SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14

Transcription

This document is for guidance only. Doses unless stated otherwise are for adults, adjust for age, size and metabolic function. Refer to current BNF for further
information. www.bnf.org Full Guidance, Evidence and Reference
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/AntimicrobialResistance/Guidelines/htm
MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE
2013 - 2015
Aims
1. To provide a simple, empirical approach to the treatment of common infections
2. To promote the safe, effective and economic use of antibiotics
3. To minimise the emergence of bacterial resistance
Principles of Treatment
1.
This guidance is based on the best available evidence but its application must be modified by clinical judgement.
2.
Prescribe an antibiotic only when there is likely to be a clear clinical benefit. A dose and duration of treatment is suggested. In severe or
recurrent cases consider a larger dose or longer course
3.
Dosage and duration will require modification in the young and elderly and in those with abnormalities of renal and liver function
4.
BNF or UKTIS advice on prescribing in pregnancy should be followed. AVOID tetracyclines, aminoglycosides, quinolones, and high dose
metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil)
or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus
5.
Limit prescribing over the telephone to exceptional cases – see GMC guidance GMC Good practice guidance on remote prescribing via
telephone
6.
Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow
spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs.
7.
Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
8.
Clarithromycin is preferred to erythromycin as it has less side-effects, greater compliance as twice rather than four times daily & generic
tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
9.
Where empirical therapy has failed or special circumstances exist, seek microbiological advice.
10.
Only 10 – 20% of patients reporting a history of penicillin allergy are truly allergic when assessed by skin testing. Taking a detailed history of
a patient’s reaction to penicillin may allow clinicians to exclude true penicillin allergy, allowing these patients to receive penicillin.
This guidance has been adapted from the Health Protection Agency Management of Infection for Primary Care Guidelines; after consultation with local Consultant Microbiologists,
local trust Antibiotic Pharmacist, General Practitioners and NECS Medicines Optimisation Pharmacists.
Full Guidance, Evidence and References are available at http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/AntimicrobialResistance/Guidelines/htm
Valid From: 01.09.2013
Review Date: July 2015
Expiry Date: 31th August 2015
Page 1 of 14
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Illness
Comments
1 line antibiotic
Self-Limiting UPPER RESPIRATORY TRACT INFECTIONS - antibiotics rarely necessary as most are self-limiting
Acute sore throat
Avoid antibiotics as 90% resolve in 7 days
Avoid antibiotics
without, and pain only reduced by16 hours
Phenoxymethylpenicillin
CKS
If CENTOR score 3 or 4: (Lymphadenopathy; No
500mg QDS for 10 days
Cough; Fever; Tonsillar Exudate) consider 3-daydelayed or immediate antibiotics
ABx to prevent Quinsy NNT > 4000
ABx to prevent Otitis Media NNT 200
Acute Otitis Media (AOM)
(child doses)
CKS
Optimise NSAID and Paracetamol
Avoid antibiotics as 60% are better in 24 hours
without: they only reduce pain at 2 days (NNT15)
and do not prevent deafness
Consider 3-day-delayed or immediate antibiotics
if:
• < 2yrs with bilateral AOM (NNT4)
• All ages with otorrhoea (NNT3)
Alternative antibiotic
Avoid antibiotics
Amoxicillin:
Child <2yrs: 125mg TDS for 5 days
2-10 yrs: 250mg TDS for 5 days
>10yrs: 500mg TDS for 5 days
(Maximum dose 1.5g gram per day)
See CKS or BNF for children for further
advice.
Penicillin Allergy:
Erythromycin
(Macrolides concentrate intracellularly and so are
less active against the extracellular H influenzae)
<2yrs 125mg QDS for 5 days
2-8yrs 250mg QDS for 5 days
8-18yrs 250-500mg QDS for 5 days
OR
≥ 12 years Clarithromycin 250 – 500mg BD for 5
days
First use aural toilet and analgesia
Acetic Acid 2% spray; 1 spray three times
a day for 7 days
(Earcalm spray® is available for sale to
the public)
Neomycin Sulphate with corticosteroid drops,
Betnesol N® or Predsol N®
Three drops TDS for a minimum of 7 days; maximum
of 14 days
OR
Otomize spray; 1 spray TDS
Avoid antibiotics
Amoxicillin 500mg TDS for 7 days
Doxycycline 200mg stat then 100mg OD for 7 days
Third-line for persistent symptoms:
Co-amoxiclav 625mg TDS for 7 days
Or Clarithromycin 500mg BD – if penicillin allergy
ABx to prevent Mastoiditis NNT >4000
Acute Otitis Externa
(AOE)
CKS
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
Acute Rhinosinusitis
CKS
Avoid antibiotics as 80% resolve in 14 days
without, and they only offer marginal benefit after
7 days( NNT 15)
Use adequate analgesia
Consider 7-day-delayed or immediate antibiotic
0
when: Fever>38 C; toothache; high ESR
Anaerobes more common in persistent
rhinosinusitis
Penicillin Allergy:
Clarithromycin 500mg BD
for 5 days
If allergic to penicillin and pregnant:
Erythromycin 500mg QDS for 7 days
Page 2 of 14
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Illness
Comments
1 line antibiotic
LOWER RESPIRATORY TRACT INFECTIONS
.
