Infection Management Summary of changes (February 2014 to December 2017)

Transcription

1 Infection Management Summary of changes (February 2014 to December 20) *Significant changes from November 20 have been highlighted in yellow DATE TOPIC CHANGE November 20 Principles of Treatment primary care update September 20; PAMM remote approval 27 th November 20) New: 3. Always check for antibiotics allergies. Unless otherwise stated, a dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course. Please refer to BNF for further dosing and interaction information (e.g. interaction between macrolides and statins) if needed and please check for hypersensitivity. 4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit, giving alternative, non-antibiotic self-care advice where appropriate. 6. In severe infection or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned. 12. In pregnancy, take specimens to inform treatment. Penicillins, cephalosporins and erythromycin are safe in pregnancy. Where possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin (except chlamydial infection), clarithromycin, and high dose metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist e.g. antiepileptic 15. This guidance should not be used in isolation, it should be supported with patient information about safety netting, back-up/delayed antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials 1 Version: AA Dec -

2 are available on the RCGP TARGET website. November 20 November 20 primary care update September 20; PAMM remote approval 27 th November 20) Scarlet fever primary care update September 20; PAMM remote approval 27 th November 20) Advise paracetamol, self-care, and safety net. Phenoxymethylpenicillin 500mg QDS or 1G BD (QDS when severe) 10 days 500mg QDS or 1gram BD (if mild) If severe: 1gram QDS 5-10 days Clarithromycin mg BD 250mg BD If severe: 500mg BD Erythromycin 500mg QDS 250mg-500mg QDS Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Observe immunocompromised individuals (diabetes; women in the 2 Version: AA Dec -

3 puerperal period; chickenpox) as they are at increased risk of developing invasive infection. November 20 November 20 November 20 Acute otitis media primary care update September 20; PAMM remote approval 27 th November 20) Acute otitis externa primary care update September 20; PAMM remote approval 27 th November 20) Sinusitis (acute) primary care update September 20; New NICE guideline NG79 Oct-; PAMM remote approval 27 th November 20) Consider 2 or 3-day delayed or immediate antibiotics for pain relief if: < 2yrs with bilateral AOM (NNT4) or bulging membrane and 4 marked symptoms < 2yrs AND bilateral AOM (NNT4), bulging membrane or symptom score 8 for: fever, tugging ears, crying, irritability, difficulty sleeping, less playful, eating less (0 = no symptoms, 1 = a little, 2 = a lot) First consider using aural toilet (if available) and analgesia. Cure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid. If cellulitis or disease extending outside ear canal, start oral antibiotics and refer to exclude malignant OE. First line: analgesia for pain relief and apply localised heat (e.g. a warm flannel). Second line: topical acetic acid or topical antibiotic +/- steroid: similar cure at 7 days. If cellulitis or disease extends outside ear canal, or systemic signs of infection, start oral flucloxacillin and refer to exclude malignant otitis externa. New: If cellulitis: Flucloxacillin 500mg QDS 7 days Good practice points: Avoid Antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days (NNT15). 3 Version: AA Dec -

4 Use adequate analgesia. Consider 7-day delayed or immediate antibiotic when purulent nasal discharge NNT8. In persistent infection use an agent with anti-anaerobic activity e.g. co-amoxiclav Symptoms <10 days: do not offer antibiotics as most resolve in 14 days without, and antibiotics only offer marginal benefit after 7 days (NNT15). Information to the public available at Symptoms >10 days: no antibiotic, or back-up antibiotic if several of: purulent nasal discharge; severe localised unilateral pain; fever; marked deterioration after initial milder phase. At any time, if: high-risk of complications, evidence of systemic upset (e.g. fever, worsening pain) or more serious signs and symptoms: immediate antibiotic. If suspected complications: e.g. sepsis, intraorbital, periorbital or intracranial: refer to secondary care. Self-care: paracetamol/ibuprofen for pain/fever. Consider high-dose nasal steroid if >12 years old. Nasal decongestants or saline may help some. Treatment First line: Phenoxymethylpenicillin 500mg QDS or Amoxicillin 500mg TDS (1g if severe) Penicillin allergy: Doxycycline 200mg stat/100mg OD For persistent symptoms: Co-amoxiclav 625mg TDS 7 days No antibiotics: self-care First line for back-up/delayed : Phenoxymethylpenicillin 500mg QDS (note Amoxicillin removed) 4 Version: AA Dec -

5 Penicillin allergy: Doxycycline 200mg stat then 100mg OD OR Clarithromycin 500mg BD For persistent or worsening symptoms: Co-amoxiclav 625mg TDS 5 days Mometasone nasal spray 200mcg BD 14 days November 20 November 20 November 20 Acute cough & bronchitis primary care update September 20; PAMM remote approval 27 th November 20) Suspected meningococcal disease primary care update September 20; PAMM remote approval 27 th November 20) UTI in women & men (no fever or flank pain) First line: self-care and safety netting advice. Second line: 7-day delayed antibiotic, safety net and advise that symptoms can last 3 weeks. Consider immediate antibiotics if > 80 years of age and ONE of: hospitalisation in past year, taking oral steroids, insulin-dependent diabetic, congestive heart failure, serious neurological disorder/stroke OR > 65 years with two of the above. If time before admission to acute hospital, and non-blanching rash, give IV or IM Benzylpenicillin or Cefotaxime, unless definite history of hypersensitivity. If time before admission to acute hospital, and non-blanching rash, give IV or IM Benzylpenicillin. Do not give IV antibiotics if there is a definite history of anaphylaxis; rash is not a contraindication. The alternative is IV or IM Cefotaxime which has a low risk of cross-reaction and risk of untreated meningococcal disease may be greater. Introduction: URINARY TRACT INFECTIONS - refer to PHE UTI guidance for diagnosis information (see Appendix 3) 5 Version: AA Dec -

