1. No category

URTI
Acute Sore
Throat CKS
Avoid antibiotics as 90% resolve in 7 days
without, and pain only reduced by 16 hours
phenoxymethylpenicillin
If Centor score 3 or 4: (Lymphadenopathy; No
Cough; Fever; Tonsillar Exudate) consider 2 or 3day delayed or immediate antibiotics or rapid
antigen test.
500 mg QDS
1G BD
(QDS when severe )
10 days
250-500mg BD
5 days
Penicillin Allergy:
Clarithromycin
Antibiotics to prevent Quinsy NNT >4000
Antibiotics to prevent Otitis media NNT 200
10d penicillin lower relapse Vs 7d in RCT <18yr
Acute Otitis
Media
(child dose)
CKS OM
Acute Otitis
Externa
CKS OE
Acute
Rhinosinusitis
CKS RS
Optimise analgesia and target antibiotics
AOM resolves in 60% in 24 h without antibiotics,
which only reduce pain at 2 days (NNT15) and
does not prevent deafness
Consider 2 or 3-day delayed or immediate
antibiotics for pain relief if:
 <2 years AND bilateral AOM (NNT4) or bulging
membrane & ≥ 4 marked symptoms
 All ages with otorrhoea NNT3
Abx to prevent Mastoiditis NNT >4000
amoxicillin
Penicillin Allergy:
erythromycin
Child doses
Neonate 7-28days
30mg/kg TDS
1 mth- 1yr: 125mg TDS
1-5 yrs: 250 TDS
5-18 yrs: 500mg TDS
5 days
< 2yrs 125mg QDS
2-8yrs 250mg QDS
8-18yrs 250-500mg QDS
First use aural toilet (if available) & analgesia
Cure rates similar at 7 days for topical acetic acid
or antibiotic +/- steroid
If cellulitis or disease extending outside ear canal,
start oral antibiotics and refer
First Line:
acetic acid 2%
Second Line:
neomycin sulphate with
corticosteroid 3A-,4D
Avoid antibiotics as 80% resolve in 14 days
without, and they only offer marginal benefit after
7 days NNT15
amoxicillin
or
doxycycline
or phenoxymethylpenicillin
500mg TDS
1g if severe 11D
200mg stat/100mg OD
500mg QDS
For persistent symptoms:
co-amoxiclav
625mg TDS
Use adequate analgesia
Consider 7-day delayed or immediate antibiotic
when purulent nasal discharge NNT8
In persistent infection use an agent with antianaerobic activity eg. co-amoxiclav
LRTI ( Low doses of penicillins are more likely to select out resistance
5 days
1 spray TDS
3 drops TDS
7 days
7 days min to 14
days max
All abx for 7 days
1,
Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal
activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms)
amoxicillin
500 mg TDS
5 days
Acute cough,
Antibiotic little benefit if no co-morbidity
or
bronchitis
Consider 7d delayed antibiotic with advice
doxycycline
200 mg stat/100 mg OD
5 days
Symptom resolution can take 3 weeks.
CKS
NICE 69
Acute
exacerbation of
COPD
NICE 12 Gold
Community
acquired
pneumonia treatment in the
community
BTS 2009
Guideline
Consider immediate antibiotics if > 80yr and
ONE of: hospitalisation in past year, oral
steroids, diabetic, congestive heart failure
OR> 65yrs with 2 of above
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, antibiotics in last 3 months
Use CRB65 score or CRP to help guide and
review: Each CRB65 parameter scores 1:
Confusion (AMT<8);
Respiratory rate >30/min;
BP systolic <90 or diastolic ≤ 60; Age >65;
Score 0: suitable for home treatment;
Score 1-2: hospital assessment or admission
Score 3-4: urgent hospital admission
Mycoplasma infection is rare in over 65s
Amoxicillin
500 mg TDS
5 days
or doxycycline
clarithromycin
200 mg stat/100 mg OD
500 mg BD
5 days
5 days
5 days
If resistance: co-amoxiclav
625 mg TDS
IF CRB65=0: amoxicillin
or clarithromycin
or doxycycline
500 mg TDS
500 mg BD
200 mg stat/100 mg OD
7 days
7 days
7 days
if CRB65=1 & AT HOME
500 mg TDS
500 mg BD
200 mg stat/100 mg OD
7-10 days
amoxicillin
AND clarithromycin
or doxycycline alone
7-10 days
UTI
UTI in adults
(no fever or flank
pain)
Treat Women with severe/or ≥ 3 symptoms
Women mild/or ≤ 2 symptoms AND
a) Urine NOT cloudy 97% negative predicted
value, do not treat unless other risk factors for
infection.
nitrofurantoin or
trimethoprim
pivmecillinam
if organism susceptible
amoxicillin
100mg m/r BD
200mg BD
400mg STAT then 200mg
TDS
500mg TDS
Women all ages 3
days.
Men 7 days
Symps:
dysuria,polyuria
frequency,
urgency, suprap
tenderness PHE
URINE, SIGN
CKS women,
CKS men
RCGP UTI
clinical module
b) If cloudy urine use dipstick to guide treatment.
Nitrite & blood or leucocytes has 92% positive
predictive value; nitrite, leucocytes, and blood all
negative 76% NPV
c) Consider a back-up/delayed antibiotic option.
Men: Consider prostatitis & send pre-treatment
MSU OR if symptoms mild/non-specific, use –ve
dipstick to exclude UTI.
SAPG UTI
In treatment failure: always perform culture
Acute prostatitis
Send MSU for culture and start antibiotics
4-wk course may prevent chronic prostatitis
Quinolones achieve higher prostate levels
Send MSU for culture and start antibiotics
Short-term use of nitrofurantoin in pregnancy is
unlikely to cause problems to the foetus
Avoid trimethoprim if low folate status or on
folate antagonist (eg antiepileptic or proguanil)
Child <3 mths: refer urgently for assessment
Child ≥ 3 months: use positive nitrite to guide
start antibiotics ALSO. Send pre-treatment MSU.
Imaging: only refer if child <6 months, recurrent
or atypical UTI
If admission not needed, send MSU for culture &
sensitivities and start antibiotics Consider IV
ertapenem if ESBL risk
If no response within 24 hours, admit
If ESBL risk and with microbiology advice
consider IV antibiotic via outpatients (OPAT)
To reduce recurrence first advise simple measures
including hydration, cranberry products. Then
standby or post-coital antibiotics. Nightly
prophylaxis: reduces UTIs but adverse effects and
long term compliance poor A short 6 month trial
of Cephalexin 125mg at night is suggested by the
Canadian Urology Society however CKS suggests
insufficient direct evidence to prefer any antibiotic
over another.
BASHH, CKS
UTI in pregnancy
PHE URINE
CKS
UTI in Children
PHE URINE
CKS
NICE
Acute
pyelonephritis
CKS
Recurrent UTI in
non-pregnant
women ≥3 uti/yr
First Line: Nitrofurantoin if GFR over 45ml/min
GFR 30-45: only use if resistance & no
alternative.
Use nitrofurantoin first line as general resistance and community multi-resistant.
Extended-spectrum Beta-lactamase E. coli are increasing. Trimethoprim (if low risk
of resistance) and pivmecillinam are alternative first line agents.
Risk factors for increased resistance include: care home resident, recurrent UTI,
hospitalisation>7d in the last 6 months, unresolving urinary symptoms, recent travel
to a country with increased antimicrobial resistance (outside Northern Europe and
Australasia) especially health related, previous known UTI resistant to
trimethoprim,cephalosporins or quinolones
If increased resistance risk, send culture for susceptibility testing & give safety net
advice. If GFR<45 ml/min or elderly consider pivmecillinam or fosfomycin (3g stat
in women plus 2nd 3g dose in men 3 days later)
ciprofloxacin
500 mg BD
28 days
or ofloxacin
200 mg BD
28 days
nd
2 line: trimethoprim
200 mg BD
28 days
First line: nitrofurantoin
100 mg m/r BD
if susceptible, amoxicillin
500 mg TDS
Second line: trimethoprim
200 mg BD (offGive folate if 1st trimester
label)
All for 7 days
Third line: cefalexin
500 mg BD
Lower UTI: trimethoprim or nitrofurantoin
Lower UTI : 3 days
if susceptible, amoxicillin.
Second line: cefalexin
Upper UTI : 7-10 days
Upper UTI: co-amoxiclav1 Second line: cefixime
ciprofloxacin
500 mg BD
or
co-amoxiclav if lab report
500/125 mg TDS
shows sensitive:
trimethoprim
200mg BD
Antibiotics.Check local
resistance patterns
nitrofurantoin
or
trimethoprim
7 days
7 days
14 days
Post coital stat (offlabel)
50–100 mg
100 mg
Prophylaxis OD at night,
review at 6 months
Hpylori
Eradication of
Helicobacter
pylori
Symptomatic
relapse
NICE dyspepsia
NICE H.pylori
PHE H.pylori
CKS
Treat all positives in known DU, GU or low grade
MALToma. In Non-Ulcer NNT is 14. Do not offer
eradication for GORD. Do not use clarithromycin or
metronidazole if used in the past year for any
infection
Penicillin allergy: use PPI plus clarithromycin &
MZ: If previous clarithromycin use PPI plus
PPI+bismuthate+metronidazole+tetracycline. In
relapse see NICE.
Relapse and previous MZ & clari: use PPI PLUS
amoxicillin, PLUS either tetracycline or levofloxacin.
