NHS The NHS in Rotherham ANTIMICROBIAL SUMMARY PROTOCOL FOR THE MANAGEMENT OF INFECTION IN PRIMARY CARE Next review due December 2019

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1 NHS ANTIMICROBIAL SUMMARY PROTOCOL F THE MANAGEMENT OF INFECTION IN PRIMARY CARE Next review due December 2019 To be used in conjunction with the detailed Antimicrobial Protocol for the Management of Infection in Primary Care Empirical Prescribing Formulary Adult doses are stated unless otherwise indicated. Refer to full Protocol or current BNF/BNFC if doses or condition not stated. CONDITION COMMENT 1 ST LINE CHOICE 2 ND LINE CHOICE SE THROAT OTITIS MEDIA NB Child doses OTITIS EXTERNA BACTERIAL RHINOSINUSITIS COUGH, BRONCHITIS EXACERBATIONS OF COPD COMMUNITY ACQUIRED PNEUMONIA See BTS guidelines for full details UNCOMPLICATED UTI - ADULTS (No fever or flank pain) FeverPAIN score can help determine high risk. If score 3 there is a 40% probability of bacterial infection use 3-day back up antibiotics if 4 or more then use immediate antibiotics if severe or 48 hour short back-up prescription. Consider 2 or 3-day-delayed or immediate antibiotics for pain relief if: < 2yrs AND bilateral AOM (NNT4) or bulging membrane & 4 marked symptoms All ages with otorrhoea (NNT3) Antibiotics to prevent Mastoiditis NNT >4000 First use analgesia and aural toilet (if available) as may not be infective. If cellulitis or disease extending outside ear canal, swab and start oral antibiotics and refer to exclude malignant otitis externa. Avoid antibiotics as 80% resolve in 14 days without treatment, and they only offer marginal benefit after 7 days NNT 15 Use adequate analgesia Consider 7-day-delayed or immediate antibiotic when purulent pharyngeal discharge NNT8 Antibiotic little benefit if no co-morbidity. Symptom resolution can take 3 weeks. Consider 7 day delayed antibiotic with symptomatic advice/leaflet Consider immediate antibiotics if > 80yr and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure > 65yrs with 2 of the above. Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume Risk factors for antibiotic resistant organisms include comorbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months Use CRB-65 score to help guide and review: Score s should not substitute clinical judgement i.e. signs of fever, cough, sputum, new focal chest signs Score 0 Low risk: consider home based care Score 1-2: Intermediate risk: consider referral to breathing space or hospital assessment Score 3-4: urgent hospital admission Mycoplasma infection is rare in over 65s WOMEN with severe/ 3 symptoms: treat WOMEN with mild/ 2 symptoms AND urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors for infection. If presence of cloudy urine use dipstick to guide treatment Nitrite + blood/leucocytes has 92% positive predictive chance of infection. No nitrite, leucocytes, and blood has a 76% negative predictive chance of no infection PENICILLIN V 500mg QDS or 1gram BD (QDS when severe) for 10 days Neonate 30mg/kg TDS (7-28days) 1 month-1year 125mg TDS 1-5 years 250mg TDS years 500mg TDS ACETIC ACID 2%, 1 spray TDS 500mg (1gram if severe) TDS, PENICILLIN V 500mg QDS 500mg TDS, for 5 days 500mg TDS for 5 days 250mg - 500mg BD, 5 days AZITHROMYCIN 6m 17Yrs 0-15kg) 10mg/kg 15-25kg 200mg 26-35kg 300mg All OD for 36-45kg 400mg 3 days > 46kg 500mg MAX 500mg /dose NEOMYCIN SULPHATE WITH CTICOSTEROID, 3 drops TDS min to 14 days max 200mg STAT, then 100mg BD, For persistent symptoms CO-AMOXICLAV 625mg TDS 200mg STAT, then 100mg OD, for 5 days 200mg STAT then 100mg BD, for 5 days 500mg BD, for 5 days If resistance risk factors CO-AMOXICLAV 625mg TDS for 5 days If CRB65=0 If CRB65 = 1,2 & AT HOME 500mg 1g TDS Use 5 days Review at 500mg BD 3 days & extend to 7-10 days 200mg STAT if poor then 100mg BD response NITROFURANTOIN 100mg MR BD Use First line if egfr>45ml/min egfr use ONLY for 3-7days if resistance and no alternative TRIMETHOPRIM 200mg BD 500mg 1g TDS for 7-10 days AND 500mg BD, for 7 10 days alone 200mg STAT then 100mg BD, for 7-10 days Always safety net and perform culture in all treatment failures. In increased resistance If GFR<45 ml/min or elderly consider pivmecillinam FOSFOMYCIN 3Gram sachet 3g stat in women

