ANTIMICROBIAL PRESCRIBING GUIDELINES

Transcription

1 Bedfordshire and Luton Community ANTIMICROBIAL PRESCRIBING GUIDELINES No. 10 (2) (May 2018) Addressing known local sensitivities Before you open this book Do you need to prescribe an antibiotic or is it a virus? Virus? Symbol means that a virus is commonly involved. These guidelines are correct at time of issue (May 2018) Consult the GP ref website or Microguide app

2 Contents Acknowledgements... 5 Major Revisions from 9 th Edition (2017)... 6 Introduction... 6 Aims... 7 Principles of treatment... 7 Specific prescribing issues... 9 Penicillin allergy... 9 Macrolides... 9 Trimethoprim and Co-trimoxazole interaction with Methotrexate... 9 Warfarin Interactions... 9 Swallowing Difficulties Prescribing in the frail elderly Antibiotic interactions with hormonal contraception Culture sensitivity reporting IV antibiotics in the community Why should we be worried about Antimicrobial Resistance (AMR)? How can we improve antimicrobial prescribing in primary care? Local antibiotic sensitivity data (1 April 2015 to 31 March 2016) Respiratory tract infections Acute Sore Throat Scarlet Fever Acute Otitis Media (AOM) Otitis Externa Acute Sinusitis Lower Respiratory Tract Infection Chronic Obstructive Pulmonary Disease (COPD) Community acquired pneumonia (CAP) Treatment and prevention of pertussis in adults Dental infections Pericoronitis (partly erupted wisdom tooth) Mucosal Ulceration and Inflammation (simple gingivitis) Dental Abscess Urinary Tract Infections Collecting MSU Samples Urinary Tract Infection in Adults (No fever or flank pain) Acute Pyelonephritis Urinary Tract Infection in Pregnancy

3 Urinary Tract Infection in Children Lower Urinary Tract Infection in Children Upper Urinary Tract Infection in Children Prophylaxis of uncomplicated Urinary Tract Infections in adults Recurrent UTI s (2 in 6 months or > 3 infections/year) Recurrent UTI s- Sexually active women (not pregnant) Non-sexually active women Risks of long term prophylactic antibiotics Risks outweigh benefits in the elderly Catheter Urines Genital Infections Prostatitis Epididymo-orchitis Vaginal Discharge in an Adult Trichomonas vaginalis Candidiasis Bacterial Vaginosis Pelvic Inflammatory Disease (PID) Chlamydia trachomatis Neisseria gonorrhoeae, uncomplicated Acute Herpes Simplex (Genital Infection) Recurrent Herpes Simplex (Genital Infection) Skin/Soft Tissue Infections Impetigo Acne Vulgaris Eczema Cellulitis Leg Ulcers and Pressure Sores Lyme Disease Mastitis Wound Infections Bites (animal and human) and contaminated wounds MRSA Infection MRSA Decolonisation Scabies Head lice Dimeticone 4%: Insecticides: Wet combing:

4 Dermatophyte Infections (scalp, body/groin/feet and nails) Scalp (Tinea Capitis) Nail (Tinea Unguium) Herpes zoster / Chicken Pox and Varicella zoster / Shingles Meningococcal Disease Prophylaxis in Meningococcal Disease Gastro-intestinal Infection Viral Parasitic Giardiasis Travellers Diarrhoea Mild Diverticular Disease Infestations Threadworms Eye Infections Conjunctivitis Blepharitis Supporting Materials Glossary Reference Sources

5 Acknowledgements Alison Franklin Dr Cliodna McNulty Dr Helen Smith Dr John Fsadni Dr Jenny Wilson Dr Nick Brown Dr R Mulla Dr Sarah Griffith Dr Simantee Guha Dr Vinod Varghese Elizabeth Beech Iain Roddick, Wendy Rice, Daniel West Nisha Patel Medicines Management Teams Sue Phillips / Jodie Deards Infection Prevention and Control Nurse, BCCG and LCCG Head of Primary Care Unit and Honorary visiting Professor, Public Health England and Cardiff University GP Chair, Bedfordshire and Luton CCGs Joint Prescribing Committee GP Locality Prescribing Lead, Bedford Locality Consultant Medical Microbiologist, Interim Lead Public Health Microbiologist, East of England. Consultant Microbiologist, L&D Hospital NHS Trust GP Locality Prescribing Lead, Ivel Valley Locality Consultant Microbiologist, Bedford Hospital NHS Trust GP Luton CCG National Project Lead - Healthcare Acquired Infection and Antimicrobial Resistance Eastern Field Epidemiology Unit, National Infection Service, Public Health England Antimicrobial Lead Pharmacist, L&D Hospital NHS Trust Bedfordshire CCG and Luton CCG Community Matrons, SEPT Many thanks to all the many more people who made comments in order that the 2013 guidelines could be updated. In addition many thanks to everyone who supported the updating process to try to ensure all interested parties were consulted. The guidelines were ratified by the Bedfordshire and Luton Joint Prescribing Committee (JPC) in September Minor amendments were ratified by the Bedfordshire and Luton Joint Prescribing Committee (JPC) in December They will be reviewed in September 2019 or earlier if required. The guidelines were edited by Naomi Currie, Pharmaceutical Adviser, Bedfordshire Clinical Commissioning Group, who would welcome any comments on the guidelines. naomi.currie@bedfordshireccg.nhs.uk Contact address: Suite 2, Capability House, Wrest Park, Silsoe, Bedfordshire MK45 4HR Further copies of the guidelines can be obtained by contacting the medicines management team of the clinical commissioning group to which you belong. Bedfordshire Clinical Commissioning Group Luton Clinical Commissioning Group These guidelines are based on the best available evidence but their application can always be modified by professional judgement. 5

6 Major Revisions from 9 th Edition (2017) Includes latest PHE Guidance on Management of Infections Guidance for Primary Care for consultation and local adaptation. October Addition of azithromycin and clarithromycin to the list of antibiotics to avoid in pregnancy following publication of new evidence of increased risk of spontaneous abortion associated with use of antibiotics in pregnancy. Addition of Scarlet fever treatment section Revised section on acute sore throat Updated section on acute sinusitis based on NICE guideline (NG79) published October 2017 Revised section on lower respiratory tract infection and COPD Addition of mastitis as per the NICE CKS for mastitis and breast abscess. Addition of blepharitis, treatment options as per PHE guidance and NICE CKS for blepharitis. Revised or new drug choices for: o Upper UTI in children treatment option changed to cephalexin o For otitis externa addition of advice to start flucloxacillin if cellulitis is seen in addition to referral to ENT o Pivmecillinam removed as an option for UTI prophylaxis and replaced with ciprofloxacin as per PHE guidance. o For prostatitis trimethoprim listed as second choice - quinolones are preferred due to better activity against urinary pathogens o For cellulitis the option of flucloxacillin plus amoxicillin has been removed, CREST guidelines for management of cellulitis state that flucloxacillin monotherapy provides sufficient staphylococci and streptococci cover. o Addition of fidaxomicin as an option for treatment of severe recurrent Clostridium difficile treatment only when recommended by consultant microbiologist Revised dosage or frequency of treatment for: o Acute sore throat penicillin dose and course length changed o UTI prophylaxis changes to trimethoprim dose o Recurrent candidiasis - Addition of a treatment option of fluconazole once weekly as per BASHH guidelines. o For Acute Herpes Simplex - 200mg five times a day dose option removed, the three times daily dose is recommended by PHE and BASHH due to improved compliance. o For Recurrent Herpes Simplex - The dose of aciclovir for episodic treatment of recurrent herpes simplex has been changed to 800mg three times a day for 2 days as per BASHH guidelines. Introduction These Guidelines are intended to provide guidance to primary care prescribers, including GPs, nurses, and pharmacists on when it is appropriate to use an antimicrobial agent and, when the decision has been taken to prescribe, the choice of appropriate antimicrobial agents for commonly encountered community Virus? acquired infections. Where a virus is commonly implicated the virus symbol is shown. For these cases, patient education on Self-Care is encouraged using patient leaflets or other tools where needed. Antimicrobial Resistance (AMR) is linked to inappropriate prescribing and taking. The UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018 advocates the timely and appropriate treatment of probable bacterial infections and the need to ensure the use of the Right drug, Right dose at the Right time and for the Right duration to limit unnecessary antibiotic exposure. The Public Health England publication, Management of Infection Guidance for Primary Care for Consultation and Local Adaptation November 2017 and local sensitivity patterns of common pathogens have been taken into account in producing these local antimicrobial prescribing guidelines. If the patient has taken an antibiotic course recently, or is taking a prophylactic antibiotic, resistant organisms may have been selected out requiring a change of therapy if further treatment is indicated. Whilst these guidelines have been prepared using current national and local information, it should be recognised that treatment of infections is a constantly changing environment. Practitioners should use 6

7 these guidelines in conjunction with national recommendations from Public Health England to assist in making informed decisions. When specimens are sent for culture, it is essential that the request forms have sufficient relevant clinical details including antibiotics used. Preliminary results are usually available the following working day if specimens are received in the laboratory by Treatment may need to be altered once culture and sensitivity results are available. More detailed advice on treatment options may be obtained from the Consultant Microbiologists at the respective hospitals. Luton and Dunstable Hospital: (01582) / Bedford Hospital: (01234) A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal and hepatic function. This is specified in British National Formulary (BNF) or Summary of Product Characteristics (SPC) for the individual antibiotic. Please refer to either for further dosing, contraindications and interaction information. Children s doses are provided when appropriate but refer to the children s BNF for full information. Always check for hypersensitivity and if patient is genuinely allergic to penicillin use clarithromycin for presumed gram positive infections. Notification of Infectious Disease and Reporting of Health Protection Emergencies should be made to:- Consultant in Communicable Disease Control (CCDC) Public Health England East of England Health Protection Team 2nd Floor, Goodman House, Station Approach, Harlow CM20 2ET Tel: ; Fax: ; ICC Fax: (Office Hours, Monday Friday, 9am 5pm) Medicom: (Outside office hours) Ask for Public Health 1st on-call Primary smh@phe.gov.uk NHS phe.smh@nhs.net Aims To minimise the emergence of bacterial resistance in the community. To aim to minimise the incidence of antibiotic associated Clostridium difficile and MRSA infections. To assist primary care prescribers in choosing empirical antimicrobial agents for common community infections. To encourage rational and cost-effective use of antibiotics. To aim to minimise the incidence of toxicity and other adverse effects associated with antibiotic prescribing. To aim to promote the safe and appropriate use of antibiotics encouraging patient education and Self- Care where appropriate. Principles of treatment These guidelines are based on the best current available evidence but their application can always be modified by professional judgement. 1. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. Antibiotic prescribing in primary care influences resistance. Evidence clearly links increased risk of opportunist infections such as Clostridium difficile with high volume prescribing of antibiotics and long term use of proton pump inhibitors. 2. It is important to initiate antibiotics as soon as possible in severe infections. Check ability of patient to be able to get their prescription dispensed to avoid delay in commencing treatment. Use an immediate release preparation in such circumstances as delayed absorption may occur with modified release or enteric coated preparations. 7

