nhs grampian staff prescribing guidance for the empirical

NHS Grampian Staff Prescribing Guidance for the Empirical Treatment of Infection in

Primary Care

Signature:

Reviewers: Dr Alexander Mackenzie Consultant Infectious Diseases, Chair AMT Dr Ian Gould Consultant microbiologist

Approver: Dr Caroline Hind Medicines Guidelines and Policies Group

Lead Author/Co-ordinator: Gillian Macartney Fiona McDonald Specialist Antibiotic Pharmacists

Identifier: NHSG/Guid/EmpP/675

Signature:

Signature:

Review Date: July 2016

Approval Date: July 2014

UNCONTROLLED WHEN PRINTED

Version 4.4 (Updated March 2015)

Executive Sign-Off

This document has been endorsed by the Medical Director of NHSG Grampian

Signature: ________________________________

UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/Guid/EmpP/MGPG675 - i - NHS Grampian Staff Prescribing Guidance for the Empirical Treatment of Infection in Primary Care – Version 4.4

This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on

(01224) 551116 or (01224) 552245.

This controlled document shall not be copied in part or whole without the express permission of the author or the author’s representative.

Title: NHS Grampian Staff Prescribing Guidelines for the

Empirical Treatment of Infection in Primary Care Unique Identifier: NHSG/Guid/EmpP/MGPG675, Version 4.4 Replaces: NHSG/Guid/EmpP/MGPG675, Version 4.3 Lead Author/Co-ordinator: Specialist Antibiotic Pharmacists Subject (as per document registration categories):

Prescribing Policy

Key word(s): Antibiotic, Antibiotics, Antimicrobials, Infections, Empirical

Therapy, Primary Care Policy, Protocol, Procedure or Process Document:

Guideline (Antimicrobial Prescribing Guideline for Primary Care)

Document application: NHS Grampian - Primary Care Purpose/description: To provide prescribers working in Primary Care in NHS

Grampian guidance on empirical antibiotic therapy choices for common infections in adults and children.

Group/Individual responsible for this document:

Antimicrobial Management Team

Policy statement: It is the responsibility of all staff to ensure that they are

working to the most up to date and relevant policies, protocols procedures. It is the responsibility of individual prescribers to ensure the management of infections in primary care patients is within the guidance laid down in this document. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced

UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/Guid/EmpP/MGPG675 - ii - NHS Grampian Staff Prescribing Guidance for the Empirical Treatment of Infection in Primary Care – Version 4.4

Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo:

Development Pharmacist – Medicines Management

Physical location of the original of this document:

Pharmacy and Medicines Directorate, Westholme

Job title of creator of this document:

Specialist Antibiotic Pharmacists

Job/group title of those who have control over this document:

Antimicrobial Management Team

Responsibilities for disseminating document as per distribution list: Lead Author/Co-ordinator: Specialist Antibiotic Pharmacists

Responsibilities for implementation: Organisational: Operational Management Team and Chief Executive Sector General Managers, Medical Leads and Nursing Leads Departmental: Clinical Leads Area: Line Manager

Review frequency and date of next review:

This policy will be reviewed at least every two years or sooner if current treatment recommendations change.

Responsibilities for review of this document: Lead Author/Co-ordinator: Specialist Antibiotic Pharmacists

Revision History:

Revision Date

Previous Revision Date

Summary of Changes (Descriptive summary of the changes made)

Changes Marked* (Identify page numbers and section heading )

April 2014 Sept 2011 Paediatric amoxicillin doses updated in line with BNF changes. Changes to co-trimoxazole information to reflect length of usage, reported adverse effects, included link to yellow card scheme, removed CSM & noted CG & RM support for unlicensed use. Addition of advice to “Consider immune deficiency and testing for HIV”, to monographs for infections which are indicators for HIV according to BHIVA guidelines. Update of CDI severity markers. Pripsen® discontinued – removed as option for

p3 p4 p5, 9, 10, 16, 17, 23 p6 p7

UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/Guid/EmpP/MGPG675 - iii - NHS Grampian Staff Prescribing Guidance for the Empirical Treatment of Infection in Primary Care – Version 4.4

threadworm. Updated hyperlinks to CKS topics (previously Prodigy). Re-ordering of influenza section and addition of morbid obesity as a risk factor (HPS). Tonsillitis – added link to non-prescription pads. Updated COPD references. CAP -Added penicillin allergy options for CRB>3, defined children’s course length as 3-5days, reduced CRB0 course length to 5 days and CRB1 to 5-10days. Added HPA guidance for UTI, moved key references to headers for section, & added SAPG references. Pyelonephritis – replaced EJU reference with CKS, added antibiotic choices for children. GUM now Sexual Health Service, new contact number. Gonorrhoea – added penicillin allergy option and warning re: sub-optimal cefixime regimen BASHH acute prostatitis guidance now replaced by CKS, chronic prostatitis section removed as not empirical. Dental abscess, severe gingivitis – amoxicillin & metronidazole doses doubled in line with HPA, SCDEP, CKS. Griseofulvin course aligned with HPA. Added links to non-prescription pads. Remove links to penicillin allergy policy in Appendix 2.

Whole document p8 p9 p9 & 30 p10, 11 p13 -16 p14 p17-20 p18 p19 p24 p29 p31 p33

October 2014

April 2014 Adjustment to the miconazole dosing.

p26 and p37

October 2014

April 2014 Correction to spelling of terbinafine.

p30

January 2015

April 2014 Link to HPS website added. p8

April 2015 January 2015 Amoxicillin dose for otitis media updated

p25 and p35

* Changes marked should detail the section(s) of the document that have been amended i.e. page number and section heading.

NHS Grampian Staff Prescribing Guidance for the Empirical Treatment of Infection in Primary Care

UNCONTROLLED WHEN PRINTED Review Date: July 2016 Identifier: NHSG/Guid/EmpP/MGPG675 - 1 - NHS Grampian Staff Prescribing Guidance for the Empirical Treatment of Infection in Primary Care – Version 4.4

Contents Page No General Notes ............................................................................................................ 2

Aim .......................................................................................................................... 2

Principles Of Treatment .......................................................................................... 2

Specialist Advice ..................................................................................................... 2

Structure Of The Guidance ..................................................................................... 3

Dosing And Duration ............................................................................................... 3

Further Reference Sources ..................................................................................... 3

Clostridium Difficile And High Risk Antibiotic Agents .............................................. 4

Co-trimoxazole ........................................................................................................ 4

Erythromycin/Clarithromycin ................................................................................... 4

Pregnancy ............................................................................................................... 4

1. Gastro-intestinal Tract and Intra-abdominal ............................................................ 5

2 Respiratory system .................................................................................................. 8

3 Central nervous System ........................................................................................ 12

4 Urinary Tract .......................................................................................................... 13

5 Genital system ....................................................................................................... 18

6 Eye ........................................................................................................................ 22

7 Ear, nose, and oropharynx .................................................................................... 24

8 Skin ....................................................................................................................... 27

Consultation List ....................................................................................................... 32

References ............................................................................................................... 33

Appendix 1: NHS Grampian Leaflet Links ................................................................ 34

Appendix 2: Summary Guide to Treatment of Common Infections in Primary Care . 35

Appendix 3: Version Control Statements .................................................................. 37 Some abbreviations used BNF - British National Formulary BSAC - British Society Of Antimicrobial Chemotherapy BTS - British Thoracic Society CKS - Clinical Knowledge Summaries HEAT - Health Efficiency And Access To Treatment HPA - Health Protection Agency HPS - Health Protection Scotland MHRA - Medicines And Healthcare Products Regulatory Agency MSU - Mid Stream Urine NICE - National Institute Of Clinical Excellence SIGN - Scottish Intercollegiate Guidelines Network SPC - Summary Of Product Characteristics

NHS Grampian Staff Prescribing Guidance For The Empirical Treatment Of Infection In Primary Care


General Notes Resistance to antibiotics and other antimicrobials is recognised locally and nationally as a major threat to public health and patient safety. The prevalence of antimicrobial resistant bacteria and other healthcare associated infections is partly governed by antimicrobial usage. Prescribers are therefore encouraged to prescribe antibiotics prudently and follow local and national guidelines as a matter of good clinical governance. Aim To provide guidance for the treatment of common infections within Primary Care as detailed in the Grampian Joint Formulary, taking into account the bacterial susceptibility patterns in Grampian. The aim is to minimise the emergence of bacterial resistance and healthcare associated infection in the community and to encourage the rational and cost effective use of antibiotics. Principles Of Treatment 1. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 2. It is important to use the correct dose and appropriate course length, modified as

required for age, weight, renal function and severity of infection. 3. Do not prescribe an antibiotic for viral sore throat, simple coughs and colds. 4. Consider delayed prescriptions for acute self-limiting upper respiratory tract

infections if symptoms suggest that an antibiotic may be indicated. 5. Lower the threshold for prescribing antibiotics in immunocompromised or those

with multiple co-morbidities; consider culture and seek advice. 6. Limit prescribing for telephone consultations to exceptional cases. 7. 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, meticillin resistant staphylococcus aureus (MRSA) and resistant urinary tract infections (UTIs).

8. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from the on call microbiologist via ARI switchboard (0845 456 6000).

Specialist Advice For patients with a history of infection with meticillin resistant staphylococcus aureus (MRSA) or extended spectrum beta-lactamases (ESBLs)/multidrug resistant organisms, specialist advice about choice of antibiotics should be sought from medical microbiology. Suitable samples should be taken where appropriate and sent to microbiology with a clinical history. On the receipt of culture results, the choice of antimicrobial* should be reviewed, taking into consideration antimicrobial sensitivities, patient factors (refer to penicillin allergy policy), toxicity, and cost-effectiveness. [*NB: antimicrobial sensitivities are listed alphabetically – please check full list before choosing most suitable option]. Further advice on treatment is available from the on-call Medical Microbiologist, Specialist Antimicrobial Pharmacist or Infection Unit Physician.



Structure Of The Guidance The guidance is organised into body systems, with the infections likely in each system listed in tables. Likely organisms are also stated, indicating the spectrum covered by the empirical antibiotics suggested. Treatment choices are listed, for most indications with a first choice, and then an alternative treatment. The alternative treatment is not a suggested 2nd line treatment for when the initial treatment has failed, but gives an alternative treatment should the first line be unsuitable, for example due to allergy. The column furthest to the right indicates reference sources which can be referred to for further information (many of which are the basis of the treatment choices) and any other information which may be of help in managing the patient. There are links to some national patient information leaflets within the comments column, links to NHS Grampian leaflets can be found in Appendix 1. Dosing And Duration Recommended adult doses and durations of treatment have been included but often this will depend upon clinical judgement in the individual case. Most infections will normally respond to a three to ten day course. Doses in the policy are for adults only unless otherwise stated, and assume normal renal and hepatic function. The table below details paediatric doses for more commonly used antibiotics, assuming average weight. See BNF for Children (BNFC) for more detailed information. COMMON PAEDIATRIC DOSES - assuming average weight.

*Some doses can be doubled in severe infections. Phenoxymethyl-

penicillin 4 x daily

Amoxicillin 3 x daily Erythromycin*

4 x daily Flucloxacillin*

4 x daily Trimethoprim

2 x daily Nitrofurantoin

4 x daily

1mth - 1 yr 62.5mg 1mth – 1 yr: 125mg 1mth - 2 yrs 125mg 1mth - 2 yrs 62.5mg 6mths-6yrs 50mg 750micrograms/kg 1-5 yrs 125mg 1-5 yrs 250mg 2-8 yrs 250mg 2 - 10 yrs 125mg 6-12 yrs 100mg 12-18 yrs 50mg 6-12 yrs 250mg Over 5 yrs 500mg Over 8 yrs 250-500mg Over 10 yrs 250mg

NB. Tetracycline antibiotics should not be used in children under 12 years of age. Quinolones are not generally recommended in children and growing adolescents (see BNFC). Doses of phenoxymethylpenicillin can be increased to ensure at least 12.5mg/kg four times daily is given (see www.bnf.org). Doses of amoxicillin can be increased to 30mg/kg eight hourly (see www.bnf.org). Please refer to BNF for Children for doses outwith the above age ranges. Further Reference Sources Prescribers should refer to the BNF (www.bnf.org), BNF for Children (www.bnf.org) or the manufacturers’ summary of product characteristics (www.medicines.org.uk) for further information. For information on the use of antibiotics in pregnant or breastfeeding women, or in patients with renal or hepatic impairment please refer to BNF (information in individual drug monographs), or contact Medicines Information (Tel: 01224 552316). Please also note the Medicines and Healthcare products Regulatory Agency (MHRA) advice for the use of cough and cold preparations in children if advising on self care (see references).

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Where the suggested antibiotic choices in the table are not suitable, prescribers are encouraged to follow guidance in any of the references indicated in the text for further treatment options (national evidence based guidelines). Clostridium Difficile And High Risk Antibiotic Agents The ‘4C’ antibiotics (clindamycin, ciprofloxacin and other quinolones, co-amoxiclav and the cephalosporins, especially third generation) are associated with a higher risk of Clostridium difficile infection (CDI). The restriction of the use of these agents across Scotland has successfully led to a reduction in the rate of this infection in line with the Scottish Government Health Efficiency and Access to Treatment (HEAT) target. These agents are therefore not recommended as first line treatments for common primary care infections. There may be situations where these are the most appropriate antibiotics to give, but should only be prescribed after careful consideration of the risks and clinical benefit of prescribing. Caution should be used when considering use of these agents in patients over the age of 65 years who are particularly at risk of the development of CDI. (NB: CDI could present in any individual, especially above 65 years, irrespective of history of previous hospital or long term care). Co-trimoxazole Co-trimoxazole is recommended as empirical treatment throughout this document on the advice of our local microbiology consultants. Co-trimoxazole is currently restricted to a very limited range of indications and empirical use in this way is unlicensed. However, this has been noted by the NHSG Clinical Governance and Risk Management committees in order to support local use empirically. Co-trimoxazole has not been restricted in the same way in other countries, including the USA. It has been used locally for over 4 years to treat urinary, intra-abdominal and severe respiratory infections. A small number of significant haematological side-effects have been reported, however the majority of noted adverse effects have been related to hyperkalaemia, rash or gastro-intestinal effects. Prescribers are encouraged to weigh the risks and benefits of this treatment, and to consider alternative treatments in patients who take concurrent interacting medication or who are at greater risk of developing serious side effects. Any adverse effects noticed should be reported to the Antimicrobial Management Team via [email protected]. Significant side-effects should be reported to the MHRA via the yellow card scheme - https://yellowcard.mhra.gov.uk/. Erythromycin/Clarithromycin Where erythromycin is indicated as a choice, please prescribe 250mg EC tablets. For patients unable to tolerate erythromycin, clarithromycin may be substituted –check BNF for equivalent dosage. (NB: Clarithromycin is not considered to be one of the ‘4Cs’). Pregnancy In pregnancy avoid tetracyclines, aminoglycosides, quinolones, and high dose metronidazole (2g). Short term use (≤7 days) of nitrofurantoin is unlikely to cause problems to the foetus. Avoid trimethoprim if low folate status or taking folate antagonist (e.g. antiepileptic or proguanil). Local recommendation is to avoid trimethoprim (and co-trimoxazole) in first trimester and nitrofurantoin in third trimester.

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1. Gastro-intestinal Tract and Intra-abdominal • Contact medical microbiology for advice if severe or prolonged illness. Severity markers include: presence of blood/ mucus in stool,

abdominal pain, fever, tenesmus or risk factors for hypochlorhydria. • For all infectious causes provide hand and environmental hygiene advice. Advise not to return to work/ school until 48 hours after symptoms

have settled. Public Health will advise on specific exclusions if required. INFECTION Likely organisms 1st Choice Treatment Alternative option Comments / notes / references Infective gastroenteritis Antibacterials not usually indicated. Frequently self limiting and may not be bacterial. Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection Consider immune deficiency and testing for HIV.

Campylobacter Usually no antibiotic therapy required.

*First choice once confirmed by culture: erythromycin 250mg oral four times daily for 5 days

Contact Medical Microbiology.

Clinical Knowledge Summaries (CKS - http://www.evidence.nhs.uk),– Gastroenteritis, Traveller’s diarrhoea; BNF * If systemically unwell (see severity markers above) and campylobacter suspected (e.g. undercooked meat and abdominal pain) consider erythromycin if treated early.

Bacillary dysentery Shigella spp Salmonella spp (not S. typhi or S. paratyphi)

If treatment indicated; ciprofloxacin 500mg oral twice daily for 1 day (5 days if Shigella dysenteriae type 1)


For children treat only according to sensitivities. Travellers’ diarrhoea – see notes below CKS, BNF, SPC

E.coli 0157 No treatment with antibiotics or antimotility drugs

Seek expert clinical advice Contact Public health

Giardia spp metronidazole 400mg oral three times daily for 5 days or 2g once daily for 3 days


Child 1–3 years : 500 mg once daily for 3 days Child 3–7 years : 600–800 mg once daily for 3 days Child 7–10 years : 1 g once daily for 3 days Child 10–18 years : as for adult dose Recurrence of Giardiasis is high even with optimal treatment, therefore follow up stool sample is advised.

Amoebiasis Entamoeba histolytica

Contact Medical Microbiology / Infectious diseases for advice.

CKS – Gastroenteritis, Traveller’s diarrhoea

Viruses No treatment with antibiotics Travellers’ diarrhoea (seek specialist advice in children)

Only consider standby antibiotics for remote areas or people at high-risk of severe illness with traveller’s diarrhoea; ciprofloxacin 500mg twice a day for 3 days (private Rx). In areas of high quinolone resistance (e.g. south Asia) consider prophylactic bismuth subsalicylate (Pepto Bismol) 2 tablets four times daily as prophylaxis or for 2 days treatment.

CKS, NHS advice website http://www.fitfortravel.nhs.uk/advice/disease-prevention-advice/travellers-diarrhoea.aspx Ref: http://www.nathnac.org/pro/factsheets/trav_dir.htm

https://www.evidence.nhs.uk/�

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have settled. Public Health will advise on specific exclusions if required. INFECTION Likely organisms 1st Choice Treatment Alternative option Comments / notes / references Clostridium difficile infection (CDI) - antibiotic associated colitis

Clostridium difficile • Ensure infection control measures are in place – do not wait for confirmation of diagnosis

• Stop any (non-Clostridium difficile) antimicrobial treatment in patients with CDI if possible

• Rehydrate patient. • Assess symptoms and severity of disease

taking into account individual risk factors for patient:

Severity Markers • Temperature >38.5°C • Consider severe co-morbidities /

immunodeficiency • Suspicion of pseudomembranous colitis,

toxic megacolon, ileus • Evidence of severe colitis on CT scan / X-

ray • White blood cell count >15 x 109cells/L • Acute rising creatinine >1.5 x baseline

For further information refer to local policy [Infection Control home page on intranet] or HPS guidance (January 2014) can be accessed online at: http://www.documents.hps.scot.nhs.uk/about-hps/hpn/clostridium-difficile-infection-guidelines.pdf

• Review any concurrent gastric acid suppressant therapy and reduce or stop if appropriate.

• Review and stop any antimotility agents to reduce the risk of toxic megacolon development.

• Ensure patient aware to stop laxatives for duration of symptoms.

NB. Alcohol gel does not kill C. difficile spores.

Patient has 0-1 severity markers

metronidazole 400mg oral three times daily for 10-14 days. If condition does not improve after 5 days, switch to oral vancomycin.

Patient has ≥2 severity markers OR no response after 5 days of metronidazole

vancomycin 125mg oral four times daily for 10-14 days. Refer to hospital.

http://www.documents.hps.scot.nhs.uk/about-hps/hpn/clostridium-difficile-infection-guidelines.pdf�

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have settled. Public Health will advise on specific exclusions if required. INFECTION Likely organisms 1st Choice Treatment Alternative option Comments / notes / references Threadworms Pinworms

Enterobius vermicularis

All over 2 years old: mebendazole 100mg oral as a single dose. A second dose may be given after 2 weeks. 6 months – 2 years: as above, but unlicensed < 6 months old: hygiene methods only

Treat all household contacts at same time PLUS advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower) PLUS wash sleepwear, bed linen, dust and vacuum on day one. Avoid shared towels. NHSG info leaflet CKS: http://cks.nice.org.uk/threadworm#!management

Cholecystitis Escherichia coli Klebsiella spp Proteus spp Enterococci

Note that it is recommended that patients be admitted to secondary care for assessment due to the high mortality rate. Non-severe cases consider: doxycycline 100-200mg for 7 days OR co-trimoxazole# 960mg twice daily for 7 days

CKS – acute cholecystitis: http://cks.nice.org.uk/cholecystitis-acute#azTab #co-trimoxazole unlicensed for this indication– see general notes

Diverticulitis Anaerobes Gram negative rods

metronidazole 400mg oral three times daily PLUS doxycycline* 100-200mg daily for 7 days

metronidazole 400mg oral three times daily PLUS co-trimoxazole# 960mg twice daily for 7 days.

CKS:acute diverticulitis - see criteria for admission. http://cks.nice.org.uk/diverticular-disease#azTab *NB doxycycline not suitable in those under 12 years. #co-trimoxazole unlicensed for this indication– see general notes

Helicobacter pylori eradication

First line: omeprazole 20mg oral twice daily PLUS clarithromycin 500mg oral twice daily PLUS amoxicillin 1g oral twice daily for 7 days

Penicillin allergy: omeprazole 20mg oral twice daily PLUS clarithromycin 500mg oral twice daily PLUS metronidazole 400mg twice daily for 7 days

Second line option: omeprazole 20mg oral three times daily PLUS De-Noltab® 120mg oral three times daily PLUS tetracycline 500mg oral three times daily PLUS metronidazole 400mg oral three times daily for 7 days Based on GI consultant recommendations due to microbiological resistance and patient compliance issues.

http://intranet.grampian.scot.nhs.uk/foi/files/ThreadwormsSeptember2006.pdf�

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2 Respiratory system INFECTION Likely

organisms Treatment choices Comments / notes / references

Influenza Antivirals only to be used when predefined threshold is reached and announcement made by the Scottish Government

Influenza A and B NB: this guidance refers to seasonal influenza and not pandemic strains

Annual vaccination is essential for all those at risk of influenza. At risk patients in whom antivirals should be considered include those over 65 years or those who have one or more of the following conditions; • Chronic respiratory disease (inc. COPD & asthma) • Chronic heart disease • Chronic renal disease • Chronic liver disease • Chronic neurological disease • Immunocompromised • Diabetes mellitus • Pregnant (including up to 2 weeks post partum) • Morbid obesity (BMI ≥ 40)

**Use oseltamivir 75mg oral twice daily for 5 days in adults and children over 13 years – see table below for children’s doses and refer to HPS guidance (once daily for 10 days for post exposure prophylaxis)

or zanamivir 10mg by inhalation twice daily for 5 days in adults and children over 5 years for treatment (not licensed in <5years) (10mg by inhalation once daily for 10 days for post exposure prophylaxis).

**Please refer to: HPS Influenza guidance http://www.hps.scot.nhs.uk/resp/seasonalInfluenza.aspx#antivirals Additional information - NICE technology appraisal 168 (treatment) and 158 (prophylaxis) Oseltamivir and zanamivir are recommended for post-exposure prophylaxis of treatment of flu if all of the following apply: • The amount of flu virus circulating is enough that if someone has a

flu-like illness it is likely that it has been caused by the flu virus • The person is in an at-risk group • The person has been in contact with someone with a flu-like illness

and can start treatment within 36 hours (for zanamivir) or within 48 hours (for oseltamivir)

• Oseltamivir and zanamivir are not recommended for seasonal

prophylaxis against influenza • Oseltamivir and zanamivir are not recommended for post-exposure

prophylaxis or treatment of otherwise healthy individuals with influenza.

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Lower respiratory tract infection – acute cough, bronchitis

Antibiotic of little benefit unless patient has co-morbidity. Symptom resolution can take 3 weeks. Consider delaying antibiotic by 7-14 days and give symptomatic advice / patient cough leaflet – see link Appendix 1.

See MHRA guidance on cough and cold preparations in children (link in references) if applicable. See community acquired pneumonia (below) for antibiotic choice if considered appropriate.

Upper respiratory tract infection – Pharyngitis/ acute sore throat

Mostly viral Avoid antibiotics 90% resolve in 7 days with no antibiotics and antibiotics only reduced pain by 16 hours. Patients with 3 or 4 Centor criteria (history of fever, purulent tonsils, cervical lymphadenopathy, absence of cough) consider prescription after 2-3 days’ delay or immediate antibiotics. You need to give antibiotics to >4000 patients to prevent one quinsy, and to 200 patients to prevent one otitis media. See NHSG sore throat leaflet link – Appendix 1 and CKS: http://cks.nice.org.uk/sore-throat-acute

Only if antibiotic indicated according to criteria in comments section: phenoxymethylpenicillin 500mg oral four times daily for 7 – 10 days

erythromycin 500mg oral four times daily for 7 – 10 days

Aspiration pneumonia

Refer to secondary care See hospital guidelines for further information.

Tuberculosis Seek specialist advice Consider immune deficiency and testing for HIV. Tonsillitis

75% viral No antimicrobial treatment* * “Non-prescription” pad links in Appendix 1 Streptococcus pyogenes

Consider no* or delayed prescription phenoxymethylpenicillin 500mg oral four times daily for 7 - 10 days

erythromycin 500mg oral four times daily for 7 - 10 days

Avoid amoxicillin, co-amoxiclav or ampicillin due to probable reactions if glandular fever present. Patients with 3 or 4 Centor criteria (history of fever, purulent tonsils, cervical lymphadenopathy, absence of cough) consider prescription after 2-3 days’ delay or immediate antibiotics. CKS: http://cks.nice.org.uk/sore-throat-acute

Infective exacerbations of COPD or chronic bronchitis (Cont’d over)

30% infections are viral, 30 – 50% are bacterial, and the rest are undetermined.

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume.

Note: use of an antibiotic is not recommended in the absence of purulent sputum. Please send sputum sample to microbiology for culture. Consider delayed prescription if appropriate.

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Mild-Moderate (Infective exacerbations of COPD or chronic bronchitis)

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis

amoxicillin 500mg oral three times daily for 5 days

erythromycin 500mg oral four times daily OR doxycycline* 200mg stat then 100mg once daily for 5 days.

Patient leaflets can reduce antibiotic use - see Appendix 1. Refs: GOLD Guidelines for COPD, 2014; NICE CG101; CKS. Refer to guidelines for advice on additional treatment with oral prednisolone. *NB doxycycline is not suitable in those under 12 years.

Community acquired pneumonia (CAP) 70% of community acquired pneumonia is due to Streptococcus pneumoniae. In NHS Grampian resistance to Streptococcus pneumoniae is rare.

Streptococcus pneumoniae (lobar pneumonia) Mycoplasma pneumoniae (atypical pneumonia) Chlamydia pneumoniae

Assessment of severity should be made using the CRB-65 criteria • Confusion – (defined as mental test score of 8 or less, or new disorientation in person, place or time) • Respiratory rate >30/minute • BP systolic <90mmHg or BP diastolic <60mmHg • 65 or more years of age

Start antibiotic immediately CRB-65 =0 without co-morbidity or clinical concern - may treat at home with oral antibiotics CRB-65 = 1-2 or co-morbidity or clinical concern - consider hospital referral CRB-65 ≥3 denotes severe pneumonia which requires urgent admission to hospital. (Give immediate IM benzylpenicillin or oral amoxicillin 1g (in penicillin allergy give oral doxycycline 200mg or co-trimoxazole 960mg) if delayed admission/ life threatening.) Also treat as severe if multilobar consolidation or cavitation on chest X-ray Refer to BTS Guidelines & primary care summary version for further information: http://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/ Consider immune deficiency and testing for HIV.

CRB-65 = 0 (Mild, uncomplicated, treat in community)

amoxicillin 500mg oral three times daily for 5 days

erythromycin 500mg oral four times daily OR doxycycline* 200mg stat then 100mg daily for 5 days

Primary treatment failure, refer to secondary care. If no response in 48 hours consider admission. If severe refer to secondary care. In children, a shorter treatment course of 3-5 days should be considered. *NB doxycycline is not suitable in those under 12 years.

CRB-65 = 1 continued overleaf…..

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http://cks.nice.org.uk/chronic-obstructive-pulmonary-disease#!scenario:1�

http://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/�








CRB-65 = 1 and at home

amoxicillin 500mg oral three times daily AND erythromycin 500mg oral four times daily for 5 – 10 days

doxycycline* 200mg stat then 100mg daily for 5 – 10 days

Primary treatment failure refer to secondary care. If no response in 48 hours consider admission. If severe refer to secondary care. *NB doxycycline is not suitable in those under 12 years.

Post influenza associated CAP

Staphylococcus aureus

ADD flucloxacillin 1g [unlicensed dose] oral four times daily. Treat for 14-21 days.

Add to empiric treatment for community acquired pneumonia.



3 Central nervous System INFECTION Likely organisms 1st Choice Treatment Alternative Treatment Comments/ notes / references Bacterial meningitis Admit to hospital Treatment should NOT be delayed in suspected cases of bacterial meningitis. Empirical antimicrobial therapy should be given prior to lumbar puncture if there is any delay.

Neisseria meningitides Streptococcus pneumoniae >50 yrs in addition: Listeria monocytogenes Aerobic Gram negative bacilli - coliforms Under 2 years: Group B streptococcus Listeria monocytogenes (more commonly <1mth) E coli H. influenzae S. pneumoniae

benzylpenicillin as single dose before admission to hospital Ideally give as IV bolus but may be given IM ≥ 10 yrs: 1200mg 1 – 9 yrs: 600mg < 1yr: 300mg

cefotaxime as single dose before admission to hospital Ideally give as IV bolus but may be given IM > 12 yrs: 1g < 12 yrs: 50mg/kg In severe penicillin allergy consider chloramphenicol IV

Contact Public Health. See British Infection Society guidelines http://www.meningitis.org/health-professionals/general-practice SIGN 102: Management of invasive meningococcal disease in children and young people http://www.sign.ac.uk/pdf/sign102.pdf NICE CG102: Bacterial meningitis and meningococcal septicaemia - http://guidance.nice.org.uk/CG102 Treatment for prevention of secondary cases of meningitis should only be prescribed on the advice of a Public Health Consultant

http://www.meningitis.org/health-professionals/general-practice�

http://www.meningitis.org/health-professionals/general-practice�

http://www.sign.ac.uk/pdf/sign102.pdf�

http://guidance.nice.org.uk/CG102�



4 Urinary Tract • Always use urine testing strips for leukocytes, nitrites, blood and protein, to help diagnosis • For elderly, males, pregnant patients or children, or where there is fever, back/loin pain always send off an MSU sample

References: HPA Diagnosis of UTI – QRG for Primary Care: http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1194947404720 SIGN 88 – Management of suspected bacterial UTI in adults: http:/www.sign.ac.uk/pdf/sign88.pdf NICE – UTI in children: http://www.nice.org.uk/nicemedia/pdf/CG54NICEguideline.pdf INFECTION Likely organisms 1st Choice

Treatment Alternative treatment

Comments / notes / references

Asymptomatic bacteriuria (including catheterised patients)

Enterobacteriaceae (e.g. Escherichia coli Proteus mirabilis Klebsiella spp.) Staphylococcus saprophyticus

No treatment required except in; • Pregnancy • Urinary tract abnormality/

obstruction • Men or women about to

undergo an invasive genitourinary procedure

Do NOT use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI.

See references above & SAPG Decision aid for management of catheter associated UTI: http://www.scottishmedicines.org.uk/files/sapg/Decision_aid_for_management_of_CAUTI.pdf See leaflet link – Appendix 1.

http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1194947404720�


http://www.nice.org.uk/nicemedia/pdf/CG54NICEguideline.pdf�

http://www.scottishmedicines.org.uk/files/sapg/Decision_aid_for_management_of_CAUTI.pdf�







Uncomplicated Lower UTI (i.e. no fever or flank pain) in men, women and children or Acute cystitis

trimethoprim 200mg oral twice daily for 3 days in women or 7 days in men. Treat for 3 days in children.

nitrofurantoin 50mg oral four times daily or 100mg MR twice daily for 3 days in women or 7 days in men Treat for 3 days in children*.

Multidrug resistant / Extended spectrum β-lactamase enzyme producing bacteria (ESBLs) are increasing so perform culture in all treatment failures. Consider specialist referral for recurrent infection. Nitrofurantoin should be avoided in renal impairment (eGFR <45mL/min). See SAPG Alternative management of UTI in non-pregnant women: http://www.scottishmedicines.org.uk/files/sapg/Alternative_management_of_lower_UTI_in_non-pregnant_women.pdf Children: Send pre-treatment MSU for all. Urgently admit all children under 3 months with suspected UTI. Refer for investigation if child <6 months, recurrent or atypical UTI. *Cefalexin suspension is a more cost-effective alternative than nitrofurantoin suspension for children under 12 years and those unable to take tablets.

Asymptomatic bacteriuria in pregnancy

Treatment should be based on sensitivity results.

Check antibiotic is suitable for use in pregnancy (BNF under individual drugs or Medicines Information (01224 552316)).




http://www.scottishmedicines.org.uk/SAPG/Quality_Improvement/Infection_Management�

http://www.scottishmedicines.org.uk/files/sapg/Alternative_management_of_lower_UTI_in_non-pregnant_women.pdf�

http://www.scottishmedicines.org.uk/files/sapg/Alternative_management_of_lower_UTI_in_non-pregnant_women.pdf�







Lower UTI in pregnancy

nitrofurantoin (avoid in 3rd trimester) 50mg oral four times daily or 100mg MR twice daily for 7 days ** see comments

trimethoprim (avoid in 1st trimester) 200mg twice daily for 7 days ** see comments

Send MSU for culture but start antibiotics immediately. Short term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. Nitrofurantoin should also be avoided in renal impairment. Avoid trimethoprim if low folate status or taking folate antagonist (e.g. antiepileptic or proguanil). **Alternative antibiotic which can be used at any stage in pregnancy (if trimethoprim not suitable in 3rd trimester or nitrofurantoin not suitable in 1st trimester): cefalexin 500mg twice daily for 7 days.

Pyelonephritis (Upper urinary tract infection) Complicated UTI

Escherichia coli Proteus spp Klebsiella spp

co-trimoxazole 960mg twice daily for 14 days [unlicensed – see General Notes]

co-amoxiclav 625mg three times daily for 14 days

Send MSU for culture. RCT shows 14 days co-trimoxazole as good as 7 days ciprofloxacin. Admit if no response in 24 hours. See CKS Pyelonephritis – acute: http:/cks.nice.org.uk/pyelonephritis-acute#!scenario For serious, or potentially life threatening, infection consider use of ciprofloxacin (500mg twice daily), take appropriate microbiology specimens, and review and rationalise treatment after 24 hours. Children: Consider referring child to paediatrician. Co-amoxiclav recommended first-line, consider cefixime in mild penicillin allergy, ciprofloxacin in severe penicillin allergy (with caution – refer to BNFC).




http://cks.nice.org.uk/pyelonephritis-acute�







Catheter UTI Escherichia coli, other intestinal aerobes

See SAPG Decision aid for management of catheter associated UTI: http://www.scottishmedicines.org.uk/files/sapg/Decision_aid_for_management_of_CAUTI.pdf Bacterial colonisation of long term indwelling catheters is very common. Antimicrobial therapy is not indicated unless the patient has evidence of systemic infection e.g. pyrexia, loin pain, raised white cell count or acute confusion in the elderly. Smelly or cloudy urine, or catheter blockage are not indications for antimicrobials. If systemic treatment is likely, treat as for pyelonephritis. Evidence suggests that catheter change prior to treatment results in more rapid symptom resolution and lower rates of treatment failure. Consider referral to continence services. Link to local guidance: GJF - catheter related UTI treatment [Antibiotic prophylaxis at catheter insertion is only indicated in patients for whom bacteriuria is associated with a high risk of sepsis or those at particular risk of infective endocarditis – refer to acute sector empirical antibiotic guidelines for high risk conditions and antibiotic options] Link to local guidance: GJF – prophylaxis of UTI and bacteraemia




http://www.scottishmedicines.org.uk/files/sapg/Decision_aid_for_management_of_CAUTI.pdf�

http://www.nhsgrampian.org/nhsgrampian/GJF_general_new.jsp?pElementID=1225&pContentID=5783&p_applic=CCC&pMenuID=464&p_service=Content.show&�

http://www.nhsgrampian.org/nhsgrampian/GJF_general_new.jsp?pElementID=1225&pContentID=7531&p_applic=CCC&pMenuID=464&p_service=Content.show&�




References: HPA Diagnosis of UTI – QRG for Primary Care: http://www.hpa.org.uk/webc/hpawebfile/hpaweb_c/1194947404720 SIGN 88 – Management of suspected bacterial UTI in adults: http:/www.sign.ac.uk/pdf/sign88.pdf NICE – UTI in children: http://www.nice.org.uk/nicemedia/pdf/CG54NICEguideline.pdf INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Long term prophylaxis (women and children) NB: Treatment options should take into account previous MSU C&S results – contact Medical Microbiology for further advice when required

trimethoprim 100mg oral stat dose post coital OR at night for up to 6 months

In treatment failure or allergy: nitrofurantoin 50-100mg oral stat dose post coital OR at night for up to 6 months <12 years cefalexin suspension 12.5mg/kg (max 125mg) at night cefalexin suspension is a more cost-effective alternative to nitrofurantoin suspension.

Recurrent UTI in women (definition - British Medical Journal): - 3 episodes of UTI in 12 months or - 2 episodes in 6 months

Refer to SAPG Guidance on management of recurrent lower UTI in non-pregnant women – http://www.scottishmedicines.org.uk/files/sapg/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf CKS Preventing recurrent UTIs: http://cks.nice.org.uk/urinary-tract-infection-lower-women#!scenariorecommendation:11 Consider prophylaxis in children with recurrent UTI. Do not prescribe prophylaxis in children with asymptomatic bacteriuria. Please see NICE guidance (above) for advice on recurrent UTI in children.




http://www.scottishmedicines.org.uk/files/sapg/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf�

http://www.scottishmedicines.org.uk/files/sapg/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf�

http://cks.nice.org.uk/urinary-tract-infection-lower-women#!scenariorecommendation:11�

http://cks.nice.org.uk/urinary-tract-infection-lower-women#!scenariorecommendation:11�



5 Genital system • For full guidelines (British Association of Sexual Health and HIV) see http://www.bashh.org/guidelines • If STI diagnosed then refer to Sexual Health Service (0845 337 9900) for partner notification and advice if required. INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Uncomplicated Genital Chlamydia in men and women

Chlamydia trachomatis azithromycin 1g oral stat

doxycycline 100mg twice daily for 7 days

Refer to Sexual Health Service for partner notification and advice. In pregnancy and breastfeeding azithromycin is the most effective option but it is ‘off label’. This is recommended by SIGN 109. Doxycycline is contra-indicated in pregnancy. Advise to avoid sexual contact until treatment complete (or 7 days after azithromycin). Consider immune deficiency and testing for HIV.

Gonorrhoea

Neisseria gonorrhoea #cefotaxime 500mg IM as single dose AND azithromycin 1g oral as single dose

Penicillin allergy: azithromycin 2g oral as single dose – test of cure at 2 weeks mandatory

#cefixime 400mg oral as a single dose followed by 200mg 6-12 hours later AND azithromycin 1g oral as single dose NB: See note under comments

# Treatment choice dependent on availability of cefotaxime IM. Note: Cefixime dosing based on expert advice but regimen sub-optimal due to increasing resistance. Test of cure at 2 weeks mandatory. Referral to Sexual Health Service for further management advice and partner notification. Ref: BASHH guideline 2011.

Pelvic Inflammatory Disease

Chlamydia trachomatis, Neisseria gonorrhoea and others

doxycycline 100mg oral twice daily AND *metronidazole 400mg oral twice daily for 14 days (see note)

Refer to GUM for further advice (e.g. in pregnancy and breastfeeding) and partner notification.

Cefotaxime 500mg IM as single dose, or cefixime 400mg oral followed by 200mg 6-12 hours later, should be added if gonorrhoea strongly suspected or confirmed. (Cefixime dosing based on expert advice due to risk of resistance) BASHH: Management of PID 2011 *Metronidazole has been added to cover anaerobes, which have a greater importance in severe PID. Metronidazole can be omitted in mild to moderate PID or if not tolerated. Consider immune deficiency and testing for HIV.

Primary Genital Herpes

Herpes simplex virus 1 or 2

aciclovir 400mg oral three times daily for 5 days

Duration may need to be longer if new lesions appear during treatment or healing incomplete. BASHH 2007. Refer for recurrent management. Consider immune deficiency and testing for HIV.

http://www.bashh.org/guidelines�



5 Genital system • For full guidelines (British Association of Sexual Health and HIV) see http://www.bashh.org/guidelines • If STI diagnosed then refer to Sexual Health Service (0845 337 9900) for partner notification and advice if required. INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Urethritis (non-gonorrhoea)

Organism unidentified azithromycin 1g oral stat

doxycycline 100mg twice daily for 7 days

Ref: BASHH guideline Dec 2008. For persistent or recurrent infection refer to Sexual Health Service. Consider immune deficiency and testing for HIV.

Trichomoniasis

Trichomoniasis vaginalis

metronidazole 2g as single dose (use 5 x 400mg as more cost-effective than 4 x 500mg)

metronidazole 400mg twice daily for 7 days

Refer to Sexual Health Service. Treat partners simultaneously. BASHH 2014. Avoid 2g single dose metronidazole in pregnancy or breastfeeding (as manufacturer advises avoidance of high dose regimens). Consider immune deficiency and testing for HIV.

Vaginal Candidiasis

Candida albicans clotrimazole pessary 500mg or 5g 10% vaginal cream as single dose at night

fluconazole 150mg oral as single dose

All topical and oral azoles give 75% cure. In pregnancy avoid oral azole. Consider immune deficiency and testing for HIV.

Bacterial vaginosis Various organisms. metronidazole 2g as single dose

metronidazole 400mg twice daily for 7 days

Avoid 2g dose in pregnancy and breastfeeding (as manufacturer advises avoidance of high dose regimens). Topical treatment gives similar cure rates but is more expensive. Antibiotics not usually required in children.

Epididymitis Cont’d over

>35yrs or low risk of STD Escherichia coli (80%), Enterococcus spp, intestinal aerobes, Coagulase negative staphylococci

doxycycline 100mg twice daily for 10 - 14 days

co-trimoxazole 960mg twice daily [unlicensed – see general notes] for 10 – 14 days

Refer to BASHH guidance 2010. Consider immune deficiency and testing for HIV.




5 Genital system • For full guidelines (British Association of Sexual Health and HIV) see http://www.bashh.org/guidelines • If STI diagnosed then refer to Sexual Health Service (0845 337 9900) for partner notification and advice if required. INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Epididymitis

<35yrs or high risk of STD Chlamydia trachomatis Neisseria gonorrhoeae

doxycycline 100mg oral twice daily for 10-14 days

Cefotaxime 500mg IM as single dose, or cefixime 400mg oral followed by 200mg 6-12 hours later, should be added if gonorrhoea strongly suspected or confirmed. (Cefixime dosing based on expert advice due to risk of resistance) Refer to BASHH guidance 2010 Refer to Sexual Health Service for further management advice/partner notification. Consider immune deficiency and testing for HIV.

Infective balanitis

Candidal clotrimazole 1% cream topically twice daily until symptoms settle

For severe symptoms; fluconazole 150mg oral stat

Ref: BASHH guideline 2008

Anaerobic metronidazole 400mg oral twice daily for 7 days

Ref: BASHH guideline 2008

Aerobic As per sensitivities

Prostatitis, acute bacterial

Escherichia coli, Proteus spp, Klebsiella spp, Pseudomonas spp, Enterococci, Staphylococcus aureus, Bacteroides spp.

co-trimoxazole 960mg oral twice daily for 28 days [unlicensed - see general notes p4]

trimethoprim 200mg twice daily for 28 days (if microbiology results available and organism sensitive)

See CKS Prostatitis – acute: http://cks.nice.org.uk/prostatitis-acute#azTab 4 weeks treatment may prevent chronicity. Note that bacterial infection (acute and chronic) account for <5% of all prostatitis diagnoses; their precise incidence is unknown. NB: IV therapy may be required.


http://cks.nice.org.uk/prostatitis-acute#azTab�



5 Genital system • For full guidelines (British Association of Sexual Health and HIV) see http://www.bashh.org/guidelines • If STI diagnosed then refer to Sexual Health Service (0845 337 9900) for partner notification and advice if required. INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Crab Lice

Phthirus pubis malathion 0.5% aqueous lotion, apply over whole body. Wash off after 12 hours or after leaving on overnight. Reapply after 7 days.

permethrin 5% dermal cream, apply over whole body and should be left on the skin for 24 hours*. The treatment areas should then be thoroughly washed. Reapply after 7 days.

Pay particular attention to the pubic hair, hair around the anus, between the legs, and other hairy areas of the body. Check for involvement of more distant sites such as eyebrows. See CKS for further information: http://cks.nice.org.uk/pubic-lice#azTab Note: re-application of permethrin is based on expert opinion and has been accepted as standard practice, although not licensed. [*Also, BNF recommends 12 hour contact time instead of licensed recommendation of 24 hours].

Endometritis Polymicrobial Chlamydia negative: co-amoxiclav 625mg oral three times daily for 7 days

Penicillin allergy and/or chlamydia positive: a) If breastfeeding: erythromycin 500mg four times daily AND metronidazole 400mg oral three times daily for 7 days b) If not breastfeeding: doxycycline 100mg twice daily AND metronidazole 400mg three times daily for 7 days


http://cks.nice.org.uk/pubic-lice#azTab�



6 Eye INFECTION Likely organisms 1st Choice Treatment Alternative

treatment Comments

Blepharitis (Treat if eyelid hygiene alone not effective or signs of Staphylococcus infection)

Staphylococcus aureus Staphylococcus epidermidis

Good lid hygiene + chloramphenicol 1% eye ointment applied four times daily for 7 days (initially and consider up to 4-6 weeks - CKS)

Good lid hygiene + fusidic acid 1% viscous eye drops applied twice daily for 7 days (initially and consider up to 4-6 weeks – CKS)

If patient cannot avoid wearing contact lenses then alternative treatments containing no preservatives should be used. Consider ophthalmic lubricant if dry eyes. If meibomian gland dysfunction or rosacea, consider tetracycline antibiotic at low dose for 6 – 12 weeks (CKS - http://cks.nice.org.uk/blepharitis#!scenario)

Chalazion– (Meibomian cyst)

Meibomian cyst generally sterile therefore no antibiotic treatment recommended. CKS - http://cks.nice.org.uk/meibomian-cyst#azTab

Conjunctivitis, viral

Herpes simplex virus, Adenoviruses Enteroviruses

aciclovir 3% eye ointment, apply 5 times daily

Adenovirus infection is often self limiting and no treatment required.

Conjunctivitis - purulent

Staphylococcus spp, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

chloramphenicol 0.5% eye drops applied every 2 hours then reduce frequency as infection controlled (use throughout the day) AND/OR chloramphenicol 1% eye ointment, apply at night only if using drops during the day, or apply 3 – 4 times daily if used alone. For 7 days or until symptom free for 48 hours

Fusidic acid 1% viscous eye drops applied twice daily for 7 days or until symptom free for 48 hours

Most bacterial infections are self limiting (65% resolve on placebo by day five) - consider offering a delayed prescription. Usually unilateral with yellow- white mucopurulent discharge. Fusidic acid has less gram-negative activity. Remove contact lenses until all symptoms and signs of infection resolved and treatment complete for 24 hours. Fusidic acid would be preferred treatment in pregnancy. CKS – Infective Conjunctivitis http://cks.nice.org.uk/conjunctivitis-infective#!scenario

http://cks.nice.org.uk/blepharitis#!scenario�



http://cks.nice.org.uk/meibomian-cyst#azTab�



http://cks.nice.org.uk/conjunctivitis-infective#!scenario�






6 Eye INFECTION Likely organisms 1st Choice Treatment Alternative

treatment Comments

Neonatal Chlamydia conjunctivitis

Chlamydia trachomatis

erythromycin oral [neonate] 12.5mg/kg four times daily for 14 days

Also refer mother and her sexual partner to Sexual Health services for screening and treatment.

Herpes simplex corneal infection

aciclovir 3% eye ointment five times daily

Urgently refer to emergency eye service. Continue for at least 3 days after complete healing.

Ophthalmic zoster

Varicella Zoster aciclovir oral 800mg five times daily for 7 days**

**Co-prescribe aciclovir 3% eye ointment.



7 Ear, nose, and oropharynx INFECTION Likely organisms 1st Choice Treatment Alternative Treatment Comments / notes / references Otitis externa (Ear swabs usually grow commensals and are not found to be helpful in directing therapy in most cases.)


Aural toilet + Analgesia

Aural toilet + Betnesol – N® [neomycin 0.5% and betametasone 0.1%] ear drops apply 3 drops into ear three times a day for 7 days

Acetic acid 2% ear spray is available OTC (if > 12 years) and gives similar cure rate as topical antibiotic + steroid at 7 days. [Link to: Manufacturer’s SPC] Neomycin is contra-indicated in patients with a perforated tympanic membrane. Consider oral antibacterial if spreading cellulitis or patient systemically unwell (flucloxacillin or erythromycin). CKS - http://cks.nice.org.uk/otitis-externa#!management

Fungal; Candida spp, airborne fungi

Aural toilet + Analgesia

Aural toilet + clotrimazole 1% topical solution instil into the ear 2-3 times daily, for at least 14 days after disappearance of infection

Acetic acid 2% ear spray is available OTC (if >12 years) and gives similar cure rate as topical antibiotic + steroid at 7 days. [Link to: Manufacturer’s SPC] These infections may be difficult to treat and it is recommended to seek specialist advice.

Pseudomonas aeruginosa

Aural toilet + gentamicin 0.3% ear drops apply 2-3 drops into the ear three to four times daily and at night for 3-5 days

More serious infection: seek specialist advice

Gentamicin is contra-indicated in patients with a perforated tympanic membrane. Seek ENT/ medical microbiology advice before prescribing an oral option.

Tonsillitis

See section 2 Consider no or delayed prescription

See leaflet link – Appendix 1.

http://www.medicines.org.uk/EMC/medicine/17298/SPC/Earcalm+Spray/�

http://cks.nice.org.uk/otitis-externa#!management�

http://cks.nice.org.uk/otitis-externa#!management�

http://www.medicines.org.uk/EMC/medicine/17298/SPC/Earcalm+Spray/�



7 Ear, nose, and oropharynx INFECTION Likely organisms 1st Choice Treatment Alternative Treatment Comments / notes / references Acute otitis media – treat only when clinically indicated. Many cases are not bacterial and resolve without antimicrobials

Viral Streptococcus pneumoniae, Haemophilus influenzae, Beta haemolytic streptococci, Staphylococcus aureus

Consider no or delayed prescription amoxicillin oral 1 month - 1yr: 125mg 3 x daily 1-5yrs: 250mg 3 x daily > 5yrs: 500mg 3 x daily (increased if necessary to 30mg/kg 3 x daily, max. 1g 3 x daily if > 5yrs) For 5 days

erythromycin oral <2yrs: 125mg 4 x daily 2-8yrs: 250mg 4 x daily >8yrs: 250 – 500mg 4 x daily For 5 days

Avoid antibiotics as 60% of patients are better in 24 hours without; they only reduce pain at 2 days (NNT 15) and do not prevent deafness. Optimise analgesia. Consider 2- 3 day delayed, or immediate antibiotics for pain relief if <2years with bilateral acute otitis media (NNT 4), or all ages with otorrhoea (NNT 3). Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, are less effective treatment.

Acute sinusitis

Many are viral (>98%) Streptococcus pneumoniae Haemophilus influenzae Beta haemolytic streptococci, Staphylococcus aureus Treatment should be based on culture results.

If antibiotics indicated: In acute sinusitis prescribe xylometazoline 0.1% 2-3 drops into each nostril 2-3 times daily for 5 days (Paediatric drops available for 6 - 12 yrs – see BNF but also see MHRA guidance on cough and cold treatments in children – link in references) Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days (NNT 15). Use adequate analgesia. Consider 7 day delayed or immediate antibiotic when purulent nasal discharge (NNT 8). CKS - http://cks.nice.org.uk/sinusitis#!scenario See leaflet link- Appendix 1

Consider no or delayed prescription amoxicillin 500mg oral three times daily for 7 days (use 1g if severe)

doxycycline* 200mg stat then 100mg daily Or phenoxymethylpenicillin 500mg four times daily for 7 days *NB doxycycline is not suitable for those under 12 years.

Chronic sinusitis (frequent or recurrent symptoms lasting more than 12 weeks)

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Group A Streptococcus

Send ear and nose swabs to microbiology. Treat as per sensitivities.

Also intranasal steroids +/- decongestant. (if treating a child, see MHRA guidance on cough and cold treatments in children – hyperlink in references) Limit treatment to one course only. Refer to ENT. CKS - http://cks.nice.org.uk/sinusitis#!scenario:1

http://cks.nice.org.uk/sinusitis#!scenario�

http://cks.nice.org.uk/sinusitis#!scenario:1�



7 Ear, nose, and oropharynx INFECTION Likely organisms 1st Choice Treatment Alternative Treatment Comments / notes / references Oral Thrush Consider immune deficiency and testing for HIV.

Candida albicans # miconazole oral gel 2.5mL four times daily after food (continue for 7 days after lesions resolve)

nystatin oral suspension 1mL four times daily after food usually for 7 days (continue for 2 days after lesions resolve)

Adult immunocompromised; Fluconazole 50 - 100mg daily once daily for 7-14 days. # Miconazole gel not licensed in those less than 4 months. Note that there have been issues of choking in young children using miconazole gel. Use nystatin in very young children.

Dental abscess, severe gingivitis

Streptococcus spp Anaerobes

Gingivitis -metronidazole 200mg* three times daily for 3 days Abscess – amoxicillin 500mg three times daily for 5 days * consider increasing to 400mg if systemically unwell

Gingivitis - amoxicillin 500mg three times daily for 3 days Abscess– metronidazole 200mg* three times daily for 5 days * consider increasing to 400mg if systemically unwell

Refer to dentist. Antibiotic treatment required only if severe infection, systemic symptoms, or high risk of complications. Refer to SDCEP ‘Drug Prescribing in Dentistry’ http://www.sdcep.org.uk/published-guidance/drug-prescribing/ .& 'Management of Acute Dental Problems' http://www.sdcep.org.uk/published-guidance/management-of-acute-dental-problems-madp/ CKS – dental abscess: http://cks.nice.org.uk/dental-abscess#azTab CKS – gingivitis: http://cks.nice.org.uk/gingivitis-and-periodontitis#!management

http://www.sdcep.org.uk/published-guidance/management-of-acute-dental-problems-madp/�



http://cks.nice.org.uk/dental-abscess#azTab�

http://cks.nice.org.uk/dental-abscess#azTab�

http://cks.nice.org.uk/gingivitis-and-periodontitis#!management�

http://cks.nice.org.uk/gingivitis-and-periodontitis#!management�



8 Skin INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Cellulitis Group A beta

haemolytic streptococci Staphylococcus aureus

flucloxacillin 500mg oral four times daily for 7 - 14 days

erythromycin 500mg oral four times daily for 7 - 14 days

If the patient is afebrile and healthy other than cellulitis, flucloxacillin alone may be used as drug treatment. If river or sea water exposure or face involved, discuss with microbiology. If febrile and ill, admit for IV treatment.

Impetigo Staphylococcus aureus

If localised, fusidic acid 2% cream, apply 3-4 times daily for 5 days OR (only if MRSA), mupirocin 2% ointment applied up to three times daily for 5 days

If widespread, flucloxacillin 500mg oral four times daily OR erythromycin 500mg oral four times daily for 7 days

Topical and oral treatment produce similar results but as resistance is increasing, reserve topical antibiotics for very localised lesions. Reserve mupirocin for MRSA. For extensive, severe, or bullous impetigo, use oral antibiotics.

Bites – Animal

Streptococcus pyogenes Pasteurella multocida

co-amoxiclav 625mg three times daily for 7 days

doxycycline* 100mg twice daily PLUS metronidazole 400mg three times daily for 7 days *Children < 12 years co-trimoxazole PLUS metronidazole (see BNFC for doses) for 7 days

Thorough irrigation is important. Assess tetanus and rabies risk. Assess risk of blood borne viruses, e.g. Hep B and C, HIV. Antibiotic prophylaxis advised for cat bite/ puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic, cirrhotic and for all human bites. *NB doxycycline is not suitable for those <12yrs. OPTION FOR CHILDREN ONLY – 1st choice (not penicillin allergic): co-amoxiclav (three times daily for 7 days) - <6yrs: 125/31mg 6 - 12 yrs: 250/62mg NB: metronidazole not required in addition to co-amoxiclav

Bites – Human

Streptococcus pyogenes Staphylococcus aureus Oral anaerobes

doxycycline* oral 100mg twice daily for 7 days metronidazole should be added for severe human bites in those over 12 years (400mg three times daily for 7 days)

clarithromycin 500mg twice daily for 7 days metronidazole should be added for severe human bites (400mg three times daily for 7 days)



8 Skin INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Herpes simplex - prodromal

aciclovir 5% cream applied 5 times daily for 5 - 10 days at first sign of attack

Cold sores resolve after 7-10 days without treatment. Topical antivirals applied prodromally reduce duration by 12-24 hours.

Herpes simplex - lesions

aciclovir 200mg oral five times daily for 5 days

Chicken pox (NB treatment not usually indicated in children)

Varicella Zoster

aciclovir 800mg oral five times daily for 7 days

If pregnant/immunocompromised/neonate seek urgent specialist advice. Consider aciclovir if started <24 hours of onset of rash AND >14 years or severe pain or dense/oral rash, or secondary household case, or on steroids or smoker.

Shingles Herpes Zoster aciclovir 800mg oral five times daily for 7 days

valaciclovir oral 1g three times daily for 7 days

If pregnant/immunocompromised/neonate seek urgent specialist advice. Treat if >50 yrs and within 72 hours of onset of rash (post-herpetic neuralgia rare in <50 yrs); or if active ophthalmic, or Ramsey Hunt or eczema.

Infected leg ulcers

Staphylococcus aureus Streptococcus spp (NB: coliforms and Pseudomonas may not be significant)

Depend on culture and sensitivities

Ulcers are always colonized by bacteria. Antibiotics do not improve healing unless active infection*. If active infection send pre-treatment swab and review antibiotic after culture results. If no improvement seek advice from Microbiology or Infectious Diseases. *Active infection = cellulitis/ increased pain/pyrexia/purulent exudate/odour.

Mastitis Staphylococcus aureus

flucloxacillin 500mg four times daily for 14 days

erythromycin 250-500mg four times daily for 14 days

Treat if there is infected nipple fissure, symptoms do not improve or are worsening after 12-24 hours despite effective milk removal, or bacterial culture is positive. Refer to CKS for further details - http://cks.nice.org.uk/mastitis-and-breast-abscess#azTab

http://cks.nice.org.uk/mastitis-and-breast-abscess#azTab�



8 Skin INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Head Lice Only treat infected individuals – not whole household.

NHS Grampian does not recommend a policy of rotating between specified insecticides Treatment must be reapplied after 7 days to ensure any lice that hatch following the first application are killed. Head lice treatments available and in use in the UK without prescription are: • Dimeticone, e.g. Hedrin lotion® • Malathion, e.g. Derbac-M liquid®

Some preparations contain alcohol or irritant vapour, which may produce adverse effects in certain individuals e.g. those suffering from eczema or severe asthma. In such cases, an aqueous/alternative preparation should be considered.

HPS Guidance Document: http://www.documents.hps.scot.nhs.uk/environmental/guidance-notes/lice.pdf HPA Guidance: http://www.phmeg.org.uk/files/1013/2920/7269/Stafford_Headlice_Doc_revise_2012_version.pdf A contact time of 12 hours, or overnight, is recommended for lotions and liquids. Additional products available OTC include: • Isopropyl myristate and cyclomethicone solution, e.g.

Full Marks Solution® • Coconut, anise, and ylang ylang spray, e.g. Lyclear®

SprayAway

Scabies Treat whole body including scalp, face, neck, ears and under nails. Treat all home and sexual contacts within 24 hours.

Sarcoptes scabiei

permethrin 5% cream, apply to the whole body, taking care to treat the webs of fingers and toes and under the nails. Wash off after 8 – 12 hours. Re-apply after 7 days. Re-apply to hands if washed within 8 hours of application.

malathion 0.5% aqueous solution, apply to the whole body taking care to treat the webs of fingers and toes and under the nails. Wash off after 24 hours. Re-apply after 7 days. Re-apply if hands washed within 24 hours of application.

Use aqueous solutions in preference to alcoholic, especially in children. Manufacturers recommend that some patient groups do not require treatment above the neck but BNF, HPA and CKS all recommend to include scalp, face, neck and ears in all patients. Treat all household contacts simultaneously.

http://www.documents.hps.scot.nhs.uk/environmental/guidance-notes/lice.pdf�

http://www.documents.hps.scot.nhs.uk/environmental/guidance-notes/lice.pdf�

http://www.phmeg.org.uk/files/1013/2920/7269/Stafford_Headlice_Doc_revise_2012_version.pdf�

http://www.phmeg.org.uk/files/1013/2920/7269/Stafford_Headlice_Doc_revise_2012_version.pdf�



8 Skin INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Onychomycosis (Fungal nail infection)

Trichophyton rubrum, Trichophyton mentagrophytes var. interdigital, Candida spp. Aspergillus, Fusarium, Scopulariopsis, Acremonium

terbinafine 250mg oral once daily for 6 to 12 weeks for finger nails and for 3-6 months for toe nails

itraconazole 200mg oral capsules once daily for 3 months or 200mg twice daily for 7 days and repeated after 21 days for 3 cycles for toe nails, or two cycles for finger nails.

Take nail clippings and only start treatment if infection is confirmed. Idiosyncratic liver reactions occur rarely with terbinafine. It is more effective than the azoles. If candida or non-dermatophyte infection confirmed, use itraconazole. For children seek specialist advice. Superficial only: amorolfine 5% nail lacquer once or twice weekly for 6 months for finger nails and 12 months for toe nails

Acute Paronychia


flucloxacillin 500mg oral four times daily for 7 days

erythromycin 500mg four times daily for 7 days in penicillin allergy.

Consider incision and drainage where appropriate. Advise warm soaks and analgesia. Antibiotics should be considered if fever or cellulitis or other co-morbidities (e.g. diabetes, immunosuppression). If no response to treatment or if infection is recurrent or chronic, the choice of antibiotic should be guided by sensitivities (CKS).

Pityriasis versicolor

Malassezia furfur ketoconazole 2% shampoo applied once daily for a maximum of 5 days (leave preparation on for 3-5 minutes before rinsing)

selenium sulphide 2.5% shampoo (unlicensed indication) used as a lotion (diluted with water to reduce irritation) and left on for 10 minutes, apply once daily for 7 days and repeat course if necessary

Selenium sulphide is not suitable for children under 5 years. If only small areas of skin are involved, an antifungal (imidazole) cream is an alternative e.g. clotrimazole. If topical therapy fails, or if the infection is widespread, treat systemically with itraconazole 200mg once daily for 7 days. For further information refer to CKS: http://cks.nice.org.uk/pityriasis-versicolor#azTab

Intertrigo Candida spp. clotrimazole 1% cream applied 2-3 times daily continuing for at least 14 days after apparent healing.

http://cks.nice.org.uk/pityriasis-versicolor#azTab�





8 Skin INFECTION Likely organisms 1st Choice Treatment Alternative treatment Comments / notes / references Fungal infection – scalp and skin (Dermatophytes/ ring worm)

Tinea capitis- Trichophyton tonsutans Microsporum spp Trichophyton verucosum

griseofulvin 1g oral once daily or in divided doses For 4 -8 weeks. May need up to 12 weeks in M. canis and T. tonsurans infections.

terbinafine 250mg oral daily (unlicensed indication) for 4 weeks (see cBNF for weight based regimen in children)

Consult specialist for scalp infections and use of oral antifungals in children. Topical treatment (e.g. ketoconazole shampoo) should be used twice weekly in addition to oral to reduce transmission. See CKS for further information: http://cks.nice.org.uk/fungal-skin-infection-scalp#azTab

Tinea corporis, cruris and pedis Epidermophyton floccosum Trichophyton rubrum Trichophyton mentagrophytes

clotrimazole 1% cream or 1% topical solution applied 2-3 times daily, continue for 14 days after lesions have healed

terbinafine 1% cream applied 1-2 times daily for up to 7 days in tinea pedis or 1-2 weeks in tinea corporis and cruris (not licensed in children < 12 yrs)

Terbinafine is fungicidal so treatment time shorter than with fungistatic imidazoles. If intractable take skin scrapings for culture. Systemic therapy is appropriate in adults if topical therapy fails, if many areas affected or if the site of infection is difficult to treat. Seek specialist advice in children. See CKS for further information: http://cks.nice.org.uk/fungal-skin-infection-body-and-groin#!management

