NHS SOUTH WEST ESSEX. Antimicrobial Prescribing Guidance For Primary Care

Transcription

1 NHS SOUTH WEST ESSEX Antimicrobial Prescribing Guidance For Primary Care 1

2 This document has been reviewed by: Dr Justin Edward, Consultant Microbiologist, BTUH Olubusola Daramola, Prescribing Advisor/Antibiotics Pharmacist, NHS SWE Jean Griffiths, Principal Pharmacist, Community Health & Clinical Governance, BTUH to be given the updated copy for comments Sue Chandler, Medicines Information Pharmacist, NHS SWE Lisa Allen, Associate Director Infection Prevention and Control, NHS SWE to be given the updated copy for comments Dr P. Martin, GP Prescribing Lead to be given the updated copy for comments Ratified by the Medicines Management Committee in February 2012 and is for review February 2014 Author: Medicines Management Team and Infection Prevention and Control Locality: NHS SOUTH ESSEX 2

3 Contents Background... 4 Aims and objectives of the guidance... 4 Principles of treatment... 5 Summary of local recommendations for antibiotic usage... 6 Section 1: Antibiotic formulary Gastro-intestinal tract infections... 7 Respiratory tract infections - lower... 9 Respiratory tract infections - upper Urinary tract infections Skin and soft tissue infection MRSA Meningitis Genital tract infections Viral infections Parasitic infections Dental infections NICE pathway for Respiratory Tract Infection Section 2: Evidence base Upper respiratory tract infection Lower respiratory tract infection Urinary tract infection References Useful Web Addresses Section 3: Information for patients Cough Bronchitis Sore throat Respiratory Tract Infection Otitis Media Urinary Tract Infection

4 Antimicrobial Prescribing Guidance for Primary Care Background The increase in antibiotic resistance has led to the more effective use of antibiotics becoming a national priority. The Standing Medical Advisory Committee has recommended for primary care: - 1 No prescribing of antibiotics for simple coughs or colds No prescribing of antibiotics for viral sore throats To limit prescribing for uncomplicated cystitis to three days in otherwise fit women To limit prescribing of antibiotics over the telephone to exceptional cases Common infective ailments account for a large proportion of the acute workload seen in general practice and cause considerable patient distress. The prescriber is sometimes put under pressure to prescribe by anxious patients who think antibiotics will provide a quick resolution, particularly if they are under pressure to return to work. However, the evidence to support antibiotic intervention is often weak or lacking and certain illnesses can be self-limiting. Good communication between the prescriber and patient, with adequate time given to the consultation, is known to bring about more selective and appropriate prescribing. Aims and objectives of the guidance The guidance is presented in three parts:- Section 1 provides an antibiotic formulary that is recommended by the local Microbiologists. Section 2 summarises the evidence base for common conditions seen in primary care, where prescribing of antibiotics is controversial. Section 3 includes patient information leaflets that can be used by the prescriber as part of a consultation. The aims are to:- Support the rational, safe and cost-effective use of antibiotics by selecting the best approach to managing common infections from the evidence available. Promote the selective use of antibiotics to reduce the emergence of bacterial resistance. Empower patients with information and support mechanisms so they can cope with illness. 4

5 The objectives are to:- Assist prescribers in managing the case by providing clear information on the likely clinical outcome with or without treatment and to indicate possible risk. Help the prescriber decide whether treatment is indicated and which antibiotic may be appropriate. Principles of treatment Prescribe an antibiotic only when there is likely to be a clear clinical benefit. Do not prescribe an antibiotic for a simple cold or viral sore throat. Use tried and tested, simple, cheap, narrow spectrum antibiotics first. Save new, more expensive, broader spectrum antibiotics for nonresponding or resistant infections. Individuals who have experienced anaphylaxis, rash or urticaria immediately after penicillin administration are at increased risk of immediate hypersensitivity to penicillin. In addition, other beta-lactam antibiotics should be used with caution in this group of patients. Avoid repeated use of topical antibiotics, as they select for resistant Organisms. Avoid certain antibiotics in pregnancy, e.g. tetracyclines, quinolones, metronidazole, trimethoprim (in first trimester), nitrofurantoin (at term) Offer a deferred prescription to equivocal cases so the patient is asked to await developments. Take account of patient s size/weight, liver and renal function when selecting the dose of antibiotic. Where a best guess therapy has failed or special circumstances exist, microbiological advice can be obtained from Basildon Hospital on or Queens Hospital on The Guidance should only be applied to individual cases with professional judgement. The recommendations apply in the absence of contra-indications. Please refer to the BNF for further information. 5

