2.1 Upper respiratory tract infections : Tonsillitis Sinusitis Acute Otitis Media Acute Otitis Externa Chronic Otitis Externa Influenza

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1 ADULT ANTIMICROBIAL TREATMENT GUIDELINES FOR PRIMARY CARE The guidelines are navigable by means of hyperlinks between sections. Please navigate around topics and sections by clicking on the underlined blue words. Click on to return to this page. 1 Introduction and RCGP TARGET Antibiotics Toolkit 1.1 Prescribing in penicillin allergy 1.2 Pregnancy and Contraception 1.3 Interaction with warfarin and other anticoagulants 1.4 Prevention of Clostridium difficile infection 1.6 Useful contact numbers Page Adult Guidelines 2.1 Upper respiratory tract infections : Tonsillitis Sinusitis Acute Otitis Media Acute Otitis Externa Chronic Otitis Externa Influenza 2.2 Lower respiratory tract infections: COPD Pneumonia Bronchitis 2.3 Urinary tract infections: UTI Pyelonephritis Prostatitis/Orchitis Recurrent UTI UTI in Pregnancy 2.4 Genital tract infections: Pelvic Inflammatory Disease STI screening Chlamydia Vaginal candidiasis Bacterial vaginosis Gonorrhoea Trichomoniasis 2.5 Gastrointestinal tract infections: Clostridium difficile Threadworm Campylobacter Giardiasis Infectious Diarrhoea Cholecystitis and Diverticulitis Eradication of Helicobacter pylori 2.6 Eye infections 2.7 Skin Infections: Acne Bites (Cats/Dogs/Human) Cellulitis Impetigo Leg Ulcers Diabetic Foot Ulcers Mastitis Scabies Varicella Zoster/Shingles Oral Candidiasis Tinea capitis Tinea corporis/cruris/pedis Onychomycosis 2.8 Meningitis 2.9 Dental infections

2 ANTIMICROBIAL TREATMENT GUIDELINES PRIMARY CARE The guidelines are navigable by means of hyperlinks between sections. This enables users to find sections easily when the document is used electronically and should avoid the need to print. Click on to return to this page. Page 3 Appendix A: Clinical Guideline: Simple management of common infections. Appendix B: Quick Reference Guide for Diagnosis and Management of Adult Lower UTI for Primary Care These notes were originally prepared by Chris Lawson (Head of Medicines Management), Jon Vinson (PCT Lead Pharmacist) & Reshma Gandecha (Practice Support Pharmacist) in conjunction with Dr J Rao (Consultant microbiologist) and Dr K McDonald (Medical Director, Primary Care). The guidelines have been updated in September 2010 and October 2012 by Caron Applebee (Prescribing support pharmacist) Review of this guideline was carried out in September 2016 by Candy Li (Medicine management Pharmacist) in consultation with Dr J.Rao and Dr Y.M.Pang (Consultant Microbiologists).The management of infection guidance for primary care published in November 2014 by Public Health England has also been considered during the update. (Guidance available at: ry_care_guidance_14_11_14.pdf) Minor update August 2017 (urinary tract section and appendix B). 1

3 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 1.0 Introduction Antimicrobial stewardship is an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobial drugs to preserve their future effectiveness. Antibiotic resistance has been recognised as a major public health concern by the World Health Organisation and the UK government. It has been estimated that 80% of all antibiotics are prescribed in the community, and that 50% of these are probably unnecessary. The approach to prescribing in line with the principles of antimicrobial stewardship recommended for primary care is as follows: Prescribe an antibiotic only if there is likely to be a clear clinical benefit. Consider a no, or delayed (back up), antibiotic strategy for acute self-limiting respiratory tract infections (e.g. acute sore throat, acute bronchitis, acute otitis media and acute sinusitis). Limit prescribing over the phone to exceptional cases. Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (for example, coamoxiclav, quinolones and cephalosporins) if narrow-spectrum antibiotics remain effective, because the former increase the risk of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and antibioticresistant urinary tract infections. AVOID/DO NOT: Use longer courses than are necessary; Use combinations where a single drug would be equally effective; Prophylactic use of antibiotics unless of proven benefit. Avoid widespread use of topical antibiotics (see below for further notes) Deferred /back- up scripts and patient information leaflets The use of deferred / back up scripts for other indications of doubtful value (e.g. otitis media) is one method of managing patient expectation. Retaining the prescription in the surgery for future collection is more successful. Providing the patient with an appropriate information leaflet such as the TARGET Treating your Infection leaflet ( can increase the patient s confidence to self care and can help facilitate the use of a back up antibiotic prescription. 2

4 1.0 Topical antibiotics Should be used very rarely, if at all (eye infections are an exception). For wounds, topical antiseptics are generally more effective. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g. fusidic acid).topical antibiotics encourage resistance and may lead to hypersensitivity. RCGP TARGET Antibiotics Toolkit The toolkit has been developed by the RCGP, PHE and The Antimicrobial Stewardship in Primary Care (ASPIC) in collaboration with professional societies including GPs, pharmacists, microbiologists, clinicians, guidance developers and other stakeholders. The aim of the toolkit is to provide a central resource for clinicians and commissioners about safe, effective, appropriate and responsible antibiotic prescribing:- Prevention of Clostridium difficile (C.diff) infection Please see section 1.5 3

