SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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 2012 - 2013

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 patients 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, General Practitioners and Pharmaceutical Advisers of NHS Co Durham and NHS Darlington. Full Guidance, Evidence and References are available at http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/AntimicrobialResistance/Guidelines/htm

Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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

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) 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 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) Avoid antibiotics Amoxicillin: Child 1 month to 18 years; 40mg/kg daily in three divided doses for 5 days (Maximum dose 1.5g gram per day) See CKS or BNF for children for further advice.

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Alternative antibiotic Penicillin Allergy: Clarithromycin 500mg BD for 5 days

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 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 Doxycycline 200mg stat then 100mg OD for 7 days Third-line for persistent symptoms: Co-amoxiclav 625mg TDS for 7 days

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

Avoid antibiotics Amoxicillin 500mg TDS for 7 days

Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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

Illness Comments 1 line antibiotic Alternative 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 Amoxicillin 500mg TDS for 5 days 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 for 5 days GOLD Risk factors for antibiotic resistant organisms OD for 5 days include co-morbid disease, severe COPD, OR frequent exacerbations, antibiotics in last 3 Clarithromycin 500mg BD 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 Amoxicillin 500mg TDS for 7 days treated in hospital but admission not possible. the community rate 30/min; BP systolic90 or diastolic60; 65 OR years of age or older. Score 0 suitable for home Clarithromycin 500mg BD for 7 days Amoxicillin 500mg TDS AND 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 OR admission or life threatening give immediate OD for 7 days CKS benzylpenicillin or amoxicillin 1G orally Doxycycline 200mg stat then 100mg OD for 7- 10 days Mycoplasma infection is rare in over 65s MENINGITIS (NICE fever guidelines)- Transfer all patients to hospital immediately Suspected Transfer all patients to hospital immediately. IV Benzylpenicillin meningococcal disease Administer benzylpenicillin prior to admission, (give IM if vein cannot be found) unless hypersensitive, i.e. Adults and children10yr:: 1200mg HPA history of difficulty breathing, collapse, loss of Children 1 9 years: 600mg consciousness, or rash Children < 1 year: 300mg

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IV Chloramphenicol Adults and Children 25mg/kg OR IV Cefotaxime (2-10% cross sensitivity with cephalosporins
& penicillin)

Adults and children >12 years 1gram Children <12 years 50mg/kg 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 Amoxicillin 500mg TDS for 5 days Metronidazole 400mg TDS for 5 days

Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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

Illness

Comments

1 line antibiotic

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Alternative 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 (unlicenced) Amoxicillin (if susceptible) 500mg for 7 days (give folic acid if first trimester) which trimester & start empirical antibiotics. HPA QRG Short-term use of nitrofurantoin in pregnancy is TDS for 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 1 /2
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episodes

Metronidazole 400mg TDS for 10 14 days

If not responding or 3 episode or severe Contact microbiologist UHND/BAGH Telephone 0191 3332445 DMH 01325 743245
Please note that Vancomycin 125mg QDS for 10days cannot be administered via PEG

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Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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

Illness STI screening Chlamydia Trachomatis SIGN, BASHH HPA, CKS

Comments

1 line antibiotic

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Alternative antibiotic

GENITAL TRACT INFECTIONS 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 Opportunistically screen all aged 15-25yrs Azithromycin 1g stat Doxycycline 100mg BD for 7 days Treat partners and refer to GUM clinic Pregnant or breastfeeding: Pregnant or breastfeeding: In pregnancy or breastfeeding: azithromycin is the most effective option. Doxycycline contraindicated in Azithromycin 1g stat Erythromycin 500mg QDS for 7 days pregnancy and lactation. Due to lower cure rate in (off-label use) OR pregnancy, test for cure 6 weeks after treatment Amoxicillin 500mg TDS for 7 days All topical and oral azoles give 75% cure. Clotrimazole 500mg pessary Clotrimazole 100mg pessary at night for 6 nights Pregnancy: avoid oral azole- use intravaginal for 7 OR 10% cream stat OR OR days Oral Fluconazole 150mg stat Miconazole 2% cream 5g intravaginally BD for 7 days Oral metronidazole is as effective as topical Oral Metronidazole 400mg BD for 7 Metronidazole 0.75% vaginal gel applicatorful (5g) at treatment but is cheaper. Less relapse at 4 wks with days OR 2g stat night for 5 nights OR 7 day course than 2g stat. Clindamycin 2% cream 5g applicatorful at night for 7 Pregnant/breastfeeding: avoid 2g stat nights Treating partners does not reduce relapse Treat partners and refer to GUM clinic Metronidazole 400mg BD for 5 7 Clotrimazole 100mg pessary at night for 6 nights In pregnancy or breastfeeding: avoid 2g single dose days OR 2g stat Metronidazole . Consider Clotrimazole for symptom relief (not cure) if Metronidazole declined Refer woman and contacts to GUM clinic Ciprofloxacin 500mg BD Ceftriaxone 500mg IM stat PLUS Always culture for gonorrhoea & chlamydia for 14 days PLUS Metronidazole 400mg BD 28% of gonorrhoea isolates now resistant to Metronidazole 400mg BD PLUS quinolones. If gonorrhoea likely use Ceftriaxone regimen or refer to GUM. Doxycycline 100mg BD For 14 days nd 2 line: Send MSU for culture and start antibiotics. Ciprofloxacin 500mg BD for 28 4-wk course may prevent chronic prostatitis days Trimethoprim 200mg BD for 28 days Quinolones achieve higher prostate levels May be due to enteric organisms or gonococcal or If probable Chlamydia or non Gonococcal: chlamydia infections gonococcal or non enteric organism Ciprofloxacin 500mg stat PLUS Doxycycline 100mg Doxycycline 100mg BD for 10 14 BD for 10 14 days days If probable enteric organism (i.e. E Coli) Ciprofloxacin 500mg BD for 10 days