Note: Low doses of penicillins are more likely to select out resistance Do not use quinolones first line due to poor pneumococcal activity. Reserve all quinolones for proven resistant
organisms.
Acute cough, bronchitis
Antibiotics have little benefit if no co-morbidity
Amoxicillin 500mg TDS
Doxycycline 200mg stat then 100mg OD for 5 days
Consider delayed antibiotic with symptomatic
for 5 days
CKS NICE 69
advice/leaflet. Symptom resolution can take 3 wks
.
Acute exacerbation of
If resistance risk factors:
Treat exacerbations promptly with antibiotics if
COPD
purulent sputum and increased shortness of
OR
Co-amoxiclav 625mg TDS
NICE 12
breath and/or increased sputum volume
Doxycycline 200mg stat then 100mg OD
for 5 days
GOLD
Risk factors for antibiotic resistant organisms
for 5 days
include co-morbid disease, severe COPD,
OR
frequent exacerbations, antibiotics in last 3
months.
for 5 days
Community-acquired
Use CRB65 score to help guide and review.
IF CRB-65 = 0
If CRB65 = 1 and severe, that would normally be
pneumonia – treatment in Each scores 1: Confusion (AMT<8); Respiratory
treated in hospital but admission not possible.
the community
rate ≥30/min; BP systolic≤90 or diastolic≤60; 65
OR
Amoxicillin 500mg TDS AND
years of age or older. Score 0 suitable for home
Clarithromycin 500mg BD for 7 days
Clarithromycin 500mg BD for 7- 10 days
BTS 2009
treatment; 1-2 hospital assessment or admission;
OR
Guideline
3-4 urgent hospital admission. If delayed
Doxycycline 200mg stat then 100mg OD
OR
admission or life threatening give immediate IV
for 7 days
CKS
benzylpenicillin or amoxicillin 1g orally
Doxycycline 200mg stat then 100mg OD for 7- 10
Mycoplasma infection is rare in over 65s
days
MENINGITIS (NICE fever guidelines)- Transfer all patients to hospital immediately
Suspected
Transfer all patients to hospital immediately.
IV Benzylpenicillin
IV or IM Cefotaxime (2-10% cross sensitivity with
cephalosporins & penicillin)
meningococcal disease
Administer benzylpenicillin prior to admission,
(give IM if vein cannot be found)
Adults and children >12 years 1gram
unless hypersensitive, i.e.
Adults and children≥10yr:: 1200mg
Children <12 years 50mg/kg
HPA
history of difficulty breathing, collapse, loss of
Children 1 – 9 years: 600mg
consciousness, or rash
Children < 1 year: 300mg
Prevention of secondary case of meningitis: Only prescribe following advice from the Health Protection Agency 08442253550 Out of hours 01912697714
Dental Infections
Emergency use only; refer patient to dentist
Metronidazole 400mg TDS for 5 days
Page 3 of 14
Illness
st
Comments
1 line antibiotic
URINARY TRACT INFECTIONS
People > 65 years: do not treat asymptomatic bacteriuria; it is common but it is not associated with increased morbidity
Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis
UTI in men & women (no
Women with severe/ ≥ 3 symptoms: treat
Trimethoprim 200mg BD
Nitrofurantoin 50mg QDS
fever or flank pain)
Women with mild/ ≤ 2 symptoms: use dipstick to
Women for 3 days
Women for 3 days
guide treatment
Men for 7 days
Men for 7 days
HPA QRG
Men: send pre-treatment MSU OR if symptoms
Second line: perform culture in all treatment failures
SIGN
mild/non-specific, use –ve nitrite and leucocytes to
Amoxicillin resistance is common; only use if susceptible
CKS, CKS
exclude UTI
Community multi-resistant Extended-spectrum Beta-lactamase E. coli are increasing: Seek advice from microbiologist; Nitrofurantoin or Fosfomycin
(available on a named-patient basis only) are options. Doses of Fosfomycin: Women: 1 sachet (= 3g fosfomycin) as a single dose. Men 1 sachet (= 3g
fosfomycin) as a single dose repeated 3 days after the first dose (total of 2 doses). Please refer to FOSFOMYCIN (Monural) SPC and Fosfomycin
Prescribing Information and Ordering Information for Primary Care
UTI in pregnancy
Send MSU for culture & sensitivity stating clearly
Nitrofurantoin 50mg QDS for 7 days
Trimethoprim 200mg BD (unlicensed)
Amoxicillin (if susceptible) 500mg TDS for for 7 days (give folic acid if first trimester)
which trimester & start empirical antibiotics.
