SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14
SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 st 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 Valid From: 01.09.2013 Review Date: July 2015 Penicillin Allergy: Clarithromycin 500mg BD for 5 days If allergic to penicillin and pregnant: Erythromycin 500mg QDS for 7 days Expiry Date: 31th August 2015 Page 2 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 st 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 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 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 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 Valid From: 01.09.2013 Review Date: July 2015 Amoxicillin 500mg TDS for 5 days Metronidazole 400mg TDS for 5 days Expiry Date: 31th August 2015 Page 3 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 st Comments 1 line antibiotic 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 (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 Valid From: 01.09.2013 Review Date: July 2015 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 Expiry Date: 31th August 2015 Page 4 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 Alternative antibiotic First Line – Triple Therapy: Lansoprazole 30mg twice daily Amoxicillin 1g twice daily Clarithromycin 500mg twice daily, for 7 days Treatment Failure – Quadruple Therapy Lansoprazole 30mg twice daily 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) Lansoprazole 30mg twice daily 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. Valid From: 01.09.2013 Review Date: July 2015 Expiry Date: 31th August 2015 Page 5 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 Amoxicillin 500mg TDS for 7 days 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 Valid From: 01.09.2013 Review Date: July 2015 Expiry Date: 31th August 2015 Page 6 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 Valid From: 01.09.2013 Review Date: July 2015 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 Expiry Date: 31th August 2015 Page 7 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 Valid From: 01.09.2013 Review Date: July 2015 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) Expiry Date: 31th August 2015 Page 8 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 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) 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 Valid From: 01.09.2013 Review Date: July 2015 Prophylaxis or treatment of human, cat or dog bite Co-amoxiclav 625mg TDS for 7 days If penicillin allergic: 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 Expiry Date: 31th August 2015 Page 9 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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. Valid From: 01.09.2013 Review Date: July 2015 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 Clarithromycin 500mg BD Expiry Date: 31th August 2015 Page 10 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 Valid From: 01.09.2013 Review Date: July 2015 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 If allergic to penicillin: Oral clarithromycin 500mg BD for 7 days If liquid formulations are required Erythromycin (See BNF for doses) Expiry Date: 31th August 2015 Page 11 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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. Valid From: 01.09.2013 Review Date: July 2015 Expiry Date: 31th August 2015 Page 12 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 Valid From: 01.09.2013 Review Date: July 2015 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 If allergic to penicillin: 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 Doxycycline 200mg stat then 100mg daily Second Line: Doxycycline 200mg stat then 100mg daily (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 Expiry Date: 31th August 2015 Page 13 of 14 SUMMARY OF ANTIBIOTIC GUIDANCE FOR PRIMARY CARE 2013-14 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 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 If allergic to penicillin: 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 If allergic to penicillin: 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 Valid From: 01.09.2013 Review Date: July 2015 Expiry Date: 31th August 2015 Page 14 of 14
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