http://cks.nice.org.uk/fungal-skin-infection-scalp#azTab�




http://cks.nice.org.uk/fungal-skin-infection-body-and-groin#!management�

http://cks.nice.org.uk/fungal-skin-infection-body-and-groin#!management�



Consultation List Updated by Gillian Macartney, Specialist Antibiotic Pharmacist, NHS Grampian, April 2014 Reviewed by Fiona McDonald, Specialist Antibiotic Pharmacist, NHS Grampian Consulted with: Dr Ambreen Butt Head of Service, Sexual Health Service, NHS Grampian Dr Steve Baguley Consultant Genitourinary Physician, NHS Grampian Dr Richard Brooker Consultant Physician, Royal Aberdeen Children’s Hospital Dr Mahendran Chetty Respiratory Consultant, NHS Grampian Dr Gordon Christie Respiratory Consultant, NHS Grampian Dr Nicholas Cohen Urology Consultant, NHS Grampian Alison Copland Respiratory Pharmacist, NHS Grampian Dr Graeme Currie Respiratory Consultant, NHS Grampian Dr Owen Dempsey Respiratory Consultant, NHS Grampian Dr Graham Devereux Respiratory Consultant, NHS Grampian Fiona Doney Development Pharmacist, Pharmacy and Medicines Directorate Dr Patrick Fitch Respiratory Consultant, NHS Grampian Dr Graham Gauld GPWSi* Dr Ian Gould Consultant Microbiologist, NHS Grampian Dr Caroline Hind Deputy Director of Pharmacy and Medicines Management Dr David Hood GPWSi* Rosemary Hutcheson Clinical Dental Lead, Aberdeen City CHP Dr Annemarie Karcher Infection Prevention and Control Doctor, NHS Grampian Mr Thomas Lam Consultant Urological Surgeon, NHS Grampian Dr Robert Liddell * GP lead Aberdeenshire North Alexandra Lowe Dental Practictioner, NHS Grampian Dr Alexander Mackenzie Infectious Diseases Consultant, NHS Grampian Dr Samuel McClinton Urology Consultant, NHS Grampian Dr Martin McCrone GP lead Aberdeenshire South* Isobel Morison Clinical Pharmacist, Aberdeen Maternity Hospital Jenny Mosley Clinical Pharmacist, Royal Aberdeen Children’s Hospital Dr Said Mishriki Urology Consultant, NHS Grampian Dr James N’Dow Urology Consultant, NHS Grampian Dr Craig Oxley Paediatric Consultant, NHS Grampian Dr Martin Pucci GP member of Antibiotic Working Party Dr Sanjay Rajpara Consultant Dermatologist and Clinical Lead Ann Smith Pharmacist, GMEDs Dr Prasima Srivastava Respiratory Consultant, NHS Grampian Dr Kuchibhotla Swami Urology Consultant, NHS Grampian Dr David Taylor Clinical Lead, GMEDs* Paula Thomson Clinical Pharmacist, Royal Aberdeen Children’s Hospital Sandy Thomson Moray CHSCP, Principal Pharmacist Dr Ivan Tonna Acute Medicine / ID Consultant, NHS Grampian CHP Lead Pharmacists Louise Black, Alison Davie, Linda Juroszek, Joan MacLeod,

Elaine Neil, Lesley Thomson *(individual GPs via cascade from GP leads)



References • Management of Infection Guidance for Primary Care for Consultation and Local

Adaptation. Health Protection Agency. Revised February 2013. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1279888711402

• British National Formulary accessed online at http://www.bnf.org • NHS Grampian Hospital Antimicrobial Empirical Therapy Guidelines September

2012. Available at http://www.nhsgrampian.org/gjf • Summary of Product Characteristics (www.medicines.org.uk) • Prodigy (previously Clinical Knowledge Summaries) (http://prodigy.clarity.co.uk) • NICE guidelines [accessed online www.nice.org.uk] • SIGN guidelines [accessed online www.sign.ac.uk]. • BASHH guidelines [accessed online www.bashh.org/Guidelines]. • GOLD guidelines 2014 [accessed online www.goldcopd.org]. • BTS CAP Guidelines & Primary care summary version. [Accessed online]

http://www.brit-thoracic.org.uk/guidelines-and-quality-standards/community-acquired-pneumonia-in-adults-guideline/ MHRA guidance on the use of cough and cold medicines in children [https://www.gov.uk/drug-safety-update/over-the-counter-cough-and-cold-medicines-for-children]

• SAPG Guidance: Catheter UTI / Alternative management of lower UTI in non-pregnant women / Management of recurrent UTI in non-pregnant women: http:/www.scottishmedicines.org.uk/SAPG/Quality_Improvement/Infection_Management

• Other guidelines indicated in the comments section where applicable.

http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1279888711402�

http://www.bnf.org/�

http://www.nhsgrampian.org/gjf�

http://www.medicines.org.uk/�

http://prodigy.clarity.co.uk/�

http://www.nice.org.uk/�

http://www.sign.ac.uk/�

http://www.bashh.org/BASHH/Guidelines/Guidelines/BASHH/Guidelines/Guidelines.aspx�

http://www.goldcopd.org/�



https://www.gov.uk/drug-safety-update/over-the-counter-cough-and-cold-medicines-for-children�

https://www.gov.uk/drug-safety-update/over-the-counter-cough-and-cold-medicines-for-children�





Appendix 1: NHS Grampian Leaflet Links • Non-prescription pad (also available in Polish, Latvian, Lithuanian, Russian)

o http://www.hi-netgrampian.org/hinet/7926.4.860.html • Cough leaflet

o http://www.nhsgrampian.org/nhsgrampian/files/English/COUGH.pdf • Sore throat leaflet

o http://www.nhsgrampian.org/nhsgrampian/files/English/SORE%20THROAT.pdf • COPD leaflet (also available in Polish)

o http://intranet.grampian.scot.nhs.uk/foi/files/COPDillustratedleaflet060208.pdf • Cystitis leaflet

o http://www.nhsgrampian.org/nhsgrampian/files/English/CYSTITIS.pdf • Earache leaflet

o http://www.nhsgrampian.org/nhsgrampian/files/English/EARACHE.pdf • Sinusitis

o http://www.nhsgrampian.org/nhsgrampian/files/English/SINUSITIS.pdf • Threadworms

o http://intranet.grampian.scot.nhs.uk/foi/files/ThreadwormsSeptember2006.pdf

http://www.hi-netgrampian.org/hinet/7926.4.860.html�

http://www.nhsgrampian.org/nhsgrampian/files/English/COUGH.pdf�

http://www.nhsgrampian.org/nhsgrampian/files/English/SORE%20THROAT.pdf�

http://intranet.grampian.scot.nhs.uk/foi/files/COPDillustratedleaflet060208.pdf�

http://www.nhsgrampian.org/nhsgrampian/files/English/CYSTITIS.pdf�

http://intranet.grampian.scot.nhs.uk/foi/files/Cystitisleaflet190707.pdf�

http://intranet.grampian.scot.nhs.uk/foi/files/Cystitisleaflet190707.pdf�

http://www.nhsgrampian.org/nhsgrampian/files/English/EARACHE.pdf�

http://www.nhsgrampian.org/nhsgrampian/files/English/SINUSITIS.pdf�

http://intranet.grampian.scot.nhs.uk/foi/files/Sinusitisleaflet.pdf�

http://intranet.grampian.scot.nhs.uk/foi/files/Sinusitisleaflet.pdf�

http://intranet.grampian.scot.nhs.uk/foi/files/ThreadwormsSeptember2006.pdf�


Appendix 2: Summary Guide to Treatment of Common Infections in Primary Care Note: Doses are oral and for adults unless otherwise stated, and apply to normal renal and hepatic function. For information on the use of antibiotics in pregnant or breastfeeding women, or in patients with renal or hepatic impairment please refer to BNF (information in individual drug monographs). For paediatric doses, see Page 2, or consult BNF for children or Summary of Product Characteristics (www.medicines.org.uk). Aim: To provide guidance for the treatment of common infections within Primary Care as detailed in the Grampian Joint Formulary, taking into

account the bacterial susceptibility patterns in Grampian. The aim is to minimise the emergence of bacterial resistance and healthcare associated infection in the community and to encourage the rational and cost effective use of antibiotics.

Principles of Treatment 1. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 2. It is important to use correct dose and appropriate course length modified as required for age, weight, renal function and infection severity. 3. Do not prescribe an antibiotic for viral sore throat, simple coughs and colds. 4. Consider delayed prescriptions for acute self-limiting upper respiratory tract infections if symptoms suggest an antibiotic may be indicated. 5. Lower the threshold for prescribing antibiotics in immunocompromised or those with multiple co-morbidities; consider culture/seek advice. 6. Limit prescribing for telephone consultations to exceptional cases. 7. 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. 8. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from the on call microbiologist

via ARI switchboard (0845 456 6000). INDICATION COMMENTS FIRST-CHOICE

TREATMENT ALTERNATIVE TREATMENT

DURATION

URINARY TRACT INFECTIONS Note: People >65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity. Catheter in situ: antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma. Uncomplicated UTI (i.e. no fever or flank pain )

Increasing incidence of multi-resistant E. coli with extended-spectrum beta-lactamase (ESBL) enzymes, so perform culture in all treatment failures.

Trimethoprim 200mg 2 x daily

Nitrofurantoin 50mg 4 x daily OR 100 mg m/r 2 x daily

3 days (7 days for men)

UTI in pregnancy Send MSU for culture. Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. Avoid trimethoprim if low folate status or taking folate antagonist (e.g. antiepileptic or proguanil).

Nitrofurantoin (avoid in 3rd trimester) 50mg 4 x daily OR 100 mg m/r 2 x daily

Trimethoprim (avoid in 1st trimester) 200 mg 2 x daily

7 days

Pyelonephritis

Send MSU for culture. RCT shows 14 days co-trimoxazole is as good as 7 days ciprofloxacin. Admit if no response in 24hrs. For serious, or potentially life threatening, infection consider ciprofloxacin (500mg twice daily) and review after 24 hours when micro results available.

Co-trimoxazole 960mg 2 x daily [unlicensed – see general notes in main guidance

Co-amoxiclav 625mg 3 x daily

14 days

LOWER RESPIRATORY TRACT INFECTIONS Note: Low doses of penicillins are more likely to select out resistance. The quinolones; ciprofloxacin and ofloxacin, have poor activity against pneumococci but they can be used to treat PROVEN sensitive pseudomonal infections. Acute cough, bronchitis

Antibiotics of little benefit if no co-morbidity. Symptom resolution can take 3 weeks- consider delaying antibiotic by 7-14 days.

No antibiotic recommended.

Acute exacerbation of COPD

Treat exacerbations promptly if purulent sputum and dyspnoea and/or increased sputum volume. Consider sputum sample for culture and delayed prescription

Amoxicillin 500mg 3 x daily

Erythromycin 500mg 4 x daily OR ¥Doxycycline 200mg stat then 100mg daily

5 days

Community-acquired pneumonia (CRB65=0)

Start antibiotics immediately. Use CRB65 score to assess severity. If no response in 48 hours consider admission. [If CRB65=1 see full guideline for further advice]

Amoxicillin 500mg 3 x daily

Erythromycin 500mg 4 x daily OR ¥Doxycycline 200mg stat then 100mg daily

5 days

UUPPPPEERR RREESSPPIIRRAATTOORRYY TTRRAACCTT IINNFFEECCTTIIOONNSS:: CCoonnssiiddeerr ddeellaayyeedd aannttiibbiioottiicc pprreessccrriippttiioonnss.. Pharyngitis / sore throat / tonsillitis Consider no or delayed prescription

Avoid antibiotics as 90% resolve in 7 days without and pain only reduced by 16 hours. If Centor criteria score 3 or 4 (history of fever, purulent tonsils, cervical lymphadenopathy, and absence of cough) consider prescription after 2-3 days’ delay, or immediate antibiotics. You need to treat 200 patients to prevent one case of otitis media, and >4000 patients to prevent one quinsy. Evidence indicates that penicillin for 7 days is more effective than 3 days.

Phenoxymethylpenicillin 500mg 4 x daily

Erythromycin 500mg 4 x daily

7 - 10 days

Otitis media (children’s doses quoted – see BNF for adult doses) Consider no or delayed prescription

Optimise analgesia. Avoid antibiotics as 60% are better in 24 hours without: they only reduce pain at 2 days and do not prevent deafness. Consider 2 or 3 day delayed, or immediate, antibiotics for pain relief if: <2years with bilateral acute otitis media All ages with otorrhoea

Amoxicillin 1 month - 1yr: 125mg 3 x daily 1-5yrs: 250mg 3 x daily > 5yrs: 500mg 3 x daily (increased if necessary to 30mg/kg 3 x daily, max. 1g 3 x daily if > 5yrs

Erythromycin <2 yrs: 125mg 4 x daily 2-8 yrs: 250mg 4 x daily >8 yrs: 250-500mg 4 x daily

5 days

Acute sinusitis Consider no or delayed prescription

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.

