North Yorkshire Guidance for use of Antimicrobials in Primary Care

North Yorkshire Guidance for use of Antimicrobials in Primary Care North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 Version 2.00 January 2012

Acknowledgements This document was developed by a North Yorkshire wide working group whose membership included North Yorkshire and York Acute Trust Consultant Microbiologists/Pharmacists, North Yorkshire and the Humber Health Protection Unit, North Yorkshire GPs, NHS North Yorkshire and York Medicines Management team and funded by Harrogate and District NHS Foundation Trust Infection Prevention and Control (Community) team. Front cover image courtesy of Dr. Jan Hobot, Cardiff University (Clostridium difficile attached to intestinal cells). About the Guidelines: These guidelines are based on the Health Protection Agency Management of Infection Guidance for Primary Care (reviewed March July 2010 1 ), and have been adapted for local use based on the best available evidence and local expert opinion. The guidelines are intended to guide the treatment of common infections in primary care. Advice from a medical microbiologist should be sought where treatment is not simple or routine. Acute Trust Contact number for antimicrobial advice For urgent cases/advice - ask for a medical microbiologist via hospital switchboard Airedale General Hospital 01535 293459 01535 652511 Harrogate District Hospital 01423 555663 01423 885959 Friarage Hospital, Northallerton 01642 282604 01642 850580 Scarborough General Hospital 01723 342334 01723 368111 York District Hospital 01904 725852 01904 631313 This document can be found at: www.hdft.nhs.uk under Community Infection Prevention and Control www.northyorkshireandyork.nhs.uk under Medicines Management Printed copies are available for all prescribers in North Yorkshire please telephone 01904 601590. Produced by: Harrogate and District NHS Foundation Trust, Infection Prevention and Control (Community) and NHS North Yorkshire and York Medicines Management Review date: January 2014 North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 2

CONTENTS Guideline Aims 4 Essential Principles for Antimicrobial Prescribing 5 Upper Respiratory Tract Infections Sore throat/pharyngitis/tonsillitis (acute) Otitis externa Acute otitis media (child doses) Rhinosinusitis (acute) Lower Respiratory Tract Infections Cough, bronchitis (acute) COPD (acute exacerbation) Community acquired pneumonia Urinary Tract Infections UTI in women (uncomplicated) UTI in women (recurrent) UTI in pregnancy UTI in men UTI in children (uncomplicated) Pyelonephritis (acute) MRSA bacteraemia prevention following catheterisation 6 6 6 7 8 9 9 9 10 11 11 12 13 13 14 14 14 Gastro-Intestinal Tract Infections Helicobacter pylori (eradication) Gastroenteritis Traveller s diarrhoea Giardiasis Threadworms Clostridium difficile infection Genital Tract Infections UK National Guidelines 15 Vaginal candidiasis 15 Chlamydia trachomatis 15 Appendix 1: Management of suspected type I 29 Bacterial vaginosis 16 penicillin hypersensitivity Trichomoniasis 16 Pelvic Inflammatory Disease 17 Abbreviations / Glossary 33 / 34 Prostatitis (acute) 18 Note: Epididymo-orchitis Doses are oral and for adults unless otherwise stated. Please 18 References 35 refer to BNF for further information. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 3 19 19 19 20 20 20 21 Skin / Soft Tissue Infections 22 Impetigo 22 Eczema 22 Cellulitis 22 Leg ulcers 23 Bite (animal) 23 Bite (human) 24 Scabies 24 Fungal infection of the proximal fingernail or toenail 25 Fungal infection of the skin 25 Varicella zoster/chicken pox and herpes zoster/shingles 26 Cold sores 26 Eye Infections Conjunctivitis Meningitis Meningococcal disease (suspected) 27 27 28 28

GUIDELINE AIMS To provide a simple approach to the management of common infections. To promote the safe, effective and economic use of antimicrobials. To reinforce that quinolones, co-amoxiclav (amoxicillin-clavulanate) and cephalosporins should not be used routinely in primary care. To encourage primary care prescribers to seek advice from a medical microbiologist when deemed appropriate. To highlight the implications of overuse (and inappropriate use) of broad spectrum antimicrobials, e.g. Clostridium difficile infection and antimicrobial resistance including Extended-Spectrum Beta-Lactamases (ESBLs). To provide a framework for GPs to comply with The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (Department of Health, December 2010) 2. To encourage cost effective use of laboratory testing. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 4

