Remember, prescribe an antibiotic only when there is likely to be a clear clinical benefit

Transcription

1 Treatment of infections in Primary Care Principles of Treatment Infections of the ear, nose and oropharynx Respiratory tract infections Meningitis Infections of the genito-urinary system and sexually transmitted diseases Infections of the gastro-intestinal system Infections and infestations of the skin Antibacterial treatments for acne Treatment of viral infections Infections of the eye Updated:

2 Principles of Treatment Do not prescribe an antibiotic for viral sore throat, simple coughs and colds. For upper respiratory tract infections consider delayed antibiotic prescriptions. Remember, prescribe an antibiotic only when there is likely to be a clear clinical benefit

3 o There is a risk of adverse effects from antibiotics and therefore patients who would have recovered without antibiotics, may suffer side effects unnecessarily o There is concern that indiscriminate prescribing increases bacterial resistance in the community Use simple generic antibiotics first whenever possible. Avoid broad-spectrum antibiotics (e.g. co-amoxiclav, quinolones and newer cephalosporins) as they increase risk of Clostridium difficile, MRSA and resistant UTIs Limit prescribing over the telephone to exceptional cases Avoid use of topical antibiotics (especially those agents also available as systemic preparations) Patient s allergy status should always be checked prior to prescribing or administering antibiotics. A distinction should be made between intolerance, e.g. diarrhoea, nausea and vomiting, and true allergy, e.g. rash, anaphylaxis, angioedema, urticaria or bronchospasm. A small number of patients who are allergic to penicillins may be allergic to other classes of betalactam antibiotics i.e. cephalosporins or carbapenems In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole, trimethoprim (in first trimester) and nitrofurantoin (in last trimester), please refer to current BNF for further information on the use of antibiotics in pregnancy. Where erythromycin is suggested, clarithromycin is an acceptable alternative in those who are unable to tolerate side effects of erythromycin Microbiological advice can be obtained from / 0313 / After hours contact via Barts & the London Trust switchboard Alternative antibiotics are appropriate if organism not sensitive to the Formulary choices. The following guidance for appropriate antibiotic use applies to immunocompetent patients without serious comorbidities Doses specified below are oral and for adults unless stated otherwise

4 Doses for children are based on age unless specified e.g. in case of azithromycin the doses are listed according to weight Back to main index Infections of the ear, nose and oropharynx Pharyngitis / sore throat / tonsillitis Rhinosinusitis - acute Oropharyngeal fungal infections Oral hygiene, plaque inhibition, oral candidiasis, gingivitis, management of aphthous ulcers Otitis externa (diffuse) Folliculitis of ear canal (Otitis externa localised) (for children and adults) Otitis media (for children and adults) Pharyngitis / sore throat / tonsillitis The majority of sore throats are viral; most patients do not benefit from antibiotics. Phenoxymethylpenicillin (penicillin V) Clarithromycin (if allergic to penicillin) Tablets Solution Tablets Capsules Suspension 500mg QDS 1g BD 250mg 500mg BD 10 days 10 days

5 Oropharyngeal fungal infections Drug Formulation Notes Duration of treatment Nystatin Miconazole (Daktarin oral gel ) Suspension Oral gel Adults and children: 1ml should be dropped into the mouth four times a day. The longer the suspension is kept in contact with the affected area in the mouth, before swallowing, the greater will be its effect. To be taken after food & drink For prophylaxis in the newborn the suggested dose is 1ml once daily. Age Dose under 2 years Half a spoonful (2.5 ml) of gel twice per day. 2-6 years One spoonful (5 ml) of gel twice per day. 6 years and over One spoonful (5 ml) of gel four times per day. Adults 1-2 spoonfuls (5-10 ml) of gel four times per day. Localised lesions, smear small amount on affected area with clean finger 4 times daily for 5 7 days (dental prostheses should be removed at night and brushed with gel) The longer the gel is kept in contact with the affected area in the mouth, before swallowing, the greater will be its effect. To be taken after food & drink Potential for absorption so interactions with other drugs need to be considered. Oral hygiene, plaque inhibition, oral candidiasis, gingivitis, management of aphthous ulcers. Continue for 2 days after lesions have cleared. Continue for 2 days after lesions have cleared. BNF Drug Chlorhexidine Formulation Notes Duration of treatment Mouthwash Rinse mouth using 5 10 ml of mouth wash for 1 minute BD. Not compatible with some ingredients in toothpaste; leave an interval of at least 30 minutes between using mouthwash and toothpaste. Can cause reversible brown staining of teeth. Mouthwash should not be used continuously for more than 1 month BNF