8 3. When antibiotics are necessary and appropriate, use simple generic ones. Avoid broad spectrum antibiotics, especially co-amoxiclav, quinolones and cephalosporins (mainly 3 rd and 4 th generation) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs. 4. Do not prescribe an antibiotic for suspected viral infections- educate patient. Use a patient information leaflet to share during the consultation. Refer to Support Materials section. 5. Samples should be sent for culture if infections are persistent or recurrent. 6. Topical antibiotics have limited indications and should be used sparingly when appropriate. 7. Avoid prescribing antibiotics over the telephone. Limit prescribing over the telephone to really exceptional cases and immunosuppressed patients. 8. Raised temperature is a good indication of infection but may be absent in the elderly or immunocompromised. 9. Prescribing of an antibacterial for infection where the cause is obscure, such as unexplained pyrexia, can lead to difficulty in establishing diagnosis. Consider taking samples for microbiological analysis. 10. Reduce patient expectation and demand by using strategies such as delayed prescriptions where there is no clinical risk to patient. A prescription may be left at reception or given with advice only to use if symptoms worsen. 11. Consider the use of patient decision aids to explain risk/benefit and emphasise the self- limiting nature of minor ailments. The figures below represent the average span of the disease: Acute otitis media 4 days Acute sore throat/pharyngitis/tonsillitis Common cold Acute rhinosinusitis 1 week 10 days 18 days Acute cough/bronchitis 3 weeks (NICE RTI CG69 July 08) For children under 5 years see NICE Fever in under 5s NICE CG Consider patient compliance issues which may influence drug choice, dose frequency and length of treatment. Check ability to swallow tablets or capsules and prescribe acceptable dose form. Although cost is a consideration, the main factors to maximise the effectiveness of an antibiotic are appropriateness and patient concordance. Explain to the patient the reasons why completing the prescribed course is important. 13. In pregnancy avoid tetracyclines, aminoglycosides, quinolones, azithromycin (except in chlamydial infection), clarithromcyin and high dose metronidazole. Nitrofurantoin should be avoided after 36 weeks pregnancy until after delivery. Although trimethoprim can be used in the second and third trimesters (and first trimester if folic acid 5mg daily is given until 12 weeks of pregnancy), the patient information leaflet warns patients not to take it when pregnant and this may cause them concern. 14. Where a best guess therapy has failed or special circumstances exist, microbiological advice can be obtained from the Consultant Microbiologists at the Luton and Dunstable Hospital, Bedford Hospital or other provider hospital. 15. Duration and dose depends on the nature of the infection and the response to treatment. Please refer to the current BNF if unsure. In addition, the principle of treatment duration should aim to be minimal length to achieve effect. In uncomplicated infections evidence would indicate 5 days to be adequate, (3 days for uncomplicated UTIs). Bacterial resistance is more likely with inadequate doses or inappropriately short courses. 16. Walk-in centres and out of hours services should be vigilant in supporting appropriate antibiotic use. Where patients have been refused antibiotics by their GP, there must be documented evidence of deterioration in symptoms so that the GP s original decision is supported wherever possible. The opportunity to reduce patient expectation for antibiotics should be maximised at these services. When 8

9 an antimicrobial is issued from walk-in centres or by the out of hours services, the antimicrobial choice should be in line with these Antimicrobial Prescribing Guidelines. 17. Immuno-compromised individuals, e.g. those taking corticosteroids or immunosuppressant medication or having a pre-existing immunological condition including HIV/AIDS, are more at risk of overwhelming infection. They in particular need early diagnosis, confirmed by culture whenever possible, and appropriate treatment. Specific prescribing issues Penicillin allergy Check history, which is often inaccurate. Patients commonly report minor skin reactions and stomach upsets as allergy. There is however, no low dose test for allergy as the allergic reaction is not dose related. The BNF quotes between 0.5 and 6.5% of penicillin-sensitive patients to be also allergic to cephalosporins. Patients with an immediate hypersensitivity to penicillin should not be given a cephalosporin (Type 1 reaction e.g. anaphylaxis, urticaria or angioedema). See individual treatment tables in this guideline for other alternatives. Macrolides Clarithromycin has better tolerability than erythromycin and patients are more likely to be compliant with its dose regimen of twice a day. The generic standard formulation should be prescribed as the more expensive modified release formulations offer no benefit. Erythromycin and clarithromycin have a number of important interactions because they inhibit the hepatic enzymes. It is advisable to check the significance of a macrolide interaction with new drugs. Drugs in common use that are affected include simvastatin, atorvastatin and amlodipine. The interaction is due to the inhibitor effect of these macrolides on the hepatic enzymes CYP3A4 which break down these drugs. If a macrolide is the only option, azithromycin can be used. A statin should be temporarily stopped until the course of antibiotic is completed or patients should be warned to be alert for any signs of myopathy (i.e. unexplained muscle pain, tenderness or weakness or dark coloured urine). If myopathy does occur, the statin should be stopped immediately. Trimethoprim and Co-trimoxazole interaction with Methotrexate The use of methotrexate for a number of medical conditions has increased. A patient should not take trimethoprim or co-trimoxazole whilst taking methotrexate because of increased risk of haematological toxicity. Warfarin Interactions Patients on warfarin who are prescribed antibiotics are at risk of over or under coagulation. How much the change of INR control is due to the antibiotic itself or due to the infection and inflammation is difficult to say. Antibiotics are not usually given to healthy people. Infections and inflammations have been shown to affect the cytochrome p450 enzyme system, which plays an important part in metabolising drugs. Fever associated with infection, use of Over the Counter (OTC) medication during the illness, antibiotic-induced diarrhoea, and poor oral intake of vitamin K all affect INR control. It is important to take all these factors into account when deciding how often patients should be tested after starting antibiotics. Some antibiotics are more likely than others to cause severe over anticoagulation, but even these antibiotics might not affect other patients at all. Patients who have reacted in a certain way to a specific antibiotic are likely to react in a similar way if given the antibiotic again. Antibiotics likely to increase the effect of warfarin and therefore cause raised INRs are clarithromycin, erythromycin, ciprofloxacin, sulfamethoxazole / trimethoprim, and metronidazole. Penicillins such as amoxicillin rarely affect INR control. Rifampicin can reduce anticoagulation such that 5-7 days later warfarin doses up to 20mg per day are needed to maintain a therapeutic INR. As rifampicin has such a marked effect on INR status it is important to refer back to anticoagulation services when it is stopped for INR to be rechecked and warfarin doses to be reduced. 9

10 If patients on Warfarin are started on an antibiotic, use one that is less likely to affect the anticoagulation when possible (e.g. a penicillin instead of clarithromycin / erythromycin), and inform the Anticoagulation Service or GP Practice monitoring the INR as soon as possible. For clarithromycin INR checks are normally carried out on days 3 or 4 and for other antibiotics day 7 dependent on the overall health of the patient. Swallowing Difficulties This can be a very common cause of antibiotic failure due to poor concordance and it is essential to establish the ability of the patient to swallow a solid formulation particularly if the infection is severe. Whilst in some cases liquids may be considerably more expensive, where alternatives may compromise sensitivities, cost should not be the prime consideration and the liquid should be prescribed. However, some liquid antibiotics are particularly unpleasant and this can compromise efficacy and result in waste. Use an alternative antibiotic liquid which is more palatable. Where an alternative is not available, for a minority of patients where risk of poor compliance due to palatability of liquid is high, capsules may be emptied and sprinkled visibly onto yogurt or other palatable food. (Off label use). Such instructions should be written on the prescription for the pharmacy to include on the label. Prescribing in the frail elderly The most important effect of age is reduced renal clearance. For many antibiotics, consideration of renal function may be specified in the SPC for each antibiotic. Fever and infection can lead to dehydration and that increases the risk of renal failure. The prescriber should take into account the patient s age, weight, co-morbidities presence or lack of renal/hepatic problems, other interactive medication etc. before choosing the most appropriate antibiotic or deciding the appropriate dose. (This is also important for paracetamol, because paracetamol dosing is also dependent on muscle mass or weight). In the elderly, it is crucial to ensure that the antibiotic dose is adequate because infection poses a greater risk in this age group than that from commonly used antibiotics. Antibiotic interactions with hormonal contraception According to current guidance from the Faculty of Sexual and Reproductive Healthcare (January 2012) on drug interactions with hormonal contraceptives, additional contraceptive precautions are only required with enzyme-inducing antibiotics, rifabutin and rifampicin, and when antibiotics or concurrent illness cause diarrhoea or vomiting. Health professionals are advised to remind women about the importance of correct contraceptive practice during periods of illness. Culture sensitivity reporting Samples sent to the laboratory for sensitivity testing carry out specific culture tests in the context of the suspected disease. The sensitivity report names a specific antibiotic within a class as it is not possible to test the whole range of antibiotics within each class. So where sensitivity to phenoxymethylpenicillin (penicillin V) is reported, the alternative of amoxicillin could be considered in the context of the suitable choices for the infection. This is also applicable to reporting sensitivity to erythromycin, as clarithromycin is the choice within the guidelines. IV antibiotics in the community The use of IV antibiotics in the community is becoming more common to prevent delayed discharge from hospital, e.g. treatment of cellulitis. Planning for the use of antibiotics in the community is currently managed on an individual patient basis and the initial choice and prescribing of the antibiotic would normally involve liaison between the microbiologist and the GP. Future arrangements for this to be managed in primary care need to be fully supported through clear patient pathways. At the time of printing there are locality differences between community services in Bedfordshire and Luton in the provision of this service. 10

11 Why should we be worried about Antimicrobial Resistance (AMR)? The growing threat of AMR to human and animal health has been well publicised since the publication of the Chief Medical Officer s (CMO) annual report on infections and the rise of antimicrobial resistance. The report highlights antibiotic resistance as a global risk requiring action at all levels and makes many recommendations including the need for better hygiene measures, the prescribing of fewer antibiotics and better surveillance across the NHS and worldwide /CMO_Annual_Report_Volume_2_2011.pdf In response to the CMO s report, the UK 5 year Antimicrobial Resistance Strategy was published in September 2013 and aims to slow the development and spread of AMR. It is a cross UK government strategy which sets out what needs to happen to tackle antimicrobial resistance. It has 3 strategic aims including to: Improve the knowledge and understanding of antimicrobial resistance. Conserve and steward the effectiveness of existing treatments. Stimulate the development of new antibiotics, diagnostic and novel therapies. It advocates the timely and appropriate treatment of probable bacterial infections and the need to ensure the use of the Right drug, Right dose at the Right time and for the Right duration to limit unnecessary antibiotic exposure. There are 7 key areas for implementation: 1. Improving infection prevention and control practices. 2. Optimising prescribing practice. 3. Improving professional education, training and public engagement. 4. Developing new drugs, treatments and diagnostics. 5. Better access to and use of surveillance data. 6. Better identification and prioritisation of AMR research needs. 7. Strengthened international collaboration. How can we improve antimicrobial prescribing in primary care? There are numerous ways healthcare professionals can get involved in improving antimicrobial prescribing. Patient focused strategies may involve: Antibiotic leaflets. Decision aids. Delayed prescriptions. No prescription patient leaflet. These strategies are aimed at educating the public in reducing expectation for antibiotic treatment. Clinician focused strategies may involve: Clinical audit within practice. Case study discussion. Availability of infection control nurse. Antibiotic stewardship leader in the practice and locality. Availability of local guidelines to all clinical staff. These strategies provide peer review and shared practice to drive local implementation of guidelines. The following programmes and tools are excellent resources to support putting these strategies into practice: The Antibiotic Stewardship programme. This is seen as a means of improving the quality of prescribing. Primary care prescribers are encouraged to adopt antimicrobial stewardship initiatives by following the Bedfordshire and Luton Antimicrobial Prescribing Guidelines and reducing their use of broad spectrum antibiotics co-amoxiclav, cephalosporins and quinolones. The RCGP TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) toolkit provides numerous tools to support the whole primary care team within the GP practice or out of hours setting 11

12 in their consultations with patients. Available at: These include: o TARGET Self-Assessment Tool where you can compare your practice with your peers in an anonymised format. o Training resources such as an elearning module on Antibiotic Resistance in Primary Care o Leaflets to share with patients available in multiple languages o Audit toolkits on a variety of symptoms o Posters and videos for clinical and waiting areas English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) is a national programme which brings together data on antimicrobial utilisation and resistance surveillance from both primary and secondary care. Recent reports are available at Become an Antibiotic Guardian. Take the pledge to become an antibiotic guardian and encourage other members of staff and patients to take the pledge also, see 12

