1. No category

OXFORDSHIRE
ADULT
ANTIMICROBIAL
PRESCRIBING
GUIDELINES FOR
PRIMARY CARE
2nd Edition
May 2012
Version 2.2 (March 2014)
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
Contents
Interim Update to Guidance– Approved by APCO March 2014 .................................. 4
INTRODUCTION................................................................................................................... 5
Aims ....................................................................................................................................... 5
Principles of Treatment ....................................................................................................... 5
Healthcare Associated Infections (HCAIs) ...................................................................... 6
Penicillin Allergy ................................................................................................................... 6
Useful Websites ................................................................................................................... 7
Current Version .................................................................................................................... 7
RESPIRATORY TRACT INFECTIONS ............................................................................. 8
UPPER RESPIRATORY TRACT INFECTIONS ............................................................ 8
Influenza ............................................................................................................................ 8
Acute Sore Throat ........................................................................................................... 9
Acute Otitis Media ........................................................................................................... 9
Acute Otitis Externa......................................................................................................... 9
Acute Rhinosinusitis ...................................................................................................... 10
Dental Abscess .............................................................................................................. 10
ANUG (Acute Necrotising Ulcerative Gingivitis) ....................................................... 11
Oral Candidiasis............................................................................................................. 11
LOWER RESPIRATORY TRACT INFECTIONS ....................................................... 12
Acute Bronchitis ............................................................................................................. 12
Acute Exacerbation of COPD ...................................................................................... 12
Community-Acquired Pneumonia ............................................................................... 13
Exacerbation of Bronchiectasis ................................................................................... 14
URINARY TRACT INFECTIONS..................................................................................... 15
UTI in Men & Women (including older people) ............................................................. 15
Recurrent UTI in Women.................................................................................................. 16
Recurrent UTIs in Men ...................................................................................................... 16
UTIs in a Person with a Catheter .................................................................................... 16
Acute Pyelonephritis ......................................................................................................... 17
UTIs in Pregnancy ............................................................................................................. 17
GENITAL TRACT INFECTIONS ..................................................................................... 18
STI screening ..................................................................................................................... 18
Chlamydia trachomatis infections ................................................................................... 18
Vaginal Candidiasis ........................................................................................................... 18
Bacterial Vaginosis ............................................................................................................ 19
Trichomoniasis ................................................................................................................... 19
Pelvic Inflammatory Disease ........................................................................................... 19
Acute Prostatitis ................................................................................................................. 19
Chronic Prostatitis ............................................................................................................. 20
Urethritis .............................................................................................................................. 20
Epididymoorchitis (<35yrs or increased risk of STI) .................................................... 20
Epididymoorchitis (>35yrs or low risk of STI) ................................................................ 20
GASTRO-INTESTINAL TRACT INFECTIONS .......................................................... 21
Eradication of Helicobacter pylori ................................................................................... 21
Gastroenteritis/ Infectious Diarrhoea .............................................................................. 21
Clostridium difficile Infection (CDI) .................................................................................. 22
Traveller’s Diarrhoea ......................................................................................................... 22
Acute Diverticulitis ............................................................................................................. 22
Giardia ................................................................................................................................. 22
Threadworms ..................................................................................................................... 22
Other Worms ...................................................................................................................... 22
SKIN & SOFT TISSUE INFECTIONS .......................................................................... 23
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
Impetigo............................................................................................................................... 23
Eczema ............................................................................................................................... 23
Cellulitis ............................................................................................................................... 23
Leg Ulcers ........................................................................................................................... 24
Diabetic Foot Infection ...................................................................................................... 24
Wound Infections (Non surgical) ..................................................................................... 24
MRSA .................................................................................................................................. 24
Bites ..................................................................................................................................... 25
Human ............................................................................................................................. 25
Cat or Dog....................................................................................................................... 25
Mastitis ................................................................................................................................ 25
Acne Vulgaris ..................................................................................................................... 26
Rosacea .............................................................................................................................. 27
Perioral Dermatitis ............................................................................................................. 27
Boils / Cysts/ Abscesses / Carbuncles ........................................................................... 27
Paronychia .......................................................................................................................... 28
Folliculitis............................................................................................................................. 28
Scabies................................................................................................................................ 28
Head Lice ............................................................................................................................ 29
FUNGAL SKIN INFECTIONS .......................................................................................... 30
Fungal / Dermatophyte infection of the skin – Dermatophytes .................................. 30
Fungal / Dermatophyte infection of the skin - Scalp Dermatophytes ........................ 31
Fungal / Dermatophyte infection of the proximal fingernail or toenail ....................... 31
Pityriasis Versicolor ........................................................................................................... 32
Intertrigo .............................................................................................................................. 32
VIRAL INFECTIONS ......................................................................................................... 33
Herpes simplex .................................................................................................................. 33
Cold Sores ...................................................................................................................... 33
First attack genital. ........................................................................................................ 33
Recurrent attacks of genital herpes - intermittent therapy. ..................................... 33
Recurrent attacks of genital herpes - suppressive therapy. ................................... 33
Varicella zoster................................................................................................................... 33
Herpes zoster ..................................................................................................................... 34
Treatment Advice: CHICKENPOX .................................................................................. 34
Treatment Advice: SHINGLES ........................................................................................ 35
Prophylaxis Advice: High Risk Contacts of Patients with Chickenpox or Shingles 35
HEPATITIS ........................................................................................................................... 36
HEPATITIS B ..................................................................................................................... 36
HEPATITIS C ..................................................................................................................... 36
EYE INFECTIONS .............................................................................................................. 36
Conjunctivitis ...................................................................................................................... 36
Styes .................................................................................................................................... 36
MENINGITIS ....................................................................................................................... 37
Bacterial Meningitis and / or Suspected Meningococcal Disease ......................... 37
Meningococcal Meningitis Prophylaxis ...................................................................... 37
ASPLENIA ............................................................................................................................. 38
Prophylaxis for Asplenia ................................................................................................... 38
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
Interim Update to Guidance– Approved by APCO March 2014
1. Advice regarding use of nitrofuratoin in renal impairment has been updated in line with
MHRA guidance. Nitrofurantoin for urinary tract infections is contraindicated in
patients with <60 mL/min creatinine clearance (previously use with caution)
Sections affected:
o
o
o
o
UTI in Men & Women (including older people)
Recurrent UTI in Women ≥ 3 UTIs/year
UTIs in a Person with a Catheter
UTIs in Pregnancy
2. Update of Acne section to include more recent guidance approved by APCO in
November 2013. If oral antibiotic required: 1st line now lymecycline and 2nd line
doxycycline.
Sections affected:
o Acne Vulgaris
3. Change of preferred macrolide from erythromycin to clarithromycin (except in
pregnancy and breastfeeding in line with HPA and CKS guidance). The cost of
clarithromycin has fallen over the past year and is now more in line with
erythromycin costs. Clarithromycin is associated with a more favourable side effect
profile than erythromycin and is therefore generally better tolerated.
Sections affected:
o Acute sore throat, penicillin allergy
o Acute Otitis Media, penicillin allergy
o Dental Abscess, penicillin allergy
o Acute bronchitis, penicillin allergy
o Acute Exacerbation of COPD, penicillin allergy
o Community Acquired Pneumonia, penicillin allergy or in combination with amoxicillin
for higher CRB score
o Exacerbation of Bronchiectasis, penicillin allergy
o Gastroenteritis/ Infectious Diarrhoea, Suspected Campylobacter
o Bites, in combination with metronidazole in penicillin allergy
o Boils / Cysts/ Abscesses / Carbuncles, penicillin allergy
o Paronychia, penicillin allergy
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
INTRODUCTION
This guidance is for Oxfordshire General Practitioners, Nurse Practitioners and members
of Primary Healthcare Teams.
It is also available for use within Oxford Health NHS Foundation Trust for Oxfordshire
patients that are provided with community services and specialist mental health services.
Aspects of this guidance may be relevant for community hospitals, as are the secondary
care
Oxford
University
Hospitals
NHS
Trust
Antimicrobial
Guidelines.
http://orh.oxnet.nhs.uk/Pharmacy/Pages/abguidelines.aspx
Aims
1. To provide a simple, empirical approach to the treatment of common infections in adults
(16 years and over).
2. To promote the safe, effective and economic use of antimicrobials.
3. To minimise the emergence of bacterial resistance in the community and wider health
economy.
4. To reduce healthcare associated infections.
Principles of Treatment
1. This guidance is based on the best available evidence but professional judgement should
be used and patients should be involved in the decision.
2. Always document the indication for antimicrobials and the rationale behind any deviations
from these guidelines within the patient’s notes.
3. A dose and duration of treatment for adults is usually suggested, but may need
modification for severity of disease, age, weight and renal function.
4. Treatment of most infections should not exceed 7 days.
5. Have a lower threshold for antimicrobials in immunocompromised or those with comorbidities.
6. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit.
7. Consider a no, or delayed, antimicrobial strategy for acute self-limiting upper respiratory
A+
tract infections.
8. Limit prescribing of antimicrobials over the telephone to exceptional cases.
9. Use simple generic antimicrobials if possible. Avoid broad spectrum antimicrobials (e.g.
co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antimicrobials
remain effective, as they increase risk of Clostridium difficile, MRSA and resistant Gram
negative infections.
10. Review microbiology results regularly, and if treatment required select the most
appropriate antimicrobial with the lowest ‘CDI or MRSA risk’
11. Avoid widespread use of topical antimicrobials (especially those agents also available as
systemic preparations, e.g. fusidic acid).
12. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole
(2 g). Short-term use of nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is
unlikely to cause problems to the foetus. Trimethoprim also unlikely to cause problems
unless poor dietary folate intake or taking another folate antagonist such as antiepileptic.
2
Avoid co-amoxiclav in patients in possible pre-term labour (may be associated with an
increased risk of necrotising enterocolitis in neonates).
13. Where a ‘best guess’ therapy has failed or special circumstances exist, advice can be
obtained during normal working hours from the OUH Duty Microbiologist on 01865
220880 or bleep 4077 via JR switchboard. Out of hours advice can be obtained by
contacting the Microbiology SpR on call via the JR switchboard.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
5
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
Healthcare Associated Infections (HCAIs)
Inappropriate use of broad-spectrum antimicrobials is associated with the acquisition of
3-6
Methicillin Resistant Staphylococcus aureus (MRSA)
and the induction of Clostridium
7-12
difficile Infection (CDI)
as well as the selection of antimicrobial resistant bacteria such as
13,14
Extended-Spectrum Beta-Lactamase (ESBL)-producing Gram-negative bacteria.
Whilst all antimicrobials are able to pre-dispose patients to CDI and MRSA, quinolones,
cephalosporins, and clindamycin are particularly associated with a high risk of causing CDI
15,16
and so should be avoided unless there are clear clinical indications for their use.
15,16
Co-amoxiclav (intermediate risk) has also been associated with CDI cases both nationally
and locally. Therefore, the above antimicrobials have been restricted, where possible, within
Oxfordshire primary care and secondary care antimicrobial guidelines.
Appropriate antimicrobial prescribing is a key element in the reduction of healthcare associated
17
infections . The evidence that use of antimicrobial agents (whether appropriate or not)
18
causes resistance is overwhelming; resistance is greatest where use of antibacterial agents
18
is heaviest . Prescribing a routine course of antimicrobials significantly increases the
19
likelihood of an individual carrying a resistant bacterial strain.
Establishing and maintaining ways of working which keep the level of potential cross
contamination between patients to an absolute minimum is a major priority in Infection Control.
20,21
The most effective way to do this is to decontaminate hands and equipment between
22
patients.
Penicillin Allergy
Penicillins are life-saving antimicrobials and patients should not be labelled ‘penicillin-allergic’
23
without careful consideration.
Life-threatening adverse reactions to penicillins due to immediate hypersensitivity (IgE
mediated, Type I) are rare.
A reliable history is key.
Severe allergy = all Type I reactions and some non-Type I reactions, depending on
clinical severity e.g. Stevens Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis
(TEN).
Non-severe allergy = most non-Type I reactions i.e. rash without systemic upset /
mucosal involvement.
Characteristics
Type I immediate reactions
Non-Type I reactions
Timing of onset
Usually 1 to 4 hours from
exposure (up to 72 hours)
More than 72 hours from exposure
Clinical signs
Anaphylaxis
Laryngeal oedema
Wheezing / bronchospasm
Angioedema
Urticaria / pruritus
Diffuse erythema
Maculopapular rash
Morbilliform rash
Drug fever (serum sickness)
Tissue injury (immune complex)
Contact dermatitis
SJS / toxic epidermal necrolysis
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
6
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
In patients with a history of clinical signs of Type I immediate hypersensitivity (life-threatening
allergy) or severe non-type I reactions e.g. SJS:
Drugs in RED are contra-indicated unless approved by microbiology/infectious
diseases or Immunology in a specific patient.
Drugs in ORANGE are NOT for use in patients with a severe penicillin allergy, unless
at the discretion of microbiology/ID.
Drugs in GREEN are considered safe.
The colour classifications below should not be confused with the Oxfordshire
Prescribing Traffic Light Classifications – for appropriate prescribing responsibility the
Oxfordshire Prescribing Traffic Lights should be consulted.
In patients with a history of a mild to moderate non-type I reactions to penicillin as exemplified
by an isolated rash but not drug fever or immune-complex type reactions drugs in the
ORANGE category can be used with caution. If in doubt, please discuss with Microbiology/ID.
Drugs in GREEN are considered safe.
Red
amoxicillin,
co-amoxiclav (amoxicillin
+ clavulanic acid)
flucloxacillin
penicillin V
(phenoxymethylpenicillin)
procaine benzylpenicillin
Orange
cefalexin,
cefotaxime
ceftriaxone
azithromycin,
ciprofloxacin
clarithromycin
clindamycin,
co-trimoxazole
(Septrin®)
doxycycline
erythromycin
metronidazole
Green
minocycline,
nitrofurantoin
oxytetracycline
sodium fusidate
(fusidic acid)
tetracycline
trimethoprim
vancomycin
Useful Websites
http://bnf.org/bnf/index.htm
http://cks.nice.org.uk/
http://www.hpa.org.uk/infections/topics_az/primary_care_guidance/menu.htm
http://www.nice.org.uk/
http://www.brit-thoracic.org.uk
Current Version
The latest version of these guidelines is available on the Oxfordshire CCG Website.
Prescribers are advised to regularly visit the website to ensure they have the most up to date
version of guidelines currently held.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
7
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
RESPIRATORY TRACT INFECTIONS
UPPER RESPIRATORY TRACT INFECTIONS
1
Also see Oxfordshire PCT Referral Guidelines: ENT and NICE Respiratory Tract Infections and NICE
Respiratory Tract Infections - Quick Reference Guide
CONDITION
COMMENTS & TREATMENT
1-6
Vaccination
Annual vaccination is essential for all those at risk of influenza. For further
information on patients within the ‘clinical risk groups’ please refer to ‘Immunisation
against infectious disease’ (‘The Green Book’ - Chapter 19 Influenza)
1-6
Influenza
Immunisation
against infe
ctious disease
(‘The Green
Book’)
NICE
Guidance TA
168
NICE
Guidance TA
158
HPA Influenza
Treatment
- NICE Guidance TA 168
Oseltamivir and zanamivir are recommended, within their marketing authorisations, for
the treatment of influenza in adults if ALL the following circumstances apply:
national surveillance schemes indicate that influenza virus A or B is circulating
(the CCDC will advise when influenza prevalence in Oxfordshire has reached
the appropriate threshold)
the person is in an ‘at-risk’ group as defined in NICE Guidance TA 168 and
below
the person presents with an influenza-like illness and can start treatment within
48 hours of the onset of symptoms as per licensed indications
For otherwise healthy adults, antivirals are not recommended.
Also see information for healthcare professionals from Health Protection Agency
At risk groups:
People ‘at risk’ within NICE Guidance TA 168 and within HPA guidance are defined as
those who have one of more of the following:
65 years or over
chronic respiratory disease (including asthma and chronic obstructive
pulmonary disease)
chronic heart disease (not hypertension)
chronic renal disease
chronic liver disease
chronic neurological conditions
diabetes mellitus
immunosuppressed
pregnant women (including up to two weeks post partum)
Therapy: - refer to current HPA recommendations for recommended treatment,
including in pregnancy.
Oseltamivir 75mg BD for 5 days
Zanamivir 10mg BD (2 inhalations by diskhaler) for 5 days
During localised outbreaks of influenza-like illness (outside the periods when national
surveillance indicates that influenza virus is circulating in the community), oseltamivir
and zanamivir may be offered for the treatment of influenza in ‘at-risk’ people who live in
long-term residential or nursing homes – however this should only be given on the
advice from the local Health Protection Unit.
1-6
Postexposure Prophylaxis
- NICE Guidance TA 158
For advice on post exposure prophylaxis, at risk groups and recommended therapy see
NICE Guidance TA 158.
Also see information for healthcare professionals from Health Protection Agency.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
8
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Acute Sore
Throat
NICE
Prodigy
COMMENTS
DRUG
Avoid antimicrobials as the
majority (over 50%) of sore
throats are viral; 90% resolve in 7
days without antimicrobials and
pain is only reduced by a mean of
2A+
16 hours.
Avoid
antimicrobials in
majority cases.
Explain soreness will
take about 8 days to
resolve.
In patients with 3 or more Centor
criteria (presence of tonsillar
exudate, tender anterior cervical
lymphadenopathy or
lymphadenitis, history of fever and
1,3,Aan absence of cough
consider
2 or 3-day delayed or immediate
1,A
antimicrobials. +
Phenoxymethyl5Bpenicillin
DOSE
DURATION
OF TX
SIGN
(Antimicrobials to prevent quinsy
4BNNT >4000.
Antimicrobials to prevent otitis
2A+
media NNT=200. )
Acute Otitis
Media
NICE
Prodigy
2,3B-
Optimise analgesia
Avoid antimicrobials as 60% are
better in 24 hours without: they
only reduce pain at 2 days
(NNT=15) and do not prevent
4A+
deafness.
1A+
Consider 2 or 3-day delayed or
immediate antimicrobials for pain
relief if there is otorrhoea
5A+
(NNT=3).
Acute Otitis
Externa
Prodigy
(Antimicrobials to prevent
6B mastoiditis NNT >4000. )
First use aural toilet (if available)
& analgesia.
Cure rates similar at 7 days for
topical acetic acid or antimicrobial
1A+
+/- steroid.
If cellulitis or disease extending
outside ear canal, start oral
antimicrobials (flucloxacillin or
clarithromycin in penicillin allergy)
2A+
and refer.