6 Rhinosinusitis - acute Many cases are viral. Symptomatic benefit of antibiotics is small. Reserve antibiotics for severe cases or symptoms (>10 days). If failure to respond use another first line antibiotic then second line. Amoxicillin Capsules, suspension 500mg TDS 7 days Phenoxymethylpenicillin Tablets, solution Doxycycline (First line option in penicillin allergy) Clarithromycin (First line option in penicillin allergy) Co-amoxiclav (Contains amoxicillin. (Reserve for second treatment failure) Ciprofloxacin+ Metronidazole (Reserve for second treatment failure if penicillin allergy) Capsules, dispersible tablets Tablets, capsules, suspension Tablets Dispersible tablets suspension Tablets 250mg QDS or 500mg BD 200mg Stat and 100mg OD 250mg 500mg BD 625mg TDS 500mg BD+ 400mg BD Patients with chronic rhinosinusitis should be referred to ENT specialist. Infections of the ear, nose and oropharynx index Otitis externa (diffuse) Flumetasone + clioquinol [Locorten Vioform ] Ear drops Age over 2 years, 3 drops into the ear twice daily 7-10 days 7 days 7 days 7 days 7 days 7 days

7 Gentamicin [Gentisin Ear drops 3 drops 4 times daily and at night 7 days ] Gentamicin* + hydrocortisone [Gentisone Ear drops 3 drops 4 times daily 7 days HC] In view of reports of ototoxicity in patients with a perforated tympanic membrane (eardrum), the CSM has stated that treatment with a topical aminoglycoside antibiotic is contra-indicated in those with a tympanic perforation. Flumetasone+clioquinol are sometimes used by specialists for short periods for patients with a perforated tympanic membrane. Non pharmacological methods i.e. local care is considered to be as important as anti-infectives. CKS Folliculitis of ear canal (Otitis externa localised) (for children and adults) This is usually self limiting. Treatment should be reserved only for severe infection or patient at high risk of severe infection (e.g. poorly controlled diabetes / compromised immunity). Age Dose to be taken on an empty stomach Flucloxacillin Capsules, suspension 1 month 2 years mg QDS 7 days 2 10 years mg QDS 10 years onwards mg QDS Age Dose Erythromycin 1 month 2 years 125mg QDS Tablets, capsules, suspension (if allergic to penicillin) 2 8 years 250mg QDS 7 days 8 years onwards 500mg QDS Clarithromycin (if allergic to penicillin and requires BD dosing for compliance) Tablets, suspension Body weight / age Dose < 8kg 7.5mg/kg BD 8 11kg 62.5mg BD 12 19kg 125mg BD 20 29kg 187.5mg BD 30 40kg 250mg BD 12 years onwards mg BD 7 days

8 Prescribe erythromycin, clarithromycin and azithromycin with care these are potent CYP450 enzyme inhibitors. See current BNF for interactions CKS Otitis media (for children and adults) Many cases are viral and 80% resolve without antibiotics. The absence of vomiting or a temperature above 38.5 o C rarely warrants an antibiotic. Paracetamol or an NSAID should be used in the first instance. Antibiotics do not reduce pain in first 24 hours or subsequent attacks or deafness. Amoxicillin Capsules, suspension Child 1 month 18 years 40mg / kg daily in 3 divided doses. Maximum 1g TDS 5 days Erythromycin (first line option in penicillin allergy) Co-amoxiclav (Contains amoxicillin) Azithromycin (second line option in Tablets, suspension Age Dose < 2 years 125mg QDS 2-8 years 250mg QDS 8 years onwards mg QDS Age Dose 125/31/5ml suspension 1 month to 1 year 0.25ml/kg TDS **dose in millilitres for this strength of suspension** 1-7 years 5ml TDS 250/62/5ml suspension **dose in millilitres for this strength of suspension** 7 12 years 5ml TDS Tablets 12 years onwards 375mg TDS Suspension Age / body weight Dose Capsules 6 months 3 years 10mg/kg OD 5 days 5 days 3 days

9 penicillin allergy) 15-25kg 200mg OD 26 35kg 300mg OD 36-45kg 400mg OD 45 kg over 500mg OD Prescribe erythromycin, clarithromycin and azithromycin with care these are potent CYP450 enzyme inhibitors. See current BNF for interactions. Infections of the ear, nose and oropharynx index Back to main index Respiratory tract infections Acute bronchitis Acute exacerbation of COPD Community acquired pneumonia Acute bronchitis Otherwise healthy adults with cough, unaccompanied by other respiratory symptoms or signs in the chest do not benefit from antibiotic therapy. Antibiotic therapy should be considered in those over 60 years of age, where pneumococcal infection is more common and those with other underlying medical disorders, especially if there are features of systemic illness or signs in the chest, other than cough. Note: Avoid quinolones (ciprofloxacin and ofloxacin) in chest infections as they have poor activity against pneumococci Amoxicillin Capsules, suspension 500mg TDS 5 days

10 Doxycycline (first line option in penicillin allergy) Capsules 200mg Stat, 100mg OD 5 days Acute exacerbation of COPD Antibiotics not indicated in absence of purulent / mucopurulent sputum. Most valuable if increased dyspnoea and increased purulent sputum. Note: Avoid quinolones (ciprofloxacin and ofloxacin) in chest infections as they have poor activity against pneumococci Amoxicillin Clarithromycin (first line option in penicillin allergy) Capsules, suspension 500 mg TDS (dose of 1g TDS recommended for severe cases) 5 days Tablets, suspension 500 mg BD 5 days Prescribe erythromycin, clarithromycin and azithromycin with care these are potent CYP450 enzyme inhibitors. See current BNF for interactions. Respiratory tract infections index Community acquired pneumonia BLT

11 Assessment of severity Clinical assessment of disease severity is important for patient management, particularly in deciding which tests to use, where the patient should be treated (community or hospital), and which antibiotic regimens to use. The key issue in patient management is distinguishing those with severe pneumonia, who are at high risk of death, from those with non-severe pneumonia. Defining severe pneumonia accurately also has the added benefit of reducing over-prescribing. The British Thoracic Society guidelines recommend that the following severity assessment to be used to determine the management of CAP in patients in the community (CRB-65 score): Confusion: new mental confusion defined as an Abbreviated Mental Test score <8 Respiratory rate: raised > 30breaths/min Blood pressure: low blood pressure (systolic <90 mmhg and/or diastolic <60 mmhg) Age > 65 years 1 point scored for each feature present. Patient stratification based on CRB65 score Patients who have a CRB-65 score of 0 are at low risk of death and do not normally require hospitalisation for clinical reasons Patients who have a CRB-65 score of 1 or 2 are at increased risk of death and hospital referral and assessment should be considered, particularly with Score 2 Patients who have a CRB-65 score of 3 or more are at high risk of death and require urgent hospital admission Obtain a sputum sample for microbiology culture and sensitivity prior to commencing antibiotics. Patients not allergic to penicillin: Start amoxicillin monotherapy. For patients allergic to penicillin: Start treatment with clarithromycin monotherapy. Failure to improve after 48hours treatment warrants review at the hospital In the severely ill admit to hospital as soon as possible. Note: Avoid quinolones (ciprofloxacin and ofloxacin) in chest infections as they have poor activity against pneumococci Click here for BTS Guidelines for the management of Community Acquired Pneumonia in Adults: update 2009

12 Amoxicillin Capsules, suspension CRB65 score = mg - 1g TDS 5 10 days Clarithromycin (first line option in penicillin allergy) Tablets, suspension CRB65 score = mg BD 5 10 days Prescribe erythromycin, clarithromycin and azithromycin with care these are potent CYP450 enzyme inhibitors. See current BNF for interactions. BLT Respiratory tract infections index Back to main index Meningitis Suspected Meningococcal Disease (for adults and children) Prevention of Secondary Cases of Meningitis (for adults and children) Suspected Meningococcal Disease (for adults and children) Transfer all patients to hospital immediately. Administer IV benzylpenicillin prior to admission, unless history of severe allergy (anaphylaxis, angioedema, difficulty in breathing, or urticaria). Administer IM if a vein cannot be found. All cases of suspected meningococcal disease must be reported to the Health Protection Unit on