5 1.1 Prescribing in antibiotic allergy Clinicians and other prescribers e.g. nurses must obtain a detailed history of the nature of reported antibiotic reactions to ensure optimal therapy is prescribed. Intolerance to penicillins e.g. GI upset or thrush does not constitute allergy. Document drug allergies and nature in medical notes. Severe penicillin allergy (Type I hypersensitivity): symptoms occur within 72hrs of administration: pruritus; flushing; urticaria (hives); angioedema; laryngeal oedema; bronchospasm; hypotension. - Non-severe infections: avoid all penicillins, cephalosporins and carbapenems. - Life threatening infections: if use of a non-beta-lactam antibiotic is suboptimal seek senior advice. Mild penicillin allergy: symptoms occur >72 hours from exposure e.g. maculopapular or morbiliform rash. Idiopathic reactions to antibiotics e.g. Stevens-Johnson syndrome, toxic epidermal necrolysis or other exfoliating dermatoses: Do not give a related antibiotic again (e.g. any beta-lactam antibiotic, including Aztreonam, after reaction to penicillins) because re-exposure can trigger recurrence. Patients with erythema multiforme minor or drug fever are also usually managed with avoidance. For IgE-mediated allergy, cross-reactivity between penicillins and cephalosporins is now thought to be between 0.5% and 6.5%. Patients with IgE-mediated allergy to amoxicillin/ampicillin should not receive a cephalosporin with a similar side-chain, e.g. cefalexin. Cephalosporins with different side-chains, e.g. ceftriaxone, cefixime, are unlikely to produce allergic reactions in penicillin- or amoxicillin-allergic patients. It is the responsibility of both the prescriber and dispenser to be aware of the patient s allergy status. If unsure a microbiologist can advise on a suitable alternative antibiotic. 4

6 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 1.2 Pregnancy The following are believed to be safe in pregnancy: Penicillins, cephalosporins, erythromycin and nitrofurantoin (for nitrofurantoin only: not after the 8 th month). In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high dose metronidazole (2g single dose). Short-term use of nitrofurantoin is unlikely to cause problems to the foetus. Nitrofurantoin has not been associated with any increased risk of congenital malformations. Significant placental transfer does not occur. At term, theoretical risk of neonatal haemolysis.it has been associated with haemolysis in people with glucose-6-phosphate deficiency (G6PD), however the risk is very small because placental transfer is so low. Trimethoprim, a folate antagonist, should be avoided in the first trimester of pregnancy. In the second and third trimester Trimethoprim unlikely to cause problems unless there is poor dietary folate intake or the patient is taking another folate antagonist, e.g. antiepileptics such as phenytoin, sodium valproate or primidone. Quinolone antibiotics should be avoided in pregnancy and breastfeeding. Rifampicin has caused teratogenic effects in animal studies in high doses and may increase the risk of neonatal bleeding. Tetracyclines have been associated with dental discolouration and should not be used in pregnancy or breastfeeding. 5

7 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 1.3 Contraception The latest recommendations for antibacterials that do not induce liver enzymes are when they are used with combined oral contraceptives no additional contraceptive precautions are required unless diarrhoea or vomiting occur. It is also currently recommended that no additional contraceptive precautions are required when contraceptive patches or vaginal rings are used with this type of antibacterials. Women taking combined hormone contraceptives who required enzyme-inducing antibacterials e.g. rifampicin should be advised to change to a contraceptive method that is unaffected by enzyme-inducers e.g. some parenteral progesterone only contraceptives or intra-uterine devices for the duration of and for 4 weeks after stopping. If a change in contraceptive method is undesirable or inappropriate. Please see BNF under Combined hormonal contraceptives- Interactions for further information 1.4 Interaction with warfarin and other anticoagulants Experience in anticoagulant clinics suggests that the INR can be altered by a course of most antibiotics. Increased frequency of INR monitoring is necessary during and after a course of antibiotics until the INR has stabilized. Patients should be advised to be vigilant for any signs of increased bleeding. If increased bleeding occurs then the patient should be advised to contact the GP or anticoagulant clinic to arrange additional INR testing and dose review. Cephalosporins, erythromycin, clarithromycin (and other macrolide), ciprofloxacin and trimethoprim seem to cause a particular problem. 6

8 1.5 Prevention of Clostridium difficile (C.diff) infection There must be a clear indication for antibiotic use, particularly in the vulnerable elderly population. The risk factors for acquiring C.difficile infection are as below:- Age - incidence is much higher in patients aged >65 years Underlying disease - patients with chronic renal disease, underlying gastrointestinal conditions, and oncology patients Antibiotic therapy - patients who have recently received or who are receiving antibiotic therapy, especially broad-spectrum antibiotics such as extended-spectrum cephalosporins e.g. (cefotaxime, cefuroxime, cefixime), clindamycin,co-amoxiclav and quinolones (e.g. ciprofloxacin) both in the community and hospital. C. difficile infection has been associated with oral, intramuscular and intravenous routes of administration of the antibiotics. Duration of hospital stay - Patients who are frequently in hospital, or who have a lengthy stay in hospital. Other medication - patients receiving anti-ulcer medications including antacids and proton pump inhibitors (e.g. omeprazole). Nasogastric tubes - patients undergoing s requiring nasogastric tubes. Surgery patients who have had surgery on the digestive system. 1.6 Useful Contact numbers Main Bacteriology Laboratory (BHNFT) enquiries and results : Virology Laboratory (BHNFT) : Dr J. Rao Consultant Medical Microbiologist and Director of Infection Control or Bleep 207 via switchboard ( ) Dr Y.M. Pang Consultant Medical Microbiologist or bleep 207 Secretary to Consultant Microbiologist and Infection Control (BHNFT) ext 2825 Public Health England (South Yorkshire for Barnsley area)