6A-
500mg
QDS
10 days
250mg –
500mg
BD
5 days
9A+
500mg
TDS
5 days
9A+
250mg500mg
BD
5 days
9A+
1 spray
TDS
7 days
3 drops
TDS
7 days min
to 14 days
1A+
max
Avoid amoxicillin as
maculopapular rash
commonly results in
patients with
glandular fever. (This
rash is not related to
true penicillin allergy).
Penicillin Allergy:
Clarithromycin
Avoid
antimicrobials in
majority cases
7A+
amoxicillin
Penicillin Allergy:
8D
Clarithromycin
acetic acid 2%*
Second line:
neomycin sulphate
3Awith corticosteroid
,4D
(Betnsol-N)
*Over the counter preparation is available for
children over 12 years.
Retail cost is £7.03 (Chemist & Druggist July 12).
Please note: if prescribed, charge to prescribing
budget is £4.10 (Chemist & Druggist July 12).
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
9
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Acute
Rhinosinusitis
5C
COMMENTS
DRUG
Avoid antimicrobials as 80%
resolve in 14 days without, and
they only offer marginal benefit
2,3A+
after 7 days NNT=15.
NICE
Use adequate analgesia.
4B+
amoxicillin
4A+,7A
Consider 7-day delayed or
immediate antimicrobial when
purulent nasal discharge NNT=8.
(In the
absence of
immediate
attention by a
dental
practitioner)
Prodigy
DURATION
OF TX
Avoid
antimicrobials in
majority cases
Prodigy
Dental
Abscess
DOSE
1,2A+
or doxycycline
In persistent infection use an
agent with anti-anaerobic activity
6B+
e.g. co-amoxiclav.
For persistent
symptoms:
6B+
co-amoxiclav
500mg
TDS
1g TDS if
8D
severe
7 days
200mg
stat/
100mg
OD
7 days
625mg
TDS
7 days
9A+
GPs should not routinely be involved in dental treatment.
Where possible, advise the person to see a dental practitioner urgently. If this is
not possible and treatment is required see below.
Do not routinely provide repeat prescriptions or switch antimicrobials if person
fails to respond. Instead advise the person to see a dental practitioner urgently.
Avoid antimicrobials in
Antimicrobials are
majority cases
generally not indicated for
otherwise healthy
individuals or when there
no signs of spreading
1-4
infection.
amoxicillin alone
Only prescribe an
250mg5 days
antimicrobial:
500mg
TDS
for people who are
or combined with
systemically unwell or if
200mg5 days
there are signs of severe metronidazole
400mg
infection (e.g. fever,
TDS
lymphadenopathy,
cellulitis, diffuse swelling, Penicillin Allergy:
Clarithromycin alone
500mg
5 days
trismus).
bd
for high risk individuals
to reduce the risk of
complications (e.g.
people who are
or combined with
200mgimmunocompromised,
metronidazole
400mg
5 days
diabetic or have valvular
TDS
heart disease).
If spreading infection
(lymph node involvement,
or systemic signs i.e. fever
or malaise) ADD
2-4C
metronidazole.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
10
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
ANUG (Acute
Necrotising
Ulcerative
Gingivitis)
Prodigy
COMMENTS
DRUG
DOSE
DURATION
OF TX
GPs should not routinely be involved in dental treatment.
Where possible, advise the person to see a dental practitioner urgently. If this is
not possible and treatment is required see below.
Do not routinely provide repeat prescriptions or switch antimicrobials if person
fails to respond. Instead advise the person to see a dental practitioner urgently.
Advise the person to see
a dental practitioner
metronidazole
200mg3 days
urgently.
AND
400mg
TDS
Antimicrobials are the first
1
line treatment.
chlorhexidine 0.2% or
BD
hydrogen peroxide 6%
Normal tooth brushing /
mouth wash
oral hygiene measures are
Second line:
very painful to carry out in
the acute phase of the
amoxicillin
250mg3 days
infection. Therefore, the
AND
500mg
patient should be
TDS
encouraged to carry out
chlorhexidine 0.2% or
tooth brushing with a soft
BD
toothbrush to remove food
hydrogen peroxide 6%
detritus.
mouth wash
Hydrogen peroxide
mouthwashes are the most
efficacious when proper
tooth brushing is difficult to
undertake.
As well as pain, and
halitosis the patient will feel
significantly systemically
unwell. The patient should
be advised not to smoke.
Oral
Candidiasis
Prodigy
Predisposing local and
systemic risk factors for
oral candida should be
managed in conjunction
1
with antifungal treatment.
Chlorhexidine should be
used to clean dentures and
may be used as an adjunct
to topical or oral treatment.
Clean and soak dentures in
chlorhexidine gluconate
0.2% mouthwash for 15
mins twice daily.
Advise to see dental
practitioner if ill-fitting
dentures.
For localized or mild oral
candidal infection, prescribe
topical treatment for 7 days
(and advise the person to
continue treatment for 2 days
after symptoms resolve).
nystan®* oral suspension
100,000
units
QDS
after food
7 days (and
continue for
2 days after
symptoms
resolve)
For extensive or severe
candidiasis: fluconazole
50mg
7 days
daily
* Nystan® oral suspension is significantly more cost
effective than generic nystatin oral suspension (March
2012: £1.80 vs. £20.80)
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
11
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
LOWER RESPIRATORY TRACT INFECTIONS
Note:
1,
Low doses of penicillins are more likely to select out resistance
Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity.
Reserve all quinolones (including levofloxacin) for proven resistant organisms.
Avoid tetracyclines in pregnancy.
CONDITION
COMMENTS
DRUG
DOSE
DURATION
OF TX
Avoid antimicrobials in
Acute
Antimicrobial little benefit if
1-4A+
majority cases
Bronchitis
no co-morbidity.
Symptom resolution can
NICE
take 3 weeks.
Prodigy
Consider 7-14 day delayed
antimicrobial with
symptomatic advice/leaflet.
1,5A-
Acute
Exacerbation
of COPD
NICE
Prodigy
Management
of COPD in
Primary Care
amoxicillin
500mg
TDS
5 days
or doxycycline
200mg
stat/
100mg
OD
5 days
or clarithromycin
250mg500mg
BD
5 days
amoxicillin
500mg
TDS
5 days
4c
or doxycycline
200mg
stat/
100 mg
OD
5 days
4c
or clarithromycin
500mg
BD
5 days
4A
625 mg
TDS
5 days
4A
Viruses may account for
over 50% of these
infections. (30% viral, 3050% bacterial, rest
undetermined)
Antimicrobials not
indicated in absence of
purulent/mucopurulent
B+
sputum.
Treat exacerbations
promptly with antibiotics if
purulent sputum and
increased shortness of
breath and/or increased
1-3B+
sputum volume.
If no response in 48 hours
of antimicrobial therapy
consider admission or add
erythromycin first line or a
C
tetracycline to cover
‘atypical’ organisms.
Risk factors for
antimicrobial resistant
organisms include: comorbid disease, severe
COPD, frequent
exacerbations,
antimicrobials in last 3
2
months.
If ‘at home’ rescue
antimicrobial has been tried
and patient is not improving
change to second line
antimicrobial.
If resistance risk factors:
co-amoxiclav
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
12
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OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
CommunityAcquired
Pneumonia
treatment in
the community
2,3,4
BTS 2009
Guideline
Adults
COMMENTS
DRUG
DOSE
DURATION
OF TX
1
Use CRB65 score to help guide and review in conjunction with clinical judgment.
Post Influenza: seek specialist advice.
Each scores 1:
Confusion (AMT<8);
Respiratory rate >30/min;
BP systolic <90 or diastolic ≤ 60;
Age >65 years
If CRB65=0: may be
suitable for home
treatment.
amoxicillin
A+
or clarithromycin
A-
or doxycycline
Score 1-2: may require
hospital assessment or
admission.
7 days
500mg
BD
7 days
200mg
stat/100
mg OD
7 days
If CRB65=1 & AT HOME:
amoxicillin
AND
A+
clarithromycin
500mg
TDS
-
or doxycycline alone
Score 3-4: may require
urgent hospital
admission.
500mg
TDS
7-10 days
500mg
BD
200mg
stat/100
mg OD
7-10 days
If no response in 48 hours
consider admission or add
clarithromycin first line or a
C
tetracycline to cover
‘atypical’ organisms.
Give immediate IM
benzylpenicillin 1.2g or
D
amoxicillin 1g po if delayed
admission/life threatening.
Start antimicrobials
Bimmediately.
In severely ill give
parenteral benzylpenicillin
C
before admission.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
13
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
COMMENTS
Exacerbation
of
Bronchiectasis
Previous sputum
microbiology cultures,
when available, may guide
antimicrobial choice.
DRUG
DOSE
DURATION
OF TX
Prodigy
When previous
microbiology cultures are
not available.
Send sputum for culture
and sensitivity testing
before starting
antibiotics (even if the
person is taking long-term
antibiotics)
amoxicillin
500mg
TDS
10–14 days
or clarithromycin
500mg
BD
10–14 days
or doxycycline
200mg
stat and
then
100mg
OD
10–14 days
For further information see
1
Prodigy
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
14
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
URINARY TRACT INFECTIONS
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with
1B+
increased morbidity.
Catheter in situ: antimicrobials will not eradicate asymptomatic bacteriuria; only treat if systemically
2B+
unwell or pyelonephritis likely.
Do not use prophylactic antimicrobials for catheter changes.
Refer to Local guidance on the management of UTIs.. Also see Oxfordshire PCT Referral Guidelines:
Urology.
Only use modified release nitrofurantoin rather than standard release if compliance is an issue.