13 Benzylpenicillin Injection (intravenous or intramuscular) Age Dose <1 year 300 mg 1-9 years 600 mg 10 years onwards 1200 mg Stat dose only For patients with a history of severe allergy to penicillins (anaphylaxis, angioedema, difficulty in breathing, or urticaria), arrange an immediate transfer to hospital. If a very rapid transfer is not possible, contact the HPU urgently for advice on Prevention of Secondary Cases of Meningitis (for adults and children) Antibiotics are given for the purpose of eliminating throat carriage in close contacts of cases of meningococcal disease - such prophylaxis should only be issued if recommended by the Health Protection Unit, Meningitis index Back to main index Infections of the Genito-urinary system and sexually transmitted diseases Empirical treatment of Urinary tract infections in non-pregnant-women and men Empirical treatment of Urinary tract infections in Pregnant women Empirical treatment of Urinary tract infections in children Acute pyelonephritis Recurrent (> 3 years) Urinary tract Infections in women Vaginal candidiasis

14 Bacterial vaginosis Trichomoniasis Chlamydia Pelvic Inflammatory Disease Acute prostatitis Syphilis & Gonorrhoea Empirical treatment of Urinary tract infections in non-pregnant-women and men Send MSU for culture and susceptibility. For UTIs in men start treatment and refer patient to urology for further investigation. Other antibiotics may be necessary for resistant organisms, dependent on microbiology results. Trimethoprim (First line if no previous antibiotic therapy) Nitrofurantoin (First line if previous antibiotic therapy unsuccessful) Tablets, suspension 200mg BD Other antibiotics depending on susceptibility and advice from microbiology 3 days (7 days for men) MR Capsules 100mg BD 3 days (7 days for men) Empirical treatment of Urinary tract infections in Pregnant women Send MSU for culture and susceptibility. Other antibiotics may be necessary for resistant organisms, dependent on microbiology results. Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus ( guidelines 2008) Trimethoprim Tablets, 200mg BD 7 days

15 (First line if no previous antibiotic therapy) Nitrofurantoin Cefalexin (second line for pregnant women) Amoxicillin (second line for pregnant women) suspension MR Capsules Capsules, suspension Capsules, suspension Avoid in the first trimester of pregnancy 100mg BD Avoid at term in pregnancy. Nitrofurantoin should be used with caution in patients with diabetes and is contraindicated in those with renal impairment 500mg BD 250mg TDS Other antibiotics depending on susceptibility and advice from microbiology 7 days 7 days 7days Empirical treatment of Urinary tract infections in children Send MSU for culture and susceptibility. Other antibiotics may be necessary for resistant organisms, dependent on microbiology results. Trimethoprim (First line if no previous antibiotic therapy) Nitrofurantoin (First line if previous antibiotic therapy unsuccessful) Cefalexin Amoxycillin Use only if organism is susceptible Tablets, suspension Tablets Capsules, suspension Capsules, suspension Click here to see Children s BNF for dosing Click here to see Children s BNF for dosing Nitrofurantoin should be used with caution in patients with diabetes and is contraindicated in those with renal impairment Click here to see Children s BNF for dosing Click here to see Children s BNF for dosing 7 days. Review if child is still unwell after hours of treatment. 7 days. Review if child is still unwell after hours of treatment.

16 Note: Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria, which is a normal finding in catheterised patients; only treat if systemically unwell or pyelonephritis likely. Alternative antibiotics are appropriate if organism not sensitive to the Formulary choices. Acute pyelonephritis Ciprofloxacin Co-amoxiclav (Contains amoxicillin) Trimethoprim Use only if organism is susceptible Tablets, suspension 500mg BD 7 days. Tablets 625mg TDS 14 days Capsules, suspension 200mg BD 14 days Recurrent (> 3 years) Urinary tract Infections in women Post coital or nightly prophylaxis is equally effective. As low compliance, consider standby antibiotic ( guidelines 2008) Trimethoprim (First line if no previous antibiotic therapy) Tablets, suspension 100mg Nitrofurantoin Tablets 50mg STAT post coital, or OD at night Infections of the genito-urinary system and sexually transmitted diseases index Vaginal candidiasis Clotrimazole 5g Vaginal cream 5g Stat dose

