 7 days. Supply 140
ml.
Amoxicillin s/f suspension: 125mg three times a day
Age from 1 month to 11 months
Amoxicillin 125mg/5ml s/f susp. Take one 5ml spoonful three times a day for 5
days. Supply 100 ml.
Clarithromycin suspension: 250mg twice a day
Age from 10 years to 11 years 11 months
Clarithromycin 250mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Amoxicillin s/f suspension: 250mg three times a day
Age from 1 year to 4 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take one 5ml spoonful three times a day for 5
days. Supply 100 ml.
Clarithromycin tablets: 250mg twice a day
Age from 12 years onwards
Clarithromycin 250mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Amoxicillin s/f suspension: 500mg three times a day
Age from 5 years to 11 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take two 5ml spoonfuls three times a day for 5
days. Supply 200 ml.
2nd-line tmt: co-amoxiclav
Amoxicillin capsules: 1g three times a day
Age from 12 years onwards
Amoxicillin 500mg capsules. Take two capsules three times a day for 5 days.
Supply 30 capsules.
Co-amoxiclav 125/31mg/5ml susp: 0.5ml/kg three times a day
Age from 1 month to 11 months
Co-amoxiclav 125/31mg/5ml susp. *WEIGHT REQUIRED* Take 0.5ml perkg
bodyweight THREE times a day for 5 days. Supply 100 ml.
1st line pen allerg: high dose erythromcyin
Erythromycin s/f suspension: 250mg four times a day
Age from 1 month to 1 year 11 months
Erythromycin 250mg/5ml sf susp. Take one 5ml spoonful four times a day for 5
days. Supply 100 ml.
Co-amoxiclav suspension: 250/62mg three times a day
Age from 1 year to 5 years 11 months
Co-amoxiclav 250/62mg/5ml susp. Take one 5ml spoonful three times a day for
5 days. Supply 100 ml.
Erythromycin s/f suspension: 500mg four times a day
Age from 2 years to 11 years 11 months
Erythromycin 500mg/5ml sf susp. Take one 5ml spoonful four times a day for 5
days. Supply 100 ml.
Co-amoxiclav suspension: 500/125mg three times a day
Age from 6 years to 11 years 11 months
Co-amoxiclav 250/62mg/5ml susp. Take two 5ml spoonfuls twice a day for 5
days. Supply 200 ml.
10

Co-amoxiclav tablets: 500/125mg three times a day
Age from 12 years onwardsCo-amoxiclav 500/125mg tabs. Take one tablet
three times a day for 5 days. Supply 30 tablets.
Analgesia
Paracetamol and ibuprofen are the mainstays of treatment for most
people with AOM. They are effective and relatively safe antipyretics and
analgesics in both children and adults
Second-line antibiotics
Co-amoxiclav is the preferred second-line antibiotic in children who
are not allergic to penicillin. It is a combination of amoxicillin and
clavulanic acid (a beta-lactamase inhibitor
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), other
than ibuprofen, are excluded because of their relatively extensive
adverse-effect profiles. In addition, aspirin should not be used in children
under the age of 16 years

Antihistamines or decongestants are not recommended for use in
AOM, as they are not effective and have adverse effects

Antibiotics
Prescribe amoxicillin first-line, if an antibiotic is required. There is
evidence from randomized controlled trials (RCTs) that it is more effective
than placebo and as effective as other antibiotics in the treatment of acute
otitis media (AOM). The following factors also favour its use Amoxicillin
provides coverage against most of the bacteria involved in AOM, including
penicillin-intermediate Streptococcus pneumoniae (bacteria in an
intermediate stage of developing full penicillin resistance) when used at
adequate doses.





Clarithromycin is generally better tolerated than erythromycin, and is
a suitable alternative if erythromycin is poorly tolerated. It also has a
more convenient dosing regimen.

It is effective against beta-lactamase-producing bacteria, including
Moraxella catarrhalis, Haemophilus influenzae and most strains of
Streptococcus pneumoniae (although it is less effective against
resistant strains). It is well absorbed and forms good concentrations in
the middle ear.
There is evidence from randomized controlled trials that co-amoxiclav
is as effective as other beta-lactamase-resistant antibiotics (e.g. thirdgeneration cephalosporins) and azithromycin.
It is taken orally, and is inexpensive. When used in short courses, it
has relatively few adverse effects.
Broad-spectrum penicillin-derived antibiotics (other than amoxicillin)
do not offer any advantages compared with amoxicillin. In general, there
is less evidence from randomized controlled trials to support the use of
alternative broad-spectrum antibiotics, and in addition:

There is no advantage in using an antibiotic to cover beta-lactamaseresistant organisms (e.g. co-amoxiclav) in the initial treatment of AOM
It demonstrates favourable pharmacokinetics, with high concentrations
forming in the middle ear.
Amoxicillin has a relatively narrow spectrum of microbiological activity
(compared with some other broadspectrum antibiotics), targeting most
of the bacteria involved in AOM. Consequently it has relatively few
adverse effects, and a lower potential for causing antibiotic resistance.
The macrolides are suitable alternatives to amoxicillin in people
allergic to penicillin. They are active against most of the bacterial
pathogens involved in otitis media, although resistance to them is
increasing, especially in H. influenzae.
Erythromycin is a commonly used option, but requires frequent
dosing and may cause adverse effects.


11
Ampicillin has to be taken more frequently than amoxicillin
Phenoxymethylpenicillin is effective against
Streptococcus pneumoniae, but lacks efficacy against Haemophilus
influenzae
Cephalosporins are not usually recommended in the first-line
treatment of AOM. Although recent RCTs have confirmed the efficacy
of ceftriaxone, it is taken as an intramuscular injection, which is
inconvenient for use in primary care. In addition, cephalosporins are
not suitable for people with allergies to penicillin, who may be crosssensitive to cephalosporins
Quinolones are contraindicated in children under 16 years of age. In
addition, they should only be used in adults when the organism
sensitivity to them is known, as there are growing concerns about the
development of resistance to these drugs in the community. If used, a
quinolone with enhanced anti-pneumococcal activity should be selected
(e.g. moxifloxacin)

Trimethoprim and co-trimoxazole are not recommended, owing to
safety and resistance issues.
PATIENT INFORMATION






The ear infection is still present.
An antibiotic is likely to clear the infection.
Amoxicillin is the common antibiotic used for ear infections.
Alternatives are:
o Co-amoxiclav, if you have already had a course of
amoxicillin that has not worked (some bacteria are resistant
to some antibiotics)
o Erythromycin or clarithromycin for people allergic to
penicillin
Antibiotics may cause side-effects such as diarrhoea or feeling
sick.
Painkillers such as paracetamol or ibuprofen are an important
treatment in addition to antibiotics. Use regularly until the pain
eases.
© NHS Institute for Innovation and Improvement
12
ACUTE SINUSITIS
If the infection is suspected to be of dental origin, refer to a dentist.
General management
Prescribe analgesia to reduce pain and temperature.
 Paracetamol or ibuprofen are usually sufficient.
 Codeine can be added if required.
Investigate?
Routine diagnostic tests are not helpful in the initial assessment of
acute sinusitis.
 Plain X-rays, blood tests, nasal swabs, sinus puncture, and
transillumination of the sinuses are of limited value in primary care,
and are not recommended.
Referral for computed tomography is not routinely recommended.
Intranasal decongestants may give additional relief to antibiotic
treatment in the short term. Other symptomatic treatments are not
generally recommended.
Antibiotics
Antibiotics should not be prescribed routinely. Prescribe if:
 Symptoms have persisted for 7 days or more.
 Symptoms are severe, or are deteriorating significantly.
If an antibiotic is indicated, prescribe:
 Amoxicillin as the first-line antibiotic.
 Doxycycline, erythromycin or clarithromycin, if amoxicillin is
unsuitable (e.g. allergy to penicillin)
 Erythromycin, in pregnant or breastfeeding women.
Follow-up advice
Routine follow-up is not required in people whose symptoms resolve
with or without treatment.
If a person is not treated with an antibiotic:
 Advise review if symptoms get worse or are not improving within
7 days.
 Consider the use of a first-line antibiotic.
If a person is being treated with an antibiotic:
 Advise review if symptoms are not improving within 72 hours or if the
antibiotic is poorly tolerated (e.g. vomiting).
 Consider the use of a second-line antibiotic
Practical prescribing points
Ibuprofen: as with other nonsteroidal anti-inflammatory drugs, ibuprofen
may worsen or precipitate gastrointestinal haemorrhage, asthma,
hypertension, renal impairment, or cardiac failure. Avoid if there is a
history of peptic ulcers, and avoid in pregnant women.
Doxycyline: contraindicated in pregnancy, breastfeeding, porphyria, and
in children aged under 12 years. Use with caution in people with hepatic
impairment. Doxycycline may cause photosensitivity reactions (avoid
exposure to excessive sunlight or sunlamps).
Intranasal decongestants can cause severe rebound effects, and should
not be used continuously for more than 7 days.
Analgesia
Paracetamol is an effective and safe analgesic and antipyretic drug.
Ibuprofen is an effective alternative to paracetamol, with a longer
duration of action.
Codeine (in combination with paracetamol): higher-dose codeine is
included for use for up to a few days with regular paracetamol for
additional pain relief. Codeine 60 mg combined with paracetamol has been
shown to provide more pain relief than either codeine 60 mg alone or
paracetamol 1000 mg
Intranasal decongestants
Intranasal decongestants are effective in relieving nasal congestion in
the short term, and may be of benefit in sinusitis. They should not be used
for more than a week because of the risk of rebound congestion on
cessation of treatment Ephedrine and xylometazoline are
sympathomimetic drugs, both available on prescription
Should I refer or investigate?
Refer?
Admit if there are:
Suspected complications (e.g. periorbital infection).
Urgently refer to an Ear, Nose and Throat (ENT) department if
there is a:
Suspected sinonasal tumour (persistent unilateral symptoms, such as
bloodstained discharge, crusting, or facial swelling).
Consider ENT referral for:
Unremitting or progressive facial pain.
Shared decision making
Sinusitis (infected sinus) is common, and often follows a cold.
Many people with sinusitis do not require any treatment. The
immune system usually clears away the infection.
13
Painkillers may be needed:



Amoxicillin 500mg capsules. Take one capsule three times a day for 7 days.
Supply 21 capsules.
Paracetamol will usually be sufficient.
Ibuprofen is an alternative.
Codeine can be added if paracetamol alone is not sufficient.
1st-line: penicillin allergy
Doxycycline capsules: 100mg once a day
Age from 16 years onwards
Doxycycline 100mg capsules. Take TWO capsules now and then take ONE
capsule once a day for the next 6 days. Supply 8 capsules.
Erythromycin s/f suspension: 125mg four times a day
Age from 1 month to 1 year 11 months
Erythromycin 125mg/5ml sf susp. Take one 5ml spoonful four times a day for 7
days. Supply 140 ml.
Erythromycin s/f suspension: 250mg four times a day
Age from 2 years to 11 years 11 months
Erythromycin 250mg/5ml sf susp. Take one 5ml spoonful four times a day for 7
days. Supply 140 ml.
Erythromycin e/c tablets: 250mg four times a day
Age from 12 years onwards
Erythromycin 250mg e/c tablets. Take one tablet four times a day for 7 days.
Supply 28 tablets.
Clarithromycin suspension: 62.5mg twice a day
Age from 1 year to 2 years 11 months
Clarithromycin 125mg/5ml susp. Take 2.5ml twice a day for 7 days. Supply 70
ml.
Clarithromycin suspension: 125mg twice a day
Age from 3 years to 6 years 11 months
Clarithromycin 125mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Clarithromycin suspension: 187.5mg twice a day
Age from 7 years to 9 years 11 months
Clarithromycin 125mg/5ml susp. Take 7.5ml twice a day for 7 days. Supply 140
ml.
Clarithromycin suspension: 250mg twice a day
Age from 10 years to 11 years 11 months
Clarithromycin 250mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Clarithromycin tablets: 250mg twice a day
Age from 12 years onwards
Clarithromycin 250mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Decongestants may help to ease symptoms. You should not use
decongestant drops or sprays for more than 5–7 days as a 'rebound'
blockage of the nose may occur.
Antibiotics are not usually needed. They may be advised if symptoms are
severe, getting worse, or last longer than 7 days.
Amoxicillin is recommended as the first-line antibiotic in most people. It
is active against most of the causative organisms implicated in acute
bacterial sinusitis, and has been shown to be effective in clinical trials. It is
inexpensive and generally well tolerated
Doxycycline is an alternative to amoxicillin if there is a true allergy to
penicillin. It has similar antibacterial activity to amoxicillin and, unlike
other tetracyclines, only requires once-daily administration. It is
contraindicated in children under the age of 12 years
Erythromycin or clarithromycin are alternatives to amoxicillin when
there is a true allergy to penicillin. Both drugs are active against most of
the causative organisms implicated in sinusitis, although resistance to
Haemophilus influenzae is increasing. Clarithromycin has fewer
gastrointestinal adverse effects than erythromycin [Erythromycin is less
effective against Haemophilus influenzae, but is recommended for use in
pregnant or breastfeeding women due to its safety record.
1st-line antibiotic: amoxicillin
Amoxicillin s/f suspension: 125mg three times a day
Age from 1 year to 1 year 11 months
Amoxicillin 125mg/5ml s/f susp. Take one 5ml spoonful three times a day for 7
days. Supply 100 ml.
Amoxicillin s/f suspension: 250mg three times a day
Age from 2 years to 9 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take one 5ml spoonful three times a day for 7
days. Supply 100 ml.
Amoxicillin s/f susp: 500mg three times a day
Age from 10 years to 11 years 11 months
Amoxicillin 250mg/5ml s/f susp. Take two 5ml spoonfuls three times a day for 7
days. Supply 300 ml.
Amoxicillin capsules: 500mg three times a day
Age from 12 years onwards
Erythromycin (IF pregnant)
Erythromycin e/c tablets: 250mg four times a day
Age from 12 years onwards
Erythromycin 250mg e/c tablets. Take one tablet four times a day for 7 days.
Supply 28 tablets.
14