6 Summary of local recommendations for antibiotic usage Where an oral antibiotic is required, NHS SWE recommends the following list of first line antibiotics to treat the majority of bacterial infections in general practice. RECOMMENDED FIRST LINE ANTIBIOTICS Amoxicillin Trimethoprim Penicillin V Tetracycline Flucloxacillin Oxytetracycline Erythromycin Metronidazole 6

7 Section 1: Antimicrobial formulary Gastro-intestinal tract infections Illness Comments Drug Dose Treatment duration Oral candida Nystatin Suspension 1ml (100,000 units) 6 hourly (QDS) After food Clostridium difficile Treatment is only recommended when the patient is symptomatic. Stop unnecessary antibiotics and/or PPIs to re-establish normal flora If metronidazole has not had any affect within 3 days, treatment should be changed to vancomycin Metronidazole Oral Vancomycin 400mg TDS 125mg QDS 14 days 14 days Eradication of Helicobacter pylori Triple therapy attains >85%eradication. Avoid clarithromycin/ metronidazole if used in past year for any infection. Only repeat triple therapy on the recommendation of the gastroenterologist. In treatment failure, consider endoscopy for culture and sensitivities. Lansoprazole plus 2 of the following antibiotics: Amoxicillin (AM) OR Metronidazole (MZ) AND 30 mg BD 1g BD 400 mg BD All for Clarithromycin 250 mg BD with MZ 500 mg BD with AM Note: Patients with active peptic ulcer should receive a 4- week course of proton pump inhibitor. Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 7

8 Gastro-intestinal tract infections continued Gastroenteritis Fluid and electrolyte replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and can cause resistance. Initiate treatment on the advice of the microbiologist if the patient remains systemically unwell. Initiate stool investigation for severe, prolonged or recurrent diarrhoea, food poisoning or for travellers diarrhoea. Always consider referral to hospital if the patient is systemically unwell e.g. with fever, dehydration, jaundice, abdominal pain. Please notify suspected cases of food poisoning to Essex Health Protection Agency Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 8

9 Respiratory tract infections lower Illness Comments Drug Dose Treatment duration Acute bronchitis Systematic reviews indicate that benefits of antibiotics are marginal in otherwise healthy adults. No antibiotics are routinely required Consider antibiotics in >60 yrs, if underlying chest disease or severe and persistent symptoms. Avoid tetracyclines in pregnancy 1 ST line Amoxicillin 2 ND Line Doxycycline 500 mg TDS 200 mg STAT/100mg OD Antibiotic show little benefit if there are no co-morbidities. Symptom resolution can take up to 3 weeks. Consider 7-14 day delayed antibiotic with symptomatic advice/leaflet Acute exacerbation of COPD 500 mg TDS 5 days Many cases are viral consider whether antibiotics are needed. Avoid tetracyclines in pregnancy 1 ST LINE Amoxicillin OR Doxycycline 200 mg STAT/100mg OD 2 ND LINE Clarithromycin 500mg BD 5 days Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months 5 days 5 days 5 days 9

10 Community acquired pneumonia IF CRB65=0 IF CRB65=1 & AT HOME 1 ST LINE Amoxicillin 2 nd LINE Clarithromycin 500 mg TDS 500 mg BD IF CRB 3 REFER TO HOSPITAL Note: The quinolones, ciprofloxacin and ofloxacin have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections. Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 10