17 10% Clotrimazole combination Fluconazole Pessary + cream Capsule 500mg pessary + 2% cream Applicator should not be used during pregnancy. 150mg Avoid in pregnancy Stat dose of pessary and use cream for up to 14 days. Stat dose avoid in pregnancy, BNF Please refer patients with risk factors for STIs (<25y, no condom use, recent (<12mth) or frequent change of sexual partner, previous STI, symptomatic partner) to genito-urinary medicine (GUM) clinic unless GP provides the Sexual Health Local Enhanced Service. Bacterial vaginosis Topical treatment gives similar cure rates but is more expensive. If treatment is ineffective, contact microbiology Metronidazole Tablets 400 mg BD 7 days Metronidazole Tablets 2g STAT STAT treatment avoid in pregnancy and breast-feeding Metronidazole 0.75% vaginal gel 5g applicatorful at night 5 nights Clindamycin 2% cream 5 g applicatorful at night 7 nights Trichomoniasis Refer to GUM clinic unless GP provides the Sexual Health Local Enhanced Service. Treat partners simultaneously. Metronidazole Tablets 400mg BD 5 days Metronidazole Tablets 2g Stat (avoid in pregnancy) Clotrimazole (symptomatic relief, not cure) pessary 100mg 6 days

18 Infections of the genito-urinary system and sexually transmitted diseases index Chlamydia Refer patient and contacts to the GUM clinic for screening for other STDs unless GP provides the Sexual Health Local Enhanced Service. Treat partners simultaneously Azithromycin Tablets, suspension 1g an hour before or 2 hours after food Stat. Doxycycline Capsules 100 mg BD 7 days Pelvic Inflammatory Disease Essential to test for N. gonorrhoea (as increasing antibiotic resistance) and Chlamydia. Refer patient and contacts to GUM clinic unless GP provides the Sexual Health Local Enhanced Service. Metronidazole mg BD + Tablets 14 days ofloxacin 400 mg BD Metronidazole + doxycycline Tablets Capsules 400mg BD + 100mg BD 14 days Acute prostatitis Send MSU before treating to determine antibiotic sensitivity consider referral to Urology Discuss infections with specialist before treating. Microbiology and/or urology Syphilis and Gonorrhoea Refer to GUM clinic Infections of the genitor-urinary system and sexually transmitted diseases index

19 Back to main index Infections of the gastro-intestinal system H pylori test and eradication Giardia Gastroenteritis Antibiotic Associated Diarrhoea Threadworms (adults and children) H pylori test and eradication Drug Formulation Dosing information and Notes Diabact UBT Testing kit lansoprazole + amoxicillin + clarithromycin lansoprazole + clarithromycin + metronidazole Capsules Capsules Tablets Capsules Capsules Tablets NB. Combination packs Heliclear and HeliMet have been discontinued Treatment Duration: 7 days Dosing: lansoprazole 30mg bd + amoxicillin 1g bd + clarithromycin 500mg bd Treatment Duration: 7 days Dosing: lansoprazole 30mg bd + clarithromycin 500mg bd + metronidazole 400mg bd 1st line for those with penicillin allergy CEG Giardia Confirm by sending stool to microbiology for microscopy for ova, cysts and parasites before treatment.

20 Tinidazole Tablets 2g Stat Dose Metronidazole Tablets, suspension Infections of the gastro-intestinal system index 2g OD 400mg TDS 3 days 5 days BLT Gastroenteritis Fluid replacement is essential. Antibiotic treatment should only be initiated on the advice of a microbiologist if the patient is systemically unwell. Please notify all suspected cases of food poisoning to and seek advice from, the Health Protection Unit. Barts and The London NHS Trust Consultant microbiologist: / 0313 / 0314 Health Protection Unit: Antibiotic Associated Diarrhoea Fluid replacement is essential. Antibiotic treatment should only be initiated on the advice of a microbiologist. Consultant microbiologist: / 0313 / 0314 Threadworms (adults and children) Treat household contacts. Advise morning shower/baths and hand hygiene. Use piperazine in children under 2. Mebendazole Chewable tablets Adults and children over 2 years mg Stat, repeat after 2 weeks if needed Piperazine + Oral powder 4g/sachet Age Dose Stat, repeat after 2 weeks senna 3 months 1 year One level 2.5ml spoonful Powder should be stirred into milk [Pripsen ] or water 1 6 years One level 5ml spoonful

