Antimicrobial Treatment Guidelines1 • Unless otherwise stated, doses are for adults. • Discuss with patient/carer what they expect as a result of the consultation. Explain risk/benefit of antibiotics. Consider a delayed antibiotic prescription when appropriate. Note. Dec. 10 – changes are in blue • Reinforce importance of self-care to patient/carer. Infection type Recommended agent(s) Notes Antibiotics unlikely to help, symptoms may take up to 3 weeks to resolve. Most infections are viral. Give patient advice on duration of cough. Consider a 7-14 day delayed antibotic prescription, if appropriate. Antibiotics have marginal benefits in otherwise healthy adults. [Amoxicillin 500 mg TDS, 5 days or doxycycline 200 mg stat then100 mg OD, 5 days] First-line - Doxycycline 200mg for 1st day, 100mg od thereafter, 5 day course Second-line - Amoxicillin 500mg tds (if a tetracycline not suitable) 5 day course • IF resistance risk factors: Co-amoxiclav 625mg tds, 5 days • IF CRB65=0: suitable for home treatment: Amoxicillin 500mg tds, 7 days Or Erythromycin 2 x 250mg qds, 7 days, st Or Doxycycline 200mg for 1 day, 100mg od thereafter 7 day course • Respiratory infections Acute bronchitis Acute exacerbation of COPD Community Acquired Pneumonia – start antibiotics immediately See:http://www.hpa.org.uk/webw/H PAweb&Page&HPAwebAutoListNam e/Page/1197637041219?p=1197637 041219 BTS 2009 Guidelines http://www.britthoracic.org.uk/Portals/0/Clinical%20I nformation/Pneumonia/Guidelines/C APGuideline-full.pdf • • • • IF CRB65=1 & AT HOME (after hospital assessment): Amoxicillin AND Erythromycin 7-10 days Not indicated in absence of purulent/ mucopurulent sputum. Treat promptly if purulent sputum and increased SOB and/or increased sputum volume. Send sputum for culture if no response to empirical treatment. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months If no response after 48 hrs consider admission or add erythromycin if risk of atypical pneumonia. During a flu pandemic, doxycycline should be the first line choice (co-amoxiclav for children). This is to cover S aureus. Detailed guidance will be sent when this change needs implementing. For CRB65, score 1 point for each of these: age ≥ 65 yrs; confusion (AMT<8); respiratory rate (>30/min); BP systolic <90 or diastolic ≤ 60. - Score 1-2: hospital assessment or admission - Score 3-4: urgent hospital admission Give immediate IM benzylpenicillin or amoxicillin 1G po if delayed admission / life threatening Or Doxycycline alone 7-10 days ENT infections Acute otitis media If clinically indicated – 60% resolve in 24 hours without antibiotics. Consider the delayed prescription option. Antibiotics unnecessary in most cases Amoxicillin – 5 day course 1 month to 1 year – 62.5-125mg tds 1 – 5 years - 125-250mg tds > 5 years - 250-500mg tds [Above doses based on 40mg/kg/daily as BNF] Or Erythromycin – 5 day course < 2yrs: 125mg qds 2 - 8yrs: 250mg qds Other: 250-500mg qds Chronic otitis media Antibiotics unlikely to help – use analgesia Sore throat/tonsillitis /pharyngitis If clinically indicated. Most sore throats are viral. Penicillin V, 10 day course Age 1 month - 1 year: 62.5mg qds Age 1 - 5 years: 125mg qds Age 6 - 12 years: 250mg qds Adult dose: 2 x 250mg qds 90% resolve in 7 days without antibiotics Consider the delayed prescription option. - Antibiotics to prevent Quinsy NNT >4,000 - Antibiotics to prevent Otitis Media NNT 200 If penicillin allergic: Erythromycin 5 day course Age 1 month - 2 years: 125mg qds Age 2 - 8 years: 250mg qds Adult & child >8 years: 250-500mg qds (or total daily dose split and given BD). • • • • • • • • • Use analgesia for symptom relief Poor outcome unlikely if no vomiting or temp <38.5oC Child is just as likely to have vomiting, diarrhoea or rashes due to the antibiotic as they are to benefit from pain relief after 2 days (NNT15) Antibiotics do not prevent deafness. To prevent mastoiditis NNT>4000 Depending on clinical assessment of severity, NICE advises to also consider antibiotics for: children with otorrhoea; or those <2years with bilateral acute otitis media Use analgesia (paracetamol or ibuprofen) for symptom relief The probability of preventing one case of glomerulonephritis or rheumatic fever is the same as causing a death by penicillin induced anaphylaxis. Erythromycin 250mg qds = less side effects than 2 x 250mg bd. Depending on clinical assessment of severity, NICE advises to also consider antibiotics for patients when 3 or more Centor criteria are present. [Centor criteria are : history of fever; tonsillar exudates; tender anterior cervical lymphadenopathy; and an absence of cough] ENT infections (continued) 1 Updated from the Health Protection Agency Antibiotic Guidance 05/08/10. http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1197637041219?p=1197637041219 Updated 22.11.10. Dr Diane Harris & Temi Omorinoye, Antimicrobial Pharmacists. Sinusitis – if clinically indicated Usually viral do not treat with antibiotics. Secondary infection or symptoms >10 days: First-line - Doxycycline 200mg for 1st day, 100mg od thereafter, 7 day course (or Erythromycin 2 x 250mg qds for 7 days) • • For persistent infection with symptoms: co-amoxiclav 625mg tds for 7days • Trimethoprim 200mg bd for 3 days or Nitrofurantoin 50mg-100mg qds for 3 days • Women (non- pregnant) with severe/≥ 3 symptoms: treat or 48hr delayed prescription • Women (non- pregnant) with mild/ ≤ 2 symptoms: use dipstick to guide treatment. Nitrite & blood or leucocytes has 92% +ve predictive value; but negative nitrite, leucocytes & blood has 76% NPV • Perform culture & susceptibility only in treatment failure, pregnant, children, men, renal impairment In the elderly (>65 years) do not treat asymptomatic bacteriuria. • • Symptomatic benefit of antibiotics is small 80% of cases resolve in 14 days without antibiotics (thus reserve for severe / symptoms > 10 days). Consider pain relief and steam inhalation. Consider 7-day delayed or immediate antibiotic when purulent nasal discharge (NNT8). Use analgesia for symptom relief Urinary/Genital Tract UTI uncomplicated in men & non-pregnant women i.e. no fever or flank pain ......................................... Recurrent UTI symptoms in non-pregnant women: Note: Treat UTIs for 7 days in men ............................................................................................ ........................................................................................................ Acute episode - review diagnosis & culture urine Recurrent UTIs ≥ 3 UTIs/year: - Consider stand by antibiotic or - nightly prophylaxis of Nitrofurantoin / Trimethoprim Obtain specialist advice before giving prophylaxis ................................................................................... UTI in pregnancy: Nitrofurantoin 50-100mg qds for 7 days (but (Important- see HPA & CKS) http://www.cks.nhs.uk/urinary_tract_infe ction_lower_women/management/quick_ answers/scenario_recurrent_cystitis See - PCT Update on UTI diagnosis & management: not to be used at term) or Trimethoprim 200mg bd for 7 days (Avoid in http://www.derbyshiremedicinesmanageme nt.nhs.uk/guidelines/prescribing_guidelines first trimester of pregnancy) Acute Pyelonephritis Loin pain and/or Pyrexia Ofloxacin 400mg bd for 7 days Acute prostatitis Ofloxacin 200mg bd for 28 days Uncomplicated Genital Chlamydia Infection Doxycycline 100mg bd for 7 days or Azithromycin 1g as a single dose Pregnancy or breastfeeding – Erythromycin 2 x 250mg qds 7days (or bd 14 days). High risk of gonorrhoea Cefixime 400 mg as a single dose PLUS metronidazole 400 mg BD for 14 days PLUS doxycycline 100 mg BD for 14 days OR (if gonorrhoea low risk) Ofloxacin 400mg bd PLUS Metronidazole 400mg bd for 14 days Trichomoniasis vaginalis • Trimethoprim: - in renal impairment use BNF for dosages; and avoid in renal transplant patients • Avoid nitrofurantoin if eGFR is less than 60ml / 2 minute /1.73m (see BNF). Nitrofurantoin – contra-indications include: G6PD deficiency; acute porphyria; infants <3months old • or Cefalexin 500mg bd for 7 days Or Co-amoxiclav 625mg tds for 14 days Pelvic Inflammatory Disease • Metronidazole 400mg bd for 5 - 7 days • • Dipstick test the urine for evidence of UTI. Take MSU for culture and sensitivity testing and then start empirical antibiotics If no response within 24 hours, admit to hospital • Send MSU for culture and then start antibiotics • Treat partners & refer to GUM for follow-up and contact tracing Tetracyclines contraindicated in pregnancy. Testing should be targeted to 15- 25s (over 25s are at much lower risk). If erythromycin is used, retest after 6 weeks, as less effective (HPA). • • • • • • • Always culture for gonorrhoea & chlamydia. 28% of gonorrhoea isolates now resistant to quinolones If high risk of gonorrhoea (defined as patient having severe symptoms or has had sexual contact abroad or partner has gonorrhoea) avoid ofloxacin regimen. Refer woman and contacts to GUM • Treat partners simultaneously & refer to GUM • • • Transfer all patients to hospital immediately If time before admission, give IV/IM antibiotic asap Benzyl penicillin should be given unless there is a clear history of ANAPHYLAXIS following previous penicillin administration (i.e history of difficulty breathing, collapse, loss of consciousness etc) A stat dose of cefotaxime is a suitable alternative in cases of penicillin allergy. [Note. 0.5 - 6.5% of penicillin sensitive patients will also be allergic to cephalosporins]. • Meningitis Emergency treatment of suspected meningococcal disease Benzylpenicillin IV or IM Infant 300mg Child 1 - 9 years 600mg Adult (10 years and over) 1200mg If penicillin allergic: Cefotaxime IV or IM Child 12 yrs & under Adult (over 12 yrs) • 50mg/kg 1gram Skin and Soft Tissue Mild – benzoyl peroxide topical 5% 1-2 times OD after washing Moderate – first-line Doxycycline 100mg od (or oxytetracycline 2 x 250mg bd) nd 2 line: Lymecycline 408mg od rd 3 line: Erythromycin 2 x 250mg bd Severe Add topical peroxide prn to oral choice Skin and Soft Tissue (continued) Acne • • • • Reserve topical antibiotics for those who cannot tolerate oral. Use oral antibiotics for 3 months and review Increasing widespread erythromycin resistance of propionibacteria may mean poor response Photosensitivity reported with doxycyline, advice adequate sun protection in patients regularly exposed to sunlight. Impetigo – if localised try Polyfax ointment If widespread Flucloxacillin 500mg qds - 7 days • If penicillin allergic – Erythromycin 2 x 250mg qds • Cellulitis Flucloxacillin 500mg qds for 7 days & review • If Penicillin allergic Erythromycin 2 x 250mg qds 7days • • Facial cellulitis Co-amoxiclav 625mg tds 7days Dermatophyte infection of finger/toe nails Terbinafine 250mg od • Fingernails 6 – 12 weeks • Toenails 3 – 6 months • • First-line - Permethrin 5 % cream • Second-line – Malathion 0.5% aqueous • • Scabies Shingles Antivirals not needed: see exceptions Aciclovir Tabs or Dispersible 800mg five times a day for 7 days Reduce dose in renal impairment (BNF) Co-amoxiclav 375 - 625 mg tds for 7 days Bites If penicillin allergic: Metronidazole 200-400mg tds, 7 days PLUS either Erythromycin 2 x 250mg qds 7 days (human bites only). or Doxycycline 100mg bd 7 days (cat/dog/human bites) • • • • • Mild infection: Flucloxacillin 500mg-1g qds for 7-14 days • • http://cks.library.nhs.uk/diabetes _foot_disease/management/deta iled_answers/how_should_i_ma nage_a_diabetic_foot_ulcer Moderate: Co-amoxiclav 625 mg tds for 7- 14 days • • • All treatments usually for 7-14 days, then review Mild cellulitis – flucloxacillin may be used as single drug treatment. Severe cellulitis may require parenteral antibiotics If slow response continue for a further 7 days Take nail clippings Consider therapy only if infection is confirmed by laboratory Discuss risk/benefit of drug treatment with patient for a self-limiting cosmetic problem Treat whole body, and wash off: after 8 - 12 hours for permethrin; and after 24 hours for malathion. Use two applications 7 days apart Treat all household & sexual contacts Exceptions • > 50 years and within 72 hours of rash • Young patients with severe acute pain and within 72 hours of rash • Immunocompromised patients (specialist advice) • Active ophthalmic/facial • Shingles with eczema • Ramsay Hunt Syndrome Infected diabetic foot ulcer If penicillin allergic: Clindamycin 300mg qds for 7-14 days Avoid topical products to minimise antibiotic resistance – if localised try Polyfax ointment. Do not use mupirocin (reserved for MRSA) • Thorough irrigation is important Human: Assess risk of tetanus, HIV, hepatitis B&C Cat/Dog: Assess risk of tetanus and rabies Review at 24-48 hours Refer to foot care multidisciplinary clinic Antibiotics should be reserved for when surrounding cellulitis is present Take swabs & start empirical antibiotic treatment Review patient within 48 hours Advise patient to seek urgent medical attention if symptoms or general condition deteriorates Clindamycin, co-amoxiclav and prolonged courses of amoxicillin may cause C.diff diarrhoea, warn patient to stop antibiotic and contact GP immediately if diarrhoea develops Dental infection (acute dento-alveolar infection) Amoxicillin 250mg tds for 5 days or Metronidazole (anaerobes) 200mg tds for 3 days Refer to dentist. Mastitis Flucloxacillin 500 mg qds for 14 days Use analgesia for symptom relief. http://www.cks.nhs.uk/mastitis/m anagement/scenario_mastitis#421194 