ESSENTIAL PRINCIPLES FOR ANTIMICROBIAL PRESCRIBING 1. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit. 2. Avoid broad spectrum antimicrobials (e.g. co-amoxiclav [amoxicillin-clavulanate], quinolones, and cephalosporins 1 ) when narrow spectrum antimicrobials remain effective, as they increase the risk of Clostridium difficile, meticillin-resistant Staphylococcus aureus (MRSA) and resistant UTIs (e.g. ESBLs), and antimicrobial resistance in Gram-negative bacteria such as coliforms. 3. Avoid use of topical antimicrobials (especially those agents also available as systemic preparations, e.g. fusidic acid). 4. Antimicrobial prescribing should not be carried out over the telephone except in exceptional cases. 5. Where a simple approach (e.g. 1st and 2nd line treatment options) has failed or special circumstances exist, contact your local medical microbiologist (contact numbers on page 2). Special Patient Groups 1. Penicillin hypersensitivity: For advice on management of suspected type I penicillin hypersensitivity, see information in Appendix 1. 2. Immunocompromised patients: is outside the scope of these guidelines, take specimens for culture and seek specialist advice. 3. Pregnancy: Special care is required when prescribing antimicrobials in pregnancy. See separate sections within the guidance and consult individual drug monographs in the BNF. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 5

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antimicrobial prescriptions 3 Sore throat/ pharyngitis/ /tonsillitis 3 (acute) Investigations: Routine use of throat swabs is discouraged. Avoid antimicrobials as 90% resolve within without, and pain only reduced by 16 hours. If Centor score 3 or 4 (fever; lymphadenopathy; tonsillar exudate; no cough) consider 2 or 3 day delayed or immediate antimicrobials. Antimicrobials to prevent quinsy NNT >4000 Antimicrobials to prevent otitis media NNT >200 Avoid antimicrobials, if needed then use: phenoxymethylpenicillin clarithromycin if hypersensitive to penicillin 500 mg QDS 250-500 mg BD 5 days Otitis externa Investigations: Ear swabs are not required routinely, but may be helpful for failure of therapy or recurrent cases. Results of susceptibility testing of topical antimicrobials do not correlate well with clinical outcome. acetic acid 2% ear spray (available over the counter and on NHS prescription) or One spray into the affected ear(s) at least TDS. Maximum of one spray every 2 to 3 hours Up to 7 days Healthcare professional to clean ear canal in all cases. Keep canal dry. This may be adequate treatment for many mild cases. If more severe, consider use of antiinfective ear drops with or without steroids depending on degree of inflammation. flumetasone 0.02% + clioquinol 1% ear drops (Locorten-Vioform) NB: use of antibacterial ear drops for > is associated with an increased incidence of fungal infection 2-3 drops into the affected ear(s) BD North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 6

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antimicrobial prescriptions 3 (cont) Otitis externa (continued) Systemic antimicrobials should be reserved for patients with systemic signs of infection or spreading cellulitis. Remember malignant otitis externa in patients with diabetes or other immunocompromise. Acute otitis media 3 (child doses) ( Investigations: If ear is discharging send pus, start empirical antimicrobials and modify following results. Avoid antimicrobials as 60% are better in 24 hours without; they only reduce pain at 2 days (NNT 15) and do not prevent deafness. Consider 2 or 3 day delayed or immediate antimicrobials for pain relief if: systemically unwell <2 years with bilateral AOM (NNT 4) all ages with otorrhoea (NNT 3). Avoid antimicrobials, if needed then use: amoxicillin erythromycin if hypersensitive to penicillin 40 mg/kg/day in 3 divided doses (max 1.5 g daily) 1 month- <2 years: 125 mg QDS 2-8 years: 250 mg QDS 8-18 years: 250-500 mg QDS 5 days 5 days Antimicrobials to prevent mastoiditis NNT >4000 North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 7