21 6 years onwards Contents of one whole sachet During pregnancy, physical removal of eggs combined with hygiene methods is the preferred treatment. Neither mebendazole nor piperazine should be used in the first trimester of pregnancy. If drug treatment is necessary in the second or third trimester of pregnancy, mebendazole is the drug of choice (unlicensed indication). Infections of the gastro-intestinal system index Back to main index Infections and infestations of the skin Headlice Scabies Impetigo Cellulitis Diabetic Leg Ulcer Animal or Human bite Dermatophyte infection of the proximal fingernail or toenail Dermatophyte infection of the skin Dermatophyte infection of the scalp Corticosteroids with antifungals for candidal infections Candidal Skin Infections Pityriasis versicolor

22 Oral ketoconazole for fungal infections Headlice Treat only infected members of the household, i.e. only if a live louse is seen (note: infestation is not indicated by the presence of nits [hatched and empty egg shells]). Family/siblings of patient, who are not proven to be infested do not need to be treated Treat all infected members of the household at the same time Get into the habit of checking the hair of everyone in the family each week, Tell friends & relatives so they can check themselves Consider wet combing method (Bug Busting ) Prophylaxis is not recommended Malathion Phenothrin Alcoholic lotion, aqueous liquid Alcoholic lotion, aqueous liquid Hair should be allowed to dry naturally avoid flames. Do not use hair dryers. Broad comb, then wet comb well conditioned hair to remove dead lice & eggs. Alcoholic lotions are suitable for people with normal healthy skin Aqueous lotions are the treatment choice for small children, asthmatics or patients with eczema or other skin disorders The same chemical should not be used for the next re-infestation (i.e. alternate treatments) Infections and infestations of the skin index Scabies Administer to dry hair and left on for 12 hours. Repeat in 7 days. Treat all household contacts/ partner THPCT, BNF Permethrin 5% cream Treat whole body, including scalp, face, neck, ears, under nails. 2 applications one week apart Malathion (if allergic to permethrin) 0.5% aqueous liquid Treat whole body, including scalp, face, neck, ears, under nails. 2 applications one week apart

23 Impetigo and infected eczema Topical and oral treatment produces similar results for impetigo Topical fucidic acid is not recommended As resistance is increasing reserve topical antibiotics for very localised lesions If no response with initial treatment, then send skin scrapings for cultures Flucloxacillin Capsules, suspension 500mg QDS 7 days Clarithromycin (if allergic to penicillin) Tablets, suspension 250mg-500mg BD 7 days, THPCT, BNF Cellulitis If febrile and ill, admit for IV treatment. Refer facial cellulitis. Flucloxacillin + amoxicillin Clarithromycin (if allergic to penicillin) Capsules, suspension Capsules, suspension 500mg QDS + 500mg TDS 7 days Tablets, suspension 500mg BD 7 days Leg Ulcers Bacteria will always be present. Antibiotics do not improve healing. Culture swabs and antibiotics are only indicated if there is evidence of clinical cellulitis; increasing pain; enlarging ulcer or pyrexia. Review antibiotics after culture results Flucloxacillin Capsules, suspension 500mg QDS 7 days BLT Refer the consultant microbiologist: / 0313 / 0314 if patient is allergic to penicillins or if infection is severe

24 Diabetic Leg Ulcer Refer the consultant microbiologist: / 0313 / 0314 Infections and infestations of the skin index Animal or Human bite Assess tetanus and rabies risk. Please refer to The Green Book (Immunisations against infectious diseases) Antibiotic prophylaxis advised for puncture wound; bite involving hand, foot, face, joint, tendon, ligament; and immunocompromised, diabetics, elderly, asplenic patients. Assess HIV/hepatitis B & C risk Co-amoxiclav Tablets 625mg TDS 7 days (Contains amoxicillin) If patient allergic to penicillin, Contact microbiologist: / 0313 / 0314 Dermatophyte infection of the proximal fingernail or toenail Take nail clippings and start therapy only if infection is confirmed by laboratory. This condition is uncommon in children; refer to specialist for treatment or advice. BLT Terbinafine Tablets 250 mg OD Idiosyncratic liver reactions occur rarely with terbinafine. Fingers: 6 12 weeks Toes: 3 6 months Itraconazole Capsules, oral liquid 200 mg BD Useful for infections with yeasts and non-dermatophyte moulds. Fingers: 7 days monthly 2 courses

