URTI

Management of Common Infections
URTI
Acute Sore
Throat
Acute Otitis
Media
(child dose)
Acute Otitis
Externa
Acute
Rhinosinusitis
Avoid antibiotics as 90% resolve in 7days
If Centor score 3 or 4: (Lymphadenopathy; No
Cough; Fever; Tonsillar Exudate)- consider 2 or 3day delayed or immediate antibiotics.
Antibiotics to prevent Quinsy NNT >4000Antibiotics to prevent Otitis media NNT 200
OM resolves in 60% in 24 h without antibiotics
Optimise analgesia; abx don’t prevent deafness
Consider 2 or 3-day delayed or immediate
antibiotics for pain relief if:
 <2 years AND bilateral AOM (NNT4) or bulging
membrane
 All ages with otorrhoea NNT3
Abx to prevent Mastoiditis NNT >4000
First use aural toilet (if available) & analgesia
Cure rates similar at 7 days for topical acetic acid
or antibiotic +/- steroid
If cellulitis or disease extending outside ear canal,
start oral antibiotics and refer
Avoid antibiotics as 80% resolve in 14 days
without
Use adequate analgesia
Consider 7-day delayed or immediate antibiotic
when purulent nasal discharge NNT8
In persistent infection use an agent with antianaerobic activity eg. co-amoxiclav
phenoxymethylpenicillin
Penicillin Allergy:
Clarithromycin
amoxicillin
Penicillin Allergy:
erythromycin
500 mg QDS
1G BD
(QDS when severe )
10 days
250-500mg BD
5 days
Child doses
40mg/kg/day in 3 doses
(max. 1.5g daily) 12B-
5 days
< 2yrs 125mg QDS
2-8yrs 250mg QDS
8-18yrs 250-500mg QDS
First Line:
acetic acid 2%
Second Line:
neomycin sulphate with
corticosteroid 3A-,4D
amoxicillin
or
doxycycline
or phenoxymethylpenicillin
For persistent symptoms:
co-amoxiclav
1 spray TDS
3 drops TDS
500mg TDS
1g if severe 11D
200mg stat/100mg OD
500mg QDS
5 days
7 days
7 days min to 14
days max
All abx for 7 days
625mg TDS
LRTI ( Low doses of penicillins are more likely to select out resistance1, Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal
activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms)
Antibiotic little benefit if no co-morbidity. Consider
amoxicillin
Acute cough,
7d delayed antibiotic with advice; Symptom
or
bronchitis
resolution can take 3 weeks.
doxycycline
Consider immediate antibiotics if > 80yr and ONE of:
hospitalisation in past year, oral steroids, diabetic,
congestive heart failure OR> 65yrs with 2 of above
Treat exacerbations promptly with antibiotics if
amoxicillin
Acute
purulent sputum and increased shortness of breath
or doxycycline
exacerbation of
and/or increased sputum volume
clarithromycin
COPD
Risk factors for antibiotic resistant organisms include
If resistance: co-amoxiclav
co-morbid disease, severe COPD, frequent
exacerbations, antibiotics in last 3 m
Use CRB65 score to help guide and review: Each
IF CRB65=0: amoxicillin or
Community
scores 1: Confusion (AMT<8); Respiratory rate
clarithromycin
acquired
>30/min; Age >65; BP systolic <90 or diastolic ≤ 60;
or doxycycline
pneumonia Score 0: suitable for home treatment;
treatment in the
if CRB65=1 & AT HOME
Score 1-2: hospital assessment or admission
community
amoxicillin
Score 3-4: urgent hospital admission
AND clarithromycin
Mycoplasma infection is rare in over 65s
or doxycycline alone
500 mg TDS
5 days
200 mg stat/100 mg OD
5 days
500 mg TDS
200 mg stat/100 mg OD
500 mg BD
625 mg TDS
5 days
5 days
5 days
5 days
500 mg TDS
500 mg BD
200 mg stat/100 mg OD
7 days
7 days
7 days
500 mg TDS
500 mg BD
200 mg stat/100 mg OD
7-10 days
7-10 days
UTI
UTI in adults
(no fever or flank
pain)Symps:
dysuria,polyuria
frequency,
urgency, suprap
tenderness
Acute prostatitis
UTI in pregnancy
UTI in Children
Women severe/or ≥ 3 symptoms: treat
Women mild/or ≤ 2 symptoms: use dipstick.
