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      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     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)   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