6 primary care update September 20; peer consensus November 20; PAMM remote approval 27 th November 20) Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless there is a history of catheter-change-associated UTI or trauma (NICE & SIGN guidance). Take sample if new onset of delirium, or two or more symptoms of UTI. Take sample if new onset of delirium, or one or more symptoms of UTI. Good practice points: Women mild/or 2 symptoms: - Pain relief, consider a back-up / delayed antibiotic prescription and give UTI leaflet (see Appendix 2) Pivmecillinam is first option for community multi-resistant Extended-spectrum Beta-lactamase E. coli. Fosfomycin as Monurol (women: 3g stat; men: 3g stat plus 2nd 3g dose 72 hours later) may be an option on advice of microbiology. Fosfomycin as Monurol (women: 3g stat; men: 3g stat plus 2nd 3g dose 72 hours later) may be an option contact microbiologist if advice required. >65 years: treat if fever 38 C or 1.5 C above base twice in 12 hours, AND dysuria OR >2 other symptoms. >65 years: treat if fever 38 C or 1.5 C above base twice in 12 hours, and >1 other symptom. Treatment: 6 Version: AA Dec -

7 Uncomplicated UTI (no admission risk and low risk of resistance): 1st line: Trimethoprim Alternatives: Nitrofurantoin or Pivmecillinam Uncomplicated UTI 1st line (if GFR 45mls/min): Nitrofurantoin If low risk of resistance: Trimethoprim 2nd line: Pivmecillinam Risk of resistance and/or frail vulnerable with associated comorbidity GFR 45ml/min 1st line: Nitrofurantoin Alternative: Pivmecillinam (3 days only) Risk of resistance, frail and/or associated co-morbidity 1st line (if GFR 45mls/min):Nitrofurantoin 2nd line and/or GFR<45mls/min: Pivmecillinam If increased risk of resistance and/or options antibiotic above are unsuitable: Fosfomycin (Monurol ) women: 3g stat men: 3g stat, plus second 3g dose 72 hours later (unlicensed) Duration of treatment change from: Women 3 days Men 7 days (except Pivmecillinam - for 3 days only) Women 3 days 7 Version: AA Dec -

8 (except Pivmecillinam - for 5 days) Men 7 days (all antibiotics) The UTI guidance has changed to recommend an increase in course duration for pivmecillinam, in contrast with BNF recommendations, on which initial guidance was based. This was based on repeated feedback from local GPs (treatment failures with 3 day courses) which led to a review of the drug pharmacokinetics. Taunton microbiologists discussed this with colleagues in Sweden, where the drug has been used for many years. The longer duration of treatment takes into account how fast the drug is excreted from the body, since pivmecillinam disappears rapidly from urine. This contrasts for example with trimethoprim which seems to have an effect for a further 2-3 days after completion of treatment. It was also noted that the SPC for the pivmecillinam generic product suggests longer courses mg BD for 7 days or alternatively 200 mg TDS for 5 days which are the treatment durations used in countries such as Sweden. (Statement from CMM added December 20) November 20 November 20 Recurrent UTI in women (not pregnant) primary care update September 20; PAMM remote approval 27 th November 20) UTI in pregnancy primary care update September 20; PAMM remote approval 27 th November 20) Third line - antibiotic prophylaxis: If recent culture sensitive Consult with microbiologist in none of above options is suitable. Review at 3-6 months or more often. First line: advise simple measures, including hydration and analgesia for symptom relief (ibuprofen if no contraindications). Over the counter cranberry products may work for some women, but good evidence is lacking. First line (avoid at term): Nitrofurantoin 8 Version: AA Dec -

9 November 20 November 20 November 20 November 20 UTI in children primary care update September 20; PAMM remote approval 27 th November 20) Clostridium difficile primary care update September 20; PAMM remote approval 27 th November 20) Traveller s diarrhoea primary care update September 20; PAMM remote approval 27 th November 20) Chlamydia trachomatis/ urethritis primary care update September 20; PAMM Imaging: refer if: -child <6 months or -recurrent UTI: 2 episodes of UTI with acute pyelonephritis/upper UTI; or 1 episode of UTI with acute pyelonephritis/upper UTI plus 1 episode of UTI with cystitis/lower urinary tract infection; or 3 episodes of UTI with cystitis/lower UTI or -atypical UTI: seriously ill, poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia. failure to respond to treatment with suitable antibiotics within 48 hour, infection with non-e. coli organisms) Upper UTI: refer to paediatrics to: obtain a urine sample for culture, assess for signs of systemic infection. If red flag sepsis/likely significant delay, refer to CCG & UK Sepsis Trust General Practice Sepsis Screening & Action Tools in Appendix 8 within this document. IM or IV Cefotaxime may be active against a significant proportion of urinary isolates. Stop unnecessary antibiotics, PPIs and antiperistaltic agents. Mild cases (<4 episodes of diarrhoea/day) may respond without metronidazole; 70% respond to metronidazole in 5 days; 92% respond to metronidazole in 14 days. Ciprofloxacin 500 mg twice a day for 3 days Azithromycin oral tablet 500mg OD 1-3 days Opportunistically screen all patients aged years. Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment. 9 Version: AA Dec -