Intranasal decongestants
Ephedrine 0.5% nose drops
Age from 1 year onwards
 Ephedrine 0.5% nose drops. Put one to two drops into each nostril
up to four times a day when required for nasal blockage. Do not
use for more than 7 days. Supply 10 ml.
Xylometazoline 0.05% nose drops
Age from 1 year to 11 years 11 months
 Xylometazoline paed nose drops. Put one to two drops into each
nostril once or twice a day when required for nasal blockage. Do
not use for more than 7 days. Supply 10 ml.
Xylometazoline 0.1% nose drops
Age from 12 years onwards
 Xylometazoline 0.1% nose drops. Put two to three drops into each
nostril 2 to 3 times a day when required for nasal blockage. Do
not use for more than 7 days. Supply 10 ml.
Co-trimoxazole should only be used under exceptional
circumstances, according to a recommendation from the Committee on
Safety of Medicines
Other drugs for symptomatic treatment
Fixed-dose combination analgesics containing weak opioids (e.g.
codeine) are not recommended, as they do not allow titration of the most
effective and safe analgesic dose to match the person's requirements.
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), other
than ibuprofen, are excluded because of their greater adverse-effect
profiles. In addition, aspirin should not be used in children under the age
of 16 years.
Oral decongestants are not as effective as intranasal decongestants, can
cause systemic adverse effects, and may interact with other medications.
Intranasal corticosteroids are unlikely to be beneficial in the treatment
of acute sinusitis, as they take time (probably at least 7 days) to exert
their effects.
Antihistamines (oral or intranasal) are not included, as they are unlikely
to reduce symptoms of bacterial sinusitis (although they may provide
some relief if a person has underlying allergic symptoms).
Mucolytics are not included, as they have not been shown to be
beneficial in acute sinusitis.
Drugs not included
Antibiotics
Penicillins other than amoxicillin are not included, as none have been
shown to have any additional benefits compared with amoxicillin:
 Phenoxymethylpenicillin has been recommended previously by
national guidelines . However, it has not been studied as extensively as
amoxicillin, and is less active against Haemophilus influenzae and
Moraxella catarrhalis.
 Co-amoxiclav is recommended for second-line treatment.
 Tetracyclines other than doxycycline are not included.
Oxytetracycline has been recommended previously in national
guidelines but requires four doses a day, which may reduce compliance
 Cephalosporins are not recommended for the first-line treatment of
acute sinusitis. Older cephalosporin drugs are not effective against
beta-lactamase-producing strains such as H influenzae, whereas newer
cephalosporins may require parenteral administration and are more
suited for second-line treatment . In addition, people who are allergic
to penicillin may be cross-sensitive to cephalosporins
 Quinolones are not recommended for the first-line treatment of acute
sinusitis. To reduce the potential for the development of antibiotic
resistance, they should be reserved for use when other antibiotics have
proved ineffective]. In addition, newer fluoroquinolones have not been
shown to be more effective than more conventional antibiotics
Metronidazole is effective against anaerobic bacteria, which are
usually associated with sinusitis secondary to dental infection.
© NHS Institute for Innovation and Improvement
15
SINUSITIS TREATMENT FAILURE
Follow up advice
Routine follow-up is not required in people whose symptoms resolve
with second-line antibiotic treatment.
People should seek medical advice if their symptoms get worse or are
not improving after second-line antibiotic treatment (or treatment with an
alternative first-line antibiotic).
 Consider seeking specialist advice.
 An alternative second-line antibiotic could be tried, if appropriate, if
symptoms are stable.
Reassess for other possible diagnoses, consider the possibility of
complications, and check compliance with treatment.
Prescribe a second-line antibiotic (co-amoxiclav) if:
An initial course of antibiotics has proved ineffective.
Symptoms are not improving after 72 hours.
If there is a true allergy to penicillin, consider prescribing a first-line
antibiotic that has not been used previously.
Use erythromycin or clarithromycin if doxycycline was used first.
Use doxycyline if a macrolide was used first.
Continue analgesia to reduce pain and temperature. Paracetamol or
ibuprofen are usually sufficient, but codeine can be added if required.
Consider recommending an intranasal decongestant if this has not
been used previously.
Other treatments should not be initiated without specialist advice.
Analgesia
Paracetamol is an effective and safe analgesic and antipyretic drug.
Ibuprofen is an effective alternative to paracetamol, with a longer
duration of action.
Codeine (in combination with paracetamol): higher-dose codeine is
included for use for up to a few days with regular paracetamol for
additional pain relief. Codeine 60 mg combined with paracetamol has been
shown to provide more pain relief than either codeine 60 mg alone or
paracetamol 1000 mg alone [
Intranasal decongestants
Intranasal decongestants are effective in relieving nasal congestion in
the short term, and may be of benefit in sinusitis. They should not be used
for more than a week because of the risk of rebound congestion on
cessation of treatment Ephedrine and xylometazoline are
sympathomimetic drugs, both available on prescription.
Practical prescribing points
Ibuprofen: as with other nonsteroidal anti-inflammatory drugs, ibuprofen
may worsen or precipitate gastrointestinal haemorrhage, asthma,
hypertension, renal impairment, or cardiac failure. Avoid if there is a
history of peptic ulcers and in pregnant women.
Intranasal decongestants can cause severe rebound effects, and should
not be used continuously for more than 7 days.uld I refer or investigate?
Refer?
Admit if there are:
Suspected complications (e.g. periorbital infection).
Urgently refer to an Ear, Nose and Throat (ENT) department if
there is a:
Suspected sinonasal tumour (persistent unilateral symptoms, such as
bloodstained discharge, crusting, or facial swelling).
Consider an ENT referral if:
 Second-line antibiotic treatment has been tried (or erythromycin in
pregnant women), and there are no alternative antibiotic options.
 There is unremitting or progressive facial pain.
If the infection is suspected to be of dental origin, refer to a dentist.
Antibiotics
Co-amoxiclav is indicated as second-line treatment when amoxicillin has
failed. It is a combination product consisting of amoxicillin and clavulanic
acid.
 It is effective against beta-lactamase-producing bacteria, including
Moraxella catarrhalis and resistant strains of Streptococcus
pneumoniae.
 Co-amoxiclav is as effective as other antibiotics that are betalactamase resistant (e.g. third-generation cephalosporins), is taken
orally, and is inexpensive.
Doxycycline is an alternative to co-amoxiclav if there is a true allergy to
penicillin and it has not been used before. It has similar antibacterial
activity to amoxicillin and, unlike other tetracyclines, only requires oncedaily administration. It is contraindicated in children under the age of
12 years
Erythromycin or clarithromycin are recommended when there is a true
allergy to penicillin and a macrolide has not been used before. Both drugs
Investigate?
Routine diagnostic tests are not helpful in the assessment of acute
sinusitis.
Plain X-rays, blood tests, nasal swabs, sinus puncture, and
transillumination of the sinuses are of limited value in primary care, and
are not recommended.
Referral for computed tomography is not routinely recommended.
16
are active against most of the causative organisms implicated in sinusitis
although resistance to Haemophilus influenzae is increasing.
Clarithromycin has fewer gastrointestinal adverse effects than
erythromycin .
Age from 2 years to 11 years 11 months
Erythromycin 250mg/5ml sf susp. Take one 5ml spoonful four times a day for 7
days. Supply 140 ml.
Erythromycin e/c tablets: 250mg four times a day
Age from 12 years onwards
Erythromycin 250mg e/c tablets. Take one tablet four times a day for 7 days.
Supply 28 tablets.
Clarithromycin suspension: 62.5mg twice a day
Age from 1 year to 2 years 11 months
Clarithromycin 125mg/5ml susp. Take 2.5ml twice a day for 7 days. Supply 70
ml.
Clarithromycin suspension: 125mg twice a day
Age from 3 years to 6 years 11 months
Clarithromycin 125mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Clarithromycin suspension: 187.5mg twice a day
Age from 7 years to 9 years 11 months
Clarithromycin 125mg/5ml susp. Take 7.5ml twice a day for 7 days. Supply 140
ml.
Clarithromycin suspension: 250mg twice a day
Age from 10 years to 11 years 11 months
Clarithromycin 250mg/5ml susp. Take one 5ml spoonful twice a day for 7 days.
Supply 70 ml.
Clarithromycin tablets: 250mg twice a day
Age from 12 years onwards
Clarithromycin 250mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Shared decision making
A second, different antibiotic is sometimes needed if the first fails to
clear an episode of sinusitis. (Some bacteria are resistant to some
antibiotics.)
In addition, painkillers may be needed:
o Paracetamol will usually be sufficient.
o Ibuprofen is an alternative.
o Codeine can be added if paracetamol alone is not sufficient.
Decongestants may help to ease symptoms. You should not use
decongestant drops or sprays for more than 5–7 days as a 'rebound'
blockage of the nose may occur.
2nd-line: co-amoxiclav
Co-amoxiclav s/f suspension: 125/31mg three times a day
Age from 1 year to 5 years 11 months
Co-amoxiclav 125/31mg/5ml susp. Take one 5ml spoonful three times a day for
7 days. Supply 100 ml.
Co-amoxiclav s/f suspension: 250/62mg three times a day
Age from 6 years to 11 years 11 months
Co-amoxiclav 250/62mg/5ml susp. Take one 5ml spoonful three times a day for
7 days. Supply 100 ml.
Co-amoxiclav tablets: 250/125mg three times a day
Age from 12 years to 15 years 11 months
Co-amoxiclav 375mg tablets. Take one tablet three times a day for 7 days.
Supply 21 tablets.
Co-amoxiclav tablets: 500/125mg three times a day
Age from 12 years onwards
Co-amoxiclav 625mg tablets. Take one tablet three times a day for 7 days.
Supply 21 tablets.
Intranasal decongestants
Ephedrine 0.5% nose drops
Age from 1 year onwards
Ephedrine 0.5% nose drops. Put one to two drops into each nostril up to four
times a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
Xylometazoline 0.05% nose drops
Age from 1 year to 11 years 11 months
Xylometazoline paed nose drops. Put one to two drops into each nostril once or
twice a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
Xylometazoline 0.1% nose drops
Age from 12 years onwards
Xylometazoline 0.1% nose drops. Put two to three drops into each nostril 2 to 3
times a day when required for nasal blockage. Do not use for more than 7 days.
Supply 10 ml.
2nd-line if penicillin allergy
Doxycycline capsules: 100mg once a day
Age from 16 years onwards
Doxycycline 100mg capsules. Take TWO capsules now and then take ONE
capsule once a day for the next 6 days. Supply 8 capsules.
Erythromycin s/f suspension: 125mg four times a day
Age from 1 month to 1 year 11 months
Erythromycin 125mg/5ml sf susp. Take one 5ml spoonful four times a day for 7
days. Supply 140 ml.
Erythromycin s/f suspension: 250mg four times a day
Drug rationale
17
Drugs not included
Antibiotics
Amoxicillin (and other beta-lactam penicillins) are not recommended
as second-line antibiotics. Amoxicillin has limited activity against
Haemophilus influenzae and Moraxella catarrhalis and resistant strains of
Streptococcus pneumoniae ].
Tetracyclines other than doxycycline are not included. Oxytetracycline
