Trust Antibiotic Policy for the Management of Common Infections in Accident and Emergency and Cromer Minor Injuries Unit (Paediatrics) Accident and Emergency, Norfolk and Norwich and For Use in: Cromer Minor Injuries Unit Medical staff, non medical prescribers and By: Emergency Nurse Practitioners working to a PGD For: Paediatrics Division responsible for document: Women s and Children s Services Key words: Antibiotic, infection, treatment Caroline Hallam (Specialist Pharmacist, Antimicrobials) Dr Catherine Tremlett (Consultant, Microbiology) Name and job title of document Dr Nandu Thalange (Consultant Paediatrician) Author s: Dr Dhananjay Kumar (Consultant, Accident and Emergency) Julie Marshall (Accident and Emergency, Emergency Nurse Practitioner) Name and job title of document Dr David Booth, Chief of Women s and Children s author s Line Manager: Services Antimicrobial Subcommittee of the Drugs and Supported by: Therapeutics Medicines Management Committee Clinical Guidelines and Assessment Panel Assessed and approved by the: (CGAP) Date of approval: 20/04/2016 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after 20/04/2019 this date but will be under review To be reviewed by: Reference and / or Trust Docs ID No: CA5108 Version No: 2 Description of changes: No clinical changes Compliance links: (is there any NICE related to guidance) No If Yes - does the strategy/policy deviate from the recommendations N/A of NICE? If so why? Clinical Standards Group and Effectiveness Sub-Board Caroline Hallam (Specialist Pharmacist, Antimicrobials), Dr Catherine Tremlett (Consultant, Microbiology), Dr Nandu Thalange (Consultant, A and E), Dr Dhananjay Kumar (Consultant, Accident and Emergency), Julie Marshall (Emergency Nurse Practitioner) This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 1 of 9
Trust Antibiotic Policy for the Management of Common Infections in Accident and Emergency and Cromer Minor Injuries Unit (Paediatrics) Table of contents Section Page number Guidance notes 3 Urinary Tract 4 Skin and Soft Tissue 5 Respiratory Tract 6 Ear, nose and throat 7 Central Nervous System 8 Eye 9 Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 2 of 9
Trust Antibiotic Policy for the Management of Common Infections in Accident and Emergency and Cromer Minor Injuries Unit (Paediatrics) Guidance Notes Introduction The objective of this guideline is to ensure the appropriate selection of antimicrobials for the empirical treatment of common infections in children (age 1 month to 16 years) who present to Accident and Emergency (A and E) and do not require admission. The aim is for this guidance to be used by doctors or Emergency Nurse Practitioners. Only use antibiotics when infection has been recognised or when there is a high degree of suspicion of infection. History of recent infections and organisms isolated should be considered when deciding which antibiotic to use, if this information is available. Remember to take appropriate diagnostic samples before starting antibiotics whenever possible Keep all courses of antibiotics as short as possible. Five days treatment is sufficient for many infections. Antibiotic choices are listed in preference of recommended use. For doses consult BNF or the appropriate PGD If a patient requires hospital admission then please prescribe according to the Trust Antibiotic Policy in Paediatrics, available on the intranet. Microbiology advice can be obtained in special circumstance or when best guess is not working from The Department of Microbiology, Norfolk and Norwich University Hospital Main switch board: 01603286286 ext 4587/4588/4589 Out of hours via main switch board PGDs For treatment by PGD please chose the correct antibiotic for the presenting complaint from this policy and then refer to the PGD for further information. Any exclusions please refer to the medical team. For patients that cannot take tablets and require flucloxacillin, co-amoxiclav liquid can be given as an alternative (as flucloxacillin liquid is not stocked in A and E). Prescribing in Penicillin allergy Patients with a history of anaphylaxis or urticaria occurring immediately after penicillin therapy are at increased risk of immediate hypersensitivity to penicillins and should not receive treatment with a beta- lactam antibiotic (this includes cephalosporins) or carbapenem, unless they have previously received a beta-lactam and had no adverse effects. Patients with a history of rash occurring more than 72 hours after administration of penicillins are probably not allergic to penicillins, (SIGN, 2000) and many patients with a history of rash after penicillins will have received cephalosporins with no ill effect. A cephalosporin may be administered with caution to a penicillin allergic patient as long as they have never experienced an anaphylactic or urticarial response to a penicillin before. Please note that penicillins include amoxicillin, co-amoxiclav (Augmentin ), flucloxacillin. Referral to GP The durations of treatment listed in this guideline are generally the minimum duration of treatment that is normally required. Patients should always be advised to consult their GP if symptoms persist after the course as further days of treatment may be required. Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 3 of 9
Urinary Tract Infection allergy (see guidance notes at start of policy for further details) Uncomplicated Urinary Tract Infection Atypical UTI including Pyelonephritis See also NICE Clinical Guideline 54. 3 days oral therapy recommended. NICE defines Atypical UTI as: Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-e. coli organisms Consider paediatric referral Co-Amoxiclav PO Cefradine capsules/cefalexin elixir PO 3 days Co-amoxiclav Cefradine capsules/cefalexin elixir PO 3 days If history of penicillin anaphylaxis Nitrofurantoin PO 3 days Consider Paediatric referral in children aged less than 6 months Ciprofloxacin Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 4 of 9