10 November 20 November 20 November 20 remote approval 27 th November 20) Vaginal candidiasis primary care update September 20; PAMM remote approval 27 th November 20) Genital herpes New topic primary care update September 20; PAMM remote approval 27 th November 20) Cold sores primary care update September 20; PAMM remote approval 27 th November 20) Opportunistically screen all patients aged years. Treat partners and refer to GUM service. Repeat test for cure in all at 3 months. (New) Pregnancy or breastfeeding: Azithromycin is the most effective option. As lower cure rate in pregnancy, test for cure at least 3 weeks after end of treatment. New: Recurrent (>4 episodes per year): 150mg oral fluconazole every 72 hours for three doses induction, followed by one dose once a week for six months maintenance. Fluconazole capsule: Induction: 150mg every 72 hours (3 doses (days 1, 4 & 7) Followed by maintenance: 150mg once a week (6 months) Advise: saline bathing, analgesia, or topical lidocaine for pain, and discuss transmission. First episode: treat within five days if new lesions or systemic symptoms, and refer to GUM. Recurrent: self-care if mild, or immediate short course antiviral treatment, or suppressive therapy if more than six episodes per year. If indicated: 1 st line Aciclovir 400mg TDS 5 days, if recurrent: 800mg TDS 2 days; 2 nd line Valaciclovir 1x500mg BD 5 days; 3 rd line Famciclovir 250mg TDS 5 days, if recurrent 1 gram BD for 1 day Most resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce reduce duration by 12-18hrs. If frequent, severe, and predictable triggers: consider oral prophylaxis: aciclovir 400mg, twice daily, for 5-7 days. 10 Version: AA Dec -

11 November 20 November 20 November 20 PVL S. aureus primary care update September 20; PAMM remote approval 27 th November 20) Impetigo primary care update September 20; Retapamulin (Altargo ) discontinuation September 20; PAMM remote approval 27 th November 20) Acne New topic primary care update September 20; drug recommendations in line with current NHS Somerset CCG formulary options; PAMM remote approval 27 th November 20) Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from boils/abscesses. Can rarely cause severe invasive infections in healthy people; if found suppression therapy should be given. Send swabs if recurrent boils/abscesses. At risk: close contact in communities (e.g. nursing homes) or contact sport, sharing equipment, poor hygiene and eczema. Panton-Valentine Leukocidin (PVL) is a toxin produced by % of S. aureus from boils/abscesses. PVL strains are rare in healthy people, but can cause invasive severe infections. Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking. Risk factors for PVL: recurrent skin infections; invasive infections; MSM; more than one case in a home or close community (school children; military personnel; nursing home residents; household contacts). Retapamulin (Altargo ) has been discontinued in the UK in September 20. Sulfadiazine cream moved to first topical option: Sulfadiazine cream (Flamazine ) (unlicensed indication) - Topically TDS 5-7 days. GOOD PRACTICE POINTS: Mild (open and closed comedones) or moderate (inflammatory lesions): -First-line: self-care (wash with mild soap; do not scrub; avoid make-up). -Second-line: topical retinoid or benzoyl peroxide. -Third-line: add topical antibiotic, or consider addition of oral antibiotic. Severe (nodules and cysts): add oral antibiotic (for 3 months max) and refer. TREATMENT, ADULT DOSE & DURATION OF TREATMENT: 1st line: self-care 2nd line: topical retinoid 11 Version: AA Dec -

12 November 20 November 20 Bites primary care update September 20; PAMM remote approval 27 th November 20) Mastitis - new PHE topic, update to local guidance primary care update September 20; PAMM remote approval 27 th November 20) 1st option: adapalene 0.1% (Differin ) thinly, ONCE daily 6-8 weeks 2nd option: benzoyl peroxide 4% or 5% (Panoxyl, Quinoderm, Brevoxyl or Acnecide ) OD-BD 6-8 weeks 3rd line: 1st option: topical retinoid (adapalene 0.1%) with benzoyl peroxide 2.5% gel (Epiduo ) thinly, ONCE daily 12 weeks 2nd option: topical clindamycin 1% with retinoid (tretinoin 0.025%) (Treclin ) thinly, ONCE daily 12 weeks OR topical clindamycin 1% with benzoyl peroxide 3% (Duac Once Daily ) thinly, ONCE daily 12 weeks If treatment failure/severe: oral oxytetracycline 2x250mg BD 6-12 weeks OR oral doxycycline 100mg OD 6-12 weeks Cat: always give prophylaxis. S. aureus is the most common infecting pathogen. Suspect if woman has: a painful breast; fever and/or general malaise; a tender, red breast. Breastfeeding: oral antibiotics are appropriate, where indicated. Women should continue feeding, including from the affected breast. Additional option if allergic to penicillin: Erythromycin mg QDS Duration changed from 14 days to 10 days. 12 Version: AA Dec -

13 November 20 Varicella zoster/ chicken pox & Herpes zoster/shingles primary care update September 20; PAMM remote approval 27 th November 20) Shingles: treat if > 50 years and within 72 hours of rash (PHN rare if < 50years); or if one of the following: active ophthalmic, Ramsey Hunt, eczema, non-truncal involvement, moderate or severe pain, moderate or severe rash. Treatment not within 72 hours: consider starting antiviral drug up to one week after rash onset, if high risk of severe shingles or complications (continued vesicle formation, older age, immunocompromised, severe pain). November 20 New Appendix 1 - Back-up/delayed prescribing patient leaflet Respiratory tract infection (RCGP/TARGET update August 20 ; PAMM remote approval 27 th November 20) November 20 New Appendix 2 - Back-up/delayed prescribing patient leaflet Urinary tract infection (RCGP/TARGET update January 20 ; PAMM remote approval 27 th November 20) November 20 New Appendix 3 - Diagnosis of UTIs Quick reference guide (PHE update June 20 ; PAMM remote approval 27 th November 20) November 20 Suspected sepsis Appendix 8 - General Practice Sepsis Screening & Action Tools (recommendation from Urgent & Emergency Care Services Clinical Assurance Committee; ; PAMM remote approval 27 th November 20) Second line for shingles if poor compliance: Valaciclovir 2x500mg TDS 7 days OR 3 rd line Famciclovir mg TDS OR 750mg BD 7 days Page 16 Page PHE flowcharts added pages 18 to 21 Added wording: NB: urine dipsticks are unreliable in catheter specimens Note: from SA - the only changes made to this guidance were reformatting changes. We are currently in the process of updating this fully, alongside some qualitative research, and I will send you this document and highlighted changes when it is final (towards the end of the year). Follow standard admission pathways. Consider IV or IM Cefotaxime (alternatively, Ceftriaxone) if time to treatment is likely to be 1 hour (obtain blood cultures prior to administration if possible) 13 Version: AA Dec -

14 November 20 November 20 June 20 June 20 New Appendix 9 - Test for Helicobacter pylori in dyspepsia - Quick reference guide for primary care (PHE update June 20; PAMM remote approval 27 th November 20) Guidelines for the management of cellulitis in adults in Somerset Appendix 4 (Retapamulin (Altargo ) discontinuation September 20; PAMM remote approval 27 th November 20) Influenza (CAS alert 12 th June-; PAMM to note 19/07/) Mastitis (correction; PAMM to note 19/07/) PHE flowcharts added pages 32 to 33 Retapamulin ointment 1% BD top (NOT fucidin). Note: Retapamulin ointment 1% is NOT active against MRSA Sulfadiazine cream (Flamazine ) topically TDS 5-7days (NOT fusidic acid). Note: Sulfadiazine cream is NOT active against MRSA. DoH update 12 th June 20: GPs and other prescribers working in primary care should no longer prescribe antiviral medicines, for the prophylaxis and treatment of influenza on an FP10 prescription form. Community pharmacists should no longer supply antiviral medicines in primary care, on presentation of an FP10 prescription form. This is in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc.) Regulations 2004), commonly known as the Grey List or Selected List Scheme (SLS). This advice stands until we write again to re-commence prescribing and supply of antiviral medicines in primary care. Warning to be used only if not breastfeeding added next to Doxycycline May 20 UTI in men & women (no fever or flank pain) primary care update May 20; PAMM to note 19/07/) Trimethoprim changed from alternative to avoid if: Risk of resistance and/or Frail vulnerable with associated comorbidity GFR 45ml/min And Risk of resistance and/or Frail vulnerable with associated comorbidity GFR<45ml/min 14 Version: AA Dec -

15 May 20 May 20 February 20 Acute Sore Throat primary care update May 20; PAMM to note 19/07/) Principles of Treatment primary care update May 20; PAMM to note 19/07/) Influenza (CAS alert 19 th December-16 & PHE Management of infection guidance for primary care updated version January 20; PAMM approval 22/02/) if pregnant & allergic to penicillin: Erythromycin 500mg QDS, 5 days In pregnancy, take specimens to inform treatment, use this guidance alternative or seek expert advice. Penicillins, cephalosporins and erythromycin are not associated with increased risks. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin, clarithromycin, high dose metronidazole (2g stat) unless the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist e.g. antiepileptic. Updated to: Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals are not recommended. DoH update 19 th December 2016: GPs and other prescribers working in primary care may now prescribe antiviral medicines for the prophylaxis and treatment of influenza at NHS expense. This is in accordance with NICE guidance, and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc.) Regulations 2004), commonly known as the Grey List or Selected List Scheme (SLS). Antiviral medicines may be prescribed for patients in "clinical atrisk groups" as well as any who are at risk of severe illness and/or complications from influenza if not treated. 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), Version: AA Dec -

16 February 20 Acute Otitis Media (in line with cbnf update; PAMM approval 22/02/) 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 treatment 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. See PHE Influenza guidance for treatment of patients under 13 years or in severe immunosuppression (and seek advice). Amoxicillin Neonate 7-28 days 30mg/kg (max. 125mg) TDS 1mth-1yr 125mg TDS 1-5yrs 250mg TDS 5-18yrs 500mg TDS 1-11mths 125mg (up to 30mg/kg) TDS 1-4yrs 250mg (up to 30mg/kg) TDS 5-11yrs 500mg (up to 30mg/kg max 1gram per dose) TDS 12-yrs 500mg (up to 1gram) TDS Erythromycin (total daily dose may alternatively be given in two divided doses) < 2yrs 125mg QDS 2-8yrs 250mg QDS 8-18yrs mg QDS 1mth-1yr 125mg QDS 2-7yrs 250mg QDS 8-yrs 250mg-500mg QDS 16 Version: AA Dec -

17 February 20 Community-acquired pneumonia - treatment in the community primary care updated version January 20; PAMM approval 22/02/) Score 0: suitable for home treatment; Score 1-2: hospital assessment or admission Score 3-4: urgent acute hospital admission Score 0: consider home based care; always give safety-net advice and likely duration of symptoms. Score 1-2: intermediate risk, consider acute hospital assessment or admission February 20 Suspected sepsis new topic (in line with NICE guidance July 2016 and Sepsis Trust UK; recommendation from Somerset Sepsis Working Group; PAMM approval 22/02/) Comments section: Transfer all suspected red flag sepsis patients to hospital immediately. If time to treatment in hospital is likely to be more than 1 hour, it is recommended that the first dose of antibiotic is administered by a primary care clinician (if possible after obtaining blood cultures). Avoid Ceftriaxone in the neonates. Note: risk of anaphylaxis is low 0.1% %; 2 nd and 3 rd generation cephalosporins are unlikely to be associated with cross reactivity due to different structure to penicillin. Drug and dose section: For suspected sepsis associated with urinary tract or lower respiratory tract: Cefotaxime IV or IM Neonates to children <12 yrs: 50mg/kg Adults and children 12yrs: 1gram Alternatively, if not available: Ceftriaxone Version: AA Dec -

18 IV Children 9-11 yrs ( 50 kg), 12 yrs & adults: 1-2grams IM Children 1mth 11yrs ( 50 kg): mg/kg Children 9-11 years ( 50 kg), 12 yrs & adults: 1-2grams February 20 UTI in men & women (no fever or flank pain) primary care updated version January 20; PAMM approval 22/02/) Heading: Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma (NICE & SIGN guidance). Take sample if new onset of delirium, or two or more symptoms of UTI. Comments section: a) Women mild/or 2 symptoms: - Urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors for infection. - If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% positive predictive value; nitrite, leucocytes, blood all negative 76% NPV. - Pain relief, and consider a back-up / delayed antibiotic. b) >65 years: treat if fever >38 C or 1.5 C above base twice in 12h AND dysuria OR >2 other symptoms. c) Nitrofurantoin: if GFR 30-45ml/min, only use as a short-course (3 to 7 days), if resistance and no alternative 18 Version: AA Dec -

19 Treatment section: a)uncomplicated UTI (no admission risk and low risk of resistance) b)risk of resistance and/or Frail vulnerable with associated comorbidity GFR 45ml/min c)risk of resistance and/or Frail vulnerable with associated comorbidity GFR<45ml/min February 20 Recurrent UTI in women (not pregnant) primary care updated version January 20; PAMM approval 22/02/) Further comments: a) Low risk of resistance: younger women with acute UTI and no resistance risks (as listed below). b) Risk factors for increased resistance include: care home resident, recurrent UTI (2 in 6 months; >3 in 12 months), hospitalisation for >7d in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance, previous known UTI resistant to trimethoprim, cephalosporins or quinolones. c) If increased resistance risk, send urine for culture and susceptibilities, and always give safety net advice. Title: Recurrent UTI in women (not pregnant) 3 UTIs/year Recurrent UTI in women (not pregnant) 2 in 6mths or 3 UTIs/year Comments section: To reduce recurrence first advise simple measures including hydration. Then standby or post-coital antibiotics. First line: Advise simple measures, including hydration & analgesia. Over the counter cranberry products may work for some women, but good evidence is lacking. 19 Version: AA Dec -

20 February 20 February 20 UTI in pregnancy primary care updated version January 20; PAMM approval 22/02/) Oral candidiasis primary care updated version January 20; in line with cbnf; PAMM approval 22/02/) Second line: Standby or post-coital antibiotics. Third line: Antibiotic prophylaxis. Consider methenamine if no renal or hepatic impairment. Treatment section - Trimethoprim or Nitrofurantoin OD at night for 3-6 months; then review recurrence rate and need - Methenamine BD (may be increased to TDS if catheterised) for 6 months Send MSU for culture & sensitivity and start empirical antibiotics Send MSU for culture: start antibiotics in all with significant bacteriuria, even if asymptomatic. Miconazole oral gel 2.5mL QDS after meals; 7-14 days 4-24mths 1.25 ml (1/4 measuring spoon) QDS after meals Adults and children 2yrs 2.5 ml (1/2 measuring spoon) QDS after meals; 7-14 days or until at least 7 days after symptoms resolve Nystan suspension 7-14 days Usually 7 days and continued 2 days after symptoms resolve Fluconazole Oral tablets 7-14 days 20 Version: AA Dec -

21 7 days; further 7 days if persistent February 20 Bacterial vaginosis (new product available; agreed by RB microbiologist & SW GUM consultant 19/01/; PAMM approval 22/02/) New: Dequalinium chloride (Fluomizin ) is an option when initial treatment is not effective or well tolerated. Second line: Dequalinium chloride (Fluomizin ) 10mg vaginal tablet OD 6 days February 20 February 20 Lyme disease (need for new option identified; PAMM approval 22/02/) Appendix 5 - General Practice Sepsis Screening & Action Tools (in line with NICE guidance July 2016 and Sepsis Trust UK; recommendation from Somerset Sepsis Working Group; PAMM approval 22/02/) New: If 12years old & allergic to penicillin: Cefuroxime Children 40kg 15mg/kg (max 250mg) BD Children 40kg 500mg BD New: Antibiotic options added to flowcharts: - Sepsis Tool for under 5's - Sepsis Tool for 5-11 year olds - Sepsis Tool for adults & young people - Sepsis Tool for women in pregnancy Consider IV or IM Cefotaxime (alternatively, Ceftriaxone) if time to treatment is likely to be 1 hour 21 Version: AA Dec -

22 Influenza (CAS alert 28 th June-16; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Acute Sore Throat (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Acute Otitis Media (NICE Advice topic March 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) DoH update 28 th June 2016: GPs and other prescribers working in primary care should no longer prescribe antiviral medicines, for the prophylaxis and treatment of influenza on an FP10 prescription form. This is in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004, commonly known as the Grey List or Selected List Scheme (SLS).This advice stands until we write again to re-commence prescribing and supply of antiviral medicines in primary are. Use FeverPAIN Score; 1 point each: Fever in last 24h (( 36.9 C), Purulent tonsils, patient Attending rapidly ( 3 days), severely Inflamed tonsils, No cough or coryza. Score 0-1: 13-18% streptococci, use NO antibiotic strategy; 2-3: 34-40% streptococci, use 3 day back-up antibiotic; 4-5: 62-65% streptococci, use immediate antibiotic if severe, or 48hr short back-up prescription. Removed: If Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) consider 2 or 3-day delayed or immediate antibiotics. Consider Otovent nasal balloon to relieve otitis media with effusion - Initially 3 inflations per day for each affected nostri; Lasts 2-3 weeks (each latex balloon may be inflated 20 times before needing replacement) Community-acquired pneumonia - treatment in the community (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) - Doxycycline placed as first line to cover for possible Mycoplasma pneumoniae presentations. - If CRB65=1, 2 & AT HOME Clinically assess need for dual therapy for atypicals 22 Version: AA Dec -