has been recommended previously in national guidelines, but requires four
doses a day, which may reduce compliance
Cephalosporins are not usually recommended in the treatment of acute
sinusitis. Older cephalosporins (e.g. cefalexin) are ineffective against most
beta-lactamase producing bacteria, whereas newer cephalosporins (e.g.
ceftriaxone), often require parenteral administration which is not
convenient in primary care. In addition, people who are allergic to
penicillin may be cross-sensitive to cephalosporins ].
Quinolones are not recommended for the routine second-line treatment
of acute sinusitis. To lower the potential for the development of antibiotic
resistance, they should be reserved for use when other antibiotics have
proved ineffectiveIn addition, newer fluoroquinolones have not been
shown to be more effective than more conventional antibiotics
Metronidazole is effective against anaerobic bacteria, which are usually
associated with sinusitis secondary to dental infection.
Co-trimoxazole should only be used under exceptional circumstances,
according to a recommendation from the Committee on Safety of
Medicines
© NHS Institute for Innovation and Improvement
Other drugs for symptomatic treatment
Fixed-dose combination analgesics containing weak opioids (e.g.
codeine) are not recommended, as they do not allow titration of the most
effective and safe analgesic dose to match the person's requirements.
Analgesics other than paracetamol, ibuprofen and codeine (in
combination with paracetamol) are not appropriate to be used
routinely for first-line symptomatic relief, as they may cause more adverse
effects and are more expensive.
Oral decongestants are not as effective as intranasal decongestants, can
cause systemic adverse effects, and may interact with other medications
Intranasal corticosteroids are unlikely to be beneficial in the treatment
of acute sinusitis, as they take considerable time (probably at least
7 days) to exert their effects.
Antihistamines (oral or intranasal) probably have no role in the acute
stage of bacterial sinusitis.
Mucolytics are not included, as they have not been shown to be
beneficial in acute sinusitis.
18
Recurrent or chronic sinusitis
Age from 14 years onwards
Flunisolide 25mcg nasal spray. Spray twice into each nostril twice a day. Supply
1 spray.
Fluticasone 50microgram nasal spray (4 years to 11 years 11 months)
Age from 4 years to 11 years 11 months
Fluticasone 50mcg nasal spray. Spray once into each nostril each morning.
Supply 1 spray.
Fluticasone 50microgram nasal spray (12 years onwards)
Age from 12 years onwards
Fluticasone 50mcg nasal spray. Spray twice into each nostril each morning.
Supply 1 spray.
Mometasone 50microgram nasal spray (6 years to 11 years 11 months)
Age from 6 years to 11 years 11 months
Mometasone 50mcg nasal spray. Spray once into each nostril once a day. Supply
1 spray.
Mometasone 50microgram nasal spray (12 years onwards)
Age from 12 years onwards
Mometasone 50mcg nasal spray. Spray twice into each nostril once a day. Supply
1 spray.
Triamcinolone 55microgram nasal spray (6 years to 11 years 11 months)
Age from 6 years to 11 years 11 months
Triamcinolone 55mcg nasal spray. Spray once into each nostril once a day.
Supply 1 spray.
Triamcinolone 55microgram nasal spray (12 years onwards)
Age from 12 years onwards
Triamcinolone 55mcg nasal spray. Spray twice into each nostril once a day.
Supply 1 spray.
Recurrent sinusitis is defined as more than three significant acute
episodes annually, each lasting for 10 days or more. Chronic sinusitis is
defined as symptoms persisting for more than 90 days.
In all people:
Prescribe analgesia to reduce pain (if necessary). Paracetamol or
ibuprofen is usually sufficient, and codeine can be added if required.
Identify predisposing factors, and manage these (where possible):
o Allergies —
o Anatomical abnormalities (e.g. nasal septal deviation) — consider
referral.
o Pre-existing asthma — optimize asthma control.
o Dental infection — give advice on good dental hygiene, and ask the
person to see a dentist promptly if a dental infection is suspected.
Smoking — advise the person to stop smoking and avoid exposure to
passive smoking.
o Divers with nasal or sinus pathology — advise on the potentially
serious consequences of sinus barotrauma, and refer for specialist
advice.
In people with recurrent sinusitis:
Treat as an acute episode and consider referral for Ear, Nose and Throat
(ENT) assessment.
In people with chronic sinusitis:
Consider a trial course of intranasal corticosteroids (for up to 3 months)
Intranasal corticosteroids
Beclometasone 50microgram nasal spray
Age from 6 years onwards
Beclometasone nasal spray. Spray twice into each nostril twice a day. Supply 1
spray.
Betamethasone 0.1% nose drops
Age from 1 year onwards
Betamethasone 0.1% nose drops. Put two drops into each nostril twice a day.
Supply 10 ml.
Budesonide 64microgram nasal spray
Age from 12 years onwards
Budesonide 64mcg nasal spray. Spray once into each nostril twice a day. Supply
1 spray.
Flunisolide 25microgram nasal spray (5 years to 13 years 11 months)
Age from 5 years to 13 years 11 months
Flunisolide 25mcg nasal spray. Spray once into each nostril up to three times a
day. Supply 1 spray.
Flunisolide 25microgram nasal spray (14 years onwards)
© NHS Institute for Innovation and Improvement
19
Otitis externa - Management
If skin is irritated by ear plugs, hearing aids, or ear rings, seek advice
from a healthcare professional.
Treat any skin condition such as eczema, psoriasis.
Consider using acidifying ear drops or spray (no prescription is needed).
Initial management
When should I investigate someone with acute diffuse otitis
externa?
Investigations are rarely useful. However, if treatment fails or otitis
externa recurs frequently, consider sending an ear swab for bacterial and
fungal microscopy and culture.
Which people with acute diffuse otitis externa should be followed
up?
Consider follow up for people with diabetes or compromised immunity, or
with cellulitis which has spread outside the auditory canal.
How should I treat acute diffuse otitis externa?
Remove or treat any precipitating or aggravating factors.
Prescribe or recommend an analgesic for symptomatic relief.
 Paracetamol or ibuprofen are usually sufficient. Codeine can provide
additional analgesia for severe pain.
Prescribe a topical ear preparation for 7 days. Options include preparations
containing:
 Both a non-aminoglycoside antibiotic and a corticosteroid e.g.
flumetasone–clioquinol (Locorten–Vioform®) ear drops.
 Both an aminoglycoside antibiotic and a corticosteroid (contraindicated
if the tympanic membrane is perforated).
 Topical preparations containing only an antibiotic (gentamicin ear
drops are contraindicated if the tympanic membrane is perforated).
If there is sufficient earwax or debris to obstruct topical medication,
consider cleaning the external auditory canal (may require referral).
If there is extensive swelling of the auditory canal, consider inserting an
ear wick (may require referral).
Provide appropriate self-care advice.
When should I refer or seek specialist advice for someone with
acute diffuse otitis externa?
Admit urgently if malignant otitis is suspected.
Consider seeking specialist advice if:
 Symptoms have not improved despite treatment and treatment failure
is unexplained.
 Treatment with a quinolone is indicated.
Consider referral to secondary care if there is:
 Extensive cellulitis.
 Extreme pain or discomfort.
 Considerable discharge or extensive swelling of the auditory canal, and
microsuction or ear wick insertion is required.
How should I manage treatment failure of acute diffuse otitis
externa?
Review the diagnosis and exclude and manage other conditions.
Assess and manage ongoing triggers (e.g. exposing ears to moisture,
trauma to the ear canal by attempts to clean or scratch it).
Assess and manage any compliance problems.
Assess and manage factors that would impede delivery of topical
medication to affected areas.
If contact dermatitis due to neomycin or other aminoglycoside is
suspected, consider switching to a preparation which does not contain an
aminoglycoside.
If there are systemic signs of infection, or if the infection is spreading
outside the ear canal, prescribe an oral antibiotic (i.e. flucloxacillin; or
erythromycin if penicillin sensitive; or clarithromycin if erythromycin and
flucloxacillin are both contraindicated).
If these measures have been tried, or are not applicable:
 Consider culturing a specimen of the ear canal to identify fungi and
resistant bacteria.
 Consider the possibility of a fungal infection and treat with topical
preparation containing an antifungal, such as clotrimazole 1% ear
What methods should I consider for cleaning the external auditory
canal in someone with acute diffuse otitis externa?
 Gentle syringing or irrigation — to remove debris, provided that the
tympanic membrane is intact; regarded as controversial by some
experts.
 Dry swabbing — to gently mop out thin secretions from the external
auditory canal.
 Microsuction — if irrigation and swabbing are ineffective or
inappropriate. Microsuction will usually require referral to secondary
care.
What advice should I give about preventing otitis externa?
Avoid damaging the external ear canal.
Keep the ears dry and clean.
Avoid ear drops containing neomycin if of an allergic disposition.
20
drops (Canesten®), or flumetasone pivalate 0.02%, clioquinol 1% ear
drops (Locorten-Vioform®).
Otherwise seek specialist advice.
.
1st-line antibiotic: flucloxacillin for 7 days
Flucloxacillin oral solution: 62.5mg four times a day
Age from 3 months to 1 year 11 months
Flucloxacillin 125mg/5ml oral solution. Take 2.5ml four times a day for 7 days.
Supply 100 ml.
Flucloxacillin oral solution: 125mg four times a day
Age from 3 months to 1 year 11 months
Flucloxacillin 125mg/5ml oral solution. Take one 5ml spoonful four times a day
for 7 days. Supply 200 ml.
Flucloxacillin oral solution: 125mg four times a day
Age from 2 years to 9 years 11 months
Flucloxacillin 125mg/5ml oral solution. Take one 5ml spoonful four times a day
for 7 days. Supply 200 ml.
Flucloxacillin oral solution: 250mg four times a day
Age from 2 years to 9 years 11 months
Flucloxacillin 250mg/5ml oral solution. Take one 5ml spoonful four times a day
for 7 days. Supply 200 ml.
Flucloxacillin oral solution: 250mg four times a day
Age from 10 years to 11 years 11 months
Flucloxacillin 250mg/5ml oral solution. Take one 5ml spoonful four times a day
for 7 days. Supply 200 ml.
Flucloxacillin oral solution: 500mg four times a day
Age from 10 years to 11 years 11 months
Flucloxacillin 250mg/5ml oral solution. Take two 5ml spoonfuls four times a day
for 7 days. Supply 300 ml.
Flucloxacillin capsules: 250mg four times a day
Age from 12 years onwards
Flucloxacillin 250mg capsules. Take one capsule four times a day for 7 days.
Supply 28 capsules.
Flucloxacillin capsules: 500mg four times a day
Age from 12 years onwards
Flucloxacillin 500mg capsules. Take one capsule four times a day for 7 days.
Supply 28 capsules.
Corticosteroid + antibiotic (clioquinol) ear drops
Flumetasone pivalate 0.02% + clioquinol 1% ear drops
Age from 2 years onwards
Clioquinol 1% / Flumetasone 0.02% ear drops. Put two to three drops into the
affected ear(s) twice a day for 7 to 10 days. Supply 7.5 ml.
Corticosteroid + antibiotic (aminoglycoside) ear drops
Hydrocortisone acetate 1% + Gentamicin 0.3% ear drops
Age from 3 months onwards
Hydrocortisone acetate 1% / Gentamicin 0.3% ear drops. Put two to four drops
into the affected ear(s) 3 to 4 times a day and at night. Use for a maximum of 7
days. Supply 10 ml.
Betamethasone 0.1% + neomycin 0.5% ear drops
Age from 3 months onwards
Neomycin 0.5% / Betamethasone 0.1% ear/eye/nose drops. Put two to three
drops into the affected ear(s) 3 to 4 times a day until symptoms improve, then
reduce frequency. Do not use for longer than 7 days. Supply 10 ml.
Prednisolone 0.5% + neomycin 0.5% ear drops
Age from 3 months onwards
Neomycin 0.5% / Prednisolone 0.5% ear/eye drops. Put two to three drops into
the affected ear(s) 3 to 4 times a day until symptoms improve, then reduce
frequency. Do not use for longer than 7 days. Supply 10 ml.
Antibiotic-only (aminoglycoside) ear drops
Gentamicin 0.3% ear drops
Age from 3 months onwards
Gentamicin 0.3% ear/eye drops. Put two to three drops into the affected ear(s) 3
to 4 times a day and at night. Use for a maximum of 7 days. Supply 10 ml.
Corticosteroid-only ear drops
Betamethasone sodium phosphate 0.1% ear drops
Age from 3 months onwards
Betamethasone 0.1% ear/eye/nose drops. Put two to three drops into the
affected ear(s) every 2 to 3 hours until symptoms improve, then reduce
frequency. Do not use for longer than 7 days. Supply 10 ml.
Prednisolone sodium phosphate 0.5% ear drops
Age from 3 months onwards
Prednisolone sodium phosphate 0.5% ear/eye drops. Put two to three drops into
the affected ear(s) every 2 to 3 hours until symptoms improve, then reduce
frequency. Do not use for longer than 7 days. Supply 10 ml.
Corticosteroid + aminoglycoside + acetic acid ear spray
Dexamethasone 0.1%+Neomycin 0.5%+acetic acid 2% ear spray
Age from 3 months onwards
Otomize ear spray. Spray once into the affected ear(s) at least three times a day.
Maximum of one spray every 2 to 3 hours. Do not use for more than 7 days.
Supply 5 ml.
1st-line in penicillin allergy: erythromycin for 7 days
Erythromycin s/f suspension: 125mg four times a day
Age from 3 months to 1 year 11 months
Erythromycin ethyl succinate 125mg/5ml oral suspension sugar free. Take one
5ml spoonful four times a day for 7 days. Supply 200 ml.
Erythromycin s/f suspension: 250mg four times a day
Age from 3 months to 1 year 11 months
Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free. Take one
5ml spoonful four times a day for 7 days. Supply 200 ml.
Erythromycin s/f suspension: 250mg four times a day
Age from 2 years to 11 years 11 months
21
Erythromycin ethyl succinate 250mg/5ml oral suspension sugar free. Take one
5ml spoonful four times a day for 7 days. Supply 200 ml.
Erythromycin s/f suspension: 500mg four times a day
Age from 2 years to 11 years 11 months
Erythromycin ethyl succinate 500mg/5ml oral suspension sugar free. Take one
5ml spoonful four times a day for 7 days. Supply 200 ml.
Erythromycin gastro-resistant tablets: 250mg four times a day
Age from 12 years onwards
Erythromycin 250mg gastro-resistant tablets. Take one tablet four times a day
for 7 days. Supply 28 tablets.
Erythromycin gastro-resistant tablets: 500mg four times a day
Age from 12 years onwards
 Erythromycin 250mg gastro-resistant tablets. Take two tablets four
times a day for 7 days. Supply 56 tablets.
2nd-choice in penicillin allergy: clarithromycin for 7 days
Clarithromycin suspension: child weighs 7.9kg or less
Age from 3 months to 3 years
Clarithromycin 125mg/5ml oral suspension. *WEIGHT REQUIRED* Take 7.5mg
per kg bodyweight TWICE a day for 7 days. Supply 70 ml.
Clarithromycin suspension: child weighs 8kg to 11.9 kg
Age from 3 months to 5 years
Clarithromycin 125mg/5ml oral suspension. Take 2.5ml twice a day for 7 days.
Supply 70 ml.
Clarithromycin suspension: child weighs 12kg to 19.9kg
Age from 6 months to 7 years
Clarithromycin 125mg/5ml oral suspension. Take one 5ml spoonful twice a day
for 7 days. Supply 70 ml.
Clarithromycin suspension: child weighs 20kg to 29.9kg
Age from 3 to 10 years
Clarithromycin 125mg/5ml oral suspension. Take 7.5ml twice a day for 7 days.
Supply 140 ml.
Clarithromycin suspension: child weighs 30kg or more
Age from 7 years to 11 years 11 months
Clarithromycin 250mg/5ml oral suspension. Take one 5ml spoonful twice a day
for 7 days. Supply 70 ml.
Clarithromycin tablets: 250mg twice a day
Age from 12 years onwards
Clarithromycin 250mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Clarithromycin tablets: 500mg twice a day
Age from 12 years onwards
Clarithromycin 500mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
© NHS Institute for Innovation and Improvement
22
UTI (lower) - women – Management
Refer?
Referral for investigation should be considered for women with
recurrent urinary tract infection (UTI), or who persistently fail to respond
to treatment.
Referral guidelines for suspected cancer published by the National
Institute for Health and Clinical Excellence [NICE, 2005] recommend
urgent referral to a team specializing in the management of urological
cancer, depending on local arrangements, for people:
 Of any age with painless macroscopic haematuria:
o If there are also symptoms suggestive of UTI, culture the urine
and treat any infection. If infection is not confirmed, or if
haematuria persists after treatment of infection, refer urgently.
 Aged 40 years or older who present with recurrent or persistent UTI
associated with haematuria.
 Aged 50 years or older who are found to have unexplained microscopic
haematuria.
 With an abdominal mass identified clinically or on imaging that is
thought to arise from the urinary tract.
Scenario: Cystitis in otherwise healthy women who are not
pregnant
Follow local guidelines if they recommend different antibiotics.
Take local rates of bacterial resistance into account when choosing
antibiotics.
The following apply to otherwise healthy women who are not pregnant,
and who have a suspected lower urinary tract infection (UTI).
 If there is vaginal irritation or discharge, consider other diagnoses.
(Bacterial vaginosis, Candida - female genital, and Chlamydia).
 If UTI is diagnosed and there is fever and flank or loin or back pain or
tenderness, upper UTI is likely and antibiotic treatment for 7 days is
indicated.
 If the symptoms are mild, the woman may wish to consider not taking
an antibiotic, as UTIs usually resolve spontaneously in a few days.
 If lower UTI is suggested by multiple typical symptoms and signs (e.g.
dysuria, frequency, suprapubic discomfort), treat empirically with
trimethoprim or nitrofurantoin for 3 days.
 If lower UTI is suggested by only one or vague symptoms and signs,
dipstick-test the urine.
o If the dipstick test is positive for nitrite and leucocyte esterase,
treat empirically with trimethoprim or nitrofurantoin for 3 days.
o Otherwise, use clinical judgement to decide on management.
 Consider culturing the urine to help make a definitive diagnosis.
 If symptoms are mild, consider waiting to confirm UTI with culture
results before treating, otherwise, treat empirically with trimethoprim
or nitrofurantoin for 3 days.
 If trimethoprim has been taken in the past 3 months, some clinicians
recommend using an alternative antibiotic for empirical treatment.
 Treat pain and raised temperature with paracetamol or ibuprofen.
Investigate?
Urine dipstick — use only in women with vague or few typical symptoms
of cystitis (e.g. dysuria, frequency, suprapubic discomfort).
 Positive for nitrite and leucocyte esterase (LE): diagnose urinary tract
infection.
 Negative for nitrite and/or LE: consider urine culture to help diagnosis.
Urine culture is indicated when:
 Cystitis is suspected, but the dipstick is negative for nitrites or
leucocytes.
 Treatment has failed.
 Symptoms recur.
Investigations for sexually transmitted diseases should be
considered in sexually active women (e.g. chlamydia screen).
Follow Up
 Follow up according to the clinical situation.
 Review is recommended if symptoms have not resolved with
treatment.
 If urine has been cultured, check the results and ensure antibiotic
treatment is appropriate.
Practical prescribing points
Nitrofurantoin should not be used in people known to be glucose-6phosphate dehydrogenase (G6PD)-deficient.
Ibuprofen, as with other nonsteroidal anti-inflammatory drugs (NSAIDs),
may worsen or precipitate gastrointestinal haemorrhage, asthma,
hypertension, renal impairment, or cardiac failure. Avoid if there is a
history of peptic ulcers.
Should I refer or investigate?
23
Drugs included
Trimethoprim is the antibiotic of choice for empirical treatment in
uncomplicated urinary tract infection (UTI). It is effective, safe, and
inexpensive. It should not be used if the patient has a history of recurrent
infections resistant to this drug, or has recently (i.e. within about 3
months) taken trimethoprim.
Nitrofurantoin is a useful alternative antibiotic, effective against most
urinary pathogens. For most people the standard tablet formulation is
suitable. The macrocrystalline capsules and the twice-daily modifiedrelease formulation may be better tolerated if nausea is troublesome, and
are offered as alternatives.
Age from 14 years onwards
Nitrofurantoin 50mg capsules. Take one capsule four times a day for 3 days.
Supply 12 capsules.
Patient Information: This medicine may cause your urine to turn more yellow
than normal. Passing urine regularly may help to relieve symptoms - do not
'hang on' if you need to go to the toilet. Also wipe from front to back to avoid
transferring germs.
Nitrofurantoin m/r capsules: 100mg twice a day
Age from 14 years onwards
Nitrofurantoin 100mg m/r caps. Take one capsule twice a day for 3 days. Supply
6 capsules.
Patient Information: This medicine may cause your urine to turn more yellow
than normal. Passing urine regularly may help to relieve symptoms - do not
'hang on' if you need to go to the toilet. Also wipe from front to back to avoid
transferring germs.
Paracetamol is an effective and safe analgesic and antipyretic.
Ibuprofen is an effective alternative to paracetamol if there are no
contraindications.
Drug rationale
Drugs not included
In general, antibiotics that are not used for first-line empirical treatment of
lower UTI are not included.
Penicillins such as amoxicillin are unsuitable for treatment unless
culture results indicate that the bacterium is sensitive. Around 50% of
urinary pathogens are amoxicillin-resistant.
First-generation cephalosporins (e.g. cefalexin) have similar
antibiotic sensitivities and adverse-effect profiles, and are more expensive.
There is greater relapse with cephalosporins than with trimethoprim
Co-amoxiclav, quinolones, and pivmecillinam should be reserved for
second-line treatment, in order to limit the development of resistance and
to preserve their efficacy.
Urine alkalinizing agents are of unproven benefit and there is some
evidence that they do not relieve the symptoms of cystitis
© NHS Institute for Innovation and Improvement
Shared decision making
An antibiotic for 3 days is the common treatment for women with
cystitis.
Paracetamol or ibuprofen will help with pain or discomfort.
 'Drink plenty of fluid' is common advice, in order to 'flush out the
bladder'. However, this is unproven, and passing urine more often may
be unpleasant.
 If symptoms have not gone or nearly gone after 3 days, consult a
doctor.
 If cystitis becomes a recurring problem, consult a doctor.
Prescriptions
1st-line antibiotic for 3 days
Trimethoprim tablets: 200mg twice a day
Age from 14 years onwards
Trimethoprim 200mg tablets. Take one tablet twice a day for 3 days. Supply 6
tablets.
Patient Information: Passing urine regularly may help to relieve symptoms - do
not 'hang on' if you need to go to the toilet. Also wipe from front to back to avoid
transferring germs.
Nitrofurantoin tablets: 50mg four times a day
Age from 14 years onwards
Nitrofurantoin 50mg tablets. Take one tablet four times a day for 3 days. Supply
12 tablets.
Patient Information: This medicine may cause your urine to turn more yellow
than normal. Passing urine regularly may help to relieve symptoms - do not
'hang on' if you need to go to the toilet. Also wipe from front to back to avoid
transferring germs.
Nitrofurantoin capsules: 50mg four times a day
24
Scenario: Recurrent cystitis in non-pregnant women

Follow local guidelines if they recommend different antibiotics. Take local
rates of bacterial resistance into account when choosing antibiotics.
Treat acute episodes of recurrent urinary tract infection (UTI) in a
woman with an analgesic/antipyretic and a 3-day course of
trimethoprim or nitrofurantoin, or an antibiotic to which the
organism is sensitive.
Treatments that are not recommended include:
Oestrogen use for the routine prevention of recurrent UTI in
postmenopausal women. Seek specialist advice before prescribing
oestrogen treatment for preventing recurrent cystitis in a
postmenopausal woman.
Practical prescribing points
Nitrofurantoin should not be used in people who are known to be
glucose-6-phosphate dehydrogenase (G6PD)-deficient.
Ibuprofen, as with other nonsteroidal anti-inflammatory drugs (NSAIDs),
may worsen or precipitate gastrointestinal haemorrhage, asthma,
hypertension, renal impairment, or cardiac failure. Avoid if there is a
history of peptic ulcers.
Cranberry extracts:
 Cranberry juice has been reported to interact with warfarin, and the
Committee on Safety of Medicines (CSM) has advised that people
taking warfarin should avoid cranberry products [
 Cranberry extracts have not been studied in older women and their
safety in this population is not established.
 Cranberry products are not available on the NHS, but are readily
available from pharmacies, health food shops, herbalists, and
supermarkets. However, cranberry products are not regulated
medicines, and preparations are not standardized.
 Cranberry capsules may be more convenient than juice; higher doses
may be more effective than lower doses.
Comprehensively assess the problem:
 Review urine culture results, or, if not available, send urine for culture
during an acute episode.
 Assess clinical presentations (mild, moderate, or severe illness).
 Review medical and surgical history (may suggest risk factors — e.g.
stones, papillary necrosis, vesicoureteric reflux).
 Review recent antibiotic treatment (bacterial resistance is more
probable).
 Assess whether previous antibiotics have been taken as prescribed,
and note that some clinicians recommend avoiding repeating
trimethoprim within 3 months.
 Check that there are no features suggestive of cancer.
Consider the following management options if there are three or
more episodes per year:
 Patient-initiated antibiotics for new episodes (i.e. 'stand-by
antibiotics'), or
 Professional-initiated antibiotics for new episodes (i.e. usual treatment
when required), or
 Continuous antibiotic prophylaxis:
o Low dose for 6 months
o Repeat course if infection recurs
o If infection occurs while taking prophylactic antibiotics, send the
urine for culture before starting treatment with a different
antibiotic. Restart prophylaxis with an antibiotic that is active
against the infecting organism.
 A trial of cranberry extract (available from shops but not the NHS)
 If recurrence is related to sexual intercourse, consider the above
options and:
o Single-dose antibiotic prophylaxis — to be taken before or soon
after intercourse
o Advising change of contraceptive method if diaphragm (female
condom) or spermicide is being used
o Advising voiding after intercourse
o Advising use of a lubricant if symptoms seem to be due to
trauma rather than infection
Refer for specialist assessment if:
 Recurrent cystitis fails to respond to the above measures
 There are features suggestive of cancer
Referral guidelines for suspected cancer published by the National
Institute for Health and Clinical Excellence [NICE, 2005] recommend
urgent referral to a team specializing in the management of urological
cancer, depending on local arrangements, for people:
 Of any age with painless macroscopic haematuria:
If there are also symptoms suggestive of urinary tract infection
(UTI), culture the urine and treat any infection. If infection is not
confirmed, or if haematuria persists after treatment of infection,
refer urgently.
 Aged 40 years or older who present with recurrent or persistent
UTI associated with haematuria.
 Aged 50 years or older who are found to have unexplained
microscopic haematuria.
25