Nitrite & blood/leucocytes= 92% PPV; No nitrite,
leucocytes, and blood = 76% NPV
Men: Consider prostatitis & send pre-treatment
MSU OR if symptoms mild/non-specific, use –
ve dipstick to exclude UTI.
Send MSU for culture and start antibiotics
4-wk course may prevent chronic prostatitis
Quinolones achieve higher prostate levels
Send MSU for culture and start abx.Short-term
use of nitrofurantoin in pregnancy is unlikely to
cause problems to foetus.Avoid trimethoprim if
low folate or on folate antagonist (eg antiepileptic
or proguanil
Child <3 mths: refer urgently for assessment
Child ≥ 3 months: use positive nitrite to start
antibiotics. Send pre-treatment MSU for all.
Imaging: only refer if child <6 months, recurrent
or atypical UTI
trimethoprim 7
200mg BD
Women all ages
or nitrofurantoin
100mg m/r BD
3/7; men 7/7
Second line: perform culture in all treatment failures
Amoxicillin resistance is common; only use if susceptible
Community multi-resistant Extended-spectrum Beta-lactamase E. coli are
increasing: consider nitrofurantoin (or fosfomycin 3g stat in women plus 2 nd 3g
dose in men 3 days later18), on advice of microbiologist
ciprofloxacin
500 mg BD
28 days
or ofloxacin
200 mg BD
28 days
2nd line: trimethop
200 mg BD
28 days
First line: nitrofurantoin
100 mg m/r BD
if susceptible, amoxicillin
500 mg TDS
Second line: trimethoprim
200 mg BD (offGive folate if 1st trimester
label)
All for 7 days
Third line: cefalexin
500 mg BD
Lower UTI: trimethoprim or nitrofurantoin ;if
Lower UTI : 3 days
susceptible, amoxicillin. ;Second line: cefalexin
Upper UTI : 7-10 days
Upper UTI: co-amoxiclav1 Second line: cefixime
Acute
pyelonephritis
If admission not needed, send MSU for C/S & and
start abx.If no response within 24 hours, admit
ciprofloxacin or
co-amoxiclav
500 mg BD
500/125 mg TDS
7 days
14 days
Recurrent UTI in
non-pregnant
women ≥3 uti/yr
Cranberry products, OR Post-coital OR standby
antibiotics may reduce recurrence.
Nightly: reduces UTIs but adverse effects
Abx: nitrofurantoin
or
trimethoprim
50–100 mg
Post coital stat (offlabel)
Prophylaxis OD at night
Eradication is beneficial in known DU, GU or low
grade MALToma and NUD ( NNT is 14)
Consider test and treat in persistent uninvestigated
dyspepsia +Do not offer eradication for GORD . Do
not use clarithromycin or metronidazole if used in the
past year for any infection . DU/GU relapse: retest for
H. pylori using breath or stool test OR consider
endoscopy for culture & susceptibility
NUD: Do not retest, offer PPI or H2RA
First line
Cheapest PPI +clarithromycin
+metronidazole (MTZ) or
amoxicillin AM
2ndline
PPI +bismuthate (De-nol tab)
PLUS 2 unused antibiotics:
amoxicillin
metronidazole
tetracycline 8C
TWICE DAILY
250 mg BD with MTZ or
500mg BD with AM
MTZ 400mg bd; AM 1g bd
Opportunistically screen all aged 15-25yrs
Treat partners and refer to GUM service
Pregnancy or breastfeeding: azithromycin is the
most effective option
Due to lower cure rate in pregnancy, test for cure
6 weeks after treatment
azithromycin
or doxycycline
1g
100 mg BD
stat
7 days
1g (off-label use)
500 mg QDS
500 mg TDS
400 mg BD
100mg BD
stat
7 days
7 days
14 days
14 days
400 mg BD
or 2 g (more relapse)
5 g applicatorful at night
5 g applicatorful at night
7 days
stat
5 night
7 nights
100 mg
Hpylori
Eradication of
Helicobacter
pylori
Symptomatic
relapse
All for
7 days
120 mg QDS
1 g BD
400 mg TDS
500 mg Q
Relapse
or MALToma
14 days
Chlamydia
Chlamydia
trachomatis/
urethritis
For suspected epididymitis in men
Pregnant or breastfeeding:
azithromycin
or erythromycin
or amoxicillin
ofloxacin
doxycycline
Genital Infections
Bacterial
vaginosis
Trichomoniasis
Pelvic
Inflammatory
Oral metronidazole (MTZ) is effective and cheap.
