MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE PRESCRIBERS IN NORTHAMPTONSHIRE Aims to provide a simple, empirical approach to the treatment of common infections to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance in the community. Principles of Treatment This guidance is based on the best available evidence but its application should be modified by professional judgement and patients should be involved in the decision. Do not take a sensitivity report from the microbiology laboratory as an instruction to treat. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. In severe or recurrent cases consider a larger dose or longer course. Lower threshold for antibiotics in immune-compromised or those with multiple morbidities; consider culture and seek advice. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. Consider a no, or delayed, antibiotic strategy for acute sore throat, common cold, acute cough and acute sinusitis, otitis media (patients > 2 years) Do not prescribe an antibiotic for viral sore throat, or for simple coughs and colds. Limit prescribing over the telephone to exceptional cases. Use simple generic antibiotics first whenever possible. The use of new and more expensive antibiotics (e.g. quinolones and cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations). In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim or nitrofurantoin is unlikely to cause problems to the foetus. Clarithromycin is an acceptable alternative to erythromycin in those who are unable to tolerate the latter because of side effects. Where initial therapy has failed or special circumstances exist, microbiological advice can be obtained from Dr Minassian or Dr Bentley at Northampton on 01604 545043 or 01604 545138 and Dr Manjula & Dr Rizkalla at Kettering on 01536 492697. 1 UPPER RESPIRATORY TRACT INFECTIONS Pharyngitis / sore throat / tonsillitis CKS - acute sore throat The majority of sore throats are viral, but there is clinical overlap between viral and streptococcal infections. Antibiotics are unnecessary for most patients with sore throat as this is a self-limiting condition, which resolves by one week in 85% of people, whether it is due to streptococcal infection or not. The Centor criteria may be useful to predict patients who are at higher risk of GABHS and complications, and who may benefit from antibiotics. The criteria are History of fever Tonsillar exudates No cough Tender anterior cervical lymphadenopathy If 3 or 4 Centor criteria present consider 2 or 3 day delayed or immediate antibiotics. Patients with more severe symptoms or history of otitis media may benefit more from antibiotics. Antibiotics only shorten duration of symptoms by 8 hours. Antibiotics can prevent non-suppurative complications of beta-haemolytic streptococcal pharyngitis but, in developed societies, such complications are rare. You need to treat 30 children or 145 adults to prevent one case of otitis media. Culture of Group A beta-haemolytic streptococcus (GABS) is inefficient as a diagnostic criterion as it is too slow and it fails to differentiate between infection and carriage. First line treatment Phenoxymethylpenicillin 500mg qds for 10 days First line treatment if allergic to penicillin Erythromycin 250mg qds for 10 days Otitis media (child doses) CKS - acute otitis media Many are viral. 80% resolve without antibiotics. Poor outcome is more likely if the condition is recurrent. Use paracetamol or NSAID. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness. A GP needs to treat 20 children >2 years or 7 children 6-24 months old to get pain relief in one child at 2-7 days. First line treatment Amoxicillin <10 yrs; 250mg tds for 5 days >10 yrs; 500mg tds for 5 days First line treatment if allergic to penicillin Erythromycin <2 yrs ; 125mg qds for 5 days 2-8 yrs ; 250mg qds for 5 days >8 yrs ; 500mg qds for 5 days Rhinosinusitis - acute on chronic CKS - sinusitis Many are viral. Symptomatic benefit of antibiotics is small - 69% resolve without antibiotics; 84% resolve with antibiotics. Reserve antibiotics for severe or persistent symptoms (>10 days). First line treatments Phenoxymethylpenicillin 500mg qds for 7 days Amoxicillin 500mg tds for 7 days Doxycycline 200mg stat/100mg od for 7 days 2 LOWER RESPIRATORY TRACT INFECTIONS Acute bronchitis NICE CG 69 CKS - acute bronchitis Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults. First line treatments Amoxicillin 500mg tds for 5 days Erythromycin 500mg qds for 5 days Doxycycline 200mg stat/100mg od for 5 days Acute exacerbation of COPD NICE CG 101 - COPD Remember - only 50% are caused by bacterial infection. Antibiotics are indicated if 2 or more of cough, production of purulent sputum or breathlessness are present. First line treatments Amoxicillin 500mg tds for 5 days Erythromycin 500mg qds for 5 days Doxycycline 200mg stat/100mg od for 5 days Second line treatment Co-amoxiclav 500/125mg tds for 5 days Community-acquired pneumonia (treatment in the community) Antibiotics should be started immediately. If there is no response within 48 hours consider admission. Most pneumonias are caused by Streptococcus pneumoniae sensitive to amoxycillin. Erythromycin is used for the treatment of Mycoplasma pneumoniae, Legionella pneumophila and to cover Staph. aureus – only 5% of mycoplasma infections occur in patients over 65 yrs of age; enquire regarding risk factors for Legionella and Staph. aureus if severely ill and consider admission. First line treatment Amoxicillin 500mg tds for 7- 10 days consider the addition of Erythromycin 500mg qds for 7-10 days if patient is 65 years of age or older or they are confused, has an increased respiratory rate >30/min or reduced BP (systolic < 90 or diastolic < 60). If they have any these signs and are 65 years of age or older, or a younger patients with 2 of these signs, consider referral to hospital First line treatment if allergic to penicillin or intolerant of erythromycin Doxycycline 200mg stat/100mg od for 7-10 days The currently available quinolones have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections. 3 MENINGITIS Suspected meningococcal disease Transfer patient to hospital immediately. First line treatment Benzylpenicillin adults and children 10yrs and over – 1.2G children 1-9yrs – 600mg children <1yr – 300mg Administer benzylpenicillin prior to admission unless there is a history of anaphylactic reaction to penicillin. Benzylpenicillin should be given IV but can be given IM if a vein cannot be found. For the prevention of secondary cases of meningitis only prescribe following advice from the Health Protection Agency. URINARY TRACT INFECTION UTI accounts for 1-3% of GP consultations in the UK and affects half of all women at some time during their life. Sexually active women aged 20-50, pregnant women, the elderly, diabetics and young girls are particularly susceptible to UTI. Prostatic enlargement in older men may cause obstruction of the urinary tract, thereby increasing the risk of infection. UTI is most commonly caused by coliforms (including E. coli) - 83%, Enterococcus sp. - 10%, Staph. epidermidis or S. saprophyticus - 3%, and Pseudomonas sp. - 3%. Management of simple UTI HPA QRG All non-pregnant women with symptoms of UTI (dysuria, frequency, urgency or nocturia) should have an early morning MSU tested using a multi-test dipstick. The four principal analytes are:Nitrite - bacteria reduce dietary nitrates to nitrites. Leucocyte-esterase - enzyme present in white blood cells. Protein and Blood - while these tests have very low sensitivity and specificity on their own they are useful in that they contribute to the overall predictive value of a negative result. The predictive value of a negative test, i.e. when all 4 indicators are negative, is very high - in patients with a negative urine dipstick other causes of the patient’s symptoms should be considered e.g. Candida or Chlamydia. The ability of the multi-test dipstick to predict positive results is lower. In nonpregnant women with clear symptoms of UTI the positive dipstick tests can be seen as confirmation of infection and antibiotic therapy can be started. Women CKS - uti lower women First line treatments Trimethoprim 200mg bd for 3 days (women) Nitrofurantoin 50mg qds for 3 days (women) Elderly women - Clinical symptoms may be less specific e.g. fever, anorexia or confusion; in addition 20% of elderly women may have asymptomatic bacteriuria. Therefore the diagnosis requires both bacteriological evidence and careful clinical judgement. Catheterised patients will almost certainly have bacteriuria; antibiotic therapy will not eradicate this and will select resistant organisms. 