With an abdominal mass identified clinically or on imaging that is
thought to arise from the urinary tract.
Penicillins such as amoxicillin are unsuitable for empirical treatment because
about 50% of all urinary pathogen isolates are amoxicillin-resistant.
First-generation cephalosporins (e.g. cefalexin) have similar antibiotic
sensitivities and adverse-effect profiles, and are more expensive. There is greater
relapse with cephalosporins than with trimethoprim
Co-amoxiclav, quinolones, and pivmecillinam should be reserved for secondline treatment, in order to limit the development of resistance and to preserve
their efficacy.
Topical oestrogens are not recommended for the routine prevention of recurrent
urinary tract infection in postmenopausal women, as they are less effective than
prophylactic antibiotics
Urine alkalinizing agents are of unproven benefit and there is some evidence
that they do not relieve the symptoms of cystitis
Investigate?
 Urine culture is needed to confirm a microbial cause for at
least one episode of urinary tract infection (before commencing
long-term prophylactic treatment). Urine culture and sensitivity
tests are helpful to manage breakthrough infections.
 Urinary tract imaging is rarely indicated.
 Cystoscopy is rarely indicated.
If prophylactic antibiotics are prescribed, follow-up after 6 months (or
sooner if clinically indicated).
Shared decision making
Some women tend to have recurrent bouts of cystitis. A kidney or bladder
problem is sometimes the cause, but usually the reason for recurring
cystitis is not clear.
Some women tend to get cystitis after having sex. In these
circumstances the chance of cystitis can be reduced by:
 Changing the method of contraception if either spermicides or a
diaphragm are used.
 Going to the toilet and fully emptying the bladder after sex.
 Lubrication — this helps if symptoms are due to irritation.
 Taking a single dose of an antibiotic after sex.
Antibiotic prevention is an option in other circumstances.
 This means taking a low dose of an antibiotic every day (or sometimes
three times a week).
 It is best to take the antibiotic at bedtime.
 It is usual to take a course for 3–6 months and then to review the
situation.
 A change of antibiotic may be needed if cystitis recurs.
Cranberry extracts:
 Cranberry extracts can help prevent cystitis. However:
 Cranberry extracts have not been shown to be safe in older people or
in young children.
 Cranberry is unsafe to take with certain medicines, for example
warfarin.
 Cranberry extracts can be bought from supermarkets, chemists, and
health stores.
 High-dose capsules may be better than low-dose capsules or juice.
If a urine culture test is done, telephone for the results in 2 or
3 days. Ask if it is necessary to change the antibiotic.
Standby antibiotics (3 days)
Standby prescriptions are offered for the woman to initiate when
symptoms recur.
Trimethoprim is effective against most urinary tract pathogens, and safe
and inexpensive. It should not be used if the patient has recently taken
trimethoprim (some clinicians recommend avoiding repeating trimethoprim
within 3 months), or has a history of recurrent infections resistant to this
drug.
Nitrofurantoin is a useful alternative antibiotic, effective against most
urinary pathogens. For most people the standard tablet formulation is
suitable. The macrocrystalline capsules and the twice-daily modifiedrelease formulation may be better tolerated if nausea is troublesome, and
are offered as alternatives.
Trimethoprim tablets: 200mg twice a day
Age from 14 years onwards
Trimethoprim 200mg tablets. Take one tablet twice a day for 3 days. Supply 6
tablets.
Nitrofurantoin tablets: 50mg four times a day
Age from 14 years onwards
Nitrofurantoin 50mg tablets. Take one tablet four times a day for 3 days. Supply
12 tablets.
Nitrofurantoin capsules: 50mg four times a day
Age from 14 years onwards
Nitrofurantoin 50mg capsules. Take one capsule four times a day for 3 days.
Supply 12 capsules.
Nitrofurantoin m/r capsules: 100mg twice a day
Age from 14 years onwards
Nitrofurantoin 100mg m/r caps. Take one capsule twice a day for 3 days. Supply
6 capsules.
Drugs not included
26
against the use of trimethoprim for women who are pregnant or
planning to become pregnant.
Nitrofurantoin should not be prescribed if the mother is glucose-6phosphate dehydrogenase (G6PD)-deficient. It can otherwise be used
during pregnancy, but should not be taken near term as it can cause
haemolysis in the fetus.
Cefalexin is a broad-spectrum antibiotic and is therefore more likely to
cause diarrhoea and vaginal thrush.
 In high dosages cefalexin may cause diarrhoea, but can be taken with
food or milk to try to avoid stomach upset.
 Rarely, cefalexin may cause pseudomembranous colitis. If
pseudomembranous colitis is suspected, stop cefalexin immediately.
 During pregnancy — cefalexin has not been shown to cause harm to
the fetus.
 Women can continue to breastfeed while taking cefalexin. Low
concentrations are present in breast milk, which may cause changes to
the bacteria in the infant's gastrointestinal tract.
Scenario: Cystitis and asymptomatic bacteriuria in
pregnancy
Follow local guidelines if available. Take local rates of bacterial
resistance into account when choosing antibiotics.
Asymptomatic bacteriuria:
 Screen for asymptomatic bacteriuria on the first antenatal visit by
sending urine for culture. If symptomatic bacteriuria is found, confirm
its presence with a second urine culture.
 Treat confirmed asymptomatic bacteriuria for 7 days with an antibiotic
to which the organism is sensitive:
o First-line options when the sensitivities are known are
trimethoprim, nitrofurantoin, amoxicillin, and cefalexin
o Send urine cultures to screen for asymptomatic bacteriuria at
every antenatal visit until delivery.
o Treat pain and raised temperature with paracetamol.
Acute lower urinary tract infection:
 Send urine for culture.
 Treat with an appropriate antibiotic for 7 days. First-line choices for
empirical treatment are trimethoprim, nitrofurantoin, cefalexin, or
amoxicillin.
 Review progress with culture results and adjust treatment accordingly.
 Send urine cultures to screen for asymptomatic bacteriuria 7 days after
completion of treatment.
 Treat pain and raised temperature with paracetamol.
Refer?
Admit if there is systemic illness or if pyelonephritis is suspected.
Refer if urine culture is still positive 1–2 weeks after treatment.
Refer if urinary tract infection recurs in pregnancy: obtain specialist advice
with regard to prophylactic antibiotics.
Investigate?
Culture urine before starting antibiotics. Empirical treatment may need to
be modified in the light of the results.
Samples taken for culture should be taken mid-stream, placed in a
preservative-containing bottle or refrigerated, and cultured as soon as
possible.
Practical prescribing points
Trimethoprim is a folate antagonist, and there have been concerns over
its use during pregnancy, as it may limit the availability of folic acid to the
fetus and impair normal development.
 In women with a low folate status (i.e. women with established folic
acid deficiency or low dietary intake, or in those already taking known
folate antagonists such as antiepileptics and proguanil), trimethoprim
should be avoided unless the woman is also taking a folate
supplement.
 In women with normal folate status, short-term use of trimethoprim is
unlikely to induce folate deficiency. Note: women who are pregnant, or
at risk of pregnancy, should be taking folic acid until week 12 of their
pregnancy in order to prevent neural tube defects in the fetus.
 However, the BNF cautions against the use of trimethoprim in the first
trimester of pregnancy because the manufacturers recommend that it
not be used then. The manufacturer's information leaflet also advises
Follow-up advice
Review according to the clinical situation, (for example, at around
72 hours) to ensure the individual is responding to treatment and to check
the results of the urine culture.
After treatment of acute lower urinary tract infection, repeat the urine
culture 7 days after an antibiotic course has been completed.
After confirmed asymptomatic bacteriuria has been treated, send urine
cultures to screen for asymptomatic bacteriuria at every antenatal visit
until delivery.
 If a group-B streptococcus is isolated, inform the antenatal care
service, as prophylactic antibiotics may be indicated during labour
and delivery.
27
Cefalexin tablets: 500mg twice a day
Age from 14 years to 59 years 11 months
Cefalexin 500mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Amoxicillin capsules: 250mg three times a day (IF sensitive)
Age from 14 years to 59 years 11 months
Amoxicillin 250mg capsules. Take one capsule three times a day for 7 days.
Supply 21 capsules.
Trimethoprim tablets: 200mg twice a day
Age from 14 years to 59 years 11 months
Trimethoprim 200mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Nitrofurantoin tabs: 50mg four times a day (NOT near term)
Age from 14 years to 59 years 11 months
Nitrofurantoin 50mg tablets. Take one tablet four times a day for 7 days. Supply
28 tablets.
Nitrofurantoin caps: 50mg four times a day (NOT near term)
Age from 14 years to 59 years 11 months
Nitrofurantoin 50mg capsules. Take one capsule four times a day for 7 days.
Supply 28 capsules.
Nitrofurantoin m/r caps: 100mg twice a day (NOT near term)
Age from 14 years to 59 years 11 months
Nitrofurantoin 100mg m/r caps. Take one capsule twice a day for 7 days. Supply
14 capsules.
Drugs included
Amoxicillin is recommended only if the organism is known to be
sensitive. Penicillins are not associated with any increased risk to the
fetus.
Cefalexin is a first-generation cephalosporin. It is not associated with any
increased risk to the fetus and is effective against most urinary pathogens.
Trimethoprim can be used during pregnancy except in women who are
folate deficient, or who are taking folate antagonists (unless a folate
supplement is taken). It should not be used if the woman has recently
taken trimethoprim (some clinicians recommend avoiding repeating
trimethoprim within 3 months), or has a history of recurrent infections
resistant to this drug.
Nitrofurantoin is effective against most urinary tract infections. It should
not be prescribed if the mother is glucose-6-phosphate dehydrogenase
(G6PD)-deficient. Nitrofurantoin can otherwise be used in pregnancy, but
may cause haemolysis in a G6PD-deficient infant if used close to term. For
most people the standard tablet formulation is suitable. The
macrocrystalline capsules and the twice-daily modified-release formulation
may be better tolerated if nausea is troublesome, and are offered as
alternatives.
Paracetamol is an effective and safe analgesic and antipyretic.
Drugs not included
Quinolones are not recommended in any trimester because of safety
concerns.
Co-amoxiclav is not generally recommended for use during pregnancy,
as there are insufficient data on the safety of clavulanic acid. It should
only be used if thought to be essential.
First-generation cephalosporins other than cefalexin have similar
antibiotic sensitivities and adverse-effect profiles, and are more expensive.
Second-generation cephalosporins are not as well absorbed orally as
first-generation cephalosporins, have a greater incidence of
gastrointestinal adverse effects, and are more expensive than the firstgeneration agents.
Third-generation cephalosporins generally require parenteral
administration and are reserved for use in secondary care for serious
infections.
Pivmecillinam is not known to be teratogenic, but it is not recommended
in pregnancy because of insufficient safety data.
Urine alkalinizing agents are of unproven benefit and there is some
evidence that they do not relieve the symptoms of cystitis. Sodium citrate
should be avoided in pregnancy because of the high sodium content.
1st-line antibiotic for 7 days
Trimethoprim tablets: 200mg twice a day
Age from 14 years to 59 years 11 months
Trimethoprim 200mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Nitrofurantoin tabs: 50mg four times a day (NOT near term)
Age from 14 years to 59 years 11 months
Nitrofurantoin 50mg tablets. Take one tablet four times a day for 7 days. Supply
28 tablets.
Nitrofurantoin caps: 50mg four times a day (NOT near term)
Age from 14 years to 59 years 11 months
Nitrofurantoin 50mg capsules. Take one capsule four times a day for 7 days.
Supply 28 capsules.
Nitrofurantoin m/r caps: 100mg twice a day (NOT near term)
Age from 14 years to 59 years 11 months
Nitrofurantoin 100mg m/r caps. Take one capsule twice a day for 7 days. Supply
14 capsules.
Cefalexin tablets: 500mg twice a day
Age from 14 years to 59 years 11 months
Cefalexin 500mg tablets. Take one tablet twice a day for 7 days. Supply 14
tablets.
Asymptomatic bacteriuria
28
Nonsteroidal anti-inflammatory drugs (NSAIDs), including
ibuprofen, are best avoided during pregnancy.
A course of an antibiotic is the usual treatment for pregnant women
with a urine infection.
Paracetamol will help with pain or discomfort. (Ibuprofen is best avoided
during pregnancy.)
Usually a urine culture test will be done. Telephone for the result after
3 days. Ask if it is necessary to change the antibiotic treatment.
'Drink plenty of fluid' is common advice, to 'flush out the bladder'.
However, this is unproven, and passing urine more often may be
unpleasant.
Your urine should be tested one week after you finish the antibiotic, to
check that the infection has gone.
Regular urine checks throughout pregnancy are usual.
© NHS Institute for Innovation and Improvement
29
Acute cystitis treatment failure