Skin and Soft Tissue allergy (see guidance notes at start of policy for further Cellulitis, Impetigo, erysipelas Wounds evident infection or risk of infection high Compound fractures NB. For tetanus prone injuries, always review patients tetanus vaccination history - need for tetanus/immunoglobulin if vaccination history unclear and consider antibacterial therapy It is not necessary to add metronidazole to coamoxiclav as it has anaerobic cover. Wound should be irrigated/cleaned, closed and a dressing applied All open or compound fractures require antibiotics. Ensure tetanus prophylaxis It is not necessary to add metronidazole to coamoxiclav as it has anaerobic cover. Flucloxacillin PO (for children aged 10 and older who can swallow 250mg capsules) Co-Amoxiclav PO (if liquid required) Co-amoxiclav PO (if liquid required) Flucloxacillin PO (for children aged 10 and older who can swallow 250mg capsules) +/- Metronidazole (if anaerobes suspected) Co-amoxiclav PO details) Clarithromycin PO (if liquid required) Clindamycin PO (in children aged 12 and over who can swallow 150mg capsules) Invasive Strepococcus A is a notifiable idsease Clarithromycin PO +/- Metronidazole (If anaerobes suspected) Cefradine capsules/cefalexin elixir + Metronidazole Clindamycin PO (in children aged 12 and over who can swallow 150mg capsules) If anaphlaxis to penicillins and clindamycin not suitable Clarithromycin PO + Metronidazole PO Animal /human bites Scabies Consider need for tetanus booster/ immunoglobulin, blood borne virus risk, and rabies prophylaxis for bites from endemic areas Treat whole body including scalp, face, neck, ears and under nails. Treat all household contacts. Advise patient to contact their GP for treatment. Treat secondary infections with antibiotics if necessary Co-amoxiclav PO 5 days Malathion 0.5% 2 applications one week apart. Clindamycin (in children aged 12 and over who can swallow 150mg capsules) Clarithomycin + Metronidazole PO 5 days Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 5 of 9
Respiratory Tract allergy (see guidance notes at start of policy Uncomplicated Community Acquired Pneumonia Amoxicillin PO +/- Clarithromycin PO 7days for further details) Clarithromycin PO Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 6 of 9
Ear/Nose and Throat allergy (see guidance notes at start of policy Acute sinusitis Acute tonsillo pharnygitis Acute otitis media Otitis externa Dental abscess Commonly viral. Avoid antibiotics as 80% resolve in 14 days without and they only offer marginal benefit after. Use adequate analgesia. Consider 7 day delayed or immediate antibiotic when purulent nasal discharge. Antibiotics are indicated when three or more of the below are present. Presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough. Approximately 80% of infections resolve spontaneously without the use of antibiotics. Most are viral infections. If discharge from ear treat with ear drops. If systemic symptoms e.g fever, severe pain or swelling treat with oral antibiotics as well. Cleaning is essential. Use topical treatment unless systemically unwell or infection is spreading. Refer to ENT if suspected malignant otitis externa, usually due to pseudomonas Advise to consult the dentist if infection not better after the 7 day treatment course. Co-amoxiclav PO Cefradine capsules/cefalexin elixir PO or Amoxycillin PO 10 days Otosporin/Sofradex 3-4 drops tds Use ciprofloxacin eye drops in the ear if chronic ear discharge (Pseudomonas spp) 3-4 drops tds If oral treatment required Amoxicillin PO 5 days or Co-Amoxiclav if no response Betnesol N or Otosporin If severe, or cellulitis or boil Flucloxacillin PO 5 days (or Co-Amoxiclav if liquid required) Co-amoxiclav PO for further details) Clarithromycin PO Clarithromycin PO 10 days If oral treatment required Clarithromycin PO 5 days Betnesol N or Otosporin If severe, or cellulitis or boil Clarithromycin 5 days Clarithromycin PO + Metronidazole Central Nervous System Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 7 of 9
allergy (see guidance notes at start of policy for further details) Meningitis Prophylaxis Liaise with Health Protection Unit before treating Ciprofloxacin PO stat Ciprofloxacin PO or Rifampicin PO stat Meningitis Treatment Give antibiotics without delay. It is imperative to give antibiotics as quickly as possible. If necessary use IM route whilst procuring venous access. Consider need for dexamethasone. Benzylpenicillin IV STAT and admit for continuing antibiotic treatment Cefotaxime IV/IM STAT and admit for continuing antibiotic treatment Cefotaxime STAT and admit for continuing antibiotic treatment in severe allergy Chloramphenicol STAT and admit for continuing antibiotic treatment Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 8 of 9
Eye allergy (see guidance notes at start of policy Uncomplicated Periorbital Cellulitis (Age 3yrs-16yrs only) Uncomplicated: Children 3y or over with periorbital oedema and erythema only Upper lid only affected White eye with full range of normal eye movements Treat with oral antibiotics. Advise that if worsening or no better at 24hrs to return via CAU for admission Co-Amoxiclav PO for further details) Clarithromycin PO Superficial ocular infections, infections of the lids and as a prophylactic antibacterial measure following minor eye surface trauma or procedures, e.g. corneal abrasions, corneal rust ring, post foreign body removal, arc eye, mild chemical injury. Acute Purulent Conjunctivitis Complicated: (admit) See Trust Guideline CA4024 V2 Periorbital oedema/erythema and one or more of : Proptosis, chemosis, pain on eye movement, pyrexial 38 0 C, <3 years old, altered vision, decreased eye movements, bilateral oedema Chloramphenicol 0.5% eye drops Severe - Moderate infections: one drop to be applied to the affected eye every two hours for the first 48 hours and 4 hourly thereafter. To be used during waking hours only. Mild infections or prophylactic use: 1-2 drops four times a day. Chloramphenicol 1% eye ointment Ointment: 3 or 4 times daily if the eye ointment is used alone or at night only if eye drops are used during the day. Chloramphenicol eye drops 0.5% 2 hourly Fucithalmic eye drops 1% bd Or if Pseudomonas aeruginosa isolated Ofloxacin 0.3% eye drops Levofloxacin 0.5% eye drops Available via Trust Docs Version: 2 Trust Docs ID: CA5108 Id 9178 Page 9 of 9