Advise women to continue to breastfeed or express milk by hand/ pump from the affected breast to ensure effective milk removal. (NICE CG37, WHO 2000, NCCPC 2006) If no improvement after 48 hours, change to: Co-amoxiclav 375-625 mg tds for 14 days Or as per culture results If penicillin allergic: Erythromycin 2 x 250mg qds 10-14 days - but if no improvement after 72 hours, add Metronidazole 400mg tds Antibiotic treatment is only indicated in the following circumstances: • cell and bacterial colony counts and culture are available and indicate infection, or • symptoms are severe from the beginning, or • a nipple fissure is visible, or • symptoms do not improve after 12 hours of improved milk removal • Send a sample of the milk for culture if no improvement after 48 hours of antibiotic • Advise ALL women to seek further information & continued breastfeeding support from their health visiting team or specialist infant feeding team 1. Updated from Health Protection Agency, 2010. Management of infection guidance for primary care. http://www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1197637041219?p=1197637041219 Note. Several Quick reference guides e.g. for Chlamydia testing and UTI testing are available from this website. Care pathway for respiratory tract infections (NICE Clinical Guideline 69 – Respiratory tract infections – antibiotic prescribing, July 2008). - for self-limiting RTIs in adults & children over 3 months, in primary care At the first face-to-face contact in primary care, including walk-in centres and emergency departments, offer a clinical assessment, including: • History (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant risk factors, relevant comorbidities) • Examination as needed to establish diagnosis. Address patients’ or parents’/carers’ concerns and expectations when agreeing the use of the three antibiotic strategies (no prescribing, delayed prescribing and immediate prescribing) Agree a no antibiotic or delayed antibiotic prescribing strategy for patients with acute otitis media, acute sore throat/pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis. No antibiotic prescribing Offer patients: • Reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash. • A clinical review if the RTI worsens or becomes prolonged. However, also consider an immediate prescribing strategy for the following subgroups, depending on the severity of the RTI. Delayed antibiotic prescribing Offer patients: • Reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash. • Advice about using the delayed prescription if symptoms do not settle or get significantly worse. • Advice about re-consulting if symptoms get significantly worse despite using the delayed prescription. The delayed prescription with instructions can either be given to the patient or collected at a later date. No antibiotic, delayed antibiotic or immediate antibiotic prescribing Depending on clinical assessment of severity, also consider an immediate prescribing strategy for: • Children younger than 2 years with bilateral acute otitis media • Children with otorrhoea who have acute otitis media • Patients with acute sore throat/acute tonsillitis when three or more Centor 1 criteria are present. 1 Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough. The patient is at risk of developing complications. Immediate antibiotic prescribing or further investigation and/or management Offer immediate antibiotics or further investigation/management for patients who: • Are systemically very unwell • Have symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital or intracranial complications) • Are at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely • Are older than 65 years with acute cough and two or more of the following, or older than 80 years with acute cough and one or more of the following: - hospitalisation in previous year - type 1 or type 2 diabetes - history of congestive heart failure - current use of oral glucocorticoids Offer all patients: • Advice about the usual natural history of the illness and average total illness length: acute otitis media: 4 days acute sore throat/acute pharyngitis/acute tonsillitis: 1 week common cold: 1½ weeks acute rhinosinusitis: 2½ weeks acute cough/acute bronchitis: 3 weeks • advice about managing symptoms including fever (particularly analgesics and antipyretics), For information about fever in children younger than 5 years, refer to ‘Feverish illness in children’ (NICE clinical guideline 47)