11 Pharyngitis/ Sore throat/ Tonsillitis Respiratory tract infections- upper Illness Comments Drug Dose Treatment duration The majority of sore throats are viral and self-limiting and antibiotics are not recommended. Exudate does not reliably indicate infection. Antibiotics may be indicated for patients with more severe symptoms or a history of otitis media, where streptococcal tonsillitis infection is suspected e.g. Fever, lymphadenopathy, scarlet fever. A degree of clinical judgement is necessary, which should be led by the evidence. THERE MAY BE BENEFITS FROM ANTIBIOTICS WHEN THREE OR MORE CENTOR CRITERIA ARE PRESENT DEPENDING ON CLINICAL ASSESSMENT AND SEVERITY.THE CENTOR CRITERIA ENCOMPASSES CLINICAL SIGNS TO PREDICT WHICH PATIENTS WITH ACUTE SORE THROAT ARE AT HIGHER RISK OF GABHS, WHO MAY BENEFIT FROM ANTIBIOTIC TREATMENT Antibiotics to prevent Quinsy NNT >4000 Antibiotics to prevent Otitis media NNT 200 CENTOR CRITERIA FOR IDENTIFYING GROUP A BETA-HEMOLYTIC STREPTOCOCCI TONSILLAR EXUDATE TENDER ANTERIOR CERVICAL LYMPH NODES ABSENCE OF COUGH HISTORY OF FEVER If you are considering prescribing antibiotics, a delayed prescription is a reasonable option Antibiotics are not indicated for glandular fever. For recurrent, more severe sore throat consult the Microbiologist for advice. First line - Penicillin V 500 mg QDS 10 days Erythromycin if allergic to penicillin 500 mg BD or 250 mg QDS 5 days Clarithromycin if intolerant of erythromycin 250mg to 500mg BD 5 days Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 11

12 Respiratory tract infections- upper continued Illness Comments Drug Dose Treatment duration Acute otitis media (AOM) (CHILD DOSES) <2 years OR bilateral AOM (NNT4) or bulging membrane (& 4 marked symptoms) All ages with otorrhoea NNT3 Antibiotic to prevent Mastoiditis NNT >4000 AOM resolves without antibiotics in 80% of cases mainly because they are viral. Antibiotics do not reduce pain in the first 24 hours, prevent subsequent attacks or deafness. Antibiotics may be indicated for severe or persistent symptoms or when the patient is systemically unwell. Use paracetamol and/or ibuprofen to treat symptoms. Amoxicillin first line Co-amoxiclav if recurrent or nonresponsive Erythromycin if allergic to penicillin CHILD DOSES 40mg/kg/day in 3 divided doses. (max 3g daily) 6-12 yrs : 250/62 mg TDS 1-6 yrs: 125/31mg TDS <2 yrs: 125 mg QDS 2-8 yrs: 250mg QDS 8-18yrs: mg QDS 5 days* days* * Standing Medical Advisory Committee guidelines suggest 3 days but longer courses of 5- may be needed to prevent relapse. Relapse at 10 days is higher with a 3 day course in otitis media but long- term outcome is similar Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 12

13 Respiratory tract infections- upper continued Sinusitis Illness Comments Drug Dose Treatment duration Many cases are viral and most resolve without 500mg TDS antibiotics. A 7 10 day period of watchful waiting would be reasonable before antibiotics are prescribed. 1 st LINE Amoxicillin 2 nd LINE Doxycycline (>12 years only) Persistent symptoms Co-amoxiclav 200mg STAT/100mg OD 625 mg TDS A delayed prescription COULD BE USED TO FACILITATE THIS watchful waiting Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 13

14 Urinary tract infections Illness Comments Drug Dose Treatment duration Asymptomatic bacteriuria occurs in 25% of women and 10% of men >65 years. Asymptomatic patients do not need antibiotics (except in pregnancy) Dipstick testing for nitrites and leucocytes should only be used to aid diagnosis of bacteriuria in women with limited signs and symptoms of UTI. Dipsticks add nothing in patients with multiple symptoms where the clinical diagnosis is fairly certain and their use is not indicated in the absence of any signs and symptoms. In women with limited signs and symptoms where the diagnosis is uncertain, positive dipsticks increase the likelihood that there is an infection and negative dipsticks increase the likelihood that there is not Uncomplicated UTI in adult female i.e. no fever or flank pain Short course advisable. Currently there is approximately 20% resistance seen to trimethoprim, therefore it should still be used first line. 1st line Trimethoprim 2 nd line Nitrofurantoin 200 mg BD mg QDS OR 100 mg MR BD 3 to 3 to UTI in catheterised Any catheters will become colonised with bacteria after insertion. Treatment is only indicated in the context of patients renal symptoms (e.g. flank pain) or systemic illness. Routine catheter change to clear bacterial colonisation is not recommended. Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 14