Follow local guidelines if they recommend different antibiotics.
Take local rates of bacterial resistance into account when choosing
antibiotics.
The following apply to otherwise healthy women who are not pregnant,
with a suspected lower urinary tract infection that has failed to respond to
first-line treatment.
If urine culture results are available, use the sensitivity report to
guide choice of a different antibiotic to which the organism is sensitive.
Otherwise:
 Send a urine sample for culture.
 If symptoms are mild, wait for sensitivity results to guide choice of
antibiotic.
 If symptoms are particularly troublesome:
o Change to a different first-line antibiotic (trimethoprim or
nitrofurantoin), or
o Consider use of a second-line antibiotic (i.e. cefalexin, coamoxiclav, a quinolone, or pivmecillinam).
 Paracetamol or ibuprofen can be used to treat pain and high
temperature.



Of any age with painless macroscopic haematuria:
o If there are also symptoms suggestive of UTI, culture the urine
and treat any infection. If infection is not confirmed, or if
haematuria persists after treatment of infection, refer urgently.
Aged 40 years or older who present with recurrent or persistent UTI
associated with haematuria.
Aged 50 years or older who are found to have unexplained microscopic
haematuria.
With an abdominal mass identified clinically or on imaging that is
thought to arise from the urinary tract.
Investigate?
Urine culture should be obtained whenever treatment has failed. The
sample should be taken with care to avoid contamination, placed in a
preservative-containing bottle or refrigerated, and cultured as soon as
possible.
Consider testing for chlamydia and other sexually transmitted
diseases in sexually active women.
Follow-up advice
Review with culture results to ensure that treatment is appropriate.
Consider reviewing by telephone.
Practical prescribing points
Nitrofurantoin should not be used in people who are known to be
glucose-6-phosphate dehydrogenase (G6PD)-deficient.
Quinolones may cause tendon damage (Committee on Safety of
Medicines advice); stop treatment if pain or inflammation of a tendon
occurs. They can induce convulsions in people with epilepsy or in those
with conditions that predispose to seizures. People concurrently taking
nonsteroidal anti-inflammatory drugs (NSAIDs) may also be susceptible.
The risks and benefits of prescribing a quinolone should be considered on
an individual basis for these people.
Ibuprofen, as with other NSAIDs, may worsen or precipitate
gastrointestinal haemorrhage, asthma, hypertension, renal impairment, or
cardiac failure. Avoid if there is a history of peptic ulcers.
Drugs included
Where available, sensitivities should guide antibiotic choice.
Trimethoprim is effective against most urinary tract pathogens, and safe
and inexpensive. It should not be used if the patient has recently (i.e.
within about 3 months) taken trimethoprim, or has a history of recurrent
infections resistant to this drug.
Nitrofurantoin is a useful alternative antibiotic, effective against most
urinary pathogens. For most people the standard tablet formulation is
suitable. The macrocrystalline capsules and the twice-daily modifiedrelease formulation may be better tolerated if nausea is troublesome, and
are offered as alternatives.
Cefalexin is a first-generation cephalosporin effective against most
urinary pathogens, but there is less relapse with trimethoprim than with
cephalosporins
Co-amoxiclav is a suitable second-line alternative. It is effective against
up to 90% of urinary pathogens.
Ciprofloxacin and norfloxacin are recommended as second-line
fluoroquinolones. They are effective against most urinary pathogens (only
around 5% of pathogens are resistant) and are currently the least
expensive of the quinolones available. Other fluoroquinolones (i.e.
Refer?
Referral for investigation should be considered for women with
recurrent urinary tract infection (UTI), or who persistently fail to respond
to treatment.
Referral guidelines for suspected cancer published by the National
Institute for Health and Clinical Excellence [NICE, 2005] recommend
urgent referral to a team specializing in the management of urological
cancer, depending on local arrangements, for people:
30
ofloxacin, levofloxacin) can be substituted according to local formulary
recommendations.
Pivmecillinam is highly active against many Gram-negative pathogens
and is an appropriate second-line treatment.
Paracetamol is an effective and safe analgesic and antipyretic.
Drugs not included
 Amoxicillin should only be used to treat urinary tract infection
when the infecting organism has been shown to be sensitive to
amoxicillin, as about 50% of all urinary pathogen isolates are
resistant to amoxicillin.
 Urine alkalinizing agents are of unproven benefit and there is
some evidence that they do not relieve the symptoms of cystitis
[Brumfitt et al, 1990].
 Drugs
1st choice antibiotic
Trimethoprim tablets: 200mg twice a day
Age from 14 years onwards
 Trimethoprim 200mg tablets. Take one tablet twice a day for 3
days. Supply 6 tablets.
Nitrofurantoin tablets: 50mg four times a day
Age from 14 years onwards
 Nitrofurantoin 50mg tablets. Take one tablet four times a day for 3
days. Supply 12 tablets.
Nitrofurantoin capsules: 50mg four times a day
Age from 14 years onwards
 Nitrofurantoin 50mg capsules. Take one capsule four times a day for
3 days. Supply 12 capsules.
Nitrofurantoin m/r capsules: 100mg twice a day
Age from 14 years onwards
 Nitrofurantoin 100mg m/r caps. Take one capsule twice a day for 3
days. Supply 6 capsules.
Shared decision making
 Cystitis sometimes does not clear with an antibiotic. This may be
because the germ is 'resistant' to the antibiotic (or in some cases,
because the cystitis has not been caused by an infection). A urine
test is needed to see whether a germ is present, and which germ it
is.
 A second antibiotic will usually work. It is best to wait until the
urine result is back to see which germ is present and which
antibiotic kills it.
 Paracetamol or ibuprofen will help with pain or discomfort.
 Telephone for the result of the urine test in 3 days. Ask if it is
necessary to change the treatment.
 'Drink plenty of fluid' is common advice, to 'flush out the bladder'.
But this is unproven, and passing urine more often may be
unpleasant.
 Consult a doctor if cystitis still does not clear, or becomes a
recurring problem.
© NHS Institute for Innovation and Improvement
2nd choice antibiotic
Cefalexin tablets: 500mg twice a day
Age from 14 years onwards
 Cefalexin 500mg tablets. Take one tablet twice a day for 3 days.
Supply 6 tablets.
Co-amoxiclav tablets: 250/125mg three times a day
Age from 14 years onwards
 Co-amoxiclav 375mg tablets. Take one tablet three times a day for
3 days. Supply 9 tablets.
Ciprofloxacin tablets: 100mg twice a day
Age from 18 years onwards
 Ciprofloxacin 100mg tablets. Take one tablet twice a day for 3 days.
Supply 6 tablets.
Norfloxacin tablets: 400mg twice a day
Age from 18 years onwards
 Norfloxacin 400mg tablets. Take one tablet twice a day for 3 days.
Supply 6 tablets.
Pivmecillinam tablets: 200mg three times a day
Age from 14 years onwards
 Pivmecillinam 200mg tablets. Take TWO tablets now and then take
ONE tablet three times a day for 3 days. Supply 10 tablets.
31