HPA QRG
Short-term use of nitrofurantoin in pregnancy is
7 days
Third line only:
CKS
unlikely to cause problems to the foetus
Cefalexin 500mg BD for 7 days
Avoid trimethoprim if low folate status or on folate
antagonist (e.g. antiepileptic or proguanil)
UTI in children
Lower UTI: Trimethoprim
Lower UTI second line
Child <3 months with suspected UTI: admit
Child ≥ 3 months: use positive nitrite to start
OR Nitrofurantoin
Cefalexin for 3 days
HPA QRG
OR Amoxicillin (if susceptible)
antibiotics. Send pre-treatment MSU for all
(See BNF for dosage)
CKS
Imaging: only refer if child <6 months or atypical
for 3 days (See BNF for dosage)
Upper UTI: Co-amoxiclav
UTI
for 7 – 10 days (See BNF for dosage)
Acute pyelonephritis
If admission not needed, send MSU for culture &
Ciprofloxacin 500mg BD
Co-amoxiclav 625mg TDS for 14 days
sensitivities and start antibiotics
for 7 days
CKS
If no response within 24 hours, admit
Recurrent UTI
See separate guidance on website
GASTRO-INTESTINAL TRACT INFECTIONS
Clostridium difficile
DH & HPA
Stop unnecessary antibiotics and/or PPIs.
70% respond to metronidazole in 5 days; 92% in 14
days
Severe if T>38.5; WCC>15, rising creatinine or
signs/symptoms of severe colitis
st
1
rd
episode
Metronidazole 400mg TDS
for 10 – 14 days
If not responding or 2 episode or severe
Contact microbiologist
UHND/BAGH Telephone 0191 3332445
DMH 01325 743245
Please note that Vancomycin capsules 125mg QDS for
10days cannot be administered via PEG
Page 4 of 14
Illness
Comments
Detection and eradication
of H. Pylori
H. pylori can be initially detected using a
stool antigen test or urea breath test. Where
re-testing is necessary a breath test should
be used.
Testing for H.pylori should not be performed
within 4 weeks of treatment with any
antibiotic or 2 weeks with any PPI.
One week triple treatment eradicates
H.pylori in >90% of cases.
No need to continue PPI beyond eradication
treatment unless ulcer is complicated by
hemorrhage or perforation.
Avoid clarithromycin or metronidazole if used in
the past year for any infection.
Combination of antibiotics + PPI increases risk
of C.difficile infection – consider if severe or
prolonged diarrhoea following treatment.
Gastroenteritis
Salmonella infection
(suspected)
Shigella (confirmed)
Campylobacter
(confirmed)
Traveller’s diarrhoea
st
1 line antibiotic
First Line – Triple Therapy:
Lansoprazole 30mg twice daily
Amoxicillin 1g twice daily Clarithromycin
500mg twice daily,
for 7 days
Treatment Failure – Quadruple Therapy
Tripotassium dicitratobismuthate 240mg twice daily
Plus two of the following antibiotics
Amoxicillin 1g twice daily or
Metronidazole 400mg twice daily (if not previously
First Line - If allergic to penicillin:
used)
or
Metronidazole 400mg twice daily
Clarithromycin 500mg twice daily (if not previously
Clarithromycin 250mg twice daily, for 7 da used)
Or
Tetracycline 500mg four times daily,
For 4 days
Fluid replacement essential
Antibiotic therapy not usually indicated.
Do not use anti-motility drugs if stools are
bloody
Treat if systemically unwell,
immunocompromised, joint or bone
prosthesis, bone metastases,
haemoglobinopathy, chronic IBD
Treat if severe, e.g. bloody stool
Treatment should be considered on advice of microbiologist in severe or invasive
infections (severe systemic upset and/or dysentery).