2 UTI - PREGNANCY Counsel women that symptoms may still be present after 3 days but that they will clear. MEN: Investigate for underlying pathology. Consider prostatitis and send pre-treatment MSU if symptoms mild/non-specific, use negative nitrite and leucocytes to exclude UTI Send MSU for culture & sensitivity and start empirical antibiotics Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus; manufacturer advises avoid at term. Avoid trimethoprim if low folate status or on folate antagonist (e.g. antiepileptic or proguanil) PIVMECILLINAM 200mg TDS (400mg TDS if resistance risk) Women for 3 days Men for 7days NITROFURANTOIN 100mg MR BD Use First line if egfr>45ml/min egfr use ONLY for 3-7days if resistance and no alternative Men 3g stat, then 2 nd 3g dose 3 days later). TRIMETHOPRIM (off label) 200mg BD 7 days Give folic acid if first trimester; 400mcg or 5mg if NTD risk If susceptible (resistance is common) 500mg TDS for 7days PYLONEPHRITIS ANTIBIOTIC ASSOCIATED DIARRHOEA - CLOSTRIDIUM DIFFICILE INFECTION CHLAMYDIA TRACHOMATIS / URETHRITIS If admission not needed, send MSU for culture & sensitivities and start antibiotics If no response within 24 hours, admit Note: Ciprofloxacin encourages emergence of MRSA and C.diff Stop unnecessary antibiotics and/or PPIs 70% respond to metronidazole in 5 days; 92% in 14 days If severe symptoms or signs (below) should treat with oral vancomycin, review progress closely and/or consider hospital referral. Admit if severe: Temp>38.5 o C ; WCC >15, rising creatinine or signs/symptoms of severe colitis Opportunistically screen all aged 15-25yrs. Treat partners and refer to GUM service Pregnancy or breastfeeding: azithromycin (off-label use) is the most effective option Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment CIPROFLOXACIN 500mg BD for 7-10 days NB Norfloxacin is NOT appropriate as does not penetrate parenchyma sufficiently 1 st episode 400mg or 500 mg TDS for 10 days if GDH +ve for 14 days if CDI toxin +ve AZITHROMYCIN 1 gram STAT 100mg BD CO-AMOXICLAV 625 mg TDS for 7-10 days If lab report shows sensitive TRIMETHOPRIM 200mg BD 14 days 2nd episode/severe/type 027 AL VANCOMYCIN 125mg QDS 14 days Recurrent disease Seek microbiology advice If Pregnant / breastfeeding AZITHROMYCIN 1 gram STAT (off label use) ERYTHROMYCIN 500mg QDS 500mg TDS VAGINAL CANDIDIASIS All topical and oral azoles give 75% cure Pregnancy: avoid oral azole drugs and use intravaginal for 6 nights/7 days CLOTRIMAZOLE 500MG pessary or 10% cream STAT FLUCONAZOLE 150mg STAT If Pregnant CLOTRIMAZOLE 100mg pessary ON for 6 nights MICONAZOLE 2% cream intravaginally BD BACTERIAL VAGINOSIS Oral metronidazole is as effective as topical treatment but is cheaper. Less relapse with 7 day than 2g stat at 4 weeks Pregnant /breastfeeding: 2g stat metronidazole C/I Treating partners does not reduce relapse 400mg BD 2 gram STAT If Pregnant 0.75% VAGINAL GEL 5gram ON for 5 NIGHTS CLINDAMYCIN 2% VAGINAL CREAM 5gram ON for 7 NIGHTS CONJUNCTIVITIS Most conjunctivitis is viral or self-limiting. Bacterial conjunctivitis is usually unilateral and also selflimiting. It is Characterised by red eye with mucopurulent, not watery discharge. Only treat if severe. 65% resolve on placebo by day five Fusidic acid has less Gram-negative activity CHLAMPHENICOL 0.5% drop 2 hourly for 2 days then 4 hourly (while awake) AND CHLAMPHENICOL 1% ointment ON BOTH for 48 hrs after resolution FUSIDIC ACID 1% GEL BD for 48 hrs after resolution MRSA IMPETIGO Use cultures to confirm MRSA infection. Only treat if active infection, MRSA confirmed by lab results, infection not severe and admission not required. Use antibiotic sensitivities to guide treatment. If severe infection or no response to monotherapy after hours, seek advice from microbiologist on combination therapy. Reserve topical antibiotics for very localised lesions to reduce the risk of resistance Avoid fusidic acid preparations to reduce risk of resistance as also available orally For extensive, severe, or bullous impetigo, use oral antibiotics Reserve MUPIROCIN TDS for 5 days for MRSA ONLY alone 200mg Stat then 100 mg BD for 5 days Stop if diarrhoea develops Topical POLYFAX OINTMENT Apply BD for up to 3 weeks HYDROGEN PEROXIDE (CRYSTACIDE ) Apply BD - TDS for up to 3 weeks SEEK MICROBIOLOGY ADVICE Oral Antibiotics FLUCLOXACILLIN 500mg QDS 500mg BD for 5 days