15 Urinary tract infections continued Illness Comments Drug Dose Treatment duration Recurrent UTI MSU for sensitivities UTI in men (increase with age or underlying disease) MSU for sensitivities. Investigation of cause. 1 st LINE Trimethoprim 2 nd LINE Nitrofurantoin 200mg BD mg QDS OR 100 mg MR BD UTI in children (lower) MSU for sensitivities. Treat empirically with trimethoprim. Referral is recommended following the first proven UTI. Trimethoprim 6 weeks up to 6 mths 25mg BD 6 mths-up to 6 yrs 50mg BD 6-12 yrs 100mg BD 12-18yrs 200mg BD Acute pyelonephritis If no response within 24 hours consider hospital admission. Must send MSU for culture. This may show negative even in the presence of infection Acute prostatitis 4 weeks treatment may prevent chronic infection. Check for Chlamydia 1 ST LINE Ciprofloxacin or Co-amoxiclav 500 mg BD 625g TDS 14 days Ciprofloxacin 500mg BD 28 days infection in younger men. Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 15

16 Skin and soft tissue infection Illness Comments Drug Dose Treatment duration Animal bites Antibiotic prophylaxis advised in First line animal bites: all cases, especially if >50 yrs, Co-amoxiclav. 625 mg TDS immunocompromised, diabetic, or asplenic Clean wound and review If penicillin allergy*; tetanus status. Assess rabies risk Doxycycline (>12 years 100mg BD and discuss high risk exposure only) and Metronidazole 400 mg TDS with microbiologist or contact Essex Health Protection Agency *If bite in a child <12 years for further advice contact microbiology Human bite Assess HIV/hepatitis B&C risk. Discuss with microbiologist or EHPA for further advice Co-amoxiclav or Doxycycline and metronidazole 625 mg TDS 100mg BD 400mg TDS 7days Cellulitis (If river or sea water exposure discuss with microbiology) Prescribe antibiotic and check wound is clean with no foreign bodies. If no response or systemically unwell, refer to hospital. Facial cellulitis low threshold for hospital admission Flucloxacillin or Erythromycin (if penicillin allergic) Clarithromycin if intolerant of erythromycin 500 mg QDS 500mg QDS 500mg BD If severe or unwell refer to hospital Leg Ulcers 16 Diagnosis and management of the underlying condition is important. Routine swabs are not recommended. Antibiotics are only indicated if cellulitis present. Selectively investigate patients and treat those that do not resolve (see under "cellulitis"). Review the management of diabetes in diabetic ulcers. Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information.

17 Skin and soft tissue infection continued Impetigo Illness Comments Drug Dose Treatment Duration Mild localised infection Fusidic acid 2% cream or Apply 3-4 times daily Up to 10 days ointment Severe and extensive infections Flucloxacillin or Erythromycin(if penicillin allergic) 500mg QDS 500mg QDS Dermatophyte infection of the proximal fingernail or toenail Adults Take nail clippings. Start therapy only if infection is confirmed by microscopy or culture. Pulsed itraconazole monthly is recommended for infections with yeasts and non-dermatophyte moulds Clarithromycin if intolerant of erythromycin Superficial only amorolfine 5% nail lacquer 1 st LINE Terbinafine 2 nd LINE Itraconazole (Monitoring of liver function is recommended) 500mg BD 250 mg OD fingers toes 200 mg BD 6-12 weeks 3-6 months, repeat course after 21 days, 2 courses for fingernails, 3 courses for toenails Note: Seek specialist advice for children with nail infection Fungal skin infections Ringworm of the feet Ringworm of the body NOTE: ringworm of scalp discuss with/refer to dermatologist Administer for 14 days after symptomatic resolution. If intractable consider oral itraconazole Take skin scrapings Topical undecenoic acid (Mycota ) OR 1% clotrimazole cream. If failure: Topical 1% 17 Twice daily Once - Twice daily 4-6 weeks terbinafine cream Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. Continue for 1-2 weeks after healing 1-2 weeks