CONDITION
COMMENTS
DRUG
DOSE
DURATION
OF TX
1B+
trimethoprim
UTI in Men &
See NHS Oxfordshire
200mg
Women 3
6-8A+
or
Women
Prescribing guidelines:
BD
days
(including
Men 7 days
Management of Simple
2B+ 3C 4B+
9,10C
nitrofurantoin*
older people)
50mg
UTIs in Non-Pregnant
No fever and
QDS or
Females in Primary Care
flank pain
100mg
Management of UTIs in
m/r BD
Adult Males in Primary
5C
HPA QRG
Care
Second
line:
use
MSU
result
to
guide
treatment – use
Management of UTIs in
SIGN
suitable antimicrobials with lowest risk for C. difficile or
Older People in Primary
MRSA infection.
Care
Prodigy,
Amoxicillin resistance is common; only use if sensitive.
11B+
Prodigy
*Avoid if patient is febrile or clinical evidence of
prostatitis. Contraindicated in renal impairment (eGFR
2
less than 60mL / min / 1.73m ). Avoid in G6PD
deficiency upper UTI/pyelonephritis and near term
pregnancy.
In older patients, community multi-resistant Extendedspectrum Beta-lactamase E. coli are increasing:
nitrofurantoin is an option.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
15
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Recurrent UTI
in Women
≥ 3 UTIs/year
HPA QRG
Prodigy
COMMENTS
Treatment of Infection
See NHS Oxfordshire
Prescribing guidelines:
Management of
Recurrent UTIs in NonPregnant Females in
Primary Care
SIGN
DRUG
trimethoprim
or
DOSE
200mg
BD
DURATION
OF TX
3 days
nitrofurantoin*
50mg
3 days
QDS or
100mg
m/r BD
Second line: use MSU result to guide treatment – use
suitable antimicrobials with lowest risk for C. difficile or
MRSA infection.
Amoxicillin resistance is common; only use if organism
sensitive.
Prophylaxis
1,
Post-coital prophylaxis
2B+
or standby antimicrobial
3B+
Recurrent
UTIs in Men
UTIs in a
Person with a
Catheter
HPA QRG
Prodigy
Prodigy
Nightly: reduces UTIs but
1A+
adverse effects
See NHS Oxfordshire
Prescribing guidelines
Management of
Recurrent UTIs in NonPregnant Females in
Primary Care
Discuss with urology or
microbiology
See NHS Oxfordshire
1
Prescribing guidelines :
Management of UTIs in
Catheterised Adults in
Primary Care
*Contraindicated in renal impairment (eGFR less than
2
60mL / min / 1.73m ). Avoid in G6PD deficiency upper
UTI/pyelonephritis and near term pregnancy
nitrofurantoin*
Post coital
50–
or
100mg
stat (off2B+,3C
label)
trimethoprim
Prophylaxis
100mg
OD at night
1A+
*Contraindicated in renal impairment (eGFR less than
2
60mL / min / 1.73m ). Avoid in G6PD deficiency, upper
UTI/pyelonephritis and near term pregnancy
Do not give prophylactic antimicrobials without first
discussing with urology or microbiology/ID.
trimethoprim
200mg
7-14 days
or
BD
nitrofurantoin*
50mg
7-14 days
QDS or
100mg
m/r BD
Second line: use MSU result to guide treatment – use
suitable antimicrobials with lowest risk for C. difficile or
MRSA infection.
SIGN
Amoxicillin resistance is common; only use if organism
susceptible.
Community multi-resistant Extended-spectrum Betalactamase E. coli are increasing: nitrofurantoin is an
option.
*Avoid if patient is febrile or clinical evidence of
prostatitis. Contraindicated in renal impairment (eGFR
2
less than 60mL / min / 1.73m ). Avoid in G6PD
deficiency, upper UTI/pyelonephritis and near term
pregnancy.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
16
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Acute
Pyelonephritis
Prodigy
SIGN
UTIs in
Pregnancy
HPA QRG
Prodigy
SIGN
COMMENTS
DRUG
DOSE
3A-
DURATION
OF TX
3A7 days
ciprofloxacin
If admission not needed,
500mg
or
send MSU for culture &
BD
sensitivities and start
1C
4C
4C
antimicrobials.
co-amoxiclav
625mg
14 days
If no response within 24
TDS
2C
hours, admit.
See NHS Oxfordshire
Prescribing guidelines:
Management of Acute
Pyelonephritis in Adults
in Primary Care
See NHS Oxfordshire Prescribing guidelines: ‘Management of UTIs in Pregnancy in
Primary Care’
Send MSU for culture &
sensitivity and start
1A
empirical antimicrobials.
Short-term use of
nitrofurantoin in pregnancy
is unlikely to cause
2C
problems to the foetus.
Avoid trimethoprim if low
3
folate status or on folate
antagonist (e.g.
2
antiepileptic or proguanil).
First line: nitrofurantoin*
50mg
QDS or
100mg
m/r BD
7 days
7C
if susceptible, amoxicillin
500mg
TDS
7 days
7C
Second line: trimethoprim
200mg
BD (offlabel)
Ensure
taking
folic acid
6
400mcg
if first
trimester
7 days
7C
Third line: cefalexin
4C, 5B-
7C
500mg
7 days
BD
* Contraindicated in renal impairment (eGFR less than
2
60mL / min / 1.73m ). Avoid in G6PD deficiency,
upper UTI/pyelonephritis and near term pregnancy
For pyelonephritis - send
MSU for culture.
Check MSU 7 days after
treatment
Pyelonephritis:
cefalexin
or
co-amoxiclav
#
If sensitivities known:
trimethoprim
or
amoxicillin
500mg
TDS
10-14 days
625mg
TDS
10-14 days
200mg
BD
10-14 days
500mg
TDS
10-14 days
#
Avoid co-amoxiclav in patients if possible pre-term
labour
For asymptomatic bacteruria in pregnancy – treat as per sensitivities with antimicrobial
with lowest risk for C.difficile or MRSA infection that is suitable in pregnancy for 7 days.
Refer to ‘Management of UTIs in Pregnancy in Primary Care’ for further details.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
17
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
GENITAL TRACT INFECTIONS
STI screening
Note: Patients with risk factors for STI should be considered for referral to GUM (and screened for
chlamydia, gonorrhoea, HIV, syphilis) especially if recurrent infections.
1,2
Risk factors are age <25, recent (<12mth)/frequent change of partner, 2 or more partners in last 6
months, non-use of condoms, STI or STI symptoms in partner.
Advice on urogenital infections is available from the Genitourinary Medicine Department, Churchill
Hospital 01865 231231 Monday to Friday 0900-1800.
For further information about investigation and treatment of vaginal discharge see local guideline:
Investigation and Management of Vaginal Discharge in Adult Women
CONDITION
Chlamydia
trachomatis
infections
SIGN, BASHH
HPA, Prodigy
COMMENTS
Opportunistically screen all
1
aged 15-25yrs.
DRUG
4A+
azithromycin
or
4A+
doxycycline
1g
1g (offlabel
use)
stat
500mg
BD
10-14 days
500mg
TDS
500mg
pessary
or 10%
cream
7 days
150mg
orally
stat
100mg
pessary
at night
6 nights
5g intravaginally
BD
7 days
clotrimazole
or
500mg
pessary
once
weekly
for 3-6
months
fluconazole
or
100mg
oral once
weekly
for 3-6
months
itraconazole
400mg
oral once
monthly
at the
expected
time of
symptom
for 3-6
months
Pregnant or breastfeeding:
5A+
azithromycin
or
Due to lower cure rate in
pregnancy, test for cure
3C
6 weeks after treatment.
erythromycin
or
amoxicillin
5A+
5A+
clotrimazole
or
1A+
BASHH
HPA
4A+
7 days
Pregnancy or
breastfeeding:
azithromycin is the most
5 A+; 6Beffective option.
All topical and oral azoles
1A+
give 75% cure.
DURATION
OF TX
4A+
stat
100mg
BD
Treat partners and refer to
2,3 B+
GUM service.
2C
Vaginal
Candidiasis
DOSE
oral fluconazole
1A+
5A+
5A+
5A+
stat
Prodigy
Investigation
and
Management
of Vaginal
Discharge in
Adult Women
In pregnancy: avoid oral
2Bazole
and use
intravaginal treatment for 7
3A+, 2,4Bdays.
Pregnant or breastfeeding:
3A+
clotrimazole
or
miconazole 2% cream
Failed vaginal candidiasis
treatment.
Recurrent proven candida
– patients experiencing
cyclical relapse that
requires suppressive
therapy.
3A+
5C
Examine and investigate.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
18
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OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Bacterial
Vaginosis
BASHH
HPA
Prodigy
Investigation
and
Management
of Vaginal
Discharge in
Adult Women
COMMENTS
Oral metronidazole is as
effective as topical
1A+
treatment
but is
cheaper.
Less relapse with 5-7 day
3A+
than 2g stat at 4 wks.
2A+
Pregnant /breastfeeding:
3A+ ,4Bavoid 2g stat.
DRUG
metronidazole
or
DOSE
1,3A+
400mg
BD
or 2g
5g
applicatorful at
night
5 nights
1A+
5g
applicatorful at
night
7 nights
1A+
400mg
BD
or 2 g
5-7 days
4A+
stat
3B+
100mg
pessary
at night
6 nights
3,5C
500mg
IM
400mg
BD
100mg
BD
stat
400mg
BD
400mg
BD
14 days
500mg
QDS
400mg
BD
14 days
500mg
BD
28 days
1C
200mg
BD
28 days
1C
200mg
BD
28 days
1C
metronidazole 0.75% vaginal
1A+
gel
or
clindamycin 2% cream
1A+
Treating partners does not
5B+
reduce relapse
Failed bacterial vaginosis
treatment
Examine and investigate.