3 BITES ANIMAL & HUMAN CELLULITIS Thorough irrigation is important Human: Assess risk of tetanus, rabies, HIV, hepatitis B/C Antibiotic prophylaxis is advised Cat or Dog: Assess risk of tetanus and rabies and give prophylaxis if cat scratch puncture wound or for Dog/Cat bite to hand, foot, face, joint, tendon, ligament; immunocompromised /diabetic/asplenic/cirrhotic/ presence of prosthetic valve or prosthetic joint Note: Ciprofloxacin encourages emergence of MRSA and C.diff Ensure correct diagnosis; if bilateral cool red legs with no fever and normal WBC, likely to be stasis dermatitis rather than cellulitis MILD (Class I): patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone MODERATE (Class II): febrile and ill, or comorbidity, use IV treatment in the community or admit for treatment SEVERE (Class III): toxic appearance: admit. If river or sea water exposure, discuss with microbiologist. Prophylaxis or Treatment CO-AMOXICLAV alone mg TDS AND review at 24&48 hrs FLUCLOXACILLIN 500mg QDS If slow response continue for a further 7 days. If penicillin allergic or cat scratch/puncture wound: 400mg PLUS 100mg BD AND review at 24&48 hrs If penicillin allergic 500mg BD for 7days If slow response continue for a further 7 days. If taking Statin s DOXYXYCLINE 200mg STAT then 100mg OD If slow response continue for a further 7 days. IF UNRESOLVING: CLINDAMYCIN mg QDS If slow response continue for a further 7 days. Stop clindamycin if diarrhoea occurs. FACIAL: CO-AMOXICLAV 625mg TDS alone If slow response continue for a further 7 days. This summary guideline accompanies NHS Rotherham CCG: Management of Infection in Primary Care and is available at The guidance in both is based on the best available evidence but its application must be modified by professional judgement. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. In severe or recurrent cases consideration of a larger dose or longer course may be necessary. This Communication was issued in partnership by NHS Rotherham CCG and Rotherham NHS Foundation Trust

4 ANTIMICROBIAL SUMMARY PROTOCOL F THE MANAGEMENT OF INFECTION OF PRIMARY CARE Next review due December 2019 NHS This summary protocol has been produced using the NHS Rotherham CCG full protocol on Management of Infection in Primary Care and is largely based on the HPA Management of Infection Guidance for Primary Care for local adaption. KEY PRINCIPLES OF ANTIMICROBIAL PRESCRIBING 1. Only prescribe antibiotics where there is evidence of a bacterial infection and there is likely to be a clear clinical benefit and in severe infections initiate antibiotics as soon as possible. 2. Do not prescribe an antibiotic before checking previous microbiology results to determine the patient s usual isolates and sensitivities if there is a chronic underlying condition and/or to make sure the patient has not grown MRSA, ESBLs (Extended Spectrum Beta-lactamase producers) or clostridium difficile since these isolates will Influence your antibiotic choice. 3. Check for hypersensitivity and allergy status determine if genuine and document description clearly and the severity of it if not documented already. 4. Use simple, well established, generic narrow spectrum antibiotics where possible and they remain effective. Avoid broad spectrum agents (e.g. coamoxiclav, quinolones and cefalosporins) as they increase the risk of c. difficile, MRSA and resistant UTIs. 5. NHS Rotherham guidelines suggest a dose and duration for empiric treatment; however in severe cases a larger dose or longer course may need to be considered. If in doubt contact Microbiology for advice. 6. Consider a no or delayed antibiotic strategy for acute self-limiting upper respiratory tract infections and urinary tract infections when appropriate 7. Antibiotics are ineffective against viral sore throats, simple coughs and colds. 8. Ensure the clinical indication, dose, route and duration of antibiotics is clearly documented in the patient s medical records. 9. Avoid the use of topical antibiotics, especially those that are available for systemic use (e.g. fusidic acid); this practice tends to compromise their effectiveness since it selects for resistance. 10. Limit prescribing of antibiotics over the telephone to exceptional cases ONLY. 11. Avoid longer courses of treatment than necessary. 12. Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice. 13. Avoid unnecessary use of combinations of antimicrobials where a single drug would be equally effective. 14. Avoid prophylactic use of antibiotics unless of proven benefit. 