18 Skin and soft tissue infection continued Illness Comments Drug Dose Treatment duration Acne vulgaris Topical benzoyl peroxide remains the first line topical agent. Benzoyl Peroxide (2.5%, 4%, 5% and 10%) OD or BD At least 6 months Varying strengths, choice dependent on severity and clinical judgement. It is usual to start with a lower strength and increase gradually. Antibiotics are appropriate for moderate to severe acne. Oxytetracycline OR Lymecycline if unresponsive or intolerant to oxytetracycline OR Erythromycin if unresponsive or intolerant to tetracyclines 500mg BD 408mg OD 500mg BD 6 months 2 months 6 months 6 months Topical antibiotics should be reserved for patients who cannot tolerate oral preparations. Clindamycin 1% lotion 18

19 Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. MRSA For wound cleansing: Clean the wound with warm normal saline and use primary dressings such as silver products, alginates/hydrofibre, iodine based products (unless clinically indicated with thyroid conditions) and honey dressings. Foam dressings, hydrocolloids or hydrogels are suitable alternatives if exudate is low. If the wound shows little or no sign of healing re-swab and ask for sensitivities. NB:PLEASE LIAISE WITH TISSUE VIABILITY NURSE FOR FURTHER ADVICE Avoid using topical and oral antibiotics as they are unlikely to clear carriage and may select for more resistance, particularly if the patient has a chronic lesion. MRSA is resistant to penicillin, amoxicillin, flucloxacillin, cephalosporins, erythromycin and ciprofloxacin. Antibiotic therapy requires microbiological investigation. Screening for MRSA when admitted to hospital became common place in early If a patient is found to be colonised they should be treated with Triclosan (e.g. Skinsan ) antimicrobial cleanser (antiseptic wash), daily for 5 days. If found to have nasal carriage mupirocin nasal ointment (e.g. Bactroban ) should be prescribed twice daily for 5 days MRSA infection is difficult to treat because the choice of antibiotic is very limited, often restricted to intravenous and expensive agents. Hence, it is important to control the spread of MRSA by basic infection control measures such as handwashing before and after contact and wearing gloves and apron for close contact procedures. Soiled dressings should be disposed of as clinical waste. Encourage a clean environment to reduce dust and contamination. Advise regular change of clothes and bed linen, which can be washed as normal but preferably on a hot cycle. Screening of non-infected sites is not usually indicated in the community. Topical decontamination is not routinely recommended in the community but should only occur prior to surgery on instruction from the admitting hospital Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 19

20 Meningitis Illness Comments Drug Dose Treatment Duration Suspected Meningococcal Disease Administer parenteral penicillin prior to rapid admission to hospital. IV if possible or IM into a part of the limb, which is warm and well perfused. IV or IM Benzylpenicillin Recommended unless there is a true history of anaphylaxis reaction after previous penicillin administration. Adults and children 10 years and over: Children 1 to 9 years: Children under 1 year: 1200mg 600 mg 300 mg IV or IM cefotaxime Age 12+ years: Child < 12 yrs: 1gram 50mg/kg Note: If there is a history of severe penicillin allergy, transfer to hospital immediately. Prevention of secondary case of meningitis Only prescribe prophylactic antibiotics following advice from Essex Health Protection Agency Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 20