Trichomoniasi
s
Treat partners and refer to
1B+
GUM service
metronidazole
BASHH
In pregnancy or
breastfeeding: avoid 2g
single dose metronidazole
2B.
Consider clotrimazole for
symptom relief (not cure) if
3B+
metronidazole declined
HPA,
Prodigy
Investigation
and
Management
of Vaginal
Discharge in
Adult Women
Pelvic
Inflammatory
Disease
Refer woman & contacts to
1,2B+
GUM service
Always culture for
gonorrhoea & chlamydia
clotrimazole
4A+
ceftriaxone
AND
6
metronidazole
AND
1, 2, 4B+
doxycycline
BASHH
2B+
Prodigy
28% of gonorrhoea isolates
now resistant to quinolones
3B+
If gonorrhoea likely
(partner has it, severe
symptoms, sex abroad)
avoid ofloxacin regimen.
or
metronidazole
AND
1, 2, 4, 6B+
ofloxacin
If woman using not using
adequate contraception.
erythromycin
AND
metronidazole
PID during established
pregnancy is very
uncommon but should be
assessed urgently by GUM
or emergency gynae.
Acute
Prostatitis
BASHH
Prodigy
Send MSU for culture and
1C
start antimicrobials .
4-wk course may prevent
1C
chronic prostatitis
Quinolones achieve higher
2
prostate levels
ciprofloxacin
or
ofloxacin
cause)
1C
DURATION
OF TX
1A+
5 -7 days
3A+
stat
1C
(if STI likely
Second line:
1C
trimethoprim
4A+
3B+
14 days
14 days
14 days
14 days
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
19
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OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Chronic
1,2
Prostatitis
COMMENTS
Refer to GUM or urology
Consider antimicrobials
after specialist advice.
BASHH
DRUG
DOSE
DURATION
OF TX
3-4 weeks
doxycycline
or
100mg
BD
ciprofloxacin
or
500mg
BD
28 days
ofloxacin (if STI likely cause)
28 days
doxycycline
or
200mg
BD
100mg
BD
azithromycin
1g
stat
doxycycline
100mg
BD
14 days
ofloxacin
200mg
BD
14 days
trimethoprim
or
200mg
BD
14 days
ciprofloxacin
500mg
BD
14 days
Prodigy
Urethritis
1,2
BASHH
Prodigy
Epididymoorch
itis (<35yrs or
increased risk
of STI)
BASHH
Prodigy
Epididymoorch
itis (>35yrs or
low risk of STI)
BASHH
Prodigy
Cause usually STI
Refer/discuss with GUM for
contact tracing & partner
treatment (See above for
contact details)
Chlamydia.
If gonorrhoea is
suspected either due to
risk or more severe
symptoms refer for
investigation and
treatment to GUM
because of the high
prevalence of resistance
to antimicrobials.
1,2
Cause usually STI
If gonorrhoea is
suspected either due to
risk or more severe
symptoms refer for
investigation and
treatment to GUM
because of the high
prevalence of resistance
to antimicrobials.
For epididymo-orchitis
most probably due to
enteric organisms
E.coli
Obtain a urine sample for
culture before starting
1,2
antimicrobial treatment.
A dipstick test should be
used to evaluate
significance of symptoms.
7 days
Refer GUM
Refer/discuss with GUM for
contact tracing & partner
treatment.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
20
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
GASTRO-INTESTINAL TRACT INFECTIONS
For further information about investigation and clinical and public health management see local guide;
Management of Acute Diarrhoea In Primary Care – Prescribing Points 19.12. Also see Oxfordshire
PCT Referral Guidelines: Gastroenterology.
CONDITION
COMMENTS
Eradication of
Helicobacter
pylori
Eradication is beneficial in
1A+
known DU, GU
or low
2B+
grade MALToma.
For NUD, the NNT is 14 for
3A+
symptom relief.
NICE
HPA QRG
Prodigy
Do not use clarithromycin
or metronidazole if used in
the past year for any
5A+, 6A+
infection.
DU/GU relapse: retest for
H. pylori using breath or
stool test OR consider
endoscopy for culture &
1C
susceptibility.
NUD: Do not retest, offer
1C, 3A+
PPI or H2RA.
Gastroenteritis
/ Infectious
Diarrhoea
Prodigy
DOSE
DURATION
OF TX
1A+
First line:
PPI (omeprazole
or
lansoprazole)
AND
clarithromycin (C)
Consider test and treat in
persistent uninvestigated
4B+
dyspepsia.
Do not offer eradication for
1C
GORD.
Symptomatic
relapse
DRUG
AND
amoxicillin (AM)
or
metronidazole (MTZ)
7A+
Second line:
PPI (omeprazole
or
lansoprazole)
AND
®
bismuthate (De-nol tab )
AND 2 previously unused
antimicrobials:
amoxicillin
20mg BD
or
30mg BD
500mg
BD with
AM or
250mg
BD with
MTZ
All for
7 days
1,9A+
1gram
BD
400mg
BD
10C
20mg BD
or
30mg BD
Relapse
or MALToma
1C
14 days
120mg
QDS
1gram
BD
metronidazole
400mg
TDS
8C
tetracycline
500mg
QDS
Most self-limiting and antimicrobial treatment is rarely required. Antimicrobial
B+
therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and
B+
can cause antimicrobial resistance or increased incidence of C.difficile.
Empirical treatment with ciprofloxacin may be given to those with dysenteric symptoms
i.e. if bloody diarrhoea is present and considered in the elderly and others at high risk
of serious complications of gastroenteritis if systemically unwell (see ‘High Risk’
patients in Prescribing Points 19.12).
Only consider empirical
therapy if the patient is
1c
systemically unwell.
Usually wait for culture
result to reassess
whether antimicrobials
are indicated.
Suspected Campylobacter
clarithromycin
250mg500mg
BD
3-5 days
Suspected Salmonella /
Shigella
ciprofloxacin
500mg
BD
3-5 days
2
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
21
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
COMMENTS
DRUG
st
DOSE
DURATION
OF TX
nd
Clostridium
difficile
Infection (CDI)
STOP unnecessary
antimicrobials and/or
1,2B+
PPIs.
1 /2 episode (whether
recurrence or relapse):
vancomycin (oral)
DH & HPA
If continued antimicrobial
treatment necessary seek
microbiology/infectious
disease advice.
3 episode/or severe
disease:
Seek gastroenterology or
microbiology /infectious
disease advice
rd
125mg
QDS
14 days
1C
Admit if severe: T >38.5;
WCC >15, rising creatinine
or signs/symptoms of
1C
severe colitis.
1C
Traveller’s
Diarrhoea
Prodigy
Acute
Diverticulitis
Prodigy
If patient is unable to
metronidazole
400mg
14 days
swallow solid dosage forms
TDS
give metronidazole
suspension.
Only consider standby antimicrobials for remote areas or people at high-risk of
1,2C
severe illness with travellers’ diarrhoea.
.
3
If standby treatment appropriate give: ciprofloxacin 500 mg stat (private Rx).
If quinolone resistance high (e.g. south Asia) and standby treatment appropriate:
consider azithromycin 1g stat (private Rx).
Antimicrobials for acute
diverticulitis should only
be used in patients with a
confirmed diagnosis of
diverticulosis unless
under specialist advice.
For people managed at
1
home:
Prescribe broad-spectrum
antimicrobials to cover
anaerobes and Gramnegative rods.
Review within 48 hours or
sooner if symptoms
deteriorate. Arrange
admission if symptoms
persist or deteriorate.
Giardia
Prodigy
co-amoxiclav
Penicillin Allergy (non-severe
allergy):
metronidazole
AND
cefalexin
Penicillin Allergy (severe
allergy):
metronidazole
AND
ciprofloxacin
Prodigy
Other Worms
Treat all household
contacts at the same time
PLUS advise hygiene
measures for 2 weeks
(hand hygiene, pants at
night, morning shower)
PLUS wash sleepwear,
bed linen, dust, and
1C
vacuum on day one.
As per BNF Guidelines
7 days
400mg
TDS
500mg
TDS
7 days
400mg
TDS
500mg
BD
metronidazole
400mg
TDS
mebendazole
100mg
1
Threadworms
625mg
TDS
7 days
5 days
1C
stat
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
22
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
SKIN & SOFT TISSUE INFECTIONS
Also see Guidelines for the effective diagnosis and management of local wound bed infection and
bacterial colonisation in primary care.
CONDITION
Impetigo
Prodigy
COMMENTS
For extensive, severe, or
bullous impetigo, use oral
1C
antimicrobials.
Reserve topical
antimicrobials for very
localised lesions to reduce
1,5C,
the risk of resistance.
DRUG
DOSE
flucloxacillin (oral)
2C
500mg
QDS
Penicillin Allergy:
2C
Clarithromycin (oral)
topical fusidic acid
3B+
DURATION
OF TX
7 days
250mg500mg
BD
7 days
TDS
5 days
4B+
3A+
Eczema
Prodigy
Cellulitis
Prodigy
MRSA only mupirocin
TDS
5 days
Reserve mupirocin for
1C
MRSA.
If no visible signs of infection, use of antimicrobials (alone or with steroids) encourages
1B
resistance and does not improve healing.