Vaginal candidiasis BASSH HPA, CKS Bacterial vaginosis BASSH HPA, CKS Trichomoniasis BASSH HPA, CKS Pelvic Inflammatory Disease RCOG BASHH, CKS Acute prostatitis BASHH, CKS Epididymo Orchitis CKS

Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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

Illness SKIN INFECTIONS Impetigo, boils, carbuncles, folliculitis, staphylococcal paronychia, and staphylococcal whitlow (only if antibiotics are indicated) CKS CKS Cellulitis CKS

Comments 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. 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.

1 line antibiotic 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

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Alternative antibiotic If penicillin allergic: Oral clarithromycin 250-500mg BD for 7 days For localised lesions topical fusidic acid TDS for 5 days MRSA Only mupirocin TDS for 5 days If penicillin allergic: Clarithromycin 500mg BD 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)

Prescribing Matters January 2012 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)

Leg Ulcers HPA QRG CKS MRSA

Bacteria will always be present. Antibiotics do not improve ulcer healing If active infection, send pre-treatment swab Review antibiotics after culture results.

Active infection if cellulitis/increased pain/pyrexia/purulent exudate/odour If active infection: Flucloxacillin 500mg-1g QDS for 7 days (see cellulitis) If active infection: Clarithromycin 500mg BD for 7 days (see cellulitis)

For MRSA screening and suppression, see HPA MRSA quick reference guide If active infection ie, MRSA confirmed by lab results, and Doxycycline 200mg stat; then Consult local microbiologists 100mg BD for 7 days admission not warranted: use sensitivities to guide treatment. If no response, seek advice from microbiologist. 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 Prophylaxis or treatment of human, If penicillin allergic: Thorough irrigation is important cat or dog bite Assess risk of tetanus, HIV, hepatitis B&C Metronidazole 400mg TDS for 7 days PLUS Doxycycline (cat/dog/human) 100mg BD for 7 Antibiotic prophylaxis is advised Assess risk of tetanus, rabies Co-amoxiclav 625mg TDS for 7 days OR Give prophylaxis if cat bite/puncture wound; bite to days Metronidazole 400mg TDS plus Clarithromycin hand, foot, face, joint, tendon, ligament; (human) 500mg BD for 7 days AND Review at 24 and 48 hours immunocompromised/diabetic/asplenic/cirrhotic

PVL S aureus HPA QRG Bites CKS

Human: Cat or dog:

Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2012-13 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

Illness Fungal infection skin CKS CKS CKS Fungal infection proximal fingernail or toenail CKS

Comments 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

1 line antibiotic Topical terbinafine BD for 1 2 weeks

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Alternative antibiotic Topical imidazole BD continuing for1 2 weeks after healing (i.e. 4-6 weeks) OR (athletes foot only) Topical undecanoate BD 1 2 weeks after healing (i.e. 4-6 weeks) Second line: Itraconazole 200mg BD (for 7 days in each month) fingers 2 courses toes - 3 courses

Varicella zoster/ chicken pox CKS & Herpes zoster/ shingles CKS Cold sores EYE INFECTIONS Conjunctivitis CKS

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 710 days without treatment. Topical antivirals applied prodomally reduce duration by 12-24hrs

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 If indicated:

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

Only If severe: Chloramphenicol 0.5% drops 1 drop 2 hourly for 2 days THEN 4 hourly Continue For 48 hours after resolution

Second line: Fusidic acid 1% gel BD For 48 hours after resolution

Final Version 5 Valid From: 01.05.2012

Review Date: January 2013

Expiry Date: 30th April 2013

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