25 CSM: Care when prescribing for patients at high risk of heart failure. Toes: 7 days monthly 3 courses Amorolfine 5% nail lacquer (for superficial infections of no more than 2 nails) Apply once or twice a week Fingers: 6 months Toes: 12 months Dermatophyte infection of the skin Take skin scrapings for culture. 1 week terbinafine treatment is as effective as 4 weeks azole. If intractable consider oral itraconazole. Discuss scalp infections with specialist. Terbinafine 1% Cream OD - BD 7 days Zinc undecenoate 20%, undecenoic acid 5% [Mycota ] Cream Clotrimazole 1% Cream BD Dermatophyte infection of the scalp Discuss scalp infections with specialist before treating. BD 7 days after lesions have healed 7 days after lesions have healed Infections and infestations of the skin index Corticosteroids with antifungals for candidal infections

26 Drug Formulation Notes on prescribing Duration of treatment Hydrocortisone 1% +Clotrimazole [Canesten HC ] Hydrocortisone 1% + Miconazole [Daktacort ] Cream Cream, ointment Apply to the affected area(s) BD - Mild potency Apply to the affected area(s) BD - Mild potency Treatment to be continued for 10 days after lesions have healed Betamethasone 0.5% +Clotrimazole [Lotriderm ] Cream Apply to the affected area(s) BD Potent Treatment to be continued for 10 days after lesions have healed THPCT, BNF Candidal Skin Infections Clotrimazole 1% Cream TDS Continue for 2 weeks after skin has healed. THPCT, BNF Pityriasis versicolor Ketoconazole Shampoo OD. Leave on for 3-5 minutes before rinsing 5 days Selenium sulphide Dilute with water, apply to skin and leave on for Use 2-7 times over 2 Shampoo (unlicensed indication) at least 30 minutes weeks Terbinafine 1% Cream BD 2 weeks then review

27 200mg OD Itraconazole (if severe) Capsules, oral liquid CSM: Care when prescribing itraconazole to patients at high risk of heart failure 7 days THPCT, BNF Oral ketoconazole for fungal infections Oral ketoconazole Ketoconazole tablets are not suitable for prescribing in primary care. Infections and infestations of the skin index Back to main index Antibacterial treatments for acne Oral antibacterials for acne Topical antibacterials for acne Oral antibacterials for acne If no benefit is obtained after 3 months of treatment, another antibacterial should be used. Treatment may be continued for 2 years or longer. Drug Formulation Dosing information and Notes Oxytetracycline Tablets 500mg BD Needs to be taken on an empty stomach. Contraindicated in pregnancy. Lymecycline Capsules 408mg OD Suitable if adherence is likely to be a problem (can be taken with food). TNDG: Lymecycline has been approved for initiation in primary care. Contraindicated in pregnancy.

28 Erythromycin Tablets, suspension 500mg BD An alternative if a tetracycline is contraindicated or otherwise unsuitable. There are significant problems with resistance associated with erythromycin use, and gastrointestinal adverse effects may restrict its use. BNF Topical antibacterials for acne Clindamycin [DalacinT ] Back to main index Solution, lotion Apply to the affected area(s) BD Treatment should be continued for at least 6 months. After that however regular reviews are necessary. BNF Treatment of viral infections Herpes simplex infections (Labial and genital and eczema herpeticum) Varicella zoster (shingles) Local treatment of herpes simplex infection - Anti-viral eye preparations Salicylic acid preparations for warts and calluses Anogenital Warts Herpes simplex infections (Labial and genital and eczema herpeticum) ECZEMA HERPETICUM Refer to secondary care and start systemic and topical treatment immediately. Drug and Formulation Dosing information and Notes Duration of treatment

29 Aciclovir 5% Cream Apply to lesions every 4 hours (5 times daily) 5 10 days, starting at first sign of attack BNF Varicella zoster (chickenpox) and herpes zozter (shingles) SHINGLES Always treat ophthalmic. Non-opthalmic: treat if >60 yrs if <72 hrs of onset of rash, as post-herpetic neuralgia rare in <50 yrs but occurs in 20% >60yrs. CHICKENPOX Clinical value of antivirals minimal unless immunocompromised, severe pain, adult, on steroids, secondary household case AND treatment started <24hr of onset of rash. ECZEMA HERPETICUM Refer to secondary care and start systemic and topical treatment immediately. Aciclovir Tablets 800mg 5 times a day 7 days Valaciclovir Tablets 1g TDS 7 days Famciclovir Tablets 250mg TDS 7 days, THPCT, BNF Local treatment of herpes simplex infection. Anti-viral eye preparations Should be initiated by ophthalmology (See Dermatology in Primary Care Guidance) Drug and Formulation Dosing information and Notes Duration of treatment Aciclovir Eye ointment 3% Apply 5 times a day (at 4 hour intervals) to the affected eye. Avoid topical steroids as this can aggravate the condition. Continue for 3 days after healing. Moorfields, THPCT, BNF Salicylic acid preparations for warts and calluses Drug Indication Formulation Notes on prescribing