15. Clarithromycin has a better side-effect profile than erythromycin, greater compliance as its dose is twice rather than four times daily & generic tablets are similar cost and may be a suitable alternative where specifically mentioned. In children erythromycin may be preferable as clarithromycin syrup is twice the cost. Where best guess or empirical therapy has failed (including any determined through culture and sensitivity) or special circumstances exist, specialist Microbiologist advice can be obtained from Rotherham Foundation Trust (RFT.) Consultant Microbiologist / Microbiology lab or via RFT Switchboard bleep no PENICILLIN ALLERGY Allergy Status Always ask for description of the reaction experienced. Document in notes and the Name of medicine and the reaction. Diarrhoea is a result of change in bowel flora and not an allergic reaction True penicillin-allergic patients will react to all penicillins. About 10% of penicillin-sensitive patients will also be allergic to cephalosporins. Where patients are penicillin allergic, use clarithromycin in place of the penicillin agent (unless an alternative is specified in the guideline or seek advice from microbiologist on suitable alternatives). DENTAL / AL INFECTIONS GPs should not routinely be involved in dental treatment and, if possible advice should be sought from the patient s dentist, who should have details of how to access treatment out-ofhours, or telephone 111 for (NHS 111 service) This summary guideline accompanies NHS Rotherham CCG: Management of Infection in Primary Care and is available at The guidance in both is based on the best available evidence but its application must be modified by professional judgement. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. In severe or recurrent cases consideration of a larger dose or longer course may be necessary. This Communication was issued in partnership by NHS Rotherham CCG and Rotherham NHS Foundation Trust MRSA Use cultures to confirm MRSA infection. For active MRSA infection use antibiotic sensitivities to guide treatment. If severe infection or no response to monotherapy after hours, seek advice from microbiologist on combination therapy. Patient s with MRSA should have an alert attached in their clinical record in active/current problems, as once a patient has been identified as MRSA positive the risk of clinical infection remains throughout their life. MRSA is resistant to Beta-lactam Antimicrobials such as flucloxacillin, coamoxiclav, cephalosporins and other agents such as ciprofloxacin and any future courses of antibiotics should be prescribed with care. MRSA READ codes: EMIS: A3B11 Systm One: XE0R6 ANTIBIOTIC ASSOCIATED DIARRHOEA CLOSTRIDIUM DIFFICLE INFECTION C. Diff Infection (CDI) may manifest whilst on antibiotics, but a significant number of cases occur following cessation of therapy, the incubation period extending to several weeks. Symptoms may include fever, abdominal pain and diarrhoea (with/without blood and or mucus). Antibiotics particularly associated with CDI include broad spectrum agents such as co-amoxiclav, cephalosporins, quinolones (including ciprofloxacin) and clindamycin (the 4C antibiotics ). Any patient with an antigen GDH positive but toxin-negative result should be treated (as below) if the diarrhoea is otherwise unexplained and persists. Patient s with a CDI should have an alert attached in their clinical record in active/current problems, as once a patient has been infected with a CDI or has been identified as antigen GDH positive and C.Diff toxin negative the risk of clinical infection remains throughout their life. C.Diff Infection (CDI) READ Code:EMIS/Systm One:A3Ay2 GDH +ve READ code: EMIS: 43k90 Systm One: XaaaT Stop unnecessary antibiotics and/or PPIs. 70% respond to metronidazole in 5 days; 92% in 14 days If severe symptoms or signs (below) should treat with oral vancomycin, review progress closely and/or consider hospital referral. Admit if severe: Temp>38.5 o C; WCC >15, rising creatinine or signs/symptoms of severe colitis