23 UTI in men & women (no fever or flank pain) (launch of new cost-effective product; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) UTI in pregnancy (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) UTI in children - Changed from: CRB65=0: use 5 days. Review at 3 days & extend to 7-10 days if poor response To CRB65=0: use 5 days. Consider extending the antibiotic course to a total of 7-10 days as a possible management strategy for patients with low-severity CAP whose symptoms do not improve as expected after 3 days. Changed from: Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology - to be prescribed in primary care as licensed Fosfomycin 3g granules produced by Lexon UK Ltd. Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology - to be prescribed as licensed product Monurol. Changed from: First line: Nitrofurantoin or Trimethoprim Give folic acid if first trimester Second line: if susceptible, Amoxicillin Third line: Cefalexin First line: Nitrofurantoin Second line: Trimethoprim (Give folic acid if first trimester) or if susceptible, Amoxicillin Third line: Cefalexin 23 Version: AA Dec -

24 (suggested by microbiologist BB; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Oral candidiasis (PHE guideline update and review May 2016; BNF; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Giardiasis (requested by microbiologist SH; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Epididymitis (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Gonorrhoea (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Pelvic Inflammatory Disease (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) MRSA (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Epidermoid and pilar cysts New topic - Pivmecillinam as 2 nd line in lower UTI if 40kg - Fluconazole dose (50mg QDS) in previous PHE guidance changed to 50mg OD - Changed from: For extensive/severe candidiasis or HIV or immunosuppression use oral fluconazole. Fluconazole if extensive/severe candidiasis; if HIV or immunosuppression use 100mg. New topic Now a stand-alone item (previously with Chlamydia trachomatis/ urethritis). New entry: Antibiotic resistance is now very high. Use IM ceftriaxone plus azithromycin and refer to GUM. Doxycycline added as an option: Low risk only Metronidazole PLUS First line: Ofloxacin OR Second line: Doxycycline Topic removed (note: local MRSA decolonisation policy currently under review) 24 Version: AA Dec -

25 ( sebaceous cysts) (requested locally; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Boils and carbuncles (requested locally; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Bites (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Blepharitis (requested locally; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Chalazion (Meibomian cyst) (requested locally; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Stye (requested locally; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Dental Infections (PHE guideline update and review May 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Appendix 1 Guidelines for the management of cellulitis in adults in Somerset (noted at TSAPG 10/08/16 & approved PAMM 14/09/16) Appendix 5 - General Practice Sepsis Screening & Action Tools (updated tools from UK Sepsis Trust July 2016; noted at TSAPG 10/08/16 & approved PAMM 14/09/16) New topic Human bites dose change for Co-amoxiclav from 625mg to mg New topic New topic New topic Dental Infections topic updated and extended to include: - Mucal ulceration and inflammation (simple gingivitis) - Acute necrotising gingivitis - Pericoronitis - Dental abscess Alternative to Retapamulin provided due to ongoing stock supply issues: (if unavailable the recommended (unlicensed) alternative is Sulfadiazine cream (Flamazine ) TDS 5-7days) Added primary care flowcharts: - Sepsis Tool for under 5's - Sepsis Tool for 5-11 year olds - Sepsis Tool for adults & young people 25 Version: AA Dec -

26 February 2016 February 2016 February 2016 February 2016 Appendix 2 - Methicillin Resistant Staphylococcus Aureus (MRSA) Decolonisation Policy (approved by TSAPG 24/02/16 & PAMM 09/03/16) Erythema chronicum migrans Lyme disease (clarification requested by GPs in West Somerset; approved by TSAPG 24/02/16 & PAMM 09/03/16) Bites (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM 09/03/16) Impetigo (approved by TSAPG 24/02/16 & PAMM 09/03/16) - Sepsis Tool for women in pregnancy Aligned with NHS Somerset CCG Infection Control MRSA decolonisation update GPs to discuss cases with Infection Control Team or Consultant Microbiologist after three unsuccessful decolonisation attempts. Octenisan 500ml bottle is the most cost-effective Chlorhexidine-based body wash (removed Skinsan ). Title change to Lyme disease and added clinical comments: If history of a recent tick bite but otherwise well: -Prophylactic antibiotics should not be routinely prescribed. -Advise to seek immediate medical advice if develop symptoms of Lyme disease. -Erythema migrans at the site of a tick bite is diagnostic of Lyme and should be treated with antibiotics without blood tests. Laboratory tests should only be performed where these is evidence of neurological, cardiac or joint involvement. Microbiology will advise on positive results. Specialist advice should be sought when: -Despite antibiotic treatment, symptoms are persisting and getting worse -Erythema migrans not present but has symptoms suggestive of Lyme disease and a recent history of a tick bite or possible exposure to ticks -There is neurological, cardiac involvement, or arthritis; severe symptoms i.e. syncope, breathlessness, or chest pain consider admission -There are any other persistent symptoms. (Note: Cefuroxime is a cephalosporin which is not recommended locally due to poor oral absorption) Prophylaxis or treatment: If penicillin allergic: Metronidazole PLUS Doxycycline (cat/dog/human) NEW: or Metronidazole PLUS Clarithromycin (human bite) Useful in children or intolerance to Doxycycline. Alternative to Retapamulin provided due to ongoing stock supply issues: If Retapamulin stock is unavailable the recommended (unlicensed) alternative is Sulfadiazine cream (Flamazine ) TDS 5-7days. Topical Fusidic Acid is not recommended due to local high resistance levels. 26 Version: AA Dec -

27 February 2016 February 2016 Acute prostatitis (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM 09/03/16) Pelvic Inflammatory Disease - high risk or likely gonorrhoea (as per DoH letter 18/12/15; approved by TSAPG 24/02/16 & PAMM 09/03/16) February 2016 Chlamydia trachomatis/ urethritis (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM 09/03/16) February 2016 Acute pyelonephritis (approved by TSAPG 24/02/16 & PAMM 09/03/16) February 2016 UTI in men & women (no fever or flank pain) (approved by TSAPG 24/02/16 & PAMM 09/03/16) February 2016 Eradication of Helicobacter pylori (following UK discontinuation of De-Noltab (tripotassium di-citrato bismuthate 120mg in December 2015; approved by TSAPG 24/02/16 & PAMM 09/03/16) February 2016 Community-acquired pneumonia - treatment in the community (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM Added option in line with PHE guidance: 1st line: Ciprofloxacin 500mg BD or Ofloxacin 200mg BD 28 days Ceftriaxone regimen change to national recommendation in place since 2011: Ceftriaxone 500mg IM stat PLUS Metronidazole 400mg BD x 14days PLUS Doxycycline 100mg BD x 14 days Ceftriaxone 500mg IM stat PLUS Azithromycin 1g (2x500mg tabs) stat Added option in line with PHE guidance: Epididymitis - low STI risk: Doxycycline 100mg BD 14 days Co-amoxiclav treatment reduced from 14 days to 7 days in line with PHE guidance. Nitrofurantoin alternative formulation provided due to ongoing stock supply issues: If Nitrofurantoin MR 100mg capsules stock is unavailable the next most costeffective alternative is Nitrofurantoin 50mg tablets (1 QDS). Entries for Bismuthate (De-nol tab ) 240mg BD changed to Bismuth subsalicylate (Pepto-Bismol chew tab ) off-label 2x262.5mg QDS IF CRB65=0: Changed from 7 days treatment to: Use 5 days. Review at 3 days & extend to 7-10 days if poor response 27 Version: AA Dec -

28 February 2016 February 2016 February 2016 August 2015 August /03/16) Acute Otitis Externa (cost-effectiveness review to align options in Somerset healthcare community as highlighted by SOMPAR 08/01/16; (approved by TSAPG 24/02/16 & PAMM 09/03/16) Influenza (added webpage links to PHE January 2016 communications approved by TSAPG 24/02/16 & PAMM 09/03/16) Introduction Principles of treatment (approved by TSAPG 24/02/16 & PAMM 09/03/16) Appendix 5 The UK Sepsis Trust General Practice Sepsis Screening & Action Tool (as suggested by Sepsis case study review group 09/07/15) Acute Diverticulitis (new topic agreed by TSAPG 12/08/15 & PAMM 08/09/15) Second line option changed from: Neomycin sulphate with corticosteroid Betnesol-N drops (Betamethasone 0.1% Neomycin 0.5%) drops TDS- QDS (can be given to babies and small children; take clinical precautions*) OR Otomize spray (Neomycin Sulphate 0.5% Dexamethasone 0.1% Glacial Acetic Acid 2.0%) - 1 spray TDS (adults and children aged 2 years) Removed previous information and added link to PHE online January 2016 resources letter to GPs and guidance on prescribing antivirals. Added link to electronic version of No Antibiotic/Back-up prescribing patient leaflet Treating your infection New appendix containing guidance for screening of sepsis in primary care. There is no robust evidence to support the use antibiotics for treating diverticulitis in primary care. Prescribers are therefore advised to exercise careful clinical judgment and keep the use of antibiotics to the necessary minimum. Contact microbiology if pregnant or breastfeeding. This local guidance takes into account safety, cost-effectiveness and antimicrobial resistance, and stratifies treatment based on episode severity: -Mild - symptoms of diverticulitis with no inflammatory response; no antibiotics required; advise fluid intake and analgesia if required -Mild to moderate - symptoms of diverticulitis with evidence of inflammatory response = 2 or more SIRS criteria: Temp 38.3ºC or 36.0ºC, Pulse 90/min, 28 Version: AA Dec -

29 RR 20/min, New confusion/drowsy, Glucose 7.7mmol/L (non-diabetic patient), WBC 12 or 4x10 9 /L -Moderate to severe acute hospital assessment/ admission August 2015 April 2015 UTI in men & women (no fever or flank pain) (new licensed product approved by PAMM 15/07/15) Eradication of Helicobacter pylori (typo identified by Vicky MM team Apri-15) In some circumstances it may be appropriate to treat mild to moderate episodes: Doxycycline 200mg STAT then 100mg OD for 7days PLUS Metronidazole 400mg TDS for 7days (Review within 48 hours) Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology - to be prescribed in primary care as licensed Fosfomycin 3g granules produced by Lexon UK Ltd. First line option with penicillin allergy incorrectly stated Amoxicillin instead of Metronidazole (main guidance document only not quick reference guide) April 2015 Community-acquired pneumonia - treatment in the community (feedback from North Sedgemoor Federation Mar-15) February 2015 UTI in men & women (no fever or flank pain) (agreed with BB at PAMM Feb-15) January 2015 Mastitis (reviewed in line with CKS guidance & local staph sensitivities; noted in PAMM Feb-15) Hyperlink to NICE guidance made clearer to improve access to CRB65 definition Further to risk stratification approval in Jan-15, Pivmecillinam has been added as first option if previous history of Trimethoprim resistance. Pivmecillinam is first option for community multi-resistant Extended-spectrum Beta-lactamase E. coli and Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology. Flucloxacillin 500mg-1G QDS (was 500mg only) If allergic to penicillin Clarithromycin 500mg BD (if not breastfeeding) Doxycycline 200mg STAT then 100mg OD 29 Version: AA Dec -

30 January 2015 January 2015 January 2015 January 2015 January 2015 Diabetic Foot Infections (04/02/15 in line with MPH & YDH guidance; noted in PAMM Feb-15) MRSA (as per PHE update Nov-14; noted in PAMM Feb-15) Acute prostatitis (review local guidance as differs from PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) Chlamydia trachomatis/ urethritis (as per PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) Acute pyelonephritis (review local guidance as differs from PHE update Nov-14; agreed with BB 04/02/15; noted in PAMM Feb-15) (2 nd option was Erythromycin) Treatment duration 14 days as per CKS recommendation (changed from 7 days). Treatment options updated to: Flucloxacillin 500g 1G QDS If allergic to penicillin Doxycycline 200mg STAT followed by 100mg OD (2 nd option was Clarithromycin) New topic Flucloxacillin 1g QDS (reduce to 500mg QDS if intolerant); if allergic to penicillin: Clarithromycin (500 mg BD; (caution in elderly with heart disease) or Doxycyline (200mg STAT followed by 100mg OD). Facial: Co-amoxiclav 500/125 mg TDS If severe infection or no response to monotherapy after hours, seek advice from microbiologist. 1st line Ciprofloxacin 2nd line Trimethoprim (removed doxycycline as only recommended for chlamydial infections) New info For suspected epididymitis in men 35 years with low risk of STI (High risk, refer to GUM). Epididymitis: low STI risk: Ofloxacin 200mg BD 14 days New info If previous or current MRGNO/ ESBL discuss with microbiology or consider admission. If ESBL risk and with microbiology advice consider IV antibiotic via outpatients (OPAT). Change in: Score urgent hospital admission Give immediate IM Benzylpenicillin if delayed admission/life threatening, and seek risk factors for Legionella and Staph. aureus infection. January 2015 Community-acquired pneumonia - treatment in the community (NICE CG191 Dec-14 has been considered and local guidance differs ; options agreed with BB 28/01/15; noted in PAMM Feb-15) January 2015 Acute Changed to 5-7 days recommended course for all options (was 7days; 14 days 30 Version: AA Dec -

31 January 2015 December 2014 December 2014 December 2014 December 2014 exacerbation of COPD (review local guidance as differs from PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) Acute cough, bronchitis (as per PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) County wide Cellulitis guideline (Appendix 1) (as agreed in SPF & TSAPG Nov-14) Genital Tract Infections (as per PHE update Nov-14) Eradication of Helicobacter pylori (following NICE CG184 Sept-14 approved by PAMM & SPF Jan-15) Recurrent UTI in women 3 UTIs/year for frequent exacerbations) Change in Comments section to: Consider 7 days delayed antibiotic with symptomatic advice/leaflet. Consider immediate antibiotics if > 80yr and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure OR > 65yrs with 2 of above. Consider 7-14 day delayed antibiotic with symptomatic advice/leaflet. Removal of SOMPAR logo and references; agreement remains valid between MPH, YDH & CCG. Contact UKTIS (Tel or use TOXBASE ), for information on foetal risks if patient is pregnant. First line treatment: -Choose the treatment regimen with the lowest acquisition cost, and take into account previous exposure to clarithromycin or metronidazole. -Metronidazole as an option in combination for people who are allergic to penicillin -Tetracycline for people allergic to penicillin and who have had previous exposure to clarithromycin. Second line treatment: - Use Clarithromycin or metronidazole (whichever was not used first-line). - A quinolone or tetracycline (whichever has the lowest acquisition cost) for people who have had previous exposure to clarithromycin and metronidazole. -Levofloxacin for people who are allergic to penicillin (and who have not had previous exposure to a quinolone). - Tetracycline people who are allergic to penicillin and who have had previous exposure to a quinolone. Methenamine hippurate changed from AMBER to GREEN status. 31 Version: AA Dec -

32 December 2014 December 2014 December 2014 December 2014 September 2014 August 2014 (application from MPH approved bypamm & SPF Jan-15) UTI in men & women (no fever or flank pain) (as per PHE update Nov-14; to be reviewed at PAMM & SPF Jan-15) Influenza (as per Public Health England update November 2014) Document Introduction Principles of treatment (as per PHE update Nov-14) Hyperlinks have all been updated mainly due to changes in PHE and CKS websites The main document now contains a new version of the county wide Cellulitis guideline. (the order of the Appendices has changed) (approved by TSAPG, PAMM & SPF) Appendix 1- Methicillin Resistant Staphylococcus Aureus (MRSA) Proposed treatment options based on risk stratification according to patient clinical status and drug cost-effectiveness. Allowed on FP10 as SLS (winter season); status change to: 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 treatment 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. See PHE Influenza guidance for treatment of patients under 13 years or in severe immunosuppression (and seek advice). Minor wording changes: and 11 New: 14. New item: Appendix 1 Guidelines for the management of Cellulitis in Adults in Somerset Added 2 nd line option: - if Mupirocin nasal treatment is unavailable the second line treatment is 32 Version: AA Dec -