21 Vaginal candidiasis Genital tract infections Illness Comments Drug Dose Treatment Duration All topical and oral azoles give 80-95% Clotrimazole pessary Single dose cure. In pregnancy: avoid oral azole and plus use intravaginal treatment for Clotrimazole 1% cream Or ON (intravaginally)bd- TDS5g ON (intravaginally) 2 weeks 10% vaginal cream Or, if original treatment fails, 150 mg capsule stat Single dose Bacterial Vaginosis A 7 day course of oral metronidazole is slightly more effective than 2 g stat; In pregnancy 400 mg BD for is preferred. Fluconazole Metronidazole or Clindamycin 2% cream or Co-amoxiclav (if intolerant to metronidazole) 400 mg BD 5g ON(intravaginally) 625mg TDS Single dose 7days 7 nights 21

22 Chlamydia Trachomatis Tetracyclines are contraindicated in pregnancy. In Pregnancy or breastfeeding, azithromycin can be used but is off label. It is recommended by WHO and is more effective than erythromycin and amoxicillin. Always treat partners. Refer patients and contacts to Sexual Health Clinic If erythromycin or amoxicillin is used, retest after 5 weeks, as less effective. Doxycycline or Azithromycin Azithromycin Erythromycin 100 mg BD 1g stat 1g (off-label use) 500mg QDS 1 hr before or 2 hrs after food 1 hr before or 2 hrs after food Amoxicillin 500mg TDS 7days Note: Refer patients with sexually transmitted infections (STIs) for contact tracing. 22

23 Genital tract infections continued Illness Comments Drug Dose Treatment Duration Trichomoniasis Treat partners. In pregnancy avoid 2g stat dose of metronidazole (400mg BD is preferred). Metronidazole 400 mg BD or 2 g stat stat dose Refer to Sexual Health Clinic to exclude other STDs. Note: Refer patients with sexually transmitted infections (STIs) for contact tracing. Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 23

24 Viral infections Illness Comments Drug Dose Treatment duration Generally does not require treatment Herpes zoster/ Chickenpox and Varicella zoster/shingles For facial/ophthalmic shingles or chickenpox in immunocompromised patients contact and /or refer to microbiology. If pregnant seek advice from microbiologist. For non-immune contacts who are immunocompromised consult microbiologist Treatment should be started within 2 days of rash. The use of aciclovir should be considered for adult family members presenting within 48 hours of the appearance of the rash. Aciclovir 800 mg 5x/day Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 24 Parasitic infections

25 Illness Comments Drug Dose Treatment Duration Scabies Itch can persist for weeks and antipruritic cream or an oral antihistamine may be indicated Permethrin (Lyclear) 30-60g Head lice Treat all household contacts Live headlice must be seen before treating. Aqueous preparations are preferred for children, and for patients with eczema, and asthma. Recurrent headlice may be due to: untreated contact failure to follow instructions Try regular wet combing and/or supervised treatment. Lotions are preferred to rinses and creams Malathion (Derbac M or Quellada M ) 50ml Carbaryl (POM) (Carylderm ) 50ml Phenothrin Full marks lotion Apply 5% dermal cream to whole body and wash off after 8-12 hours; repeat application after 7 days Note: Include face, neck, scalp, ears 0.5% liquid 1% liquid 0.2% alcoholic lotion Lotions and liquids should be left on overnight before washing off. 2 applications 1 week apart. Household contacts 1 application to all at same time. Note: Crusted scabies may need 2-3 applications on consecutive days. If in doubt, ask for dermatologist opinion. If there is more than one case in a care home contact EHPA for advice. 2 applications apart Note: Not more than 3 applications in 3 weeks or in total Advise on wet combing for long term prevention 25

26 Parasitic infections continued Illness Comments Drug Dose Treatment Duration Threadworm Treat household contacts In children under 2 use Piperazine Mebendazole (not suitable in pregnancy) or Piperazine (Pripsen sachets) (not suitable in the 1 st trimester of pregnancy) 100mg stat 1 sachet stat Repeat after 2 weeks Repeat after 2 weeks Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. Periapical/ peridontal abscesses Pericoronitis Dental infections Illness Comments Drug Dose Treatment duration Make an appointment to mg TDS 5- see the dentist mg QDS 5- Amoxicillin or Erythromycin if allergic to penicillin. Add metronidazole for severe infections and poor dentition. 400mg TDS 5- +/- chlorhexidine mouthwash Metronidazole 400mg TDS 5- Note: Doses are standard adults unless otherwise stated. Some of these doses may be doubled in severe infections. Please refer to BNF for further information. 26