9 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.1 UPPER RESPIRATORY TRACT INFECTIONS Clinical Diagnosis Comments Drug Duration of TONSILLITIS/PHARYNGITIS /SORE THROAT Appendix A-Use FeverPAIN Score to assess patient. You can access the FeverPAIN Score via the below website. The majority of sore throats are self limiting (lasting up to ) & do not respond to antibiotics. Antibiotics are rarely needed 1 st line: Phenoxymethylpenicillin 500mg QDS 10 days Consider deferred antibiotic script. Use adequate analgesia Patients with 4 or more FeverPAIN score present use immediate antibiotic if severe, or 48hr short back up prescription. Penicillin allergy: Clarithromycin 250mg-500mg BD 5 days SINUSITIS Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit. Consider deferred script. Use adequate analgesia Reserve antibiotics only for severe or symptoms >10 days. Many are viral 90% of patients with colds have x-ray evidence of sinus disease which usually resolves spontaneously within 2 to 3 weeks. Symptomatic benefit of antibiotics is small and may be offset by the risk of adverse reaction. 80% resolve in 14 days without antibiotics. Pain relief and steam inhalation often sufficient 1 st line: Amoxicillin 500mg TDS Penicillin allergy: Clarithromycin 500mg BD or Doxycycline 200mg on first day then 100mg od (only to be used in adults) Persistent infection: Co-amoxiclav 625mg TDS (If not penicillin allergic) If allergic to penicillin consult microbiology. 8

10 2.1 UPPER RESPIRATORY TRACT INFECTIONS Clinical Diagnosis Comments Drug Duration of ACUTE OTITIS MEDIA Further information in Appendix A Consider deferred script. Caused by respiratory viruses in 50% of cases. Illness resolves over 4 days in 80% without antibiotics. Optimise analgesia using NSAID or paracetamol. In patients who are not acutely unwell, delayed prescription approach could be used with the delay being 2-3 days. 1 st line: Amoxicillin Neonate 7-28days:30mg/kg TDS 1 month-1year old: 125mg TDS 1-5 years: 250mg TDS 5 years old-adult: 500mg TDS 5 days Antibiotics should be used in an acutely ill child fever, vomiting, pain for >48 hours and a discharging ear. Consider a 2-3 day delayed or immediate prescription, if <2yrs with bilateral AOM or any age with otorrhoea Penicillin allergic: Erythromycin <2 years: 125mg QDS 2-8 years: 250mg QDS 8 years-adults: 500mg QDS 2 nd line if 1 st line failure: Co-amoxiclav (if not penicillin allergic) 1mth-1yr: 0.25mls/kg of 125/31mg suspension TDS 1-6 yrs: 5mls of 125/31mg suspension TDS 6-12 yrs: 5mls of 250/62mg suspension TDS Adult and child >12yrs: 250/125mg tablets TDS 5 days 5 days If allergic to penicillin consult microbiology. RECURRENT OTITIS MEDIA Seek advice from ENT specialist and Consultant microbiology. Do not initiate long-term antibiotics. 9

11 2.1 UPPER RESPIRATORY TRACT INFECTIONS Clinical Diagnosis Comments Drug Duration of ACUTE OTITIS EXTERNA Local of aural toilet should be carried out before the use of topical agents or oral antibiotic (gentle dry mopping, gentle syringing and suction where available) 1 st line: Acetic acid 2% one spray TDS (for mild otitis externa) 2 nd line: Neomycin sulphate with corticosteroid 7-14 days Topical usually effective. Avoid oral antibiotics wherever possible (only required in severe infection) Pain reliefparacetamol Local of aural toilet (gentle dry mopping, gentle syringing and suction where available) Severe infection: Systemically unwell/spreading cellulitis: Flucloxacillin 500mg QDS Penicillin allergic: Clarithromycin 500mg BD 5 days 5 days Send swab for culture in severe cases (cellulitis/disease extending outside ear canal) and patients with diabetes or immunocompromised For Candida infections: Clotrimazole 1% solution as ear drops 2 or 3 drops TDS Continue for 14 days after symptoms resolve In severe cases refer to specialist ENT to exclude malignant otitis externa. 10

12 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.1 UPPER RESPIRATORY TRACT INFECTIONS CHRONIC OTITIS EXTERNA INFLUENZA No antibacterials or antifungals are normally needed. Treat flares as for acute otitis externa. Consider referral if to ENT specialist if :- -Does not respond to appropriate in primary care/contact sensitivity is suspected and patch testing would be useful to guide further management -Ear canal is occluded or becomes occluded -Malignant otitis externa is suspected Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not recommended. Keep ear clean, dry and clear of debrisavoid irritants. Treat at risk patients, when influenza is circulating in the community and ideally within 48 hours of onset (do not wait for lab report) or in a care home where influenza is likely. At risk: pregnant (including up to two weeks post-partum), 65 years or over, chronic respiratory disease (including COPD and asthma), significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease, morbid obesity (BMI>=40). Use 5 days with oseltamivir 75mg bd. If resistance to oseltamivir or severe immunosuppression, use zanamivir 10mg BD (2 inhalations by diskhaler for up to 10 days) and seek advice. Post-exposure prophylaxis Seek advice from Consultant microbiology for of patients under 13 years or in severe immunosuppression. For post-exposure prophylaxis for at risk group seek advice from Consultant microbiology or see NICE guideline. 11

13 2.2 LOWER RESPIRATORY TRACT INFECTIONS Note: Low doses of penicillins are more likely to select out resistance, 500mg of amoxicillin is recommended. Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. Clinical Diagnosis Comments Drug Duration of ACUTE INFECTIVE EXACERBATION OF COPD If home management is appropriate: Antibiotics are indicated if patient has increased shortness of breath with increased purulent sputum. 1 st line: Amoxicillin 500mg TDS or Doxycycline 200mg stat dose then 100mg OD or Clarithromycin 500mg BD 5-5- Risk factors for increased antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months If resistant organism is suspected then: 2 nd line: Co-amoxiclav 625mg TDS 5-12