In eczema with visible signs of infection,
2C
use treatment as in impetigo for treatment of infection, also ensure treatment of
eczema.
If patient afebrile and
healthy other than cellulitis,
use oral flucloxacillin alone.
1,2C
If febrile and ill, admit for IV
1C
treatment.
flucloxacillin
1,2,3C
Facial: co-amoxiclav
4C
Penicillin Allergy:
1,2C
clindamycin
If failure of first line therapy
seek microbiology
/infectious disease advice.
500mg
QDS
All for
7 days.
625mg
TDS
If slow
response
continue for
a further 7
1C
days
450mg
TDS
If river, sea or flood water
exposure, discuss with
microbiologist.
Note: Control of oedema, good skin emollient therapy and elevation of the affected limb
is a key part of treatment.
Discontinue compression therapy during the acute phase of cellulitis.
Dermatitis is often misdiagnosed as cellulitis: Review diagnosis if it appears bilateral.
Recurrent cellulitis in lymphoedema is a common problem: Consider prophylactic
treatment if patients have had 2 or more attacks of cellulitis (in lymphoedema) in a year.
phenoxymethylpenicillin 250mg BD (500mg BD if weight > 75kg) or erythromycin
500mg daily if penicillin allergic is recommended.
5
Dosage may be reduced to 250mg daily after 1 year of successful prophylaxis.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
23
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Leg Ulcers
Prodigy Venous
Diabetic Foot
Infection
COMMENTS
DRUG
DOSE
DURATION
OF TX
1A+
Bacteria will always be present. Antimicrobials do not improve healing.
Culture swabs and antimicrobials are only indicated if there is evidence of clinical
infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid
2,3c
deterioration of ulcer or pyrexia.
If these signs are present: treat as for Cellulitis (see
section above). Review antibiotics after culture result available; select most suitable
antibiotic with lowest risk for C.difficile or MRSA infection.
Ensure vascular assessment and podiatry review.
Mild diabetic foot
Prodigy
flucloxacillin
Penicillin Allergy:
cefalexin
IDSA
Moderate diabetic foot
infection (moderate
diabetic foot infection - e.g.
gangrene or deep tissue
1-3
involvement).
500mg
QDS
500mg
TDS
7-14
days; may
extend to 28
days if slow
to resolve*
If IV antimicrobials NOT
required:
co-amoxiclav oral
AND
625mg
TDS
metronidazole
400mg
TDS
14 -28 days*
If IV antimicrobials
required refer to
specialist.
Penicillin Allergy:
ciprofloxacin oral
AND
500mg
BD
14 -28 days*
clindamycin
450mg
TDS
Severe diabetic foot
Refer to specialist
infection i.e., causing
1-3
systemic illness.
* Review the patient regularly for signs of improvement – if no / limited response to
antibiotics within 2 weeks seek specialist advice.
Wound
Infections
(Non surgical)
Swabbing not normally necessary.
Treat as per cellulitis and leg ulcers.
For surgical wound infections – seek microbiology/infectious disease advice.
MRSA
For MRSA screening and suppression, see HPA MRSA quick reference guide.
Prodigy
For active MRSA infection
If active infection, MRSA confirmed by lab results,
1,2B+
infection not severe and admission not required
: Use
antimicrobial sensitivities to guide treatment, selecting
most suitable antimicrobial with lowest risk for C. difficile
or MRSA infection e.g. doxycycline 100mg BD for 7 days
if tetracycline sensitive
If severe infection or no response to monotherapy after
24-48 hours, seek advice from microbiologist on
combination therapy.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
24
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Bites
Prodigy
Human
Cat or Dog
COMMENTS
Thorough irrigation is
1C
important.
Consider need for surgical
debridement.
Assess risk of tetanus,
1C
HIV, hepatitis B&C.
The Health Protection Unit
and ‘On Call’ Public Health
team are available to help
on risk assessment. 9am–
5pm: 0845 2799879. Out
of hours: 0844 967 0083.
Antimicrobial prophylaxis is
3Badvised.
Assess risk of tetanus and
2C
rabies.
3
Give prophylaxis if cat
bite/puncture wound; bite
to hand, foot, face, joint,
tendon, ligament;
immunocompromised/
diabetic/asplenic/
cirrhotic.
DRUG
Prophylaxis or treatment:
co-amoxiclav
Penicillin Allergy:
metronidazole
AND
doxycycline (cat/dog/human)
DOSE
DURATION
OF TX
375mg 625mg
4C
TDS
400mg
TDS
100mg
5C
BD
All for 7 days
4,5,6C
metronidazole
AND
clarithromycin(human bite)
400mg
TDS
AND review at 24 and
7C
48hrs
250mg 500mg
6C
BD
flucloxacillin
500mg
QDS
14 days
500mg1g BD or
250mg500mg
QDS
14 days
For animals not covered in
this guidance (for example
monkeys, pigs, exotic pets
etc), seek microbiology/
infectious diseases advice.
Mastitis
Prodigy
Antimicrobials only
1
required if:
Symptoms have not
improved or are
worsening after 12–
24 hours despite
effective milk removal
The woman has a nipple
fissure that is infected
Penicillin Allergy:
erythromycin alone
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
25
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Acne Vulgaris
Prodigy
OCCG Acne Prescribing Guidelines November 2013
1
Lavender
Statement
OCCG Acne
Primary Care
Prescribing
Guidelines
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
26
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Rosacea
Prodigy
1
COMMENTS
DURATION
OF TX
Ensure steroids are not being used on the face; ensure inhaled steroids, steroid eye
drops etc are not inadvertently contacting the face.
Mild & localised
papulopustular
DRUG
metronidazole 0.75%
cream *
DOSE
BD
Review after
7-8 weeks.
If not responding after 8
weeks:
azelaic acid 15%
BD
* some gel preparations are ~3 times the cost of the
cream.
Moderate or severe
papulopustular
doxycycline *
(unlicensed)
Consider adding in topical
treatment for patients
receiving oral antimicrobial
therapy that have not
responded at review, or
seek specialist advice.
If compliance is an issue:
lymecycline (unlicensed)
Switching to an alternative
oral antimicrobial (unless
compliance issues) is
unlikely to be of benefit.
Severe & resistant / not
responding.
408mg
OD
Review after
3-4 weeks
and if
improving
review 6
monthly.
Pregnant or breastfeeding:
erythromycin
500mg
BD
* 40mg capsules are licensed for papulopustular facial
roseacea (without ocular involvement) but are ~4 times
the cost of the 100mg capsules.
Seek specialist advice.
Perioral
Dermatitis
Aggravated by steroids.
oxytetracycline
Boils / Cysts/
Abscesses /
Carbuncles
Antimicrobials treatment
not required unless
1
person has:
fever
cellulitis
lesion is on the face
lesion is a carbuncle
person is in pain or
severe discomfort
there are other
comorbidities (such as
diabetes or
immunosuppression
Antimicrobial treatment
not usually indicated
Prodigy
100mg
OD
flucloxacillin
Penicillin Allergy:
clarithromycin
500mg
BD
4 weeks
500mg
QDS
7 days
250mg500mg
BD
7 days
Recurrent boils may need
incision and drainage.
Check for diabetes.
Consider diagnosis of
hidradenitis suppurativa if
axillae and groin involved.
If a boil is drained then a
sample should be taken.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
27
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Paronychia
Prodigy
COMMENTS
Consider antimicrobials if
1
incision and drainage:
is not required (because
the lesion is nonfluctuant).
was performed, but the
person has signs of
cellulitis or fever, or has
other comorbidities (such
as diabetes or
immunosuppression).
flucloxacillin
Penicillin Allergy:
clarithromycin
DOSE
250mg500mg
QDS
DURATION
OF TX
7 days
250mg500mg
BD
7 days
5%
cream
2
applications
1 week apart
Antimicrobials not required
Folliculitis
Scabies
Prodigy
DRUG
Treat all members of the
household, close contacts
& sexual contacts within
1C
24h.
Treat whole body from
ear/chin downwards and
under nails. If under
2
2/elderly, also face/scalp.
Ensure appropriate
management of ‘itch’ and
any associated eczema.
permethrin
3A+
If allergy:
3C
malathion
0.5%
aqueous
liquid
1C
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
28
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Head Lice
Prodigy
Lavender
Statement
COMMENTS
DRUG
DOSE
Treatment is not necessary
unless a live louse is
found. Ensure all
affected individuals in a
household are treated
1,2
simultaneously.
Wet combing: sole
treatment of regular wet
combing with conditioner, or
combine with below. Wet
combing should be
continued until no full-grown
lice have been seen for 3
consecutive sessions.
Treatment
involves
methodically
combing
wet hair
with a
finetoothed
comb to
remove
lice
Consider dimeticone
(physical insecticide)
especially if resistance to
other treatments.
Rub
lotion
onto dry
hair and
scalp.
Allow to
dry
naturally.
Shampoo
after
minimum
of 8
hours or
overnight
2
applications
7 days apart
Another option is malathion
(traditional insecticide)
Rub
lotion into
dry hair
and scalp
allow to
dry
naturally.
Remove
by
washing
after 12
hours
2
applications
7 days apart
MHRA
Offer a choice of treatment
strategies: wet combing,
dimeticone lotion or an
insecticide.
No treatment is 100%
effective.
Choice of treatment
depends on the preference
of the individual/parent and
on the treatment history.
Use lotions or liquids
formulations; shampoos
are diluted too much in use
to be effective.
Preparations with a contact
time of 8-12 hours or
overnight are
recommended; a 2 hour
treatment is not sufficient
to kill eggs.
