Antibiotic Guidelines Cephalosporins, Quinolones and Co-Amoxiclav The aims of using antibiotics is to provide a simple, effective, economical and empirical approach to the treatment of common infection and to minimise the emergence of bacterial resistance in the community. Principals of treatment in relation to cephalosporins, quinolones and co-amoxiclav  Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones, and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs. Where possible, avoid quinolones in pregnancy. Clostridium difficile Infections: Prevention and Reduction  Antibiotic use is the most significant and frequently reported predisposing risk factor for C diff. – associated diarrhoea (CDAD) in hospital and community settings.Proliferation of C diff. is most likely to occur with those antibiotics which have an effect on normal GI flora and including cephalosporins.  Current evidence indicates that second or third generation cephalosporins, (e.g. cefuroxime, cefixime, cefotaxime, ceftriaxone) are significantly more likely to provoke C. diff associated diarrhoea (CDAD). Studies from North America have specifically identified the role of quinolones in C diff. outbreaks. There is also increasing evidence for the implication of fluoroquinolones, first-generation cephalosporins(e.g. cephalexin,) and co-amoxiclav. These antibiotics should be used sparingly, especially for the elderly, for patients in institutions with CDAD, and in patients previously diagnosed and treated for CDAD. Indications for use of cephalosporins, quinolones and co-amoxiclav Cephalosporin Illness Suspected meningococcal disease Choice of drug Benzylpenicillin (IV/IM) Cefotaxime (IV/IM) UTI in pregnancy UTI in Children Adult Dose Age 10+ yrs: 1200mg Child 1-9 yrs: 600mg Child <1 yr: 300mg Age 12+ yrs: 1 gram Child < 12 yrs: 50mg/kg 1st line: Nitrofurantoin 100mg m/r BD If susceptible, Amoxicillin 500mg TDS 2nd line: Trimethoprim 200mg BD (off-label) 3rd line: Cefalexin 500mg BD Lower UTI: Trimethoprim or Nitrofurantoin, if susceptible, Amoxicillin. 2nd line: Cefalexin Upper UTI: Co-Amoxiclav. 2nd line: Cefixime Pelvic Inflammatory Quinolones Acute prostatis Acute pyelonephritis Co-Amoxiclav Acute Rhinosinusitis Duration Give IM if vein cannot be found All for 7 days Lower UTI 3 days Upper UTI 7-10 days 14 days 14 days Metronidazole plus Ofloxacin If high risk of GC: Ceftriaxone plus Metronidazole plus Doxycycline Ciprofloxacin or Orfloxacin 2nd line: trimethoprim Ciprofloxacin or Co-Amoxiclav 400mg BD 400mg BD 500mg IM 400mg BD 100mg BD 500mg BD 200mg BD 200mg BD 500mg BD 500/125mg TDS Stat 14 days 14 days All for 28 days Amoxicillin 500mg TDS, 1G (severe) 200mg stat/100mg OD 500mg QDS All for 7 days Doxycycline or Phenoxymethylpenicillin 7 days 14 days 625mg TDS Acute exacerbation of COPD For persistent symptoms: Co-Amoxiclav Amoxicillin Or Doxycycline Clarithromycin If resistance: Co-Amoxiclav UTI in Children Acute Pyelonephritis Cellulitis Bites (human or animal) Flucloxacillin If penicillin allergic: Clarithromycin or Clindamycin Facial: Co-Amoxiclav Prophylaxis/treatment: Co-Amoxiclav If penicillin allergic: Metronidazole plus Doxycycline(cat/dog/man) Or metronidazole plus Clarithromycin (human bite) AND review at 24/48 hrs 500mg TDS 200mg stat/100mg OD 500md BD Comments Transfer all patients to hospital immediately. If time before admission, and non-blanching rash, give IV benzylpenicillin or cefotaxime, unless definite history of hypersensitivity. Send MSU for culture and start antibiotics. 4 week course may prevent chronic prostatitis. Quinolones achieve higher prostate levels. Child <3 months: refer urgently for assessment. Child ≥3 months: use positive nitrite to start antibiotics. Send pre-treatment MSU for all. Imaging: refer only if child <6 months, recurrent or atypical UTI. Refer woman & contacts to GUM service. Always culture for gonorrhoea & chlamydia. 28% of gonorrhoea isolates now resistant to quinolones. If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or GUM referral. Send MSU for culture and start antibiotics. 4 week course may prevent chronic prostatis. Quinolones achieve higher prostate levels. If admission not needed, send MSU for culture &sensitivities and start antibiotics. If no response within 24 hours, admit. Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days. Use adequate analgesia. Consider 7-day delayed or immediate antibiotic when purulent nasal discharge. In persistent infection use an agent with antianaerobic activity (e.g. co-amoxiclav). Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, 625mg TDS antibiotics in last 3 months. As above: see previous entry regarding UTI in Children As above: see previous entry regarding Acute Pyelonephritis 500mg QDS 500mg BD 300-450mg QDS 500/125mg TDS 375-625mg TDS 200-400mg TDS 100mg BD 200-400mg TDS 250-500mg BD All for 5 days All for 7 days. If slow response continue for further 7 days All for 7 days If patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone. If river or sea water exposure, discuss with microbiologist. If febrile and il, admit for IV treatment. Stop clindamycin if diarrhoea occurs. Thorough irrigation is important. Assess risk of tetanus, HIV, hepatitis B&C. Antibiotic prophylaxis is advised. Assess risk of tetanus and rabies. Give prophylaxis if cat bite/puncture wound, bite to hand, foot, face, joint, tendon, ligament, immunocompromised/asplenic/cirrhotic.