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antimicrobial prescriptions 3 (cont) Rhinosinusitis 3 (acute) Investigations: Nasal swabs are unhelpful. Avoid antimicrobials as many are viral and 80% resolve within 14 days without. Antimicrobials only offer marginal benefit after (NNT 15). Use adequate analgesia. Avoid antimicrobials. (Note: use of doxycycline is to be avoided to prevent resistance) amoxicillin clarithromycin if hypersensitive to penicillin 500 mg TDS 250-500 mg BD Consider 7 day delayed or immediate antimicrobial when purulent nasal discharge (NNT 8) or worsening symptoms. failures or persistent infections: requires antimicrobial with antianaerobic activity co-amoxiclav. Consult an ENT specialist for patients who still do not improve. co-amoxiclav second line 625 mg TDS North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 8

LOWER RESPIRATORY TRACT INFECTIONS Note: Low doses of penicillins are more likely to select for resistance. The quinolones ciprofloxacin and ofloxacin have poor activity against pneumococci. Quinolones should only be used on the advice of a medical microbiologist. Cough, bronchitis 3 (acute) COPD (acute exacerbation) Investigations: Sputum samples are generally unhelpful. Systematic reviews indicate antimicrobials have only marginal benefits in otherwise healthy adults. Symptom resolution may take 3 weeks or more. Consider a delayed antimicrobial prescribing strategy with symptomatic advice/leaflet 3. For patients with significant co-morbidity, suitable antimicrobials are the same as those for the treatment of acute exacerbation of COPD. Investigations: Not routinely required. Consider sputum cultures for: frequent exacerbations treatment failure. Treat exacerbations promptly with antimicrobials if purulent sputum and increased shortness of breath and/or increased sputum volume. amoxicillin clarithromycin if hypersensitive to penicillin 250-500 mg TDS 5 days 250-500 mg BD 5 days For frequent exacerbations consult a medical microbiologist. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 9

LOWER RESPIRATORY TRACT INFECTIONS (continued) Community acquired pneumonia 1,4 Use CRB65 score to help guide and review 4. Each scores 1: Confusion (AMT <8) Respiratory rate 30/min BP systolic <90 or diastolic 60 Score 0: suitable for home treatment Score 1-2: hospital assessment or admission Score 3-4: urgent hospital admission Give immediate IM benzylpenicillin 1.2 g or amoxicillin 1 g orally if delayed admission/ life threatening. Mycoplasma infection is rare in over 65s. Start antimicrobials immediately amoxicillin clarithromycin if hypersensitive to penicillin add clarithromycin if no response in 48 hours Add flucloxacillin if pneumonia associated with influenza (contact a medical microbiologist if penicillin hypersensitive) 500 mg - 1 g TDS 500 mg BD 500 mg BD 1 g QDS North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 10

URINARY TRACT INFECTIONS HPA UTI quick reference guidance 5 ESBLs 6 Notes: 1. Amoxicillin resistance is very common, therefore, ONLY use if culture confirms susceptibility. 2. In the elderly (>65 years), do not treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with increased morbidity. 3. In the presence of a catheter, antimicrobials will not eradicate bacteriuria; only send samples if systemically unwell or pyelonephritis likely. Local complications, e.g. catheter blockage and local irritation, should be minimised by replacing the catheter appropriately or at the time that they occur. 4. 50% of women with cystitis-like symptoms are likely to have urethral syndrome that does not respond to antimicrobials. 5. Investigate according to advice under each heading. NB: The cost of processing a urine sample is approximately 8.00: many samples received by the laboratory are unnecessary. 6. Nitrofurantoin and trimethoprim should be avoided in renal impairment seek advice from a medical microbiologist. UTI in women 1,7, (uncomplicated) i.e. no fever or flank pain in the absence of urinary tract abnormalities Investigations: Routine diagnostic and clearance cultures are not required where symptoms are clear-cut. Send MSUs only for diagnostic uncertainty and failure of therapy. Treat women with severe/ 3 of the following (dysuria, urgency, frequency, polyuria, suprapubic tenderness, fever, flank or back pain 7 ). Women with mild/ 2 of the above: use dipstick to guide treatment. Nitrite and blood/leucocytes has 92% positive predictive value; -ve nitrite, leucocytes, and blood has 76% NPV. trimethoprim 200 mg BD 3 days or nitrofurantoin 50-100 mg QDS 3 days North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 11