14 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.2 LOWER RESPIRATORY TRACT INFECTIONS Note: Low doses of penicillins are more likely to select out resistance, 500mg of amoxicillin is recommended. Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. Clinical Diagnosis Comments Drug Duration of COMMUNITY ACQUIRED PNEUMONIA (CAP) Microbiological investigations are not recommended routinely for those managed in the community. Only consider investigation if no response to antibiotic after 48hr of antibiotic. Investigation for Mycobacterium tuberculosis should be considered for patients with persistent productive cough especially associated with weight loss, night sweats or if other risk factors exist. Treat according to clinical judgement and use CRB65 severity score to help guide and review. Each CRB65 parameter scores 1: Confusion AMT<8 Respiratory rate >30/min BP systolic <90 or diastolic <60 Age >65 Score 0: suitable for home Score 1-2: hospital assessment or admission Score 3-4: urgent hospital admission Mycoplasma infections are rare in over 65s. Further information about pneumonia: Appendix A CRB65 score=0 Amoxicillin 500mg TDS or Clarithromycin 500mg BD or Doxycycline 200mg stat then 100mg OD CRB65=1 and patient at home: Amoxicillin 500mg TDS and Clarithromycin 500mg BD or Doxycycline alone 200mg stat then 100mg OD If atypical chest infection is suspected (e.g.mycoplasma) and no response after hours of above antibiotic consider adding oral Clarithromycin 500mg BD and consider referral to specialist. If Staphylococcal infection suspected (following influenza / viral illness) add Flucloxacillin 500mg QDS 7-10 days 7-10 days 7-10 days 7-10days 7-10days 13

15 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.2 LOWER RESPIRATORY TRACT INFECTIONS Note: Low doses of penicillins are more likely to select out resistance, 500mg of amoxicillin is recommended. Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. Clinical Diagnosis Comments Drug Duration of ACUTE BRONCHITIS Consider deferred script. Consider checking C-reactive protein (CRP) and White Cell Count to check for evidence of bacterial infection if antibiotic prescription is being considered. Antibiotics have little benefit if no comorbidity most cases associated with viral infection (This can be confirmed easily by sending a green top coloured viral swab for respiratory viral PCR to provide reassurance to patient). Consider delayed antibiotic with symptomatic advice/leaflet. Symptoms including cough commonly persists for 2-3 weeks regardless of whether or not an antibiotic has been given. 1 st line: consider no antibiotics if co-morbidities are not present 2 nd line: Amoxicillin 500mg TDS If allergic to Penicillin: Doxycycline 200mg stat then 100mg OD 5 days 5 days Antibiotics or further investigation/management is appropriate for patients who meet any of the following criteria: -Systemically very unwell -Symptoms and signs suggestive of serious illness and/or complications -High risk of serious complications due to pre-existing co-morbidity (heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely) -65 years with acute cough and two or more of the following, or older than 80 years with acute cough and one or more of the following: hospitalisation in previous year, type 1 or type 2 diabetes, history of congestive heart failure, current use of oral glucocorticoids 14

16 2.3 URINARY TRACT INFECTIONS Note: Resistance and E. Coli bacteraemia in the community is increasing. ALWAYS safety net by checking previous microbiology urine culture results and consider the risks for resistance. See Appendix B. Clinical Diagnosis Comments Drug Duration of URINARY TRACT INFECTION (UTI) 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 asymptomatic bacteraemia; - Positive nitrites and leucocytes on dipstick increases likelihood of UTI. - Do not dipstick urine from patients with indwelling catheters. UTI in Males send a pre MSU or if symptoms mild use negative nitrite and leucocytes to exclude UTI. See Appendix B for Treatment of Asymptomatic bacteriuria. In failure: always perform culture. Pivmecillinam appears to have a lower risk of causing C. diff infection Low risk of resistance: younger women with acute UTI and no resistance risks. First line: Nitrofurantoin MR 100mg BD (use first line if GFR >45ml/min; if GFR 30-45, only use if resistance and no alternative) Alternative options if nitrofurantoin contraindicated: Trimethoprim 200mg BD (if low risk of resistance) Pivmecillinam 400mg STAT dose then 200mg TDS if resistance risk (Pivemecillinam is a penicillin; do not use if penicillin allergic) Amoxicillin 500mg TDS (only use if organism susceptible as resistance is common) Women: 3 days Men: Women: 3 days Men: Women: 3 days Men: Women: 3 days Men: Risk factors for increased resistance: care home resident, recurrent UTI (2 in 6 months, 3 in 12 months), hospitalisation for > in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased resistance, previous UTI resistant to trimethoprim, cephalosporins or quinolones). Fosfomycin (if high risk of resistance) Adult (female): 3g for 1 dose Adult (male): 3g for 1 dose then 3g after 3 days (unlicensed) Fosfomycin - for uncomplicated lower urinary-tract infections caused by multiple-antibacterial resistant organisms when other oral antibacterials cannot be used. 15

17 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.3 URINARY TRACT INFECTIONS Note: Resistance in community is increasing ALWAYS safety net by checking previous microbiology urine culture results. See Appendix B. Clinical Diagnosis Comments Drug Duration of ACUTE PYELONEPHRITIS If admission not needed, send MSU for culture & susceptibility and start antibiotics. If no response within 24 hours, admit. If ESBL risk (Extended Spectrum Beta-Lactamase coliform in previous urine culture) please discuss antibiotic choice with Consultant microbiology. Ciprofloxacin 500mg BD or Co-amoxiclav 625mg TDS ACUTE PROSTATITS Send MSU for culture and start antibiotics. 4-week course may prevent chronic prostatitis Quinolones achieve higher prostate levels. Ciprofloxacin 500mg BD or Trimethoprim 200mg BD 28 days 28 days EPIDIDYMO- ORCHITIS Patient presents with acute scrotal pain : EXCLUDE TESTICULAR TORSION Torsion is more common in men who are younger than 20 years but it is important to recognise it can occur at any age ** Please see page 18 for further information. Testicular torsion is the most important differential diagnosis. It is a surgical emergency. It should be considered in all patients and should be excluded first as testicular salvage IS REQUIRED WITHIN 6 HOURS and becomes decreasingly likely with time. * Patients with severe epididymo orchitis or features suggestive of bacteraemia may require in patient management. 16