Frequently self-limiting – treat if illness
persists over one week
Clarithromycin 500mg four times a day
for 5 days
Seek advice from microbiology / infectious diseases
Seek advice from microbiology/infectious diseases
Consider private prescription (ciprofloxacin 500mg twice daily x 3 days) to be carried by people travelling to remote areas or in whom an
episode of diarrhoea could be dangerous – to be taken if illness develops
Empirical antibiotic treatment is unnecessary in most people. Seek advice from microbiology / infectious diseases on cases which cause
concern.
Page 5 of 14
Threadworms
All household contacts should be treated
simultaneously.
Adult and Child > 6 months:
Advise morning shower/baths and hand
hygiene.
(A second dose may be needed
after 2 weeks)
Mebendazole is unlicensed for children under
2yrs. However it is an accepted treatment in
children >6 months and is endorsed by the
BNF for children and secondary care
Child 3 months – 6 months:
Mebendazole 100mg single dose
Piperazine + senna oral powder
(Pripsen®), one level 2.5ml
spoonful of dry powder mixed with
milk or water to be given in the
morning.
Repeat after 2 weeks
GENITAL TRACT INFECTIONS
STI screening
People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer to GUM clinic or GP with level 2 or 3 expertise in GUM.
Risk factors: < 25y, no condom use, recent (<12mth) or frequent change of partner, symptomatic partner
Chlamydia Trachomatis
Azithromycin 1g stat
Doxycycline 100mg BD for 7 days
SIGN, BASHH
HPA, CKS
Opportunistically screen all aged 15-25yrs
Treat partners and refer to GUM clinic
In pregnancy or breastfeeding: azithromycin is the
most effective option. Doxycycline contraindicated in
pregnancy and lactation. Due to lower cure rate in
pregnancy, test for cure 6 weeks after treatment
Pregnant or breastfeeding:
Azithromycin 1g stat
(off-label use)
Pregnant or breastfeeding:
Erythromycin 500mg QDS for 7 days
OR
Vaginal candidiasis
BASSH
HPA, CKS
All topical and oral azoles give 75% cure.
Pregnancy: avoid oral azole- use intravaginal for 7
days
Clotrimazole 500mg pessary
OR 10% cream stat OR
Oral Fluconazole 150mg stat
Clotrimazole 100mg pessary at night for 6 nights
OR
Miconazole 2% cream 5g intravaginally BD for 7 days
Bacterial vaginosis
Oral metronidazole is as effective as topical
treatment but is cheaper. Less relapse at 4 wks with
7 day course than 2g stat.
Pregnant/breastfeeding: avoid 2g stat
Treating partners does not reduce relapse
Oral Metronidazole 400mg BD for 7
days OR 2g stat
Metronidazole 0.75% vaginal gel applicatorful (5g)
at night for 5 nights OR
Clindamycin 2% cream 5g applicatorful at night for 7
nights
BASSH
HPA, CKS
Page 6 of 14
Trichomoniasis
Treat partners and refer to GUM clinic
In pregnancy or breastfeeding: avoid 2g single dose
Metronidazole . Consider Clotrimazole for symptom
relief (not cure) if Metronidazole declined
Refer woman and contacts to GUM clinic
Always culture for gonorrhoea & chlamydia
28% of gonorrhoea isolates now resistant to
quinolones. If gonorrhoea likely use Ceftriaxone
regimen or refer to GUM.
Metronidazole 400mg BD for 5 – 7
days OR 2g stat
Clotrimazole 100mg pessary at night for 6 nights
Ciprofloxacin 500mg BD
for 14 days
PLUS Metronidazole 400mg BD
Ceftriaxone 500mg IM stat
PLUS
Metronidazole 400mg BD
PLUS
Doxycycline 100mg BD
For 14 days
Refer to Sexual Health Service for confirmation of
diagnosis or (if first episode) send viral swab to lab
Consider need for full STI screening in all cases
Commence treatment within 5 days of the start of
the episode. Extend course if new lesions appear
during treatment or healing incomplete
Advise abstinence until lesions have cleared.
May be due to enteric organisms or gonococcal or
chlamydia infections
Aciclovir 400mg TDS for 5 days or
200mg five times a day for 5 days
Balanitis
CKS
Treat according to age of patient and likely infective
organism
Consider prescribing hydrocortisone 1% cream or
ointment for up to 14 days for inflammatory
discomfort
If no improvement in symptoms after 7 days, swab
for fungal or bacterial infection and treat accordingly
Candidal balanitis
Clotrimazole 1% cream, apply BD, or
Fluconazole 150mg single dose (>16yrs
only)
Acute prostatitis
BASHH, CKS
Send MSU for culture and start antibiotics.
A 4-week course may prevent chronic prostatitis.
Quinolones achieve higher prostate levels
Ciprofloxacin 500mg BD for 28 days
BASSH
HPA, CKS
Pelvic Inflammatory
Disease
RCOG
BASHH, CKS
Genital Herpes
CKS
Epididymo Orchitis
CKS
Immunocompromised/HIV patients
Aciclovir 400mg five (5) times a day for
7 – 10 days
If probable Chlamydia or non
gonococcal or non-enteric organism
Doxycycline 100mg BD for 10 – 14
days
Gonococcal:
Ciprofloxacin 500mg stat PLUS Doxycycline 100mg
BD for 10 – 14 days
If probable enteric organism (i.e. E Coli)
Ciprofloxacin 500mg BD for 10 days
If more Information available
Gardnerella-associated balanitis
Adults, Metronidazole 400mg BD for 7 days
Streptococcal balanitis (in adults)
Amoxicillin 500mg QDS for 7 days
If penicillin allergy
Clarithromycin 250mg BD for 7 days
Bacterial balanitis (in children – see BNF for child
doses)
Flucloxacillin for 7 days
Clarithromycin (if penicillin allergy) for 7 days
nd
2 Line
Trimethoprim 200mg BD for 28 days
Page 7 of 14
SKIN INFECTIONS
Impetigo, boils, carbuncles,
folliculitis, staphylococcal
paronychia, and
staphylococcal whitlow (only
if antibiotics are indicated)
CKS
For extensive, severe, or bullous impetigo, use oral
antibiotics.
Reserve topical antibiotics for very localised lesions
to reduce the risk of resistance
Soak and remove excess crust prior to application of
topical therapy
Reserve mupirocin for MRSA
Scabies
Treat whole body including scalp, face, neck, ears,
under nails – re-apply to hands if washed within 8 hrs
of application.
Treat all household contacts, though only once if
asymptomatic
Eczema
Using topical antibiotics or adding them to steroids in eczema management encourages resistance and does not improve healing. In infected
eczema, use antiseptic bath additives (e.g. Oilatum Plus) and treat with systemic antibiotics as for impetigo if clinically indicated.
Head Lice
All regular household contacts should be checked
Only those with living, moving head lice should be
treated
All affected individuals should be treated
simultaneously
Choice of treatment will depend on patient
preference and treatment history
Oral flucloxacillin 500mg – 1g QDS
for 7 days
See BNF for dose for children.
Flucloxacillin liquid preparations are currently
expensive please see link for alternatives
Prescribing Matters January 2012
Permethrin 5% dermal cream x 30g.
Repeat application after 7 days
If penicillin allergic:
Oral clarithromycin 500mg BD for 7 days
If liquid formulations are required
Erythromycin (See BNF for doses)
For localised lesions topical fusidic acid TDS for 5
days
MRSA Only mupirocin TDS for 5 days
Malathion 0.5% aqueous liquid x 200ml.
Repeat application after 7 days.
Treatment options:
Wet combing – thoroughly comb wet,
conditioner-covered hair with detection
comb for 30 mins, twice weekly for two
weeks
Insecticides
Malathion 0.5% aqueous liquid x 50ml.
Apply from root to tip, allow to dry
naturally and rinse off after 12 hrs.
Repeat after 7 days (plus wet combing
as above)
Dimeticone 4% lotion x 50ml (suitable
for people with asthma). Apply to dry
hair from roots to tips. Leave to dry
naturally. Wash off after 8 hrs. Repeat
after 7 days (plus wet combing as
above)
Page 8 of 14
Cellulitis
CKS
If patient afebrile and healthy other than cellulitis,
use oral flucloxacillin alone. Ensure adequate dose
of flucloxacillin is prescribed
If water exposure, discuss with microbiologist.
If febrile and ill, admit for IV treatment
Stop clindamycin if diarrhoea occurs.
Leg Ulcers
Bacteria will always be present.
Antibiotics do not improve ulcer healing
If active infection, send pre-treatment swab
Review antibiotics after culture results.