30 [Salatac Warts, verrucas, ] corns and calluses Gel Contains 12% salicylic acid [Salactol Warts, verrucas, ] corns and calluses Paint Contains 16.7% salicylic acid [Occlusal ] Warts Solution Contains 26% salicylic acid THPCT, BNF Anogenital Warts Patients with genital warts should be referred to a genito-urinary medicine (GUM) Clinic for treatment Treatment of viral infections index Back to main index Infections of the eye Acute bacterial conjunctivitis Acute bacterial conjunctivitis Most bacterial infections are self-limiting (64% resolve on placebo). They are usually unilateral with yellow-white mucopurulent discharge. Eye drops 0.5% 1 st choice for superficial eye infections. Chloramphenicol Eye ointment 1% (Preservative free eye drops for single use 0.5%) Severe infections: 1 drop into the affected eye every ½ - 2 hours Minor infections: 1 drop into the affected eye 4 times a day Continue for 48 hours after resolution

31 Gentamicin Eye drops 0.3% (Preservative free eye drops for single use 0.3%) Broad spectrum for Gram ve including Pseudomonas aeruginosa. Staphylococcus usually resistant. Severe infections: 1 drop into the affected eye every ½ - 2 hours Continue for 48 hours after resolution Fucidic acid [Fucithalmic ] Eye drops 1% Minor infections: 1 drop into the affected eye 4 times a day One drop into the affected eye twice a day For Staphylococcal infections Liquifies on contact with the eye Fucidic acid has less Gram-negative activity Continue for 48 hours after resolution Moorfields Back to main index

32 Key: BLT Barts and The London NHS Trust Empiric Antibiotic Treatment Guidelines BNF British National Formulary CEG Clinical Effectiveness Group Guidelines CKS Clinical Knowledge Summaries Health Protection Agency. Management of Infection Guidance for Primary Care For Consultation & Local Adaptation Moorfields Moorfields Eye Hospital NHS Foundation Trust. Pharmacists Handbook THPCT Treatment Guidelines References: Joint Formulary Committee. British National Formulary. 55 th Ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2008 Joint Paediatric Formulary Committee. British National Formulary for Children British Medical Association, the Royal Pharmaceutical Society of Great Britain, the Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group ; 2007 BLT Antimicrobial Review Group. Emperic Antibiotic Treatment Guideline. Barts and the London NHS Trust. Produced November 2007 Summary of Product Characteristics. Ceftriaxone. Available from: Accessed 16/02/08. Clinical Knowledge Summaries. Otitis externa, otitis media, impetigo, bites human and animal, fungal candidal nail infection. SCHIN Ltd, Centre for Health Informatics at Newcastle. Available from: Accessed 16/02/08 British Thoracic Society, Guidelines for the management of Community Acquired Pneumonia in adults update. Available from: Health Protection Agency. Management of Infection Guidance for Primary Care For Consultation & Local Adaptation. Produced 2001 Reviewed April 2006 Amended December Health Protection Agency. Meningococcal disease. Available from: Accessed 20/02/2008 MHRA. Moxifloxacin: hepatotoxicity and serious skin reactions prescribing update Drug Safety Update: Volume 1, Issue 4, November 2007 MHRA. Drug Safety Update. Ketoconazole: restricted indications. March 2008; Volume 1, Issue 8. NPC. MeReC Extra. UTI: SIGN guidance for UTI. No /2007 Moorfields Eye Hospital NHS Foundation Trust. Pharmacists Handbook Moorfields Pharmaceuticals. D2 printing Ltd. UTI: Three days of trimethoprim is sufficient for simple UTI in women. MeReC Extra. 2005/2006; No.19 Back to main index