4 Men CKS - uti lower men It is wise to consider the possibility of chlamydial urethritis in younger men. Symptomatic older men should be investigated for prostatic hypertrophy. First line treatments Trimethoprim 200mg bd for 7 days Nitrofurantoin 50mg qds for 7 days Management of complicated UTI A complicated UTI is one occurring in pregnant women, children, men or the elderly, or one that either recurs or ascends to the upper tract. The latter produces symptoms such as fever, nausea, malaise or loin pain. All patients with complicated UTI should have an MSU sent for MC&S and treatment should be based on the results. In general, treatment of complicated UTI should be for 7 days. Acute pyelonephritis CKS - acute pyelonephritis :– First line treatments Ciprofloxacin 500mg bd for 7 days (ensure patient is not at risk of C dificile) Trimethoprim 200mg bd for 14 days Consider referral if no response within 48 hours. Pregnant women HPA QRG CKS - uti lower women :- An MSU should be sent if symptoms of UTI occur. First line treatments Nitrofurantoin 50mg qds Trimethoprim 200mg bd (off-label). Give folic acid in 1 st trimester Cefalexin 500mg bd If cultures remain positive after treatment or symptoms recur then seek advice regarding prophylaxis for the remainder of pregnancy. Pregnant women with signs of acute pyelonephritis should be referred to hospital. This is more likely to occur in women with a history of UTI, diabetes or chronic renal impairment. Children HPA QRG CKS - uti children - The information gained from multi-test dipstick on a carefully taken urine sample can be used to judge whether antibiotic therapy. First line treatments Trimethoprim – see BNF for dosage Nitrofurantoin – see BNF for dosage. A specimen should always be sent for MC&S and therapy adjusted on the basis of sensitivity results. Children should be referred for further investigation following their first proven UTI 5 GASTROINTESTINAL INFECTIONS Helicobacter pylori Diagnosis is via faecal antigen in patients with relevant symptoms. First line treatments Lansoprazole 30mg bd PLUS Clarithromycin 500mg bd PLUS Amoxicillin 1g bd OR Lansoprazole 30mg bd PLUS Clarithromycin 250mg bd PLUS Metronidazole 400mg bd Triple or quadruple treatment attain >85% eradication. As resistance is increasing, avoid Clarithromycin or Metronidazole if used in the previous year for any infection. In treatment failure consider endoscopy for culture & sensitivities. Second line treatment Lansoprazole 30mg bd PLUS Bismuth (DE-NOL) 240mg bd PLUS Two antibiotics from: Amoxicillin 1g bd Metronidazole 400mg tds Oxytetracycline 500mg qds Clostridium difficile associated diarrhoea See separate policy. Gastroenteritis Fluid replacement is essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and can cause resistance. Initiate treatment, on the advice of a microbiologist, if the patient is systemically unwell. Please notify suspected cases of food poisoning to, and seek advice on exclusion of patients from the Public Health Doctor. Send stool samples in these cases. GENITAL TRACT INFECTIONS Vaginal candidiasis CKS - vaginal candidiasis All topical and oral azoles give 80-95% cure. First line treatments Clotrimazole 10% vaginal cream or 500mg pessary Fluconazole 150mg tablet Note - In pregnancy avoid oral azoles. Bacterial vaginosis HPA CKS - bacterial vaginosis First line treatments Metronidazole 400mg bd for 7 days (this is slightly more effective than Metronidazole 2g stat. The high dose should be avoided in pregnancy. Metronidazole 0.75% vaginal gel 5g at night for 5 nights Clindamycin 2% cream 5g at night for 7 nights. 6 Chlamydia trachomatis HPA CKS - chlamydia First line treatments Azithromycin 1g stat (1hr before or 2hrs after food). Azithromycin is expensive but compliance is higher. Patients with positive chlamydia swabs should be referred to a GUM clinic for screening for other STDs, contact tracing and partner treatment. Doxycycline 100mg bd for 7 days Trichomoniasis HPA CKS - trichomoniasis Treat partners simultaneously First line treatments Metronidazole 400mg bd for 5 -7days or 2g stat. Note - The high dose should be avoided in pregnancy. Clotrimazole 100mg pessaries for 6 days Topical clotrimazole can be used for symptomatic relief (not cure). Pelvic inflammatory disease RCOG CKS - pid Ensure specimens for chlamydia and gonorrhoea are taken. First line treatments Ofloxacin 400mg bd PLUS Metronidazole 400mg bd for 14 days Doxycycline 100mg bd PLUS Metronidazole 400mg bd for 14 days PLUS Cefixime 400mg STAT. Contacts should be referred to a GUM clinic. Acute Prostatitis CKS - prostatitis First line treatments Ciprofloxacin 500mg bd 28 days (ensure patient is not at risk of C dificile) Trimethoprim 200mg bd should be used for 28 days SKIN AND SOFT TISSUE INFECTIONS Impetigo CKS - impetigo First line treatment Flucloxacillin 500mg qds for 7 days First line treatment if allergic to penicillin Clarithromycin 250-500mg bd for 7 days. Cellulitis CKS - acute cellulitis If patient is afebrile and healthy apart from cellulitis First line treatment Flucloxacillin 500mg qds for 7-14 days First line treatments if allergic to penicillin Clarithromycin 500mg bd for 7-14 days Clindamycin 300mg- 450mg qds for 7-14 days. (Discontinue Clindamycin treatment immediately if diarrhoea develops). Facial cellulitis Co-amoxiclav 500/125mg tds for 7-14 days. If patient is febrile and ill admit to hospital for IV treatment 7 Bites CKS - bites human and animal For the prophylaxis and treatment of human or animal bites. In the management of bites surgical cleaning is most important. The tetanus and rabies risks must always be assessed. Antibiotics should be used prophylactically in bites over 24hrs old, cat bites and human bites, bites to the hand and in at-risk patients e.g. diabetics and the elderly. First line treatment Co-amoxiclav 500/125mg tds for 7 days First line treatment if allergic to penicillin Metronidazole 200-400mg tds 7days PLUS Doxycycline 100mg bd 7 days For human bites the hepatitis B and HIV risks must be assessed. Conjunctivitis CKS - infective conjunctivitis Bacterial conjunctivitis is usually begins unilaterally with a yellow/white mucopurulent discharge. First line treatments Chloramphenicol 0.5% eyedrops (every 2hours reducing to every 4 hours) and 1% ointment at night. Fusidic acid 1% gel every 12hours. (easier to use but has less activity against Gram-negative pathogens e.g. Haemophilus influenzae Treatment should be used for 48 hours after resolution of symptoms. Other pathogens requiring different and specific treatment include chlamydia, gonococcus and pseudomonas. Dermatophyte infection of the nails CKS - fungal nail infection Take nail-clippings and start therapy only if the laboratory confirms infection. First line treatments Terbinafine 250mg od should be used for 6-12 weeks for fingernail infections and for 3-6 months for toenail infections. Yeast and non-dermatophyte mould infections pulsed Itraconazole can be used. The dose is 200mg bd for 7 days on/21 days off for 2 months for fingernail infections and for 3 months for toenail infections. Before treating children seek advice. Dermatophyte infection of the skin CKS body & groin CKS foot CKS scalp First line treatments A topical Clotrimazole 1% cream once or twice daily for 4-6 weeks. If this fails consider topical Terbinafine 1% cream once or twice daily for 1-2 weeks. For intractable cases consider oral Itraconazole 200mg once or twice daily for 7 days Methicillin resistant Staph. aureus (MRSA) Treat only when there is clinical evidence of infection and not purely on laboratory results. Where oral therapy is required please discuss with Microbiologist. 8 VIRAL INFECTIONS Chicken pox and shingles CKS - chickenpox The clinical value of antivirals is minimal unless the patient is an adolescent or adult who is a secondary household case of chickenpox or a patient with facial or ophthalmic shingles or has shingles with severe pain. Treatment should be started within 24 hours of the onset of the rash. First line treatment Aciclovir Adult - 800mg 5x/day for 7 days Children - see the BNF Second line treatment only if compliance a problem (ten times the cost) Valaciclovir 1g tds for 7 days Predictors of post-herpetic neuralgia include age >50yrs, severe pain, severe skin rash and prolonged prodromal pain. Please seek advice regarding chickenpox in pregnancy. Guidance based on “HPA Management of Infection Guidance For Primary Care For Consultation + Local Adaptation (March –July 2010)” Consultant Microbiologists at NGH & KGH. August 2010 Northamptonshire Prescribing Management Group 5.10.10 9