HPA QRG
CKS
Foot ulceration in
patients with diabetes
MRSA
Bites
CKS
for 7 days (if slow response continue for another 7
days)
OR
Clindamycin 300-450mg QDS
for 7 days (if slow response continue for another 7
days)
Active infection if cellulitis/increased pain/pyrexia/purulent exudate/odour
If active infection:
Flucloxacillin 500mg-1g QDS for 7
days (see cellulitis)
Refer to be seen immediately (less than 24hrs) to
Flucloxacillin 500mg QDS for 14 days
local High Risk Foot clinic
Take swab for culture and sensitivity then start
empirical treatment
For MRSA screening and suppression, see HPA MRSA quick reference guide
If active infection i.e., MRSA confirmed by lab results,
and admission not warranted: use sensitivities to
guide treatment. If no response, seek advice from
microbiologist.
PVL S aureus
HPA QRG
Flucloxacillin 500mg -1g QDS
for 7 days (if slow response continue for
another 7 days)
Facial:
Co-amoxiclav 625mg TDS for 7 days (if
slow response continue for another 7
days)
Doxycycline 200mg stat; then 100mg
BD for 7 days
If active infection:
Clarithromycin 500mg BD for 7 days (see cellulitis)
If allergic to penicillin:
Doxycycline 100mg bd for 14 days
Consult local microbiologists
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of S aureus. Can rarely cause severe invasive infections in healthy people. Send swabs
if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene
Human:
Cat or dog:
Thorough irrigation is important
Assess risk of tetanus, HIV, hepatitis B&C
Antibiotic prophylaxis is advised
Assess risk of tetanus, rabies
Give prophylaxis if cat bite/puncture wound; bite to
hand, foot, face, joint, tendon, ligament;
immunocompromised/diabetic/asplenic/cirrhotic
Prophylaxis or treatment of human,
cat or dog bite
Co-amoxiclav 625mg TDS for 7
days
Metronidazole 400mg TDS for 7 days
PLUS Doxycycline (cat/dog/human) 100mg BD for 7
days OR
Metronidazole 400mg TDS plus Clarithromycin
(human) 500mg BD for 7 days
AND Review at 24 and 48 hours
Page 9 of 14
Fungal infection – skin
CKS
CKS
CKS
Fungal infection –
proximal fingernail or
toenail
CKS
Terbinafine is fungicidal, so treatment time shorter
than with fungistatic imidazoles
If candida possible, use imidazole
If intractable: send skin scrapings If infection
confirmed, use oral terbinafine/itraconazole
Scalp: discuss with specialist
Take nail clippings: start therapy only if infection is
confirmed by laboratory
Terbinafine is more effective than azoles
Liver reactions rare with oral antifungals
If candida or non-dermatophyte infection confirmed,
use oral itraconazole
For children, seek specialist advice
Pityriasis versicolor
See BNF 13.10.2
Topical azole creams may be used, but large
quantities may be needed
For resistant or widespread infection, use systemic
treatment
Repigmentation requires exposure after treatment
Acne
Treatment depends on type of acne and severity of
disease – patients with severe disease (e.g.
nodulocystic acne) should be referred.
Treat with oral antibiotics for at least 3 months – if
clinical improvement continues for a further 3 months;
if no improvement try an alternative antibiotic before
referral
Lymecycline - lower risk of photosensitivity, once daily
dosage, but 2.5x more expensive than doxycycline.
Topical terbinafine BD for 1 – 2
weeks
Topical imidazole BD continuing for1 – 2 weeks after
healing (i.e. 4-6 weeks)
OR (athlete’s foot only)
Topical undecanoate BD 1 – 2 weeks after healing (i.e.
4-6 weeks)
Superficial only:
Amorolfine 5% nail lacquer
1-2x/weekly: fingers - 6 months
toes - 12 months
First line:
Terbinafine 250mg OD for
Fingers - 6-12 weeks
Toes
- 3 - 6 months
Ketoconazole 2% shampoo
applied to the affected area once
daily; leave on for 3 – 5 mins
before rinsing.
Second line:
Mild disease (comedonal):
Benzoyl peroxide 5 – 10% gel,
applied 1-2 times daily after
washing; start with lower strength
preps, or
Tretinoin 0.01-0.025% gel,
applied 1-2 times daily
Mild disease (inflammatory):
Lymecycline 408mg daily or
Oxytetracycline 500mg BD for up
to 6 months, in combination
with either of the above.
Avoid in pregnancy,
breastfeeding and <12yrs
AVOID MINOCYCLINE – can
cause liver damage
If tetracyclines contra-indicated:
Itraconazole 200mg BD
(for 7 days in each month)
fingers – 2 courses
toes - 3 courses
For resistant/widespread infection:
Itraconazole 200mg daily for 7 days
Page 10 of 14
Varicella zoster/ chicken
pox
CKS
&
Herpes zoster/ shingles
CKS
Cold sores
If indicated:
Pregnant/immunocompromised/neonate: seek urgent
specialist advice
Chicken pox: if adult or severe pain/ secondary
Aciclovir dispersible tablets
household case/on steroids AND can start within 24
800mg five times a day for 7 days
hrs of rash, consider aciclovir
Shingles: treat if >50 yrs and within 72 hrs of rash
(PHN rare if <50yrs); or if active ophthalmic or
Ramsey Hunt or eczema.
Cold sores resolve after 7–10 days without treatment. Topical antivirals applied prodomally reduce duration by 12-24hrs
EYE INFECTIONS
Conjunctivitis
CKS
Most bacterial conjunctivitis self-limiting. 65%
resolve on placebo by day five
Red eye with mucopurulent (not watery) discharge.
Starts in one eye but may spread to both
Fusidic acid has less Gram-negative activity
Blepharitis
Essential eyelid hygiene is a priority and often
adequate in uncomplicated seborrhoeic Blepharitis
Topical antibacterial agents should be used if there is
marked eyelid infection
Artificial tears can provide symptom relief from dry
eyes
If persistent or severe, swab eyelid margin for culture
and sensitivities before starting oral treatment.
PROPHYLAXIS IN ASPLENIA/SPLENIC DYSFUNCTION
Refer to 2011 BCSH
Guideline for full
information about the
management of asplenia
patients
Ensure patient is fully vaccinated – the following
vaccines are recommended (see table 7.1 in “Green
Book” for details):
- Haemophilus influenzae type b (Hib)
& Meningococcal group C (Men C)
conjugate vaccine (Menitorix)
- Meningococcal A, C, W135 and Y
conjugate vaccine(MenACWY)
- Influenza vaccine
- Pneumococcal vaccine
Only If severe: Chloramphenicol 0.5%
drops
1 drop 2 hourly for 2 days THEN 4
hourly
Continue For 48 hours after
resolution
Chloramphenicol 1% ointment, apply
once daily after eyelid hygiene
Continue treatment for one month after
inflammation has settled
N.B. Do not use chloramphenicol
during third trimester of pregnancy –
consider Fucilthalmic eye drops.
Second line:
Fusidic acid 1% gel BD
For 48 hours after resolution
Prevention of pneumococcal
infection: Lifelong prophylactic
antibiotics should be offered to patients
considered at continued high risk of
pneumococcal infection. Refer to
BCSH 2011 guidance at:
http://www.bcshguidelines.com/docum
ents/Review_of_guidelines_absent_or
_dysfunctional_spleen
_2012.pdf
Oral clarithromycin 500mg BD for 7 days
If liquid formulations are required
Erythromycin (See BNF for doses)
Page 11 of 14
Advise patient to carry splenectomy card and present
immediately if unwell. Patients developing infection
must be given systemic antibiotics and admitted
urgently to hospital.
Patients should be aware of the potential risks of
overseas travel, particularly with regards malaria and
unusual infections, e.g. those resulting from animal
bites.
Phenoxymethylpenicillin
Adult & child over 5 years:
twice daily
Child 1 – 5 years:
twice daily
Child under 1 year:
twice daily
250mg
125mg
62.5mg
MRSA ERADICATION
Use all antibiotics cautiously in patients with a history of MRSA infection or colonisation as they are at high risk of recurrence. If systemic antibiotic therapy is required
then use antibiotics which cover MRSA – seeks specialist advice.
Not all isolates of MRSA indicate that there is an infection. Colonisation with MRSA is not an indication to use antibiotics.
For further information please refer to the practice MRSA policy and seek specialist advice if necessary
When eradication is needed:
Not all patients will require eradication treatment. Refer to MRSA Risk
Mupirocin nasal ointment 2%, apply to both anterior nares three times daily
assessment tool for guidance
Plus
For patients undergoing eradication encourage daily change of flannel, towel
Octenisan body wash once daily for 5 days. (If excessive skin drying occurs consider Oilatum
and personal clothing and, if possible, bedding.
Plus as an alternative).
Rescreen 2 days after completion of eradication treatment. A patient
Plus
cannot be regarded as MRSA- negative until they have had three negative swabs
Hair wash with Octenisan twice in five-day treatment period.
taken at weekly intervals following eradication treatment. Such patients may still
carry MRSA and MRSA should still be considered as the potential cause of any
subsequent infections.
Page 12 of 14
QUICK REFERENCE GUIDE TO THE MOST COMMON INFECTIONS
Otitis media
Refer to:
NICE CG69,
Respiratory
Tract Infections
– antibiotic
prescribing,
July 2008
Acute
Bronchitis
Refer to: NICE
CG69 as
above
Acute
exacerbation
of COPD
80% resolve over 4 days without antibiotics. Consider non- or
delayed prescription strategy.
Unilateral pain in children >1 yr should not routinely require antibiotic.
Consider immediate prescription if:
<2 years with bilateral pain, OR
otorrhoea (all ages)
systemically very unwell
Antibiotics do not reduce pain in first 24 hours, subsequent attacks or
deafness.
Use regular paracetamol or ibuprofen for symptom relief
If a patient with otitis media has ever previously been positive for
MRSA, please seek microbiological advice.
Antibiotics are not indicated for otherwise healthy people without
co- morbidities
Cough may persist for 4 weeks irrespective of whether or not antibiotics
are given.
Antibiotics only needed if:
Increase in sputum purulence
OR
Increase in sputum volume
If the patient has ever previously been positive for MRSA then use
Doxycycline 100mg twice daily alone for 5 days
Uncomplicated
UTI in women
Positive nitrites and leucocytes in morning urine increase likelihood of
UTI
– MSU should not be necessary.
2
Avoid nitrofurantoin in CKD stage 3/4/5 (eGFR <60ml/min/1.73m ), as
ineffective
When antibiotics are needed: First line:
Amoxicillin <2 yrs: 125mg three times daily
2-10yrs: 250mg three times daily
>10 yrs: 500mg three times daily
Adults & children able to take tablets:
Clarithromycin (see BNF for doses)
Children & adults requiring liquid formulation:
Erythromycin (see BNF for doses)
nd
2 line options – co-amoxiclav, azithromycin (if penicillin-allergic)
When antibiotics are needed:
First line options:
Amoxicillin 500mg three times daily or
Doxycycline 200mg stat then 100mg daily
When antibiotics are needed: First line options:
Amoxicillin 500mg three times daily, or
Second Line:
(if not already tried), or
Clarithromycin 500mg twice daily
5 days
5 days
5 days
5 days in total
5 days
5 days in total
5 days in total
5 days
First line options:
Trimethoprim 200mg twice daily, or
2
Nitrofurantoin 50mg four times daily
line treatments according to C&S
3 days
3 days
nd
Page 13 of 14
Impetigo
Cellulitis
Patients are infectious until lesions have crusted over, or they have
received antibiotic treatment for 48 hours.
Reserve topical antibiotics (fusidic acid) for very localised, non-bullous
lesions only – have a low threshold for systemic treatment
Reserve mupirocin for nasal eradication of MRSA.
If febrile, ill or rapidly worsening infection admit for IV treatment
In facial cellulitis use co-amoxiclav
If cellulitis is improving but not completely resolved after the initial 7 day
course consider continuing for up to a further 7 days.
If associated with lymphoedema, consider referral to specialist
service
A consensus document on the Management of Cellulitis in
Lymphoedema from the British Lymphology Society available at:
http://www.thebls.com/patients/files/cons
ensus_on_cellulitis_aug_10.pdf
Use clindamycin cautiously – stop immediately if diarrhoea
occurs
First line:
Flucloxacillin 500mg four times daily
Adults & children able to take tablets:
Clarithromycin (see BNF for doses)
Children & adults requiring liquid formulation:
Erythromycin (see BNF for doses)
7 days
7 days
7 days
First line:
Flucloxacillin 500 mg – 1g four times daily (NB. 1g four times a day
is not a liscensed dose)
7 - 14 days
Clarithromycin 500mg twice daily
nd
2 line if (poor response to above) :
times daily
7 - 14 days
7 - 14 days
Clindamycin 300mg four
If facial involvement:
Co-amoxiclav 500/125mg three times daily
7 - 14 days
If cellulitis has been caused by trauma or wound exposed to salt or
fresh (not tap) dirty water – seek microbiology or ID advice re.
appropriate antibiotic treatment
If the patient has ever previously been positive for MRSA then
please use doxycycline 100mg twice daily for 7-14 days
Page 14 of 14

SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14

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