Amoxicillin 500mg 3 x daily (use 1g if severe)

*Doxycycline 200mg stat then 100mg daily OR Phenoxymethylpenicillin 500mg 4 x daily

7 days

Prescribers are reminded that any treatment choices should be patient specific. If the treatment choices listed in the table are unsuitable for the patient, please refer to the full guideline which refers to national guidelines which will list alternative treatment

http://www.bnfc.org/�

http://www.medicines.org.uk/emc/�

Appendix 2: Summary Guide to Treatment of Common Infections in Primary Care


COMMON PAEDIATRIC DOSES -assuming average weight. See BNF for children. Some doses can be doubled in severe infections*. Phenoxymethyl-

penicillin 4 x daily

Amoxicillin* 3 x daily

Erythromycin* 4 x daily

Flucloxacillin* 4 x daily

Trimethoprim 2 x daily

Nitrofurantoin 4 x daily

1mth - 1 yr 62.5mg 1mth – 1 yr 125mg 1mth - 2 yrs 125mg 1mth - 2 yrs 62.5mg 6mths-6yrs 50mg 750micrograms/kg 1-5 yrs 125mg 1-5 yrs 250mg 2-8 yrs 250mg 2 - 10 yrs 125mg 6-12 yrs 100mg 12-18yrs 50mg 6-12 yrs 250mg Over 5 yrs 500mg Over 8 yrs 250-500mg Over 10 yrs 250mg

¥ NB. Tetracycline (doxycycline) antibiotics should not be used in children under 12 years of age. Doses of phenoxymethylpenicillin may be increased to ensure at least 12.5mg/kg four times daily in severe infections. Clarithromycin may be substituted for erythromycin if issues with patient tolerability.

INDICATION COMMENTS FIRST-CHOICE TREATMENT

ALTERNATIVE TREATMENT

DURATION

SKIN/SOFT TISSUE INFECTIONS Impetigo

For extensive, severe, or bullous impetigo, use oral antibiotics. Reserve topical antibiotics for very localised lesions to reduce the risk of resistance.

If localised: Fusidic acid 2% cream topically 3-4 x daily OR Mupirocin (only if MRSA) topically 3 x daily

If widespread: Flucloxacillin 500mg 4 x daily OR Erythromycin 500mg 4 x daily

5 days for topical 7 days oral

Eczema

If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing. In eczema with visible signs of infection, use treatment as for impetigo.

Cellulitis If patient afebrile and healthy other than cellulitis flucloxacillin alone may be used. If water exposure or face involved, discuss with microbiology. If febrile and ill, admit for IV treatment.

Flucloxacillin 500mg 4 x daily

Erythromycin 500mg 4 x daily

7 – 14 days

Leg ulcers

Ulcers always colonised. Antibiotics do not improve healing unless active infection. If active infection (cellulitis, increased pain, pyrexia, purulent exudate, odour) send pre-treatment swab and review antibiotics after culture results.

Bites (animal) Thorough irrigation important. Antibiotic prophylaxis advised for – cat bite/ puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetic, elderly, cirrhotic, asplenic, and for all human bites. Co-amoxiclav doses for < 12 years: 1 month- 1year: 0.25mL/kg of 125/31 suspension 1yr - <6 years: 5ml of 125/31 suspension 6-12 years: 5mL of 250/62 suspension - three times daily for 7 days; dose doubled in severe infection

Co-amoxiclav 625mg 3 x daily

¥Doxycycline 100mg 2 x daily PLUS Metronidazole 400mg 3 x daily (Co-trimoxazole PLUS Metronidazole should be used in <12 years - see BNFC).

7 days

Bites (human) ¥Doxycycline oral 100mg 2 x daily + (if severe) Metronidazole 400mg 3 x daily (Co-amoxiclav alone for children <12 years – see BNFC)

Clarithromycin 500mg 2 x daily + (if severe) Metronidazole 400mg 3 x daily

7 days

Purulent Conjunctivitis

Most bacterial conjunctivitis is self-limiting. 65% resolve on placebo by day 5. It is usually unilateral with yellow-white mucopurulent discharge but may spread. Fusidic acid has less gram-negative activity.

Chloramphenicol 0.5% drops 2 hourly reducing to 4 x daily AND/OR 1% ointment at night (3-4 x daily if used alone)

Fusidic acid 1% gel 2 x daily

48 hours after resolution

Herpes zoster If pregnant/immunocompromised seek advice. Aciclovir 800 mg 5x/day Valaciclovir 1g 3 x daily 7 days GENITAL TRACT INFECTIONS Note: If STI diagnosed then refer to Sexual Health Service (SHS) -0845 337 9900 for partner notification and advice if required. Vaginal candidiasis All topical and oral azoles give 75% cure. In

pregnancy avoid oral azole- use intravaginal for 7 days.

Clotrimazole 500 mg pessary OR 10% 5g vaginal cream

Fluconazole 150 mg orally

Stat (topical treatment at night)

Bacterial vaginosis Avoid 2g dose in pregnancy and breastfeeding. Topical treatment gives similar cure rates but is more expensive.

Metronidazole

2g as single dose

Metronidazole 400mg twice daily

Stat or 7 days

Uncomplicated genital Chlamydia infection in men and women

Treat contacts and refer to SHS clinic. In pregnancy or breastfeeding: azithromycin is most effective option but is ‘off label’. Doxycycline contraindicated in pregnancy. Retest within 3 – 12 months.

Azithromycin 1 g single dose

*Doxycycline 100 mg 2 x daily

Stat or 7 days

Acute bacterial prostatitis

4 weeks treatment may prevent chronicity. Note that bacterial infection (acute and chronic) account for <5% of all prostatitis diagnoses; their precise incidence is unknown. (BASHH guidance) NB: IV therapy may be required.

Co-trimoxazole 960mg 2 x daily [unlicensed – see general notes in main guidance]

Trimethoprim 200 mg 2 x daily (if microbiology results available and organism sensitive)

28 days

GASTRO-INTESTINAL TRACT INFECTIONS Infectious diarrhoea Antibiotic therapy not usually indicated. Contact microbiology if severe or prolonged illness. Clostridium difficile

Stop unnecessary antibiotics and/or PPIs to re-establish normal flora. Review and stop antimotility agents and laxatives. Admit if severe: T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis.

1st episode Metronidazole 400mg oral 3 x daily

2nrd episode/severe Vancomycin 125mg oral 4 x daily

10-14 days

MENINGITIS Suspected meningococcal disease

Transfer all patients to hospital immediately. Administer benzylpenicillin or cefotaxime prior to admission, unless hypersensitive. Ideally IV but IM if a vein cannot be found.

Benzylpenicillin ≥10 yr: 1200 mg 1 - 9 yr: 600 mg <1 yr: 300 mg

Cefotaxime >12 yrs: 1g <12 yrs: 50mg/kg

Single dose

Prevention of secondary case of meningitis: Only prescribe following advice from Public Health Consultant


Appendix 3: Version Control Statements Changes from Version 3 (October 2011) General Notes Section 1. Update of the co-trimoxazole wording to reflect

length of usage and reported adverse effects. 2. Paediatric amoxicillin doses updated in line with

BNF changes. 3. Added nitrofurantoin dose for 12-18years to

common paediatric doses table. Section 1: Gastrointestinal 1. Infective gastroenteritis - addition of

recommendation to “Consider immune deficiency and testing for HIV” as an indicator infection for HIV.

2. Traveller’s diarrhoea removed from bacillary dysentery section as covered in separate section below.

3. CDI – updated HPS guidance & severity markers. 4. Threadworm – Pripsen® discontinued so removed

as option. 5. Cholecystitis – removed warning re: doxycycline in

under 12 years as not a condition in that age group.

Section 2: Respiratory 1. Influenza – re-ordering of wording and addition of

morbid obesity as a risk factor according to HPS. 2. Upper RTI /pharyngitis/ acute sore throat –

clarified wording of first comment to ‘90% resolve in 7 days with no antibiotics and antibiotics only reduced pain by 16 hours’.

3. Tonsillitis – added link to non-prescription pad 4. Infective exacerbation of COPD – updated GOLD

& NICE references. 5. CAP - addition of recommendation to “Consider

immune deficiency and testing for HIV” as an indicator infection for HIV.

6. CAP CRB65>3 – added penicillin allergy options of doxycycline or co-trimoxazole.

7. CAP CRB65=0 – define ‘shorter treatment course in children’ as 3-5 days, and 5 days for adults (according to NICE 2014 and Respiratory advice).

8. CAP CRB=1, course length changed to 5-10days.

Section 3: Central nervous system 1. Meningitis – added NICE guidance Section 4: Urinary Tract 1. Whole section – added HPA guidance and moved

key references to headers 2. Pyelonephritis – replaced EJU reference with

CKS, added advice on antibiotic choices in children.

3. Asymptomatic bacteriuria, uncomplicated UTI, catheter UTI and long term prophylaxis – added links to relevant SAPG guidance.

4. Asymptomatic bacteriuria – removed ‘childhood’ as a reason for prescribing & moved first two comments relating to first UTIs in children to the uncomplicated UTI section.

5. Uncomplicated UTI – clarified that cefalexin suspension is more cost-effective than nitrofurantoin for ‘under 12 years and those unable to take tablets’.

6. Uncomplicated UTI – under comments relating to children updated guidance to state “send pre-treatment MSU for all” and “Refer for investigation if < 6 months, recurrent or atypical UTI.”

7. Pyelonephritis – clarified that co-amoxiclav is first-line in children, and to consider ciprofloxacin in severe penicillin allergy.

Section 5: Genital System 1. Whole section – changed GUM to Sexual health

Services and updated contact number. 2. Chlamydia, PID, Primary Genital Herpes,

Urethritis, Trichomoniasis, Vaginal candidiasis, Epididymitis – addition of recommendation to “Consider immune deficiency and testing for HIV” as an indicator infection for HIV.

3. Gonorrhoea –added penicillin allergy option (2g azithromycin) and warning that cefixime regimen is sub-optimal (need for test of cure at two weeks for both.

4. Bacterial vaginosis – removed formulation advice (use 5 x 400mg as more cost-effective than 4 x 500mg) as picked up in ScriptSwitch system.

5. Acute prostatitis – BASHH guidance replaced by CKS.

6. Chronic prostatitis – section removed as not empirical (should be guided by microbiology results as 95% non-bacterial)

Section 7: Ear, nose and oropharynx 1. Sinusitis – added >98% to ‘many are viral’ in line

with CKS information. 2. Oral thrush – addition of recommendation to

“Consider immune deficiency and testing for HIV” as an indicator infection for HIV. Miconazole dosing change incorporated (reduced from 5-10mL to 2.5mL)

3. Dental abscess, severe gingivitis – increased doses of amoxicillin and metronidazole in line with SCDEP, HPA and CKS.

Section 8: Skin 1. Head lice – link to updated HPA guidance. 2. Fungal infection, scalp – changed griseofulvin

course length to 4-8 weeks in line with HPA guidance.

nhs grampian staff prescribing guidance for the empirical

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