Retest for H.pylori post DU/GU or relapse after
second line therapy: using breath or stool test OR
consider endoscopy for culture & susceptibility
Always use PPI
First and second line
PPI WITH amoxicillin
PLUS either clarithromycin
OR metronidazole
Penicillin allergy & previous
MZ + clari: PPI PLUS
bismuthate (De-nol tab) PLUS:
metronidazole PLUS
tetracycline hydrochloride 8C
Relapse & previous MZ+clari:
PPI WITH amoxicillin PLUS
tetracycline hydrochloride OR
levofloxacin
TWICE DAILY
1g BD
500mg BD
400 mg BD
All for
7 days
240 mg BD
400mg BD
500mg QDS
MALToma
14 days
1 g BD
500 mg QDS
250mg BD
Chlamydia
Chlamydia
trachomatis/
urethritis
SIGN, BASHH
PHE, CKS
azithromycin
Opportunistically screen all aged 15-25yrs
Treat partners and refer to GUM service
Pregnancy or breastfeeding: azithromycin is the
most effective option
Due to lower cure rate in pregnancy, test for cure
6 weeks after treatment
For suspected epididymitis in men over 35 years
with low risk of STI (High Risk, refer GUM)
1g
100 mg BD
stat
7 days
1g (off-label use)
500 mg QDS
500 mg TDS
stat
7 days
7 days
200 mg BD
100mg BD
14 days
14 days
400 mg BD
or 2 g (more relapse)
5 g applicatorful at night
5 g applicatorful at night
7 days
stat
5 night
7 nights
or doxycycline
Pregnant or breastfeeding:
azithromycin
or erythromycin
or amoxicillin
Epididymitis in men: low STI
risk ofloxacin or
doxycycline
Genital Infections
Bacterial
vaginosis
BASHH
PHE, CKS
Trichomoniasis
BASHH
PHE, CKS
Oral metronidazole (MTZ) is as effective as
topical treatment but is cheaper.
Less relapse with 7 day than 2g stat at 4 wks
Pregnant/breastfeeding: avoid 2g stat +Treating
partners does not reduce relapse
oral MTZ
Treat partners and refer to GUM service
In pregnancy or breastfeeding: avoid 2g single
dose MTZ. Consider clotrimazole for symptom
relief (not cure) if MTZ declined
metronidazole (MTZ)
400 mg BD
or 2 g
5-7 days
stat
clotrimazole
100 mg pessary at night
6 nights
or MTZ 0.75% vag gel
or clindamycin 2% crm
Pelvic
Inflammatory
BASHH, CKS
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 refer to GUM.
metronidazole PLUS
ofloxacin If high risk of GC
Ceftriaxone PLUS
Metronidazole PLUS
doxycycline
400 mg BD
400 mg BD
500 mg IM
400 mg BD
100 mg BD
14 days
14 days
Stat
14 days
14 days
oral flucloxacillin
If penicillin allergic:
oral clarithromycin
topical fusidic acid
MRSA only mupirocin
flucloxacillin
If penicillin allergic:
clarithromycin
or clindamycin
facial: co-amoxiclav
500 mg QDS
7 days
250-500 mg BD
TDS
TDS
500 mg QDS
7 days
5 days
5 days
All for 7 days.
If slow response
continue for a
further 7 days
Skin
Impetigo
CKS
Cellulitis
CKS
For extensive, severe, or bullous impetigo, use oral
antibiotics
Reserve topical antibiotics for very localised lesions
to reduce the risk of resistance
Reserve mupirocin for MRSA
If patient afebrile and healthy other than cellulitis, use
oral flucloxacillin alone
If river or sea water exposure, discuss with
microbiologist.
If febrile and ill, admit for IV treatment
Stop clindamycin if diarrhoea occurs.
500 mg BD
300–450 mg QDS
500/125 mg TDS
General Advice





Lower threshold for antibiotics in immunocompromised or those with multiple morbidities.
Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
Limit prescribing over the telephone to exceptional cases.
Use simple generic antibiotics if possible. Avoid broad spectrum
Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g. fusidic acid).
Useful Information




Cold and flu symptoms will not get any better with antibiotics.
50 % who visit for cold and flu expect anibiotics and 25 % want reassurance.
25% of those prescribed anitibiotics do not finish them; some keep them for future use.
If you have had antibiotics in the last 6 months the next infection is twice as likely to be resistant to antibiotics.
Antibiotic Stewardship (AS)


Antibiotic stewardship refers to the optimal selection of antibiotics for use at the correct dose and duration to maximise clinical outcome while
diminishing toxicity and minimising the impact on antimicrobial resistance.
‘Start smart, then focus’ is an initiative that aids AS. ‘Start smart’ consists of avoiding antibiotics when there is no clinical evidence of bacterial
infection, using local prescribing guidelines and considering allergies.. ‘Then focus’ calls for a review of antibiotics therapy at 48 hours if there is no
improvement with cessation of antibiotics, switching to an alternative or IV therapy.
West Essex CCG Medicines Management Team: Updated February 2015
Date to be revised: February 2016