Do not use insecticide
lotion more than once for
three consecutive weeks
Pregnant or breastfeeding
DURATION
OF TX
4 sessions
over 2
weeks
Wet combing or dimeticone
If a traditional insecticide is required as an alternative in
treatment failure, malathion is recommended.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
29
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
FUNGAL SKIN INFECTIONS
CONDITION
Fungal /
Dermatophyte
infection of the
skin –
Dermatophyte
s
Prodigy
Prodigy
HPA
COMMENTS
DRUG
Athletes Foot/ Fungal
Groin Infection /
Ringworm.
1
Terbinafine is fungicidal ,
so treatment time shorter
than with fungistatic
imidazole.
1 week terbinafine is as
effective as 4 weeks azole.
A-
Topical 1% terbinafine
or
OD-BD
DURATION
OF TX
4A+
2 week*
topical 1% imidazole e.g.
clotrimazole / miconazole
(Not nystatin as is NOT
effective against
4A+
dermatophytes )
OD-BD
4 – 6 weeks*
BD
4 – 6 weeks*
or (athletes foot only)
topical undecanoates
® 4B+
(Mycota )
DOSE
4A+
If inflammation is marked,
consider prescribing a
topical antifungal combined
with a mildly potent
corticosteroid for a
maximum of seven days.
Use a combination
preparation with caution on
fungal infection of the
groin, because of the
increased risk of adverse
effects with topical
corticosteroids in occluded
areas.
If intractable: send skin
2C
scrapings If infection
confirmed, use oral
3B+
terbinafine/itraconazole
terbinafine oral
250mg
OD
ringworm 4 weeks*
2-4 weeks*
groin
* duration of treatment is given as an approximation.
Treatment should be continued for 1-2 weeks after the
disappearance of all signs of infection.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
30
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Fungal /
Dermatophyte
infection of the
skin - Scalp
Dermatophyte
s
Prodigy
HPA
COMMENTS
Scalp Ringworm.
1
Take scalp scrapings – this
often pulls out infected hair
stumps which are critical
for successful culture &
microscopy. Hair plucking
does not produce the best
samples. A soft toothbrush
can be used if scrapings
2
are not possible.
DRUG
DOSE
Adults: terbinafine oral (off
license)
250mg
OD
selenium shampoo in severe
cases may be appropriate in
addition. This reduces the
risk of spreading the
infection to others.
Twice a
week
DURATION
OF TX
4 weeks
2 - 4 weeks
Also ketoconazole shampoo
and povidone iodine
Scalp scrapings for
culture are essential as
choice of treatment is
species dependent: M
canis responds well to
griseofulvin whereas T.
tonsurans (greater recent
prevalence especially in
cities) responds well to
terbinafine. Dermatologists
advise initiating treatment
with terbinafine and being
prepared to switch
treatment to griseofulvin if
culture shows M canis.
Fungal /
Dermatophyte
infection of the
proximal
fingernail or
toenail
Lavender
Statement
HPA
Prodigy
Unsightly nails due to
fungal infection are
primarily a cosmetic
problem.
Therefore the Priorities
Committees considers the
treatment of
onychomycosis (fungal nail
infection) with terbinafine to
be a Low Priority and
recommends that it is not
normally prescribed, with
the exception of patients
1
with :
peripheral vascular
disease
diabetes or
other
immunocompromised
patients.
Prescribe only in line with
Priorities Committee
Lavender Statement
terbinafine oral
2A+
250 mg
OD
fingernails
toenails
Second line:
2A+
itraconazole
200mg
BD
fingernails
toenails
6-12 weeks
3-6 months
2 courses of
7 days per
month
3 courses of
7 days per
month
In these patients,
mycological confirmation
should always be sought
prior to treatment.
When treatment is
indicated, only oral
terbinafine should be
prescribed as topical
terbinafine has inferior
efficacy.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
31
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Pityriasis
Versicolor
COMMENTS
Caused by an overgrowth
of Pityrosporum orbiculare
1
(Malassezia furfur).
DRUG
First Line:
selenium shampoo
Prodigy
Most adults have
Pityrosporum orbiculare on
their skin; however, in a
few people its presence
results in a harmless skin
disease.
or
Pityrosporum orbiculare
also plays a role in the
development of
seborrhoeic dermatitis
(including cradle cap).
Poorly responsive to
terbinafine and completely
unresponsive to nystatin
and griseofulvin.
ketoconazole shampoo
If initial therapy fails, verify
that the treatment regimen
has been followed
adequately. Consider a
second topical therapy
before considering
systemic treatment.
Third line (adults):
itraconazole (only in severe
unresponsive cases due to
benefit risk ratio)
Intertrigo
Prodigy
Combination preparations
containing corticosteroids
e.g. trimovate cream
should only be applied if
there is marked
1
inflammation.
They should be applied
sparingly to avoid skin
atrophy on areas of thin
skin (e.g. facial areas) and
for a maximum of 1 week.
clotrimazole 1% cream
DOSE
DURATION
OF TX
Apply
DAILY to
the
affected
area –
leave on
for 10
mins
before
rinsing.
(Diluting
with a
small
amount
of water
can
reduce
irritation)
7 days
Apply
once
daily –
leave
preparation on
for 35mins
before
rinsing
Max 5 days
200mg
daily
7 days
Apply
BD-TDS
Continue for
at least 2
weeks after
the affected
area has
healed
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
32
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
VIRAL INFECTIONS
CONDITION
Herpes
simplex
COMMENTS
Cold Sores
Prodigy
Prodigy
Prodigy
Immunisatio
n against
Infectious
Disease
2006 (‘The
Green
Book’)
(Chapter 34)
Chickenpox
in adults –
Clinical
management
DURATION
OF TX
Cold sores resolve after 7–10d without treatment.
Topical over the counter antivirals (aciclovir) can be
bought. If applied prodromally (early) reduce duration by
1,2,3B+,4
12-24hrs.
#
First attack genital.
aciclovir
Recurrent attacks of genital
herpes - intermittent
therapy.
Specific treatments usually
not beneficial as recurrences
are self-limiting and
generally cause minor
5
symptoms.
Recurrent attacks of genital
herpes - suppressive
therapy.
aciclovir
Only indicated if at least six
recurrences per annum.
Varicella
zoster
/ Chickenpox
DRUG
#
DOSE
200mg
FIVE x
daily
5 days
400 mg
BD
Interrupt
therapy
every 6-12
months for
reassessment of
disease
#
Use normal oral dose every 12 hours if eGFR less than
2
10mL/minute/1.73m .
If pregnant/ neonate /
immunocompromised seek
advice re treatment and
prophylaxis from
microbiology or infectious
1B+
disease.
Chickenpox: Use aciclovir
if less than <24h of rash
and >14 years or severe
pain or dense/oral rash or
o
2 household case or
-5
steroids or smoker.
If indicated:
3B+, 6A+
aciclovir*
3B+
800 mg
7 days
five times
a day
* use normal oral dosage every 8 hours if eGFR 10-25
2
mL/minute/1.73m (every 12 hours if eGFR less than 10
2
mL/minute/1.73m ).
See below for additional
advice on treatment and
prophylaxis.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
33
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
CONDITION
Herpes
zoster
/ Shingles
Prodigy
Immunisatio
n against
Infectious
Disease
2006
(‘The Green
Book’)
(Chapter 34)
COMMENTS
DRUG
DOSE
DURATION
OF TX
If pregnant/ neonate /
immunocompromised seek
advice re treatment and
prophylaxis from
microbiology or infectious
1B+
disease.
Shingles: treat if >50
6A+
yrs
and within 72 hrs of
7B+
rash
(PHN rare if <50yrs
8B); or if active ophthalmic
9B+
10C
or Ramsey Hunt
or
eczema.
See below for additional
advice on treatment and
prophylaxis.
If indicated:
3B+, 6A+
aciclovir*
Second line if compliance a
problem, as ten times cost.
Consult BNF if renal
impairment:
11B+
valaciclovir
or
famciclovir
800 mg
five times
a day
7 days
3B+
1gram
TDS
7 days
11B+
12B+
12B+
250mg
7 days
TDS or
750mg
OD
* use normal oral dosage every 8 hours if eGFR 10-25
2
mL/minute/1.73m (every 12 hours if eGFR less than 10
2
mL/minute/1.73m ).
Treatment Advice: CHICKENPOX
Immunocompromised Patients: (Immunisation against Infectious Disease 2006 (‘The Green Book’) –
for definition of immunosuppressed patients see Chapter 6 & 34)
 Refer urgently to a specialist for intravenous aciclovir.
Immunocompetent Patients: (Also see: Chickenpox in adults – Clinical management).
 Treatment is indicated for all persons over 14 years of age.
 Treatment should start as soon as possible, preferably within 24 hours and certainly within 72
hours of the onset of the rash.
 Treat adults for 7 days as for shingles above.
 Pregnant women may have more serious disease and the benefits of treatment should be
balanced against any potential harm to the foetus. (NB: Chickenpox in adults – Clinical
management).
 Chickenpox in pregnancy should be treated with aciclovir 800 mg 5 times daily for 7 days. There is
no evidence so far that aciclovir causes congenital abnormalities in humans.
 Additional risk factors for Chickenpox pneumonitis include smoking, chronic lung disease,
underlying immunosuppression and > 36 weeks gestation.
 Symptoms/signs of more severe Chickenpox include respiratory symptoms, haemorrhagic rash,
bleeding, densely cropping vesicles, any neurological changes, and persisting fever with new
vesicles erupting more than 6 days after onset.