Pregnant/breastfeeding: avoid 2g stat +Treating
partners does not reduce relapse
oral MTZ
Treat partners and refer to GUM service
In pregnancy or breastfeeding: avoid 2g single
dose MTZ. Consider clotrimazole for symptom
relief (not cure) if MTZ declined
metronidazole (MTZ)
400 mg BD
or 2 g
5-7 days
stat
clotrimazole
100 mg pessary at night
6 nights
Refer woman & contacts to GUM service
Always culture for gonorrhoea & chlamydia
28% of gonorrhoea isolates now resistant to
quinolones. If gonorrhoea likely (partner has it,
severe symptoms, sex abroad) use ceftriaxone
regimen or refer to GUM.
metronidazole PLUS
ofloxacin If high risk of GC
Ceftriaxone PLUS
Metronidazole PLUS
doxycycline
400 mg BD
400 mg BD
500 mg IM
400 mg BD
100 mg BD
14 days
14 days
Stat
14 days
14 days
For extensive, severe, or bullous impetigo, use oral
antibiotics
Reserve topical antibiotics for very localised lesions
to reduce the risk of resistance
Reserve mupirocin for MRSA
If patient afebrile and healthy other than cellulitis, use
oral flucloxacillin alone
If river or sea water exposure, discuss with
microbiologist.
If febrile and ill, admit for IV treatment
Stop clindamycin if diarrhoea occurs.
oral flucloxacillin
If penicillin allergic:
oral clarithromycin
topical fusidic acid
MRSA only mupirocin
flucloxacillin
If penicillin allergic:
clarithromycin
or clindamycin
facial: co-amoxiclav
500 mg QDS
7 days
250-500 mg BD
TDS
TDS
500 mg QDS
7 days
5 days
5 days
All for 7 days.
If slow response
continue for a
further 7 days
or MTZ 0.75% vag gel
or clindamycin 2% crm
Skin
Impetigo
Cellulitis
500 mg BD
300–450 mg QDS
500/125 mg TDS
General Advice
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Lower threshold for antibiotics in immunocompromised or those with multiple morbidities.
Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
Limit prescribing over the telephone to exceptional cases.
Use simple generic antibiotics if possible. Avoid broad spectrum
Avoid widespread use of topical antibiotics (especially
Useful Information
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Cold and flu symptoms will not get any better with antibiotics.
50 % who visit for cold and flu expect anibiotics and 25 % want reassurance.
25% of those prescribed anitibiotics do not finish them; some keep them for future use.
If you have had antibiotics in the last 6 months the next infection is twice as likely to be resistant to antibiotics.
Antibiotic Stewardship (AS)

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Antibiotic stewardship refers to the optimal selection of antibiotics for use at the correct dose and duration to maximise clinical outcome while
diminishing toxicity and minimising the impact on antimicrobial resistance.
‘Start smart, then focus’ is an initiative that aids AS. ‘Start smart’ consists of avoiding antibiotics when there is no clinical evidence of bacterial
infection, using local prescribing guidelines and considering allergies.. ‘Then focus’ calls for a review of antibiotics therapy at 48 hours if there is no
improvement with cessation of antibiotics, switching to an alternative or IV therapy.
West Essex CCG Medicines Management Team: December 2013
Expires November 2014