5 ANTIMICROBIAL SUMMARY PROTOCOL F THE MANAGEMENT OF INFECTION OF PRIMARY CARE Next review due December 2019 NHS LOWER RESPIRATY TRACT INFECTIONS Note: Low doses of penicillin s are more likely to select out resistance. Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. COUGH, BRONCHITIS Antibiotic little benefit if no co-morbidity Symptom resolution can take 3 wks. Consider 7 day delayed antibiotic with symptomatic advice/leaflet Consider immediate antibiotics if > 80yr and ONE of: Hospitalisation in past year, oral steroids, diabetic, congestive heart failure > 65yrs with 2 of the above. COMMUNITY-ACQUIRED PNEUMONIA TREATMENT IN THE COMMUNITY Use CRB-65 score to help guide and review: Score s should not substitute clinical judgement i.e. signs of fever, cough, sputum, new focal chest signs etc. See BTS guidelines for full details Each scores 1: Confusion (AMT< 8) ; Respiratory rate 30/min; BP systolic < 90 or diastolic 60; Age 65 MYCOBACTERIAL INFECTIONS Infection control risk for appropriate isolation and infection control precautions: Refer to Consultant Chest Physician and Infection control team via Rotherham Foundation Trust switchboard Advice available from TB Specialist Nurse on Mon Thurs 9 am 5 pm Self Limiting UPPER RESPIRATY TRACT INFECTIONS SE THROAT Avoid antibiotics as 90% resolve in 7 days without treatment, and pain only reduced by16 hours OTITIS MEDIA (AOM) Optimise Analgesia and target antibiotics as 60% resolves in 24 hours without antibiotics, which only reduce pain at 2 days (NNT15) and does not prevent deafness RHINO-SINUSITIS Avoid antibiotics as 80% resolve in 14 days without treatment, and they only offer marginal benefit after 7 days NNT 15. Use adequate analgesia URINARY TRACT INFECTIONS People >65 years: do not treat asymptomatic bacteriuria in the absence of white cells or <10 5, CFU/ml; it is common but is not associated with increased morbidity unless pathogen isolate is MRSA. Typical UTI Symptoms: dysuria, urgency, frequency, polyuria, suprapubic tenderness, haematuria. Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI Risk factors for increased resistance include: care home resident, recurrent UTI, hospitalisation >7d in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones. If increased resistance risk, send culture for susceptibility testing & give safety net advice. If GFR<45 ml/min or elderly consider pivmecillinam 400mg TDS or fosfomycin (3g stat in women plus 2nd 3g dose in men 3 days later). STI SCREENING GENITAL TRACT INFECTIONS People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to GUM service. Risk factors: < 25y, no condom use, recent (<12mth) /frequent change of partner, symptomatic partner, area of high HIV. CONJUNCTIVITIS Most conjunctivitis is viral or self-limiting. Bacterial conjunctivitis is usually unilateral and also self limiting. It is characterised by red eye with mucopurulent, not watery discharge. Only treat if severe. 65% resolve on placebo by day five fusidic acid has less Gram-negative activity MENINGITIS Transfer all patients to hospital immediately. If time before admission, give IV benzylpenicillin unless hypersensitive, i.e. history of difficulty breathing, collapse, loss of consciousness, or rash. GIVE: IV or IM benzylpenicillin or cefotaxime (give IM if vein cannot be found) benzylpenicillin: Children <1 yr: 300 mg, Children 1-9 yr: 600 mg, Age 10+ years: 1200 mg cefotaxime :Children < 12 yrs: 50mg/kg, Children 12+ years: 1gram Prevention of secondary case of meningitis: Only prescribe following advice from: PHE South Yorkshire Health Protection Team Tel: Out of hours: GASTRO- INTESTINAL TRACT INFECTIONS INFECTIOUS DIARRHOEA Refer previously healthy children with acute, painful or bloody diarrhoea to exclude E. coli 0157 infection. Antibiotic therapy not indicated unless systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin mg BD for 5 7 days if treated early. GASTROENTERITIS Antimicrobials usually NOT required. May be necessary in invasive salmonellosis. Seek advice from microbiology. Cases of food poisoning should be notified. TRAVELLER S DIARRHOEA Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers diarrhoea Medical attention should be sought in the country of travel for assessment of whether antibiotics are required. This summary guideline accompanies NHS Rotherham CCG: Management of Infection in Primary Care and is available at The guidance in both is based on the best available evidence but its application must be modified by professional judgement. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. In severe or recurrent cases consideration of a larger dose or longer course may be necessary. This Communication was issued in partnership by NHS Rotherham CCG and Rotherham NHS Foundation Trust