 Individuals with additional risk factors or symptoms/signs of more severe disease should be
referred to the local infectious diseases unit for consideration of IV aciclovir.
 These management guidelines also apply to pregnant women who develop Chickenpox despite
being given VZIG.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
34
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
Treatment Advice: SHINGLES
Immunocompromised: (Immunisation against Infectious Disease 2006 (‘The Green Book’) – for
definition of immunosuppressed patients see Chapter 6 & 34).
 Refer to specialist as intravenous therapy may be required.
Immunocompetent including pregnancy:
 Refer all patients with eye involvement to an Ophthalmologist.
 Treat all patients > 50 years old with aciclovir 800 mg 5 times daily for 7 days. If compliance is an
issue consider valaciclovir 1gram TDS or famciclovir 250 mg TDS or 750 mg once daily for 7 days
as valaciclovir and famiciclovir are ten times the cost. Commence within 72 hours of onset of rash
or up to one week after onset for ophthalmic zoster.
Prophylaxis Advice: High Risk Contacts of Patients with Chickenpox or Shingles
High risk contacts are patients without a definite history of Chickenpox or Shingles and a negative test
for varicella antibody, and who have had a significant contact with Chickenpox or Shingles
(Immunisation against Infectious Disease 2006 (‘The Green Book’) – Chapter 34 Varicella) and are at
high risk of serious disease.
These include:
1. Immunocompromised patients (see Immunisation against Infectious Disease 2006 ) (‘The Green
Book’).
2. Pregnant women.
3. Neonates of non-immune mothers who:
develop Chickenpox between 7 days before and 7 days after delivery
are exposed to Chickenpox or Herpes zoster (other than in the mother) in the first seven days of
life.
4. Infants of any age, exposed to Chickenpox or Herpes zoster while still requiring intensive or
prolonged special care nursing.
Contact the Microbiology SpR/Consultant 01865-220880 or Bleep 4077 (in hours) or via JR switchboard
(out of hours) for specific advice, to arrange urgent antibody testing and for supplies of VZIG if
required.
If patient is eligible for varicella-zoster immune globulin (VZIG) this will prescribed by the Microbiology
SpR/consultant. Give varicella-zoster immune globulin (VZIG) 250 mg (1 vial) to 1000mg (4 vials)
intramuscularly depending on age. Give preferably within 96 hours of contact, but may be efficacious up
to 10 days post exposure.
VZIG will need to be collected from the JR pharmacy site by the patient or representative. VZIG does
not prevent infection but may reduce severity.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
35
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
HEPATITIS
HEPATITIS B
 All patients with hepatitis B not previously assessed by a hepatologist should be referred for
assessment and consideration of treatment.

Contact Follow Up has a significant role to play. All household and sexual contacts of HbSAg+ve
patients should be screened offered HBV vaccine and advice on minimising risk of spread. Further
guidance is available from the Health Protection Unit 9am–5pm: 0845 2799879. Out of hours:
0844 967 0083.

Also see Antenatal screening Hepatitis B flowchart.
HEPATITIS C
 Patients who are both hepatitis C antibody and Hepatitis C RNA positive should be referred for
assessment and consideration of treatment by a hepatologist.

Also see Hepatitis C: diagnosis and referral flowchart.
EYE INFECTIONS
Also see Oxfordshire PCT Referral Guidelines: Ophthalmology
CONDITION
COMMENTS
DRUG
Conjunctiviti
s
Prodigy
Treat if severe; most are viral
or self-limiting.
Treatment often not
required.
Bacterial conjunctivitis is
usually unilateral and also
2C
self-limiting; it is
characterised by red eye with
mucopurulent, not watery,
discharge;
65% resolve on placebo by
1A+
day five.
If severe:
chloramphenicol 0.5%
drops
Fusidic acid has less Gram3
negative activity.
chloramphenicol 1%
ointment
See Prodigy for advice on for
1
management.
DURATION
OF TX
4,5B+,6B-
and
Second line:
fusidic acid 1% gel
Styes
Prodigy
DOSE
2 hourly
for
2 days
then
4 hourly
(whilst
awake)
All for 48
hours after
resolution
at night
BD
Systemic or topical antimicrobials not required.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
36
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
MENINGITIS
CONDITION
Bacterial
Meningitis
and / or
Suspected
Meningococ
cal Disease
HPA
HPA
NICE
COMMENTS
DRUG
DOSE
DURATION
OF TX
Suspected bacterial
meningitis without non1,2,3,4
blanching rash
transfer directly to
secondary care as an
emergency via ambulance
without giving parenteral
antibiotics.
if urgent transfer to hospital
is not possible (for example,
remote locations or adverse
weather conditions),
antibiotics should be
administered to someone
with suspected bacterial
meningitis.
Suspected meningococcal
disease (meningitis with
non-blanching rash or
meningococcal
1,2,3,4
septicaemia).
transfer directly to
secondary care as an
emergency via ambulance.
IV or IM benzylpenicillin*
1200mg
IV or IM benzylpenicillin*
1200mg
(give IM if
vein cannot
be found)
(give IM if
vein cannot
be found)
parenteral antibiotics should
be given at the earliest
opportunity, either in
primary or secondary care,
but urgent transfer to
hospital by emergency
ambulance should not be
delayed in order to give
the parenteral antibiotics.
*Withhold benzylpenicillin only in adults who have a history of significant allergic response
to penicillin; a history of a rash is not considered as significant in this context.
Meningococ
cal
Meningitis
Prophylaxis
*An alternative for adults who have a significant allergic response to penicillin is not given
as the most important aspect of care is to transfer urgently to hospital – transfer should
not be delayed in order to administer an antimicrobial in the community.
1,2,3,5
Only prescribe following advice from HPA:
9am–5pm:
0845 2799879
Out of hours: 0844 967 0083
st
Adults (1 choice)
ciprofloxacin
500mg oral single dose
HPA
Adults (alternative)
rifampicin
600mg oral BD for 2 days
Pregnant women
ciprofloxacin
or
500mg oral single dose
ceftriaxone
(unlicensed)
250mg IM or IV
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
37
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
ASPLENIA
CONDITION
COMMENTS
Prophylaxis
for Asplenia
Lifelong antimicrobial
prophylaxis is recommended,
especially for patients with
functional hyposplenism and
those whose splenectomy was
1
for underlying disease.
Immunisatio
n against
Infectious
Disease
2006
(‘The Green
Book’)
(Chapter 7)
DRUG
DOSE
phenoxymethylpenicillin
(Adult dosage)
500 mg
BD
Penicillin Allergy:
erythromycin
(Adult dosage)
500 mg
BD
DURATION
OF TX
See below
See below
It is recognised that many
patients are unable to comply
and the value is less certain
1
after the first two years.
Note: Antimicrobial
prophylaxis is not fully
reliable and vaccines
should be considered.
Further advise on vaccination
for asplenics is available via;
Immunisation against
Infectious Disease 2006 (‘The
Green Book’).
1.
2.
3.
4.
Patients should keep a supply of appropriate antimicrobials (e.g. amoxicillin) at home to be used
should infective symptoms of raised temperature, malaise or shivering develop. This is particularly
important for those not taking prophylaxis.
Patients taking prophylactic erythromycin should increase their dose to therapeutic range (500mg
QDS) at first symptom of infection.
Patients with such symptoms should also seek immediate medical help.
Severe sepsis can occur despite the use of antibacterial prophylaxis
Adults should receive pneumococcal vaccine, Hib vaccine, MenACWY vaccine and influenza vaccine
(DOH recommendations). When possible, the first doses (or booster doses) of the vaccines should be
given simultaneously at different sites, at least four weeks before splenectomy. Refer to Immunisation
against Infectious Disease 2006 for further information. An NHS ‘Splenectomy Information for Patients’
leaflet is also available.
Based on the Health Protection Agency and British Infection Association; ‘Management of Infection Guidance
for Primary Care for Consultation and Local Adaptation’.
Editors / Authors: Dr Bridget Atkins, Consultant Microbiologist; Dr Andrew Woodhouse, Consultant in
Infectious Diseases; Jo Stanney, Interface Medicines Management Lead, OCCG; Julie Dandridge, Chief
Pharmacist, OCCG.
Specialist advice from:
OUH: Dr Katie Jeffery & Dr Ian Bowler Consultant Microbiologists; Dr Chris Conlon, Consultant in Infectious
Diseases; Dr Jackie Sherrard, GUM Consultant; Dr Roger Chapman & Dr Jonathan Marshall, Consultant
Gastroenterologists; Dr Steve Chapman, Respiratory Consultant; Dr Simon Brewster, Consultant Urologist; Dr
Graham Ogg, Dr Vanessa Venning, Dr Sue Burge, Dr John Reed, Dr Jonathan Bowling & Dr Richard Turner,
Consultant Dermatologists; Dr Penny Lennox, ENT Consultant; Mel Snelling, Lead HIV/Infectious Diseases
Pharmacist.
HPA: Dr Noel McCarthy, Consultant Communicable Disease Control.
OCCG: Dr Nick Elwig & Dr Lucy Jenkins, GPs; Dr George Moncrieff GP with Special Interest.
Buckinghamshire & Oxfordshire Cluster: Amanda Le Conte, Infection Control Manager; Chris Evans &
Mandy Crosse, Dentists.
Oxford Health: Neil Oastler, Dentist; Sarah Gardner & Julie Hewish, Tissue Viability Nurses.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
38
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015