18 EPIDIDYMO- ORCHITIS Clinical Assessment:- Likely STI (Gonorrhoea (GC)/Chlamydia) cause: Younger age High risk sexual history No previous UTI/catheterisation/instrumentation Urethral discharge Leucocytes only on urine dipstick Laboratory Investigations 1. All patients: MSU Likely Coliform organism cause: Older age Low risk sexual history Previous urological procedure/uti No urethral discharge Urine dipstick positive for leucocytes AND nitrites 2. If likely STI a) First voided urine (white sterile universal container, patient must not urinate for at least 1hour before sample collection) for Chlamydia PCR and b) Urethral swab (Fine Wire Mini Tips) for Gonococcal gram stain and culture. Consider c) HIV test Commence empirical antibiotics for all patients with epididymo-orchitis. Follow up is required :- If suspecting STI cause: refer patient to GUM clinic. If suspecting coliform cause: Follow-up with GP by day 3, checking clinical progress and MSU result. If there is no improvement in the patient's condition after 3 days, the diagnosis should be reassessed Most likely due to a sexually transmitted pathogen: Discuss empirical antibiotic choice with GUM and also refer patient to GUM clinic. Antibiotics used for sexually transmitted pathogens may need to be varied according to local knowledge of antibiotic sensitivities. Most likely due to Coliform organisms: Ciprofloxacin** 500mg po bd 10 days **Risk of tendon damage with quinolones increases with age and steroid use. It may occur within 48hr of starting antibiotic. 17

19 RECURRENT UTI IN NON- PREGNANT WOMEN Definition of recurrent UTI: Patients with 2 or more UTI episodes over 6 month period or 3 or more UTI over 12 months (It does not include episodes of bacteriuria without UTI symptoms (asymptomatic bacteriuria) Several strategies are possible: To reduce recurrence first advice simple measures including hydration, cranberry products. Then standby or post-coital antibiotics. Nightly prophylaxis reduces UTIs but adverse effects and long term compliance poor. **Please see further information on recurrent UTI and sampling of urine section. Please discuss with Consultant microbiology. Review again at 3 months and stop antibiotic prophylaxis if it is not making any difference to patient s symptoms. 18

20 2.3 Recurrent urinary tract infection (UTI) Prophylactic antibiotics for patients with recurrent UTI should not be initiated without an assessment of the likely benefits and risks. Cases may be discussed on an individual basis with a microbiologist or specialist e.g. urology or incontinence clinic. As an alternative to long-term prophylaxis, it may be helpful to supply an antibiotic course for a patient to initiate (as soon as symptoms occur. Susceptibility results from microbiological specimens should be used to guide the choice of antimicrobial agents. Persistent UTI should be considered if the same strain of microorganism responsible for the initial infection is still present in the urine 2 weeks after completing a course of appropriate. Distinguishing between Persistent and Recurrent UTI s may be useful as a persistent UTI may require further management, such as more extensive urological evaluation or longer duration of antibiotic therapy. Rule out red-flag factors (patients presenting with recurrent urinary tract infection) requiring specialist referral (e.g. urology referral):- Pregnancy Male patients Neurological disease (spina bifida, spinal cord injury) Long-term urine catheters Other significant urological problems (e.g. renal stones) Pneumaturia (air in urine) History of frank haematuria not associated with proven UTI Persistence of microscopic haematuria (dipstick positive) in the absence of UTI Symptoms persisting for greater than Back to section Back to RECURRENT UTI IN NON-PREGNANT WOMEN section 19

21 2.3 General principles of urine sampling and culture. MSUs sent in the absence of symptoms are unlikely to be helpful and may be counterproductive. Presence of bacteriuria in the absence of symptoms of UTI (i.e. asymptomatic bacteriuria) does not need except in certain key groups (e.g. pregnant women). Antibiotic of asymptomatic bacteriauria is more likely to be harmful than beneficial. Do not send urine for culture in asymptomatic elderly women and men > 65years old with positive dipsticks. Only send urine for culture if there are signs of lower urinary tract infections (frequency, dysuria or new onset of confusion). Follow-up urine samples to check for clearance are usually not indicated, except when treating asymptomatic bacteriuria in pregnancy. Patients with consistently sterile urine (absence of white blood cells in urine microscopy) but with persistent symptoms of dysuria and lower urinary tract symptoms should be assessed for other diagnoses including urethral diverticulum or bladder pathology (consider specialist referral e.g. urology) or screened for sexually transmitted disease (STI) where appropriate. All patients with long-term indwelling urinary catheters have bacteriuria and therefore urine dipstick and/or microscopy are not useful in making a diagnosis of catheter-associated UTI. Inappropriate use of multiple antibiotic s may not eradicate colonising bacteria but will induce multi-resistance. Symptoms suggestive of a UTI in a catheterised patient are: new costovertebral or suprapubic tenderness; rigors; delirium; fever; features of systemic inflammatory response syndrome. Send a catheter sample of urine (CSU) for culture if patient has symptoms suggestive of UTI. DO NOT collect 'routine' CSU samples from catheterised patients. If done incorrectly this procedure may introduce infection to the urinary tract. CSU samples should only be sent if the urinary tract is a suspected source of the systemic infection. Back to section Back to RECURRENT UTI IN NON-PREGNANT WOMEN section 20

22 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.3 URINARY TRACT INFECTIONS Note: Consider risks for resistance by checking previous microbiology urine culture results. Clinical Diagnosis Comments Drug Duration of URINARY TRACT INFECTION IN PREGNANCY UTI in pregnancy - Send a specimen for culture/sensitivity and start antibiotic. Short-term use of nitrofurantoin during 1 st and 2 nd trimester of pregnancy is unlikely to cause problems to the foetus. Avoid use during 3 rd trimester or if mother is G6PD deficient Avoid trimethoprim in the first trimester, or in women who have a low folate status or on folate antagonists e.g. anti-epileptic or proguanil. Cystitis in pregnancy 1 st line: Nitrofurantoin MR 100mg BD (avoid 3 rd trimester) or Amoxicillin 500mg TDS (if susceptible) 2 nd line: Trimethoprim 200mg BD - unlicensed. (Avoid 1 st trimester) 3 rd line: Cefalexin 500mg BD See Appendix B for Treatment of Asymptomatic bacteriuria algorithm. 21

23 2.4 GENITAL TRACT INFECTIONS Contact UKTIS (UK Teratology Information Service: ) for information on foetal risks if patient is pregnant. IDEALLY REFER ALL patients to GUM clinic for screening / follow-up, for other infections, contact tracing and health promotion BEFORE starting antibiotics. Only treat those who are unlikely to attend - the use of antibiotics will affect screening results. In order to prevent re-infection and failure it is important to treat the patient and their sexual partner(s), plus advise to avoid sexual contact during. N.B. Pregnant patients need follow-up to ensure successful eradication of infections (ideally by GUM clinic). Clinical Diagnosis Comments Drug Duration of PELVIC INFLAMMATORY DISEASE (PID) Refer woman and contacts to Genito Urinary Medicine Service. Metronidazole 400mg BD and Ofloxacin 400mg BD or Doxycyline 100mg BD 14 days Always culture for gonorrhoea and chlamydia. If gonorrhoea likely (partner has it, severe symptoms, sex abroad), resistance to quinolones is high, use ceftriaxone regimen or refer to GUM. 28% of gonorrhoea isolates now resistant to quinolones. If high risk of gonorrhoea Ceftriaxone 500mg IM stat PLUS Metronidazole 400mg BD PLUS Doxycycline 100mg BD or Ofloxacin 400mg BD 14 days. 22

24 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.4 GENITAL TRACT INFECTIONS Contact UKTIS (UK Teratology Information Service: ) for information on foetal risks if patient is pregnant. IDEALLY REFER ALL patients to GUM clinic for screening / follow-up, for other infections, contact tracing and health promotion BEFORE starting antibiotics. Only treat those who are unlikely to attend - the use of antibiotics will affect screening results. In order to prevent re-infection and failure it is important to treat the patient and their sexual partner(s), plus advise to avoid sexual contact during. N.B. Pregnant patients need follow-up to ensure successful eradication of infections (ideally by GUM clinic). Clinical Diagnosis Comments Drug Duration of STI SCREENING People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to GUM service. Risk factors: <25yr, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner, area of high HIV. UNCOMPLICATED GENITAL CHLAMYDIA INFECTION Consider referral to GU Med for follow-up and contact tracing. Azithromycin 1g Stat or Doxycycline 100mg BD Single Dose Pregnancy or breastfeeding: Azithromycin is the most effective option but is unlicensed. The safety data are reassuring but limited when compared with amoxicillin and erythromycin, however these are less well tolerated and noncompliance may be a problem. Pregnancy and Breastfeeding: Azithromycin 1g stat (unlicensed) or Erythromycin 500mg QDS or Amoxicillin 500mg TDS Single Dose 14 days 23

25 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.4 GENITAL TRACT INFECTIONS Contact UKTIS (UK Teratology Information Service: ) for information on foetal risks if patient is pregnant. IDEALLY REFER ALL patients to GUM clinic for screening / follow-up, for other infections, contact tracing and health promotion BEFORE starting antibiotics. Only treat those who are unlikely to attend - the use of antibiotics will affect screening results. In order to prevent re-infection and failure it is important to treat the patient and their sexual partner(s), plus advise to avoid sexual contact during. N.B. Pregnant patients need follow-up to ensure successful eradication of infections (ideally by GUM clinic). Clinical Diagnosis Comments Drug Duration of STI SCREENING People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to GUM service. Risk factors: <25yr, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner, area of high HIV. VAGINAL CANDIDIASIS For frequent, recurrent episodes refer to GU Med. Clotrimazole 500mg pessary/10% cream or Fluconazole 150mg orally Stat Stat In pregnancy: avoid oral azoles and use intravaginal for Pregnant: Clotrimazole 100mg pessary at night or Miconazole 2% cream 5g intravaginally BD 6 nights 24

26 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.4 GENITAL TRACT INFECTIONS Contact UKTIS (UK Teratology Information Service: ) for information on foetal risks if patient is pregnant. IDEALLY REFER ALL patients to GUM clinic for screening / follow-up, for other infections, contact tracing and health promotion BEFORE starting antibiotics. Only treat those who are unlikely to attend - the use of antibiotics will affect screening results. In order to prevent re-infection and failure it is important to treat the patient and their sexual parter(s), plus advise to avoid sexual contact during. N.B. Pregnant patients need follow-up to ensure successful eradication of infections (ideally by GUM clinic). Clinical Diagnosis Comments Drug Duration of BACTERIAL VAGINOSIS Less relapse with regimen 1st line: Metronidazole 400mg BD (or Metronidazole 2g as a single dose, but only if adherence is an issue). Provide advice on topical cleansing agents. Treating partners does not reduce relapse Avoid Metronidazole 2g stat dose in pregnancy and breastfeeding) 2nd line: Topical agents: Metronidazole 0.75% vaginal gel or Clindamycin 2% cream (5g applicatorful) if metronidazole not tolerated 5 nights 7 nights Gonorrhoea Antibiotic resistance is now very high. Use IM ceftriaxone plus azithromycin and refer to GUM Ceftriaxone 500mg IM PLUS azithromycin 1g Stat Stat 25

27 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.4 GENITAL TRACT INFECTIONS Contact UKTIS (UK Teratology Information Service: ) for information on foetal risks if patient is pregnant. IDEALLY REFER ALL patients to GUM clinic for screening / follow-up, for other infections, contact tracing and health promotion BEFORE starting antibiotics. Only treat those who are unlikely to attend - the use of antibiotics will affect screening results. In order to prevent re-infection and failure it is important to treat the patient and their sexual parter(s), plus advise to avoid sexual contact during. N.B. Pregnant patients need follow-up to ensure successful eradication of infections (ideally by GUM clinic). Clinical Diagnosis Comments Drug Duration of TRICHOMONIASIS Advise patient no sexual contact for 1 week or until 1 week after partner(s) treated. Treat partners and refer to GUM service. 1 st line : Metronidazole (MTZ) 400mg BD or Metronidazole 2g stat 5- In pregnancy or breastfeeding: avoid 2g single dose Metronidazole. Consider clotrimazole for symptom relief (not cure) if metronidazole declined. Clotrimazole 100mg pessary at night 6 nights 26

28 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.5 GASTROINTESTINAL TRACT INFECTIONS Faecal specimens should be sent to the local microbiology department. Please state clinical details e.g. patient have travelled abroad or are a known contact so that other specific pathogens are looked for. Indicate in clinical details if there are any risk factors for Clostridium difficile infection i.e. recent hospitalisation, recent antibiotics use within last 8 weeks, previous Clostridium difficile infection or colonisation, on proton pump inhibitors and recent chemotherapy. Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days in uncomplicated infections and can cause bacterial resistance. If severe diarrhoea present or if patient systemically unwell discuss with Consultant Microbiologist. Antibiotic therapy is contraindicated if patient is infected with Escherichia coli (E.coli) O157 as it can lead to Haemolytic Uraemic syndrome. Please notify known or suspected cases of food poisoning or infectious bloody diarrhoea to local Public Health England team and seek advice on exclusion of patients with diarrhoea. Send stool samples in these cases. Clinical Diagnosis Comments Drug Duration of CLOSTRIDIUM DIFFICILE : Oral Vancomycin :- GPs may be asked to prescribe oral vancomycin at a dose of 125mg QDS for 14 days. The request will come from Consultant Microbiology or Infection Control. Stop unnecessary antibiotics and/or Proton Pump Inhibitors Do not prescribe anti-motility agents. Any of the following may indicate severe infection. Patient should be admitted for assessment: Temperature >38.5 C; WCC >15 x 10 9 /L, rising creatinine or signs/symptoms of severe colitis 1 st episode (non severe): Metronidazole 400mg TDS 2 nd episode/ severe symptoms/ Clostridium difficile ribotype 027 or no clinical response to 1 st line after 5 days of : Oral vancomycin 125mg QDS 3 rd episode Discuss with Consultant Microbiologist 14 days 14 days 27

29 2.5 GASTROINTESTINAL TRACT INFECTIONS THREADWORM Treat all household contacts at the 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. >6 months: Mebendazole 100mg (off label if <2 years) 3-6 mths: piperazine (2.5ml spoonful) + senna < 3mths: 6 weeks hygiene Stat Stat, repeat after 2 weeks Pregnant / breast-feeding, preferred is rigorous attention to hygiene. If drug is considered necessary, available data suggest no increased risk of malformations with piperazine (Pripsen ) or mebendazole (but delay with mebendazole until after 1st trimester whenever possible). CAMPYLOBACTER Antibiotics are NOT usually indicated. Antibiotics may be indicated if: High fever / bloody diarrhoea / > 8 stools per day / worsening clinical condition / ill for > / pregnancy / immunocompromised. Erythromycin mg QDS or Clarithromycin 250mg BD ** Please check antibiotic susceptibility by contacting Microbiology laboratory to ensure organism is susceptible to the above antibiotic prior to prescription. 5- GIARDIASIS It can take 2 to 3 specimens to confirm. Prescribe antibiotics only if giardiasis is confirmed. Metronidazole 400mg TDS or Metronidazole 2g daily (Avoid 2g dose in pregnancy and breastfeeding) 5 days 3 days 28

30 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.5 GASTROINTESTINAL TRACT INFECTIONS Faecal specimens should be sent to the local microbiology department. Please state clinical details as special investigations are carried out if: patient has travelled abroad or is a known contact so that other specific pathogens are looked for. Also indicate if there are any risk factors for Clostridium difficile infection i.e. recent hospitalisation, recent antibiotics use within last 8 weeks, previous Clostridium difficile infection or colonisation, on proton pump inhibitors and recent chemotherapy so that Clostridium difficile is tested on the stool specimen. Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days in uncomplicated infections and can cause bacterial resistance. If severe diarrhoea present or if patient systemically unwell discuss with Consultant Microbiologist. Antibiotic therapy is contraindicated if patient is infected with Escherichia coli (E.coli) O157 as it can lead to Haemolytic Uraemic syndrome. Please notify known or suspected cases of food poisoning or infectious bloody diarrhoea to local Public Health England team and seek advice on exclusion of patients with diarrhoea. Send stool samples in these cases. Clinical Diagnosis Comments Drug Duration of GASTROINTESTINAL INFECTIONS/INFECTIOUS DIARRHOEA Antibiotics are NOT usually indicated in gastroenteritis. If considering their use please discuss with a microbiologist. Antibiotics are contraindicated if E. coli 0157 is a possibility. CHOLECYSTITIS AND DIVERTICULITIS For an infective exacerbation of known diverticulosis which does not require hospital admission. 1st line: Co-amoxiclav 625mg TDS 2nd line or Penicillin allergy: Ciprofloxacin 500mg BD AND metronidazole 400mg TDS 5 days and review 5 days and review 29

31 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.5 GASTROINTESTINAL TRACT INFECTIONS Clinical Diagnosis Comments Drug Duration of ERADICATION OF HELICOBACTER PYLORI Treat all positives in known Duodenal Ulcer (DU), Gastric Ulcer (GU) or low grade MALToma. Always use PPI (Proton Pump Inhibitor) First and second line Do not offer eradication for Gastro Oesophageal Reflux Disease. Do not use Clarithromycin, Metronidazole or Quinolone if used in past year for any infection Retest for H. pylori post DU/GU or relapse after second line therapy: using breath or stool test OR consider endoscopy for culture and susceptibility. Further information: PHE Helicobacter pylori quick reference guide. PPI WITH Amoxicillin 1g BD PLUS either Clarithromycin 500mg BD OR Metronidazole 400mg BD Penicillin allergy & previous Metronidazole+ Clarithromycin: PPI WITH Bismuthate (De-nol tab ) 240mg BD OR Bismuth Subsalicylate (Pepto-Bismol) 525mg QDS PLUS Metronidazole 400mg BD PLUS Tetracycline Hydrochloride 500mg QDS Relapse & previous Metronidazole + Clarithromycin: PPI WITH Amoxicillin 1g BD PLUS Tetracycline Hydrochloride 500mg QDS OR Levofloxacin 250mg BD All for All for MALToma treat for 14 days 30

32 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.6 EYE INFECTIONS Clinical Diagnosis Comments Drug Duration of IINFECTIVE CONJUNCTIVITIS Consider delayed script for mild cases as condition often resolves without Treat until 48 hours after symptoms resolved 1 st line: Chloramphenicol eye drops (2 hourly for 2 days then 4hourly) or eye ointment (QDS for 2 days then BD) 2 nd line: Fusidic acid gel 1% apply BD All for 48hours after resolution All for 48hours after resolution BACTERIAL BLEPHARITIS Careful cleansing of lid margins is essential and should continue indefinitely. Consider baby shampoo. Topical antibacterial to conjunctival sac / lid margins required. 1st line: Chloramphenicol 1% eye ointment 2nd line: Fusidic acid 1% eye ointment (both to the eyelid margins, after cleansing and at night before sleep). 6 weeks 6 weeks 31

33 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.7 SKIN INFECTIONS Clinical Diagnosis Comments Drug Duration of ACNE (moderate to severe) Give 3-6 months course Oral preparations should be used in moderatesevere cases or if topical preparations have proved inadequate. Where possible use nonantibiotic topical agents [e.g. benzoyl peroxide, azelaic acid (Skinoren ) or a topical retinoid (adapalene or tretinoin)]. 1 st line: Oxytetracycline or Tetracycline 500mg BD 2 nd line: Doxycycline 100mg BD or Lymecycline 408mg Once Daily If Tetracycline/Doxycycline is contraindicated: Erythromycin 500mg BD 3-6 months 3-6 months 3-6 months Refer all people with severe acne for specialist assessment and 32

34 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.7 SKIN INFECTIONS Clinical Diagnosis Comments Drug Duration of BITES FROM CATS OR DOGS/HUMAN BITES For bites from other animals seek advice from a microbiologist Surgical toilet most important. If skin is not broken just clean the wound / affected area. Prophylaxis and doses (Cats/Dogs/Human bites) 1st line: Co-amoxiclav 625mg TDS Penicillin allergy: Cats/dogs: Metronidazole 400mg TDS plus Doxycycline 100mg BD Human: Metronidazole 400mg TDS plus one of the following: Doxycycline 100mg BD or Clarithromycin 500mg BD Bites from cats/dogs: If not infected and presenting within 24 hours of injury consider prophylactic antibiotics ONLY if high risk of infection, i.e. deep puncture-type bite (not easily cleaned), suspicion of bone or joint involvement, severe bite to hand, foot or face, at risk patient, e.g. asplenic, diabetic, elderly or immunocompromised. Assess Tetanus and Rabies risk. Human bites: Antibiotic prophylaxis recommended for all patients. Assess tetanus and HIV / Hepatitis B & C risk. 33

35 ANTIMICROBIAL TREATMENT GUIDELINES Primary Care (Doses stated are adult doses unless otherwise indicated) 2.7 SKIN INFECTIONS Clinical Diagnosis Comments Drug Duration of CELLULITIS **Please check previous microbiology results in the past. If patient has been screened positive for Methicillin Resistant Staphylococcus aureus (MRSA) in the past or present from screening, beta-lactam type of antibiotic e.g. Flucloxacillin is of no use in the management of cellulitis. Please discuss antibiotic options in these patients with Consultant microbiology. Class I: If afebrile and otherwise healthy use oral flucloxacillin alone.. Class II: If febrile and ill, or comorbidity, (severe cellulitis) admit to Acute Medical Unit for intravenous, or use Outpatient Parenteral Antimirobial Therapy (if available). Class III: Toxic appearance: refer patient for inpatient admission. If river or sea water exposure, discuss with specialist. Review patient if no improvement within 48 hours. Failure to respond: Consider adding amoxicillin, according to sensitivities, but may necessitate urgent parenteral antibiotics 1st line: Flucloxacillin 500mg QDS If facial cellulitis use: Co-amoxiclav 500/125 TDS alone. Penicillin allergy: Clarithromycin 500mg BD If on statins: Doxycycline 200mg stat then 100mg OD ** Please check antibiotic susceptibility if swabs have been sent for culture. Duration depends on severity and response. Usually for 7 days. If slow response continue for a further 7 days Review patient if no improvement within 48 hours. Severe cellulitis or if no improvement with oral therapy, may require parenteral antibiotics. MRSA: For active MRSA infection, confirmed by lab results use antibiotic sensitivities provided on results to guide. 34