13 Local antibiotic sensitivity data (1 April 2015 to 31 March 2016) This data helps to guide local prescribing choices and provides comparative information to indicate sensitivity changes. The data is an indication of sensitivity and is dependent on numbers of cultures tested which if small may give an unrepresentative result. Antibiotic Sensitivity data for the period April March % Sensitive Bedford Luton Milton Keynes Addenbrookes Stoke Mandeville E.coli (urine) Cephalexin Co-amoxiclav Nitrofurantoin Trimethoprim Amoxicillin Not tested Strep.pneumoniae (Sinus, middle ear, sputum) Penicillin Erythromycin/ Clarithromycin H.influenzae Amoxicillin Tetracycline Strep.pyogenes Penicillin not reported too few reported Erythromycin/ Clarithromycin not reported too few reported Staph.aureus (not MRSA) Erythromycin/ Clarithromycin Staph.aureus Methicillin (including flucloxacillin) Source: Eastern Field Epidemiology Unit, National Infection Service, Public Health England and Consultant Microbiologists and Bedford Hospital and the Luton & Dunstable Hospital. 13

14 Respiratory tract infections Antibiotics are rarely indicated for upper respiratory tract infections and an NNT value of 4000 to prevent one serious complication has been calculated. (Peterson et al BMJ :982). Patient education is particularly important in this area in line with National programmes to reduce prescribing. In both upper and lower respiratory tract infections, excluding Pharyngitis, Streptococcus pneumoniae is the commonest pathogen, and if antibiotics are indicated, this organism must be covered. The only quinolone with sufficient activity against S. pneumonia is levofloxacin which would not normally be indicated in primary care. Acute Sore Throat Antibiotics should not be used to secure symptomatic relief in sore throats as 90% resolve in 7 days. Antibiotics only shorten duration of symptoms by about 16 hours overall. Antibiotics can prevent nonsuppurative complications of beta-haemolytic streptococcal pharyngitis but, in developed societies, such complications are rare. Antibiotics to prevent Quinsy NNT>4000, antibiotics to prevent otitis media NNT 200. NICE CG69 recommends an immediate antibiotic strategy for patients who are systemically very unwell, have signs and symptoms of serious illness or complications, or at high-risk due to co-morbidities. Otherwise, a no prescribing or delayed prescribing strategy should be agreed with the patient or carer after addressing their concerns and expectations. Always share self-care advice and safety net. Results of a bacterial throat swab can be available within 2 working days but a Group A streptococcal infection will be notified in 24 hours. Use FeverPAIN Score (1 point for each): Sign (Score 1 point for each) Fever in last 24 hours Purulence Attend rapidly (under 3 days) Score Severely Inflamed tonsils No cough or coryza Total FeverPAIN Score: Score 0-1: 13-18% streptococci, use NO antibiotic strategy; Score 2-3: 34-40% streptococci, use delayed prescription for antibiotics (3 day delay); Score 4-5: 62-65% streptococci, use immediate antibiotic if severe, or use delayed prescription for antibiotics (48 hour delay). Acute Sore Throat Virus? Virus? First choice None Second choice Phenoxymethylpenicillin (Penicillin V) If penicillin allergic Clarithromycin Almost certain to be viral. Advise paracetamol, self-care and safety net. 500mg Four times daily 5-10 days (consider longer course lengths for FeverPAIN 4-5) 14 If a liquid preparation is needed choice could be amoxicillin (at the clinician s discretion) due to unpalatable nature of phenoxymethylpenicillin (penicillin V) liquid (especially for children)*. Or 1gm Twice daily 5 days If mild (FeverPAIN 2-3) mg Twice daily 5 days Tablets are recommended for children over 12 years. Children under 12 years who are able to swallow tablets should be offered them. If a liquid preparation is needed and the patient finds clarithromycin liquid unpalatable, erythromycin liquid is an alternative, but this is given four times a day and may not be as well tolerated.

15 If penicillin allergic AND pregnant Erythromycin mg Four times a day 5 days * Clinical judgement important as it is sometimes difficult to differentiate a streptococcal sore throat from glandular fever and morbilliform rashes have been associated with glandular fever in patients receiving amoxicillin. Scarlet Fever Scarlet fever is caused by Streptococcus pyogenes, or group A streptococcus (GAS). Prompt treatment with antibiotics significantly reduces the risk of complications. Observe immunocompromised individuals as they are at increased risk of developing invasive infection. First choice Phenoxymethylpenicillin (Penicillin V) If penicillin allergic Clarithromycin 500mg mg Four times a day Twice a day 10 days If a liquid preparation is needed choice could be amoxicillin due to the unpalatable nature of phenoxymethylpenicillin (penicillin V) liquid (especially for children). 5 days Acute Otitis Media (AOM) Acute Otitis Media (AOM) is a self-limiting infection that mainly affects children and can be caused by viruses and bacteria. Symptoms usually last for 3-7 days. No antibiotic prescription is recommended in the majority of cases as available evidence shows that antibiotics do not significantly reduce pain compared with placebo at 24 hours and acute complications are rare with or without antibiotics. A back up prescription may be considered with appropriate counselling that it should only be used if symptoms do not start to improve within 3 days or if there is rapid or significant worsening at any time. Immediate antibiotics should be given to children or young people who are systemically very unwell, have symptoms and signs of more serious illness or are at high risk of complications. Antibiotics seem to be more beneficial, based on subgroup analyses, in the following groups, Children under 2 years with bilateral AOM Children with AOM and otorrhoea (discharge following eardrum perforation) These children may be considered for no antibiotics, a delayed prescription or immediate antibiotics depending upon clinical assessment. Self-care and safety netting advice should be given to all children and young people with AOM to include regular paracetamol or ibuprofen for pain relief. Acute Otitis Media (AOM) First choice Amoxicillin Refer to BNF for Children 5-7 days If penicillin allergic: Clarithromycin Refer to BNF for Children (dose based on weight) 5-7 days Second choice (worsening symptoms on first choice after at least 2-3 days) Co-amoxiclav Refer to BNF for Children 5-7 days Consider erythromycin in pregnant young women who are allergic to penicillin, or if clarithromycin liquid is unpalatable. Consult Consultant Microbiologist for second line choice in penicillin allergy. 15

16 Otitis Externa Antibiotics are often not appropriate and good local hygiene may solve the problem. Culture of any discharge is valuable at first presentation to guide rational prescribing. Non- resolving problems may be fungal. Acetic acid can be tried for one week and can be purchased as EarCalm. Repeated use of topical antibiotics can result in the selection of antibiotic resistant organisms including fungi. Where topical antibiotic is appropriate, use neomycin with a corticosteroid ear preparation 3 drops three times a day for no less than 7 days and no more than 14 days. (Contraindicated in perforated ear drum). Discontinue if no clinical improvement in 7 days. Sensitivity to neomycin is possible. Recurrent problems especially in the elderly may be worsened by baths or showers. Using a wick of olive oil in ear during personal care may help. If cellulitis or disease extending outside ear canal, or systemic signs of infection start oral flucloxacillin ( mg QDS for 7 days) and refer to ENT to exclude malignant otitis externa. Acute Sinusitis Virus? Usually self-limiting, watch and wait. Reserve treatment for severe or persistent cases of at least 7-10 days duration in adults and days duration in children. There is very little evidence that antimicrobials are effective in children and many infections are viral, resolving in 7 days. First choice None Give Self-Care advice including steam inhalation. Consider a high dose nasal corticosteroid for 14 days for adults and children aged over 12 years who have had symptoms for more than10 days with no improvement. Second choice Phenoxymethylpenicillin 500mg Four times a day 5 days Penicillin allergy: 200mg stat Daily 5 days Doxycycline then 100mg Clarithromycin 500mg Twice a day 5 days Use erythromycin in pregnant women with penicillin allergy Third choice (if worsening symptoms on the above antibiotics for at least 2-3 days) Co-amoxiclav 500/125 Three times a day 5 days Consult microbiology for advice in penicillin allergic patients who require alternative treatment Lower Respiratory Tract Infection Virus? Systematic reviews indicate benefits of antibiotics are marginal in adults with no co-morbidities. Patient leaflets can reduce antibiotic use. There is insufficient evidence to prescribe cough preparations and they have limited value. Antibiotic treatment is not indicated for the majority of otherwise well patients with coughs and patients should be advised that symptoms can last for 3 weeks. Delayed prescriptions may work well for these patients. An immediate antibiotic prescription is necessary for those: Who appear unwell with symptoms and signs suggestive of pneumonia. Who are systemically unwell or at high risk of complications due to pre-existing co-morbidities. 16

17 Older than 80 with ONE or more the following or older than 65 with TWO or more of the following criteria: o Hospitalisation in previous year for respiratory related causes o Taking long term oral steroids o Insulin dependent diabetic o History of congestive heart failure o Serious neurological disorder/stroke o Immunosuppressed Patients should be reassured that upper respiratory tract infections or acute bronchitis can last on average 3 weeks and analgesics can give symptomatic relief. (NICE CG69 July 2008). Amoxicillin 500mg Three times daily 5 days In penicillin allergy: 200mg stat Daily 5 days If penicillin allergic and can be used Doxycycline then 100mg cautiously in renal impairment. Chronic Obstructive Pulmonary Disease (COPD) An exacerbation is an acute event characterised by a worsening of the patients respiratory symptoms that is beyond normal day to day variation, and leads to a change in medication. It can be associated with 2 or more of the following: Worsening breathlessness Increased sputum volume / purulence Changing sputum colour Increased cough Treat infective exacerbations promptly with: Increase frequency of short acting bronchodilator Oral antibiotics Prednisolone 30mg daily for 7 days for all patients with significant increase in breathlessness, unless contraindicated, especially if affecting their daily activities of living. Patients suffering frequent exacerbations should be provided with rescue / standby medication (prednisolone and oral antibiotics as above) supported by a clear written self-management plan. Prescriptions can be left for patients to access medication without delay in line with their management plan or if they have no ready access to collect such a prescription they can keep a supply of the relevant medication at home. Further information is detailed in the Bedfordshire COPD/ ACOS guidelines 2016 available on GP Ref. A separate patient advice leaflet on rescue medication is also available on this site which can be printed off for patients. NB: Culture of the sputum is advised where multiple exacerbations are occurring and first line treatments are not effective. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD (MRC >3), frequent exacerbations or antibiotics in last 3 months. First choice Amoxicillin 500mg Three times daily 7 days Give patient advice leaflet on COPD exacerbations. Second choice Doxycycline 200mg stat then 100mg Daily 7 days If penicillin allergic and can be used cautiously in renal impairment. Third choice Clarithromycin 500mg Twice daily 7 days If penicillin allergic or option if poor response to 1 st line choice. Co-amoxiclav 625mg Three times daily 7 days Only if at risk of resistance. 17

18 Community acquired pneumonia (CAP) According to a widespread consensus reflected in all authoritative guidelines, assessment of severity is the key step in the management of patients with community acquired pneumonia (CAP). It is a major criterion in the decision where to treat a patient and it widely determines the amount of diagnostic workup as well as the selection of initial empiric antimicrobial treatment. BTS updated guidance (2009) recommends that clinical judgement is supported by the CRB65 scoring. The following tables assist in the decision of where to treat. Severe staphylococcal pneumonia can occur following viral influenza such patients require urgent referral. Start antibiotic treatment immediately. Clinical factor Points Confusion 1 Respiratory rate > 30 breaths per minute 1 Systolic blood pressure < 90mm Hg Or 1 Diastolic blood pressure < 60mm Hg Age > 65 years 1 Total Points CRB-65 score Mortality (%) Recommendation 0 Less than 1 Low risk; consider home based care 1 or Intermediate risk; consider hospital assessment 3 or 4 More than 10 Urgent hospital admission If CRB65=0 choices are: Amoxicillin 500mg Three times daily 5 days Review at 3 days and extend to 7-10 days if poor response. Clarithromycin 500mg Twice daily 5 days If penicillin allergic. Review at 3 days and extend to 7-10 days if poor response. Doxycycline 200mg stat then 100mg Daily 5 days If penicillin allergic. Review at 3 days and extend to 7-10 days if poor response. If CRB65=1, 2 and at home choices are: Amoxicillin PLUS Clarithromycin Doxycycline 500mg 500mg 200mg stat then 100mg Three times daily Clinically assess need for dual therapy 7-10 days for atypicals Twice daily of each Daily 7-10 days If penicillin allergic. Treatment and prevention of pertussis in adults Outbreaks of pertussis can occur in households, schools, healthcare settings and in the community. If outbreaks are detected at an early stage, prompt action including chemoprophylaxis and vaccination can limit the spread. Chemoprophylaxis and vaccination of close contacts may also be of benefit in reducing transmission to those who are most at risk of severe or complicated infection and is therefore recommended in settings where there is a vulnerable person or an individual who may facilitate on-going transmission to vulnerable groups. As such, a list of priority groups for public health action has been defined within HPA Guidelines for the Public Health Management of Pertussis (updated October 2012). 18

19 For suspected, epidemiologically linked or confirmed cases, recommended antibiotics should be administered as soon as possible after onset of illness in order to eradicate the organism and limit ongoing transmission. The effect of treatment on reducing symptoms however, is limited or lacking especially when given late during the disease and therefore antibiotic treatment for the case is recommended within three weeks of onset of illness. Whilst early administration may improve the efficacy of chemoprophylaxis in preventing secondary transmission, this requires a clinical diagnosis. This is likely to be a challenge given that adolescents and young adults, who are often the source of infection, generally do not seek timely health advice. (HPA Guidelines for the Public Health Management of Pertussis) Risk assessment for pertussis should be based on a combination of clinical and epidemiological factors such as clinical presentation, vaccination history and epidemiological links. Management should proceed based on this risk assessment without waiting for the results of laboratory testing. Any person with an acute cough lasting for 14 days or more, without an apparent cause plus one or more of the following:- o Paroxysms of coughing o Post-tussive vomiting o Inspiratory whoop So in summary the indications for antibiotics are: 1. To shorten clinical course of illness in the case 2. To reduce transmission from the case to close contacts Full details of choices for different age ranges are in the HPA document but for adults recommendation is: Clarithromycin 500mg Twice daily 7 days Co-trimoxazole 960mg Twice daily 7 days To be used only for intolerance to macrolides. For pregnant contacts a risk assessment would need to be done to look at the risks and benefits of antibiotic therapy/prophylaxis. Erythromycin would be the preferred choice as it is not known to be harmful. The aim of treating/ providing prophylaxis for women in pregnancy is to prevent transmission to the newborn infant. Where possible, pregnant women should begin treatment 3 days prior to delivery. Dental infections Some general guidance is provided below as it is recognised that patients present themselves to GPs in some cases attempting to avoid dental care or through genuine fear of dental procedures. The GMC s Good Medical Practice is very clear about working within the limits of one s knowledge and training most GPs have very little or no training in dentistry. Therefore, GPs should not be treating dental problems. Patients requiring dental access urgently should contact their regular dentist for advice or if they do not have a regular dentist, telephone 111 (NHS 111). Good mouth hygiene is paramount to preventing mouth infections and GPs should not prescribe antiseptic mouthwashes or toothpastes (such as chlorhexidine) long-term on repeat prescription. Chlorhexidine has been associated with idiosyncratic allergic reactions and it stains the teeth and leads to development of resistance. These products may be requested in cases of dementia or learning disabilities where it is common to refuse mouth cleaning. Staff need to explore simple methods of encouragement such as trying different flavoured toothpastes. Encourage carers to contact a dentist to give advice. 19

20 Pericoronitis (partly erupted wisdom tooth) Refer to dentist for irrigation and debridement. For persistent swelling or systemic symptoms e.g. lymph node involvement Amoxicillin 500mg Three times daily Metronidazole 400mg Three times daily 3 days 3 days Use antiseptic mouthwash in combination with antibiotics if pain and trismus limit oral hygiene. See Mouth Ulceration and Inflammation section for antiseptic mouthwash choices. Mucosal Ulceration and Inflammation (simple gingivitis) The primary cause for mucosal ulceration or inflammation needs to be evaluated and treated. As a temporary solution, the treatment should be used until lesions resolve or less pain allows oral hygiene measures. These are suitable for Self-Care. Simple saline mouthwash Chlorhexidine % ½ teaspoon salt dissolved in glass of warm water. 5ml diluted with 5-10ml of water. Twice daily Twice daily Until lesions resolve or less pain allows oral hygiene. Until lesions resolve or less pain allows oral hygiene. Always spit out after use. Rinse mouth for 1 minute. Always spit out after use. Do not use within 30 minutes of toothpaste. Hydrogen peroxide 6% (20 volume) 15ml diluted in ½ glass warm water. Three times daily Until lesions resolve or less pain allows oral hygiene. Rinse for 2 minutes. Always spit out after use. Dental Abscess GP s should not routinely be involved in treatment as the abscess requires drainage by dentist. Patients may present to a GP in order to avoid dental care. Advise urgent dental consultation as repeated courses of antibiotics for abscess are not appropriate. Antibiotics are only recommended if there are signs of severe infection, systemic symptoms e.g. diffuse swelling, pyrexia or high risk of complications e.g. co-morbidities such as diabetes, cardio-vascular disease or compromised immunity and should be prescribed by a dentist if needed. Otherwise, self-care with regular analgesia should be advised until a dentist can be seen such as ibuprofen 400mg four times a day, paracetamol 1g four times a day or both (if not contraindicated). Codeine is not recommended for dental pain. Patients with infection causing air restriction and systemic symptoms should be referred to Hospital / A & E. 20

21 Urinary Tract Infections A Quick Reference Guide for primary care on the diagnosis of UTIs is available at: The Royal College of General Practitioners (RCGP) has a free training module on managing UTIs available at It is important that clinicians are aware that local sensitivities have determined first and second line choices as supplied by microbiology. These should be followed to minimise the risks of resistance developing. The use of co-amoxiclav, a quinolone or a 3rd or 4th generation cephalosporins can favour Clostridium difficile colitis and should ONLY be used where there is no other option. There is also evidence of increasing numbers of patients with Extended Spectrum Beta Lactamase positive organisms (ESBL) where IV antibiotics may be necessary. ESBL producing E.coli are able to resist penicillins and cephalosporins. Consultant Microbiologists can advise on treatment options. Patients may choose to purchase cranberry products to minimise occurrence of UTIs. It is not an appropriate treatment during an acute attack of cystitis as it contains hippuric acid and will worsen symptoms and reduce the effectiveness of antibiotics. It also interacts with medication, in particular warfarin. Collecting MSU Samples Many samples sent into microbiology are inappropriately contaminated and results are meaningless. This can delay appropriate treatment. Advice sheets have been produced for patients and carers to instruct on collecting samples. These are available on clinical systems and should be printed off for patients. It is also essential that sample bottles are provided to prevent inappropriately contaminated containers being used by patients. Urinary Tract Infection in Adults (No fever or flank pain) Treat women with severe/or 3 symptoms. Women with mild/or 2 symptoms and urine not cloudy- 97% negative predictive value, so 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% negative predictive value. Consider a back-up / delayed antibiotic option. Nitrofurantoin is first line choice if GFR over 45ml/min. GFR ml/min: only use if resistance and no alternative. In treatment failure, always perform culture. First choice Nitrofurantoin MR Second choice Trimethoprim Third choice Pivmecillinam Only if MSU indicates sensitivity: Amoxicillin Fosfomycin (Monuril ) 100mg Twice daily 3 days (women); 7 days (men) 200mg Twice daily 3 days (women); 7 days (men) 400mg immediately then 200mg 500mg Three times daily Three times a day 3 days (women) 7 days (men) 3 days (women) 7 days (men) 3g single dose (women) 3g immediately then 3g dose 3 days later (men) 21 If GFR over 45ml/min. GFR ml/min: only use if resistance and no alternative. If MR form not available use immediate release nitrofurantoin mg four times a day for 3 days. Use only if low risk of resistance. Use if GFR<45 ml/min. If high risk of resistance. Second dose unlicensed use in men.

22 Men: Consider prostatitis and send pre-treatment MSU or if symptoms mild/non-specific, use negative dipstick to exclude UTI. Always adopt safety net approach. Patients over 65 may be regarded as complicated in many cases due to their co-morbidities and commonly poor fluid intake. Patients >65 years: treat if fever 38 o C or 1.5 o C above base twice in 12 hours AND dysuria OR 2 other symptoms. Do not treat asymptomatic bacteriuria as it is common but not associated with increased morbidity. Adequate fluid intake is often difficult but encouragement should be for frequent small volumes or jellies and frozen lollies as options. GPs may initiate fosfomycin treatment in patients with high risk of resistance, but this would normally be on the advice of a Consultant Microbiologist first. Fosfomycin (Monuril ) is available via wholesalers within 24 hours of ordering (PIP code is ). Acute Pyelonephritis If admission is not needed, send an MSU for culture and susceptibility and start antibiotics. Acute pyelonephritis requires appropriate choice of antibiotic which reaches sufficient blood levels. (See treatment table). If no response within 24 hours, admit to hospital. If ESBL risk, consult microbiologist for advice. Acute Pyelonephritis First choice 500mg Twice daily 7 days Ciprofloxacin Second choice Co-amoxiclav 625mg Three times daily 7 days Trimethoprim 200mg Twice daily 14 days May be used if organism is susceptible. Urinary Tract Infection in Pregnancy Where possible, antibiotic choice should be informed by culture and sensitivity tests. The decision on which drug to use should be based on the clinical condition of the pregnant woman, weighing any risks to the foetus against the potential adverse effects for the mother and foetus from an untreated infection. Send MSU for culture, start antibiotics in all with significant positive culture even if asymptomatic. First choice Nitrofurantoin MR 100mg Twice daily 7 days Avoid after 36 weeks pregnant until after delivery. If MR form not available use immediate release nitrofurantoin mg four times a day for 7 days. egfr should be over 45ml/min; egfr 30-45: only use if resistance & no alternative. Second choice Trimethoprim Third choice Cefalexin Only if MSU indicates susceptibility: Amoxicillin 200mg Twice daily 7 days Where treatment with trimethoprim is clinically indicated it should not be withheld on account of the pregnancy, however, concomitant folate supplementation is recommended. Give folic acid 5mg daily if in 1 st trimester until 12 weeks of pregnancy. Off-label use. 500mg Twice daily 7 days Use with caution if penicillin allergic. 500mg Three times a day 7 days Nitrofurantoin MR is the first line choice where clinically appropriate, and its short-term use in pregnancy is unlikely to cause problems to the foetus. However, there is a theoretical risk of haemolytic anaemia in 22

23 the foetus or neonate, and BNF recommends avoid at term ; furthermore, an increased incidence of neonatal jaundice has been reported with use of nitrofurantoin in the last 30 days of pregnancy. The recommendation is to avoid nitrofurantoin after 36 weeks of pregnancy until after delivery, unless otherwise clinically more appropriate. Also, the egfr should be over 45ml/min; egfr 30-45: only use if resistance and no alternative. Avoid in G6PD deficiency upper UTI/pyelonephritis. Urinary Tract Infection in Children The NICE Clinical Guideline on Urinary Tract Infection in children: Diagnosis, treatment and long-term management CG54 advises that infants and children who have bacteriuria and fever of 38 C or higher should be considered to have acute pyelonephritis/upper urinary tract infection. Infants and children presenting with fever lower than 38 C with loin pain/tenderness and bacteriuria should also be considered to have acute pyelonephritis/upper urinary tract infection. All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have cystitis/lower urinary tract infection. Only refer for imaging if child < 6 months or recurrent or atypical UTI. Children under 3 months with suspected UTI should be referred urgently for assessment. Children 3 months or older with positive nitrite should commence antibiotics and a pre-treatment MSU taken. Check current Children s BNF for dosages and frequency. Liquids may be suitable for children unable to take capsules or tablets. Please refer to Primary Care Formulary for cost-effective preparations. Trimethoprim suspension, if suitable, should be used in preference to nitrofurantoin suspension which is very costly. Lower Urinary Tract Infection in Children Drug Name Dose and Frequency Duration Comments Trimethoprim Refer to 3 days Tablets and suspension available. Children s BNF Nitrofurantoin Refer to Children s BNF 3 days Use tablets or capsules where possible as nitrofurantoin suspension is very costly. Second line: Refer to 3 days Capsules, tablets and suspension available. Cefalexin Children s BNF Only if susceptible: Amoxicillin Refer to Children s BNF 3 days Capsules and suspension available. Upper Urinary Tract Infection in Children Consider referral to a paediatric specialist Drug Name Dose and Frequency Duration Comments First choice Co-amoxiclav Refer to Children s BNF 7-10 days Tablets and suspension available. Second choice Cefalexin Refer to Children s BNF 7-10 days Capsules, tablets and suspension available Prophylaxis of uncomplicated Urinary Tract Infections in adults Prophylactic antibiotics are actively discouraged in primary care. Assuming any need for referral has been eliminated, particularly following the referral guidelines for suspected cancer (NICE 2015 NG12), the use of prophylactic treatments is not supported in most cases by the consultant microbiologist. Recommendations for prophylaxis may come from urologists and paediatricians. Increasing resistance to trimethoprim and nitrofurantoin is encouraged by overuse of prophylactic antibiotics. 23

24 Recurrent UTI s (2 in 6 months or > 3 infections/year) Relapse is defined as a recurrent UTI with the same strain of bacteria, usually two or less weeks after treatment which suggests the possibility of a reservoir of infection. Re-infection is more likely in recurrences over two weeks after a previous infection and involves infection with a different strain or species of bacteria. This is the commonest occurrence. Management of recurrent infections involves assessing and eliminating risk factors. In the older person, risk factors such as oestrogen deficiency, incontinence, incomplete voiding and sometimes quite violent objection to personal hygiene attempts particularly in dementia can be linked to recurring infections. Review all medication in the elderly in particular reviewing the need for drugs which cause urine retention such as anticholinergics, anti-depressants etc. and re-evaluate clinical need. GPs should not initiate prophylactic treatment before undertaking the following steps: Frail elderly do not consume enough fluid and should be encouraged in ways of increasing fluid intake with ice lollies, jellies etc. Advice on good personal hygiene and referral to social work teams in cases of dementia. Check bowel management to ensure that frequent constipation is not a problem leading to residual urines and faecal incontinence thereby increasing risk of UTI. Use the MSU sensitivity for each episode to determine treatment. This is especially important for repeated infections. Management of complex patients with multiple resistance patterns can be supported by advice from an urologist and/or microbiologist. In all cases check concordance with treatment. Is the patient taking the whole course prescribed as instructed? Risk factors for increased antimicrobial resistance include: care home resident, recurrent UTI, hospitalisation >7days in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones. If increased resistance risk, send culture for susceptibility testing and give safety net advice. If GFR<45 ml/min or elderly consider pivmecillinam or fosfomycin (3g stat in women plus 2nd 3g dose in men 3 days later). Fosfomycin has been approved for use by the JPC for the treatment of uncomplicated lower urinary tract infections caused by identified multi-resistant organisms to avoid admission to hospital for the administration of intravenous antibiotics. Recurrent UTI s- Sexually active women (not pregnant) This is a cohort of patients where prophylactic antibiotics are sometimes initiated in primary care but a current literature search reveals that evidence to support this practice is based on small studies insufficient to present as a recommendation of good practice. The risk of increasing antimicrobial resistance is now of prime concern and before offering prophylactic drug treatment, consider the frequency, severity, and impact of recurrent cystitis, and whether referral for urological investigation would be appropriate to exclude an underlying cause. To reduce recurrence first line: advise simple measures including hydration, cranberry products. Second line: Standby or post-coital antibiotics. Third line: Antibiotic prophylaxis which reduces UTIs but adverse effects and long term compliance poor. 24

25 Recurrent UTI s- Sexually active women (not pregnant) First line: Self-Care advice Second line: Standby or post-coital antibiotics First choice: Nitrofurantoin Second choice: Ciprofloxacin Void bladder, local washing and on-going adequate fluid intake, cranberry products. Provide Urinary Tract Infection Information Leaflet. Standby course- 100mg MR twice daily for 3 days. Post-coital -100mg single dose within 2 hours of sexual intercourse. Post-coital -500mg single dose within 2 hours of sexual intercourse. Trimethoprim Post-coital -200mg single dose within 2 hours of sexual intercourse. Third line: Antibiotic prophylaxis 25 For patients assessed to be suitable to keep a supply for use when symptoms appear. Encourage to collect MSU sample before treatment if possible. If MR form not available use immediate release nitrofurantoin mg four times a day for 3 days. Post-coital- Off-label use. Off-label use. If recent culture sensitive. Off-label use. First choice: Nitrofurantoin 100mg At night Treat for 3 to 6 months then review recurrence rate and need. Second choice: Ciprofloxacin 500mg At night Treat for 3 to 6 months then review recurrence rate and need. Trimethoprim 100mg At night If recent culture sensitive. Treat for 3 to 6 months then review recurrence rate and need. Methenamine hippurate 1g Twice daily 6 months Use if no renal or hepatic impairment. If a continuous course is deemed appropriate, nitrofurantoin mg would be the local recommendation but its effectiveness should be frequently reviewed and no longer than 6 month s duration without appropriate monitoring. Non-sexually active women Robust evidence for benefits of prophylactic use of antibiotics in older women in particular is not available and is not supported locally by the consultant microbiologist. Following treatment failure in both sexually active and non-sexually active: In cases where symptoms fail to resolve despite therapy, the possibility of an alternative diagnosis should be considered and patients referred to urology for further investigation. Advice to initiate prophylactic antibiotics should come from secondary care in the majority of cases and should be time defined Prophylactic courses need to be reviewed every six months and appropriate monitoring carried out. Risks of long term prophylactic antibiotics Minimising antibiotic exposure is essential if we are to maintain the effectiveness of the currently available antibiotic classes in an era of increasing resistance while still providing effective treatment. Prophylaxis does not stop UTI infections and increases the risks to the patient of acquiring Clostridium difficile. Risks outweigh benefits in the elderly Do not treat asymptomatic bacteriuria; it is common but is not associated with increased mortality. The manufacturer of trimethoprim recommends regular blood counts on long term therapy, checking for hyperkalaemia and depression of haematopoiesis. Reference to the BNF highlights symptoms of blood disorders and such risks are increased in long term treatment.

26 Long-term treatment with nitrofurantoin requires monitoring of liver function and the development of any respiratory or peripheral neuropathic symptoms. Nitrofurantoin is now contraindicated in most patients if egfr is less than 45ml/minute/1.73m 2. A short course (3 to 7 days) may be used with caution in certain patients with an egfr of 30 to 44 ml/min/1.72m2. Catheter Urines 1. Do not use prophylactic antibiotics for catheter changes unless there is a history of catheter-changeassociated UTI or trauma (see NICE CG139 Infection control guidance). 2. Catheters inevitably become colonised by bacteria after a few days, and therefore there is NO VALUE in sending urine from asymptomatic patients with longstanding catheters. Cloudiness and smell in the urine are not reasons for culturing urine. 3. If patient is systemically unwell, send a CSU for antibiotic sensitivity before starting treatment and treat according to results. Ensure urine specimen is labelled CSU. 4. Inappropriate use of multiple antibiotic treatment may not eradicate colonising bacteria but will induce multi-resistance. 5. Antibiotic and antiseptic bladder washouts are not recommended. Occasionally calcium and ammonium phosphate salts encrust the catheters. Advice should be obtained from continence team where there is a persistent problem. 6. Community nurses utilise the catheterisation procedures and catheter care within the Royal Marsden Clinical Nursing Guidelines. 26

27 Genital Infections UK national guidelines on the management of Sexually Transmitted Infections (STIs) and related conditions in General Practice was published by BASHH in conjunction with Royal College of General Practitioners and outlines how primary care practitioners can provide high quality service to patients with STIs. Lazaro N. Sexually Transmitted Infections in Primary Care 2013 (RCGP/BASHH) available at and Specific STIs All sexually transmitted infections are becoming more common. Syphilis Serology is advisable. Patients with sexually transmitted diseases and their partners require full microbiological investigation and referral to the GUM clinic. Self-referral is also possible. (Bedford Hospital GUM Clinic and L&D Hospital GUM Clinic /497070). People with risk factors should be screened for chlamydia, HIV, gonorrhoea and syphilis. Risk factors include younger than 25, no condom use, recent (less than 12 months) or frequent change in partners, symptomatic partner. Prostatitis An MSU should be sent for culture and start antibiotics. Antimicrobial choice should be reassessed when urine culture results are available and referral made to GUM clinic if a sexually transmitted infection is identified. A 4 week course may prevent chronic prostatitis. Quinolones achieve higher prostate levels. First choice 500mg Twice daily 28 days This is a cost-effective choice. Ciprofloxacin Ofloxacin 200mg Twice daily 28 days Second choice Trimethoprim 200mg Twice daily 28 days Quinolones are the preferred to trimethoprim as they are active against a wider range of urinary pathogens. Epididymo-orchitis For epididymo-orchitis most probably due to any sexually transmitted pathogen: Ceftriaxone PLUS Doxycycline 500mg 100mg Single dose intramuscularly Twice daily days If ceftriaxone is contraindicated e.g. patient has a serious penicillin allergy, e.g. history of immediate hypersensitivity to penicillin, contact GUM / local microbiology for advice. If most probably due to chlamydia or other non-gonococcal organisms (i.e. where gonorrhoea considered unlikely as microscopy is negative for Gram negative intracellular diplococci and no risk factors for gonorrhoea identified) could consider: Doxycycline 100mg Twice daily days OR Ofloxacin 200mg Twice daily 14 days Refer to GUM clinic for advice in sexually active men. 27

28 Common risk factors for gonorrhoea are: previous N. gonorrhoea infection; known contact of gonorrhoea; presence of purulent urethral discharge, men who have sex with men and black ethnicity. For epididymo-orchitis most probably due to enteric organisms in non-sexually active men: Ciprofloxacin 500mg by mouth Twice daily 10 days Or changed according to sensitivity results. Vaginal Discharge in an Adult Common causes are chlamydia, trichomonas, candidiasis and bacterial vaginosis. Culture samples required as listed under Pelvic Inflammatory Disease. Trichomonas vaginalis Treatment of the sexual partner may be indicated, especially if there is recurrence of the infection. Metronidazole 400mg Twice daily 7 days Metronidazole 2g One dose only Not in breast feeding or pregnancy. Clotrimazole pessary 100mg At night 6 nights For symptom relief (not cure) if metronidazole is declined. Candidiasis For vulval symptoms only use topical clotrimazole 1% cream. With recurrent infections (> 4 infections in 12 months), consider treating the sexual partner and check predisposing factors such as pregnancy, contraceptive pills, antibiotics, diabetes and reservoir infections. BASHH guideline does not suggest the use of any other diagnostic tests and makes no reference to the use of high vaginal swabs. If there is uncertainty regarding the diagnosis following history and examination, a referral to GUM services should be made for microscopy and consideration of candida resistance. Women should be advised to: Avoid local irritants (e.g. soaps, bath salts and shower gels containing perfumes) Use vulval moisturisers as a soap substitute Avoid tight fitting synthetic clothing Clotrimazole pessary 500mg Once at night One night only Available OTC. Clotrimazole pessary 100mg Once at night 6 nights For use in pregnancy. Available OTC. Fluconazole capsules 150mg Once daily One day only. Available OTC. Not in pregnancy. For recurrent infection (>4 episodes / year) Fluconazole capsules 150mg One dose every 72 hours for 3 doses then one dose once a week for 6 months 6 months 28

29 Bacterial Vaginosis Patients may be asymptomatic. Oral metronidazole is as effective as topical treatment and is less expensive. Treating partners does not reduce relapse. Metronidazole 400mg Twice daily 7 days Preferred regimen in pregnancy. Less relapse with 7 days than 2g stat at 4 weeks. Metronidazole 2g One dose only Not in breast feeding or pregnancy. Metronidazole 0.75% 5g Once at night 5 nights Vaginal Gel Clindamycin 2% cream 5g Once at night 7 nights Pelvic Inflammatory Disease (PID) Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens in PID.(The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) is currently monitoring the emergence of decreased susceptibility to the third generation cephalosporins, in particular, treatment with Cefixime 400mg. Consequently the UK National Guidelines (BASHH) have been revised and now recommend the use of IM ceftriaxone instead of cefixime). A chlamydia swab of the cervix (and urethra) and bacterial swabs from both the cervix and high vagina are important to determine the correct aetiology. Occasionally organisms forming part of the normal vaginal flora may be implicated. Treatment, until the identity of the pathogen is known, is broad spectrum: Ofloxacin PLUS Metronidazole 400mg 400mg Twice daily Twice daily 14 days 14 days Not suitable for patients who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK 28% of Neisseria gonorrhoea isolates now resistant to quinolones.. Pregnancy / breastfeeding refer to GUM / Local microbiology. If high risk of gonococcal PID use ceftriaxone regimen below or refer to GUM. Ceftriaxone injection is available as 1g vials. When reconstituted, half of the resultant solution is given. Ceftriaxone is supplied as a powder which is reconstituted with 1% lidocaine injection, consult current SPC for full details. Gonococcal PID is likely if partner has gonorrhoea, patient has severe symptoms, or patient has had sexual contact abroad. Ceftriaxone PLUS Doxycycline PLUS Metronidazole 500mg by deep IM injection 100mg 400mg Single dose intramuscularly Twice daily Twice daily days 14 days This is an unlicensed use of ceftriaxone. If ceftriaxone is contraindicated e.g. patient has a serious penicillin allergy, contact GUM / Local microbiology for advice. Pregnancy / breastfeeding refer to GUM / Local microbiology. Metronidazole is included to improve coverage for anaerobes which are of greater importance in severe PID. If urine test for Chlamydia is done, there is no need for swabs. When swabs are taken however, tests for Gonorrhoea can be done which is of value in follow up and partner notification. (If laboratory subsequently reports N. gonorrhoea, consult with GUM/microbiology with regards choice of antibiotic treatment and duration of treatment required.)

30 In addition note: 1. Urine test may be sufficient for gonorrhoea if patient is asymptomatic, however if a patient presents with symptoms such as dysuria and/or discharge it is important to take urethral swab for culture and sensitivity (in view of emergency of resistant strains of Neisseria gonorrhoea). 2. If a patient had just a urine test and urine test for Gonorrhoea is reported positive it is important to take a swab for culture and sensitivity before starting treatment (to confirm the diagnosis and to ensure appropriate treatment is given based on culture and sensitivity). Treatment according to guidelines can be started while waiting for the culture and sensitivity report and may be modified later based on the final report. Chlamydia trachomatis As there is a lower cure rate in pregnancy test for cure at least 3 weeks after end of treatment. Azithromycin 1 gram One dose Off label use. In pregnancy or breastfeeding: only azithromycin is the most effective option. Doxycycline 100mg Twice daily 7 days Contraindicated in pregnancy. Erythromycin 500mg Four times daily Amoxicillin 500mg Three times daily 7 days Use in pregnancy. 7 days Use in pregnancy. Neisseria gonorrhoeae, uncomplicated When treating for Gonorrhoea, GUM department recommends that treatment for Chlamydia is included in the regimen (see above). The Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) is currently monitoring the emergence of decreased susceptibility to the third generation cephalosporins, in particular, treatment with Cefixime 400mg. Consequently BASHH has revised the treatment recommendations for uncomplicated anogenital infection in adults and now recommend the use of IM ceftriaxone instead of cefixime: Ceftriaxone injection is available as 1g vials. When reconstituted, half of the resultant solution is given. Ceftriaxone is supplied as a powder which is reconstituted with 1% lidocaine injection, consult current SPC for full details. Ceftriaxone injection PLUS Azithromycin 500mg by deep IM injection 1g orally Single dose for both This is an unlicensed use of ceftriaxone. If ceftriaxone is contraindicated e.g. patient has a serious penicillin allergy, contact GUM / Local microbiology for advice. Pregnancy / breastfeeding refer to GUM / Local microbiology. Alternative Regimen is an option ONLY if IM ceftriaxone is contraindicated or refused by patient. Clinicians should consult with microbiology/gum before prescribing this regimen due to resistance issues. Cefixime tablets PLUS Azithromycin 400mg 1g orally Single dose for both If cefixime is contraindicated e.g. patient has a serious penicillin allergy, contact GUM / Local microbiology for advice. Pregnancy / breastfeeding refer to GUM / Local microbiology. 30

31 Acute Herpes Simplex (Genital Infection) The diagnosis of genital herpes should be carried out by specialist in Genito-Urinary Clinic as follow up is necessary. Aciclovir 400mg Three times a day 5 days Off label use. May improve compliance versus 5 times a day dosing. Recurrent Herpes Simplex (Genital Infection) (From NICE Clinical Knowledge Summaries: Herpes Simplex Genital Scenario recurrent episodes age 13 onwards, April 2017 available at ) Self-care measures may be helpful for some people. If not already tried, advise the person to: Clean the affected area with plain or salt water to help prevent secondary infection and promote healing of lesions. Apply vaseline or a topical anaesthetic (e.g. lidocaine 5%) to lesions to help with painful micturition, if required. Increase fluid intake to produce dilute urine (which is less painful to void). Urinate in a bath or with water flowing over the area to reduce stinging. Avoid wearing tight clothing (which may irritate lesions) and use adequate pain relief (e.g. oral paracetamol). Avoid sharing towels and flannels with household members (although it is very unlikely that the virus would survive on an object long enough to be passed on, it is sensible to take steps to prevent this). Try to avoid identified trigger factors (e.g. ultraviolet light, excess alcohol). If self-care measures are not controlling symptoms, prescribe oral aciclovir 800 mg three times a day for 2 days. For future attacks use either: Episodic antiviral treatment if attacks are infrequent (e.g. less than six attacks per year). Consider selfinitiated treatment, so antiviral medication can be started early in the next attack. Suppressive antiviral treatment (e.g. oral aciclovir 400 mg twice daily for 6 12 months) if attacks are frequent (e.g. six or more attacks per year), causing psychological distress, or affecting the person's social life: - After 1 year, stop treatment for a minimum period of two recurrences. - If attacks are still considered problematic, restart suppressive treatment. If attacks are not considered problematic (off treatment), future attacks can be controlled with episodic antiviral treatment (if needed). - If the person has breakthrough attacks on suppressive treatment, seek specialist advice. 31

32 Skin/Soft Tissue Infections Impetigo For extensive, severe or bullous impetigo, use oral antibiotics. You are advised not to use mupirocin (Bactroban ) as this should be reserved for the treatment of MRSA. Topical sodium fusidate One acute prescription, should not be repeated. Three times daily 5 days Suitable for treating a single or few confluent areas of infection. Topical use promotes resistance especially when used long term as repeated courses. Flucloxacillin mg Four times 7 days daily Clarithromycin mg Twice daily 7 days If penicillin allergic. Acne Vulgaris Mild to moderate acne is generally treated with topical preparations. Comedones and inflamed lesions respond well to benzoyl peroxide (available OTC), or to a topical retinoid and these should be tried first. Azelaic acid is an alternative. For moderate acne they can be combined if tolerated. Alternatively, topical application of an antibacterial such as erythromycin or clindamycin may be effective for inflammatory acne. If topical preparations prove inadequate, oral preparations may be needed. Systemic treatment with oral antibacterials is generally used for moderate to severe acne (inflammatory type), where topical preparations are not tolerated or ineffective, where application to the site is difficult such as to the back or shoulders, if there is a significant risk of scarring or substantial pigment change. Oral antibiotics should not be prescribed alone as they should be combined with either a topical retinoid or benzoyl peroxide and should not be prescribed with a topical antibiotic. Oral antibiotic treatment length should be limited to the shortest possible period, and be discontinued when further improvement of acne is unlikely. Treatment failure is often due to a lack of knowledge of the interactions associated with tetracyclines. The absorption of tetracyclines may be affected by the simultaneous administration of calcium, aluminium, magnesium, bismuth and zinc salts, antacids, bismuth containing ulcer-healing drugs, iron preparations and quinapril. These products should not be taken within two hours before or after taking the tetracycline. Unlike earlier tetracyclines, absorption of lymecycline is not significantly impaired by moderate amounts (e.g. a glass) of milk. Minocycline is NOT recommended. Erythromycin is an alternative if a tetracycline is poorly tolerated or contraindicated (such as in pregnancy). There are particular problems with the development of bacterial resistance to erythromycin. Drug Name Dose Frequency Initial Comments Duration Oxytetracycline 500mg Twice daily 8 weeks Then review if responded continue for additional 4-6 months but consider reducing the dose of antibiotic by half for latter half of period then stop. Take on an empty stomach (1 hour before or 2 hours after food). Lymecycline 408mg Daily 8 weeks Then review if responded continue for additional 4-6 months. Erythromycin 500mg Twice daily 8 weeks Then review if responded continue for additional 4-6 months. Only use when a tetracycline is poorly tolerated or contraindicated. Eczema If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing. In eczema with visible signs of infection, use acute treatment as in impetigo. Staphylococcus resistance to fusidic acid is common in eczema and as it is often a chronic condition longterm use of topical antibiotics should be avoided. 32

33 Cellulitis Group A haemolytic streptococci (Streptococcus pyogenes) and Staphylococcus aureus are often both involved. Treat for 7 days and review, if slow response continue for a further 7 days. Class I disease: patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone. If river or sea water exposure, discuss with microbiologist. Class II: febrile and ill, or co-morbidity, admit for intravenous treatment or out-patient antibiotic treatment (if available). Class III: toxic appearance: admit. Erysipelas: often facial and unilateral. Prescribe flucloxacillin for non-facial erysipelas, prescribe coamoxiclav for facial (non-dental) erysipelas. Flucloxacillin 500mg Four times a day 7-14 days Clarithromycin 500mg Twice a day 7-14 days If penicillin allergic. Doxycycline 200mg stat then 100mg Daily 7-14 days If penicillin allergic and on a statin. Clindamycin 300mg Four times a day 7-14 days If unresolving. Co-amoxiclav One 500/125mg strength tablet Three times a day 7-14 days If facial only. Leg Ulcers and Pressure Sores These inevitably become colonised by bacteria. Routine swabs are not indicated. Antibiotic treatment should be reserved for patients with cellulitis, from whom a wound swab should be taken and treatment commenced as for cellulitis. Do not treat leg ulcers unless there is clinical evidence of an infection. Lyme Disease Consider Lyme disease in patients presenting with erythema migrans. Refer to the NICE Guideline on Lyme Disease for advice on diagnosis and management. Mastitis S. aureus is the most common infecting pathogen. In breastfeeding the oral antibiotics recommended are appropriate. Women should continue feeding, including from the affected breast. Flucloxacillin 500mg Four times daily days Clarithromycin 500mg Twice daily days If penicillin allergic. Wound Infections It is often useful to send a swab, with the site and nature of the wound specified, especially from a postoperative wound. Infection is commonly due to Staphylococcus aureus. If wounds become infected and were originally contaminated with soil, manure or faeces; puncture wounds or lacerations that have a significant degree of devitalized tissue then treat as for bites. Flucloxacillin 500mg Four times daily 5 days Clarithromycin 500mg Twice daily 5 days If penicillin allergic. 33

34 Bites (animal and human) and contaminated wounds Pasteurella multocida (animal only) and anaerobes may well be involved. A swab should be sent. For animal bites, assess rabies risk. For human bites, assess HIV / Hepatitis B risk. Cat bites are more prone to infection than dog bites because of the needle-like shape of the cat s teeth as opposed to the flatter teeth of a dog. Furthermore, infection from a cat bite can start quite deeply, whereas an infected dog bite is likely to be more visible. Local thorough cleansing of wound is essential. Consider rabies prophylaxis for bites from animals in endemic countries and assess risk of blood borne viruses. Co-amoxiclav Clarithromycin PLUS Metronidazole Doxycycline PLUS Metronidazole One 250/125 or one 500/125mg strength tablet 500mg 200mg-400mg 100mg 400mg Three times a day 7 days If soil / faeces contamination consider adding in metronidazole 400mg three times a day for 7 days. Twice daily 7 days If penicillin allergic and human bite. Review at 24 & 48 hours. Three times a day Twice daily Three times a day 7 days If penicillin allergic and animal bite. Review at 24 & 48 hours. MRSA Infection Seek microbiologists advice regarding treatment if infection is suspected as sensitivities must be determined. In the majority of cases the presence of MRSA indicates colonisation such patients may require decolonisation as detailed below. Patients who are found to be positive prior to in-patient treatment Patients who are at high risk of developing invasive infection e.g. those with an intravenous catheter, urinary catheter, PEG or other invasive device. Patients who are immuno-compromised Patients with wounds Some patients who reside in care homes MRSA Decolonisation Apply mupirocin 2% ointment to the inner surface of the nostrils and any wound areas or device exit sites, 3 times daily for 5 days. Bathe daily with Octenisan * wash lotion for 5 days. Use of disposable wipes is recommended for application. The solution should be applied directly to the disposable wipe and not be added to the water. Wet the skin and apply the solution to all areas of the body, paying particular attention to the axilla and groin areas. The solution requires a contact time of 3 minutes so it is best to cover the whole body in solution then rinse. Wash the hair with Octenisan * wash solution twice in the 5 days. Use a freshly laundered towel for each day of the treatment regime. After bathing put on fresh, clean clothes and change the bedding each day for the 5 day treatment regime. * Octenisan is available as 150ml or 500ml bottles. There is a 5 day eradication protocol leaflet available from the manufacturer (Schulke) which explains how to use the product. This should be explained and given to the patient with the solution. Mupirocin should not be used for prolonged periods or for more than 2 courses. 34

35 Scabies Treat all family members of the household, close contacts and sexual contacts simultaneously. Treat whole body including scalp, face, neck, ears and under nails within 24 hours. If the patient is in a residential/nursing home, inform the CCDC as instructed in introduction. Drug Name Dose Frequency Comments 5% Permethrin dermal cream 2 applications 1 week apart Available OTC from pharmacy. 0.5% Malathion aqueous lotion 2 applications 1 week apart If allergy to permethrin. Available OTC from pharmacy. Head lice Treatment is not necessary unless a live louse is found. All treatments can be purchased from pharmacies. There is currently no local policy for the rotation of pesticides. There are several treatment strategies that can be used: Dimeticone 4%: this is not an insecticide and works on the principle that the lice are coated and made immobile so that they starve. It can be used as frequently as necessary as it does not cause resistance and contains no solvents that might be a problem with asthma sufferers. It is suitable from 6 months old to adult. It can be purchased as Hedrin. Insecticides: two applications of an insecticide are used 7 days apart (Note: this is different to the packaging information, which states that a single application is sufficient). Success is checked by detection combing 2-3 days after the final application. If treatment fails or re-infestation occurs, a course of a different insecticide is used. Wet combing: this must be undertaken meticulously to be successful. It must be undertaken every 4 days for at least 2 weeks. If lice are found on the second, third, or fourth session, it should be continued until no lice have been seen for three consecutive sessions. Families using this method must be well motivated because of the time involved. Dermatophyte Infections (scalp, body/groin/feet and nails) These are chronic infections often requiring prolonged treatment. It is therefore very important to send appropriate specimens and confirm the diagnosis microbiologically. Should a case fail to respond to first line treatment or there is evidence of recurrence, repeat sampling and seek specialist advice. Do not change to another topical antifungal as they all have the same spectrum of activity. Terbinafine is fungicidal so treatment time is shorter than the fungistatic imidazoles. Terbinafine is not recommended for patients with chronic or active liver disease. Liver function tests (LFTs) should be performed before prescribing and checked periodically during treatment. Any pre-existing liver disease should be assessed. Terbinafine should be immediately discontinued if LFTs are raised. Body/Groin/Feet (Tinea Corporis/Cruris/Pedis) Take skin scrapings Tea tree oil not recommended If inflammation is marked consider prescribing hydrocortisone with antifungal for 7 days. Do not use corticosteroids alone. Clotrimazole 1% cream Twice daily 1 to 4 weeks Terbinafine 1% cream Twice daily 1 to 4 weeks Not licensed for use in children. Topical undecenoic acid (e.g. Mycota ) See BNF for preparations Twice daily 4 to 6 weeks For Tinea Pedis, administer for 14 days after symptomatic. 35

36 Scalp (Tinea Capitis) Take scalp scrapings including hair root. If oral antifungal treatment is being considered in children, seek specialist advice. Terbinafine is not licensed for treatment of scalp but may be needed if confirmed by microbiology. Topical imidazole creams and topical corticosteroids are not recommended although they have a role in reducing transmission to close contacts in first 2 weeks. Griseofulvin should not be initiated in primary care. Nail (Tinea Unguium) Many people have long standing fungal infections of their toenails, but many have no symptoms apart for the change in appearance of the nail. In such cases no treatment is necessary, avoiding the risk of rare but serious complications associated with systemic therapy. Superficial infections may respond to Amorolfine 5% nail lacquer available to purchase from pharmacies. There is little evidence for effectiveness in established infections. Take nail clippings. Treatment should be started only when results of mycological examination are available because it is easy to misdiagnose fungal nail infections and the choice of treatment may be affected by the results. If there is no response, review the diagnosis or seek specialist help. If there is no response, review the diagnosis or seek specialist help. To prevent recurrence apply weekly topical antifungal cream to the entire toe area, stop treatment when there is continual, new, healthy proximal nail growth. Terbinafine Second line Itraconazole 250mg tabs Once daily 6 weeks (fingers) or 12 weeks (toes) Not recommended for children. 200mg Twice daily 7 days monthly Not licensed for use in -2 courses (fingers) children. -3 courses (toes) Herpes zoster / Chicken Pox and Varicella zoster / Shingles Oral antivirals are not indicated in healthy adults under 50 years of age, as such individuals are unlikely to have severe symptoms and are at very low risk of developing post-herpetic neuralgia. Oral antiviral treatment should be offered to any age presenting within 72 hours of the shingles rash who are at high risk e.g. have ophthalmic shingles, immunocompromised, rash affecting neck, limbs or perineum or who have moderate or severe pain. Consider starting antiviral treatment up to one week after rash onset if there is a high risk of severe shingles. Ophthalmic zoster - treatment is always indicated with urgent referral to the eye clinic. Further information is contained in Clinical Knowledge Summaries Aciclovir 800mg Five times daily 7 days 36

37 Meningococcal Disease If Meningococcal septicaemia or meningitis is suspected give benzylpenicillin as a stat dose immediately whilst admission to hospital is arranged. Drug Name Dose Comments Benzylpenicillin Cefotaxime Age 10+ years 1.2g IV or IM In children aged 1-9 years 600mg In children <1 year 300mg >12 years and adults 1g IV/IM <12 years 50mg/kg (maximum 1g) IV / IM For penicillin allergy. If there is a history of penicillin anaphylaxis transfer to hospital immediately. All forms of meningitis particularly meningococcal meningitis or septicaemia should be notified on suspicion to the CCDC at Public Health England East of England. Phone: Fax: (Office Hours, Monday Friday, 9am 5pm). Medicom: (Outside office hours) Ask for Public Health 1st on-call. GPs should report to the CCDC as soon as possible even when the patient is admitted to hospital or the diagnosis is uncertain. GPs should not assume that the hospital will report the case. Prophylaxis in Meningococcal Disease Prophylaxis should only be initiated after discussion with the CCDC or Consultant in Public Health Medicine. Prophylaxis is given to those who had ongoing and continuous contact with the index case, such as household contacts, to eradicate any carriage. Staff who gave mouth-to-mouth resuscitation should be given prophylaxis. Please note that the prophylaxis does not offer complete protection against the disease. CCDC will decide on the wider public health control measures where these are required. Drug Name Dose Frequency and Duration Ciprofloxacin 12 years to adult Single dose 1 st choice for 500mg orally ALL age 5-12 years Single dose groups and in 250mg orally pregnancy. Children < 5 years 30mg/kg up to maximum of 125mg Single dose orally Comments Not licensed for this indication in children. Children s doses are as specified in the HPA document March 2012*. Ciprofloxacin 250mg/5ml is available. Refer to BNF or SPC for full list of contraindications or cautions for use of ciprofloxacin. Where patients are unsuitable for treatment with ciprofloxacin, the Consultant in Public Health will advise alternative treatment on a case by case basis. *NB: The children s doses listed in the HPA document (in table above) differ from those listed in the BNF for children (BNFC). Ref: Guide for Public Health Management of Meningococcal Disease in the UK. Health Protection Agency, Meningococcus and Haemophilus Forum. March

38 Virus? Gastro-intestinal Infection Please note food poisoning is a statutorily notifiable to the CCDC. Stool specimens should be sent for microbiological examination, which helps in the surveillance of the diseases. Viral Viral infections are self-limiting and common. Norovirus is extremely contagious and people can remain contagious from the time they begin to feel ill up to at least 3 days after recovery (immunocompromised individuals may excrete the virus for 2 weeks or longer). Immunity is short lived (up to 6 months). Testing: stool samples may be required to confirm outbreaks on the advice of the CCDC. There is no treatment. Most people improve in 1-2 days. The very young, frail elderly and immunocompromised may need treatment for dehydration. Bacterial The commonest bacterial causes are campylobacter, salmonella (non-typhoid) and shigella spp. Most infections are self-limiting and do not require antibacterial therapy. Helicobacter pylori is associated with gastric and duodenal ulcers. Local guidelines should be followed to decide which patients should be appropriately tested for the presence of the bacterium. Eradication treatment should not be initiated until confirmation is received. Post treatment samples should not be sent as test can remain positive for up to 6 weeks. Consult BNF for current price and Bedfordshire Primary Care Formulary for current cost-effective choice of PPI. Helicobacter pylori eradication Please refer to PHE / NICE guidance for further information on treatment options. Drugs given as triple therapy Most cost effective PPI* PLUS Amoxicillin PLUS Clarithromycin OR Metronidazole Most cost effective PPI* PLUS Clarithromycin PLUS Metronidazole 1g 500mg 400mg 250mg 400mg Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily All for 7 days together. MALToma 14 days. All for 7 days together. MALToma 14 days. First choice regimen providing no penicillin allergy or previous treatment. Alternative regimen If penicillin allergy. Most cost effective PPI* PLUS Bismuth subsalicylate PLUS Metronidazole 250mg 400mg Twice daily Twice daily Twice daily All for 7 days together. MALToma 14 days. Alternative regimen for penicillin allergies and previous clarithromycin PLUS Tetracycline 500mg Four times daily Most cost effective PPI* PLUS Amoxicillin PLUS Tetracycline 1g 500mg Twice daily Twice daily Four times daily All for 7 days together. MALToma 14 days. For relapse and previous metronidazole and clarithromycin 38

39 OR Levofloxacin 250mg Twice daily Most cost effective PPI* PLUS Tetracycline PLUS Levofloxacin 500mg 250mg Twice daily Four times daily Twice daily All for 7 days together. MALToma 14 days. For relapse and previous metronidazole and clarithromycin and penicillin allergy Parasitic The commonest parasitic causes are giardia sp and cryptosporidium sp. There is no specific therapy for cryptosporidial diarrhoea. Giardiasis Metronidazole 2 grams Once daily 3 days Travellers Diarrhoea Only consider standby antibiotics for remote areas or people at high risk of severe illness. If appropriate, use Ciprofloxacin 500mg twice a day for 3 days (private prescription as this is not treatment for a current condition). If quinolone resistance high (e.g. South Asia) consider Pepto-Bismol Tablets (available OTC at a pharmacy) 2 tablets four times a day as prophylaxis or for 2 days as treatment. Clostridium difficile Clostridium difficile is a spore forming bacteria commonly found in the normal gut flora of infants and a small proportion (less than 5%) of adults. In the environment Clostridium difficile spores can survive for long periods in harsh conditions and are resistant to heat, drying and many disinfectants. Diarrhoeal illness can occur when the normal flora of the bowel is disrupted. When Clostridium difficile is not held in check, the bacteria flourishes and produces toxins that damage the cells of the intestine, resulting in diarrhoea. Symptoms vary in severity from mild discomfort to severe colitis and death. Since 2008 it has been mandatory to report all cases of Clostridium difficile infection via the Healthcare Associated Infection data capture system. The following tables show how numbers of Clostridium difficile infection have decreased since that time. Sensible antibiotic prescribing has helped to deliver this decrease. 39

40 Foul smelling, profuse diarrhoea (described as a barn-yard smell ) is the most common symptom. Non-specific symptoms include temperature, abdominal pain and tenderness and loss of appetite. A stool sample of the diarrhoea must be taken as soon as possible. Only liquid stool samples are tested for Clostridium difficile (Bristol stool chart type 6-7). Please give a detailed description of the symptoms and all recent antibiotic use on the laboratory request form. Testing for Clostridium difficile is a combination of two tests, the first of which is GDH EIA followed by a sensitive toxin EIA test. Laboratory reporting of the presence of Clostridium difficile glutamine dehydrogenase environmental impact assessment (GDH EIA) and A and B toxins in a patient with diarrhoea confirms a positive case. Patients found to be GDH EIA positive and toxin negative may be carriers. Patients found to be carriers of Clostridium difficile may require treatment if they have symptoms of diarrhoea (Bristol stool chart type 6-7). Please contact the microbiologist for advice in each individual case. Do not take repeat stool samples following diagnosis or after treatment unless another cause is suspected and please state this on the request form. 40

41 Clostridium difficile can remain in the stools for long periods of time and therefore the presence of the bacteria in stools, when the patient has no symptoms, is not significant. Antibiotic treatments should be stopped whenever possible. Antimotility agents such as loperamide must not be used. Proton pump inhibitor drugs should be discontinued if possible when infection is confirmed. Consider stopping iron treatments temporarily as they may mask or interfere with symptoms. Continue good hygiene including washing hands well with soap and water, careful handling of any soiled linen and thorough environmental cleaning. Seek microbiology advice if patient condition deteriorates. It is important to prescribe at least 10 days of treatment. More than one course of treatment may be required if symptoms do not improve. Recurrence of symptoms can occur and the patient may require a second course of treatment. There is no requirement to send a repeat specimen. Severe cases may require hospitalisation. Contact the microbiologist if you have any concerns about the patient. 1 st episode positively identified - Metronidazole tablets 400mg Three times daily days 2 nd episode / severe/ type 027- Oral Vancomycin 125mg Four times daily days 70% respond to metronidazole in 5 days; 92% in 14 days. Definition of severe: Temp>38.5 o C, or WCC>15, or rising creatinine or signs / symptoms of severe colitis. Review progress closely and /or consider hospital referral. Recurrent disease - Oral Vancomycin mg Severe disease at high risk of recurrent disease - Fidaxomicin Four times daily consider tapering course days 41 Tapering course: 125mg QDS for one week, 125mg TDS for one week, 125mg BD for one week, 125mg daily for one week, 125mg on alternate days for one week, 125mg every third day for one week. Seek microbiology advice for alternative treatment. 200mg Twice a day 10 days Only on the advice of a Consultant Microbiologist Mild Diverticular Disease Treatment of mild diverticular disease includes a high fibre diet, bran supplements and bulk forming drugs such as Macrogols. Antispasmodics provide symptom relief when colic present and anti-motility drugs are contraindicated. Antibiotics only given on microbiology advice. Mild, uncomplicated acute diverticulitis can be managed at home with paracetamol, clear fluids, and antibiotics. The antibiotic choice needs to cover anaerobes and Gram-negative rods and so co-amoxiclav alone or ciprofloxacin plus metronidazole (if allergic to penicillin) for 7 days are recommended in the Clinical Knowledge Summary (CKS) on management at home of acute diverticulitis available at: CKS acknowledge that evidence on the use of antibiotics for the treatment of uncomplicated diverticulitis is sparse, of low quality, and conflicting. Generally, there is little evidence mandating the use of antibiotics in uncomplicated diverticulitis, although several guidelines recommend this. Recent evidence suggests that the routine use of antibiotics in uncomplicated diverticulitis may not be of value, and may be restricted to specific groups. CKS base the recommendation to use co-amoxiclav (or metronidazole plus

42 ciprofloxacin in penicillin allergy) on published expert review articles and the spectrum of antibiotic activity against the most common bacteria found in the colon anaerobes and Gram-negative rod Infestations Threadworms Diagnosis can be confirmed by a sellotape slide. Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene- keep fingernails short, wash hands and scrub nails before each meal and after each visit to the toilet), pants at night, morning shower (include perianal area) plus wash sleepwear, bed linen and dust, vacuum on day one. For children < 6 months add perianal wet wiping or washes 3 hourly during the day. Drug Name Dose Frequency and duration Mebendazole 100mg One dose only Comments Offer Self-Care advice as mebendazole is available OTC for > 2year olds. All patients over 6 months: mebendazole 100mg Stat (off-label if used < 2 years). Also, repeat in 2 weeks if infestation persists. Patients < 6 months mebendazole is unlicensed, use hygiene measures alone for 6 weeks. Do not treat during pregnancy. 42

43 Eye Infections Most acute superficial infections (conjunctivitis and blepharitis) are often caused by staphylococci and can be treated topically. Most bacterial conjunctivitis is self-limiting and resolves within 1-2 weeks with careful hygiene and bathing with boiled salt water. Encourage self-care as chloramphenicol eye drops and eye ointment can be purchased OTC for > 2 years olds (not pregnant or breast feeding). True conjunctivitis presents as a red eye with mucopurulent (not watery) discharge which starts in one eye but often spreads to both. Severe infections may require treatment and for school children and some childcare, treatment may be needed. Refer if no improvement and particularly if patient wears contact lens. Microbiological investigations are not considered necessary in primary care when a person presents with a short history of infective conjunctivitis because most cases will settle spontaneously. However, management of chronic infections requires microbiological identification of the causative organism. Failure to respond or worsening symptoms require urgent referral to ophthalmologist. Long term use of chloramphenicol can lead to bone marrow suppression and should not be prescribed on repeat. Endophthalmitis and keratitis may be bacterial, viral or fungal and require URGENT referral for specialist management. Fucithalmic 1% eye drops are expensive and less effective, appropriate alternatives are available. Conjunctivitis None Chloramphenicol 0.5% eye drops AND/OR Chloramphenicol 1% eye ointment Ciprofloxacin eye drops 0.3% OR Ciprofloxacin eye ointment 3mg/g One drop Apply small amount (1cm) One drop 1.25 cm 2 hourly for 2 days, then 4 hourly (whilst awake). Apply four times daily for 2 days then twice daily or once at night if used with eye drops. 2 hourly for 2 days, then 4 times daily (whilst awake). Three times daily for 2 days, then twice daily for 5 days. Use for 48 hours after resolution. Maximum 7 days. Maximum duration of treatment 21 days. Advise on Self-Care as above. Use in severe infections. Avoid in pregnancy and breast feeding. Use in severe infections. Only use in pregnancy if benefits outweigh risks. Caution in use in breast-feeding. Adults and children 1 year and above. Blepharitis Good lid hygiene is the mainstay of treatment. The eyelids should be cleaned twice daily initially then reduced to once daily as symptoms improve. Consider prescribing a topical antibiotic (Chloramphenicol 1% ointment twice a day for a 6 week trial) if there are clear signs of staphylococcal infection or if hygiene measures are ineffective after 2 weeks. Oral antibiotics should be considered ONLY if topical antibiotics are ineffective or there are signs of Meibomian gland dysfunction or acne rosacea. See table below for oral antibiotic dose recommendations. Oxytetracycline 500mg Twice a day 4 weeks Initial dose Then Twice a day 8 weeks Maintenance dose 250mg Doxycycline 100mg Once a day 4 weeks Initial dose Then 50mg Once a day 8 weeks Maintenance dose 43

44 Supporting Materials There are a range of support materials available from Public Health England (PHE), Department of Health (DH) and the Royal College of General Practitioners (RCGP) which can be downloaded and used by the whole primary care team within the GP practice or out of hours setting: TARGET (Treat Antibiotics Responsibly, Guidance, Education and Tools): Antibiotic toolkit for primary care. The TARGET Antibiotics Toolkit available on the RCGP website aims to help influence prescribers and patients personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers and patients responsible antibiotic use, helping to fulfil CPD and revalidation requirements. These include: Leaflets to share with patients- Many are available in multiple languages. They are designed to be shared with patients during the consultation and aim to improve the patient s confidence to Self-Care and the prescriber s communication with the parents. Audit toolkits -Templates for accurate and easy auditing, including Read codes, current guidance and action plans. Audits available include sore throat, urinary tract infection, otitis media and acute cough. 44

45 National Antibiotic Management Guidance Training resources including an antibiotics group presentation, online training courses on antibiotic resistance in primary care, skin infections, managing acute respiratory tract infections, urinary tract infections and managing infectious diarrhoea. Resources for clinical and waiting areas - Posters for clinical and waiting areas -Videos for clinical and waiting areas Self-assessment checklist Antimicrobial Resistance Resource Handbook April 2016 contains a list of current national policy, guidance and supporting materials on antimicrobial resistance, antimicrobial stewardship and infection prevention and control resources which are relevant for primary care (and other healthcare) settings. Available at: 45