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28 References 1. House of Lords Select Committee on Science and Technology. Resistance to antibiotics and other microbial agents. London The Stationery Office, Health Protection Agency: Management Of Infection Guidance For Primary Care. Extensively reviewed March-July 2010 with minor amendments to otitis media and pneumonia June National Prescribing Centre. The management of common infections in primary care Sore throat. MeReC Bulletin 2006; 17(3): Anon. Diagnosis and treatment of streptococcal sore throat. Drug and Therapeutics Bulletin 1995; 33(2): Little P and Williamson I. Sore throat management in general practice. Family Practice 1996; 13(3): Sore Throat-Acute, Clinical Knowledge Summaries. Accessed via 07/10/ Little P et al. Re-attendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 1997; 315: Little P et al. Open randomised trial of prescribing strategies in managing sore throat. BMJ 1997; 314: Otitis Media-Acute, Clinical Knowledge Summaries. Accessed via 07/10/ National Prescribing Centre. The management of common infections in primary care Acute otitis media. MeReC Bulletin 2006; 17(3): Sanders S, Glasziou PP, Del Mar C, Rovers M. Antibiotics for acute otitis media in children. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD DOI: / CD pub2 Accessed from on 09/10/ Little P et al. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 2001; 322: Cates C. An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study. BMJ 1999; 318: Anon. Management of acute otitis media and glue ear. Drug and Therapeutics Bulletin 1995; 33(2): National Prescribing Centre. The management of common infections in primary care Acute bronchitis. MeReC Bulletin 2006; 17(3): National Institute for Clinical Excellence. Respiratory tract infections antibiotic prescribing CG 69 Full guidance 17. Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD DOI: / CD pub2 Accessed from on 08/10/09. 28

29 18. McFarlane J et al. Prospective case-control study of role of infection in patients who reconsult after initial antibiotic treatment for lower respiratory tract infection in primary care. BMJ 1997; 315: McFarlane J et al. Influence of patients expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997; 315: Scottish Intercollegiate Guidelines Network. Community management of lower respiratory tract infection in adults. SIGN guideline No. 59 June Accessed via on 10/01/ Anon. Antibiotic treatment of adults with chest infection in general practice. Drug and Therapeutics Bulletin 1998; 36(9): National Institute for Clinical Excellence. Chronic obstructive pulmonary disease - management of chronic obstructive pulmonary disease in adults in primary and secondary care Quick reference guide. Accessed via on 08/10/ National Institute for Clinical Excellence. Chronic obstructive pulmonary disease - management of chronic obstructive pulmonary disease in adults in primary and secondary care CG12 Full guideline Thorax 2004, 59 (Suppl 1) British Thoracic Society. Guidelines for the management of community acquired pneumonia in adults. Thorax 2009; 64 (suppl III) and 2009 update. Accessed via on 08/10/ British Thoracic Society. Guidelines for the management of community acquired pneumonia in childhood. Thorax 2002; 57 (suppl I). Accessed via on 08/10/ Anon. Managing childhood pneumonia. Drug and Therapeutics Bulletin 1997; 35(12): National Prescribing Centre. The management of common infections in primary care Acute uncomplicated urinary tract infection in women. MeReC Bulletin 2006; 17(3): Anon. Managing urinary tract infections in women. Drug and Therapeutics Bulletin 1998; 36(4): Urinary Tract Infection (lower) women, Clinical Knowledge Summaries. Accessed via 07/10/ Anon. Cranberry and urinary tract infection. Drug and Therapeutics Bulletin 2005; 43(3): Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary tract infection in adults. SIGN guideline No. 88 July Accessed via on 11 /01/ Anon. The management of urinary tract infection in children. Drug and Therapeutics Bulletin 1997; 35(9):

30 Useful Websites Health Protection Agency Hospital Infection Society Infection Prevention Society National Institute for Health and Clinical Excellence National Patient Safety Agency The (UK) Patients Association Department of Health - Immunisation Clinical Knowledge Summaries (CKS) 30