URINARY TRACT INFECTIONS (continued) UTI in women (recurrent) >3 episodes per year Investigations: Send MSU. Long-term prophylaxis is generally discouraged because of development of resistance. Other options include: post coital single dose treatment for patients in whom this has been identified as risk factor keeping a course of antimicrobials at home for early initiation when symptoms begin use of non-antimicrobial treatments such as cranberry juice. Suitable antimicrobials for prophylaxis trimethoprim or nitrofurantoin 100 mg ON 50 mg ON continuous continuous If prophylaxis considered appropriate, review after 3 to 6 months. Note: Nitrofurantoin has been associated with acute and chronic lung reactions including dyspnoea, cough, interstitial pneumonitis, pleural effusions and fibrosis. Acute reactions occur mainly in women aged 40-50 years. Chronic lung reactions, although less common, mainly affect older patients 8. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 12

URINARY TRACT INFECTIONS (continued) UTI in pregnancy 1 Investigations: Send MSU and start empirical antimicrobials. Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems for the foetus (at term theoretical risk of neonatal haemolysis) 1. Short-term use of trimethoprim is unlikely to cause problems for the foetus. Avoid trimethoprim if low folate status or on another folate antagonist (e.g. antiepileptic), theoretical risk in first trimester 1. nitrofurantoin if susceptible, amoxicillin trimethoprim second line cefalexin third line 50-100 mg QDS 500 mg TDS 200 mg BD (off-label) Give folic acid if 1st trimester 500 mg BD UTI in men Investigations: Send MSU. Consider urologist referral for further investigation. trimethoprim or 200 mg BD nitrofurantoin 50-100 mg QDS Note: for younger males be aware that symptoms presenting as UTI may reflect an underlying problem of prostatitis: if there are clinical features of prostatitis then treat as such. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 13

URINARY TRACT INFECTIONS (continued) UTI in children (uncomplicated) Pyelonephritis (acute) MRSA bacteraemia prevention following catheterisation Investigations: Send pre-treatment MSU for all children. Child <3 months: refer urgently for assessment by a paediatrician. Child >3 months: use positive nitrite to start antimicrobials. NB: this may be falsely negative in some infections. Follow local criteria for when to refer. Investigations: Send MSU. In severe cases or if no response within 24 hours, admit. Patients undergoing catheterisation who have certain risk factors should be given a stat dose of gentamicin to avoid MRSA bacteraemia. A protocol and Patient Group Direction are available from the Community Infection Prevention and Control team on 01845 573869. trimethoprim or nitrofurantoin or cefalexin or amoxicillin (if documented susceptible) or according to MSU result cefalexin ciprofloxacin if hypersensitive to penicillin 1 month-18 years: 4 mg/kg (max 200 mg) BD See cbnf for dosages 500 mg QDS 500 mg BD 3 days 14 days IM gentamicin 80 mg stat stat dose North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 14

GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES Vaginal discharge quick reference guide 9 BASHH 10 Note: Refer patients with risk factors for STIs (<25 years, no condom use, recent [<12 months] or frequent change of sexual partner, previous STI, symptomatic partner), for specialist sexual health advice to GUM clinic or general practices with level 2 or 3 expertise in GUM. Submission of high vaginal swabs is unnecessary in many cases (see Vaginal Discharge Quick Reference Guide 9 ). Recurrence or failure to resolve should prompt further microbiological assessment. Vaginal candidiasis BASHH 10 Investigations: Not routinely required, diagnosis can be based on symptoms, ph and signs (BASHH 10 ). All topical and oral azoles give 75% cure. In pregnancy avoid oral azole. clotrimazole 10% or fluconazole 10% vaginal cream or 500 mg pessary 150 mg orally stat dose stat dose Chlamydia trachomatis Chlamydia quick reference guide 11 Treat partners. Refer contacts for specialist sexual health advice. Pregnancy Refer for specialist sexual health advice. Patients should have a test of cure three weeks after discontinuing therapy. Monitor the neonate for signs of C. trachomatis. azithromycin In pregnancy: azithromycin erythromycin second line 1 g stat stat dose 1g (off label use) stat dose 500 mg QDS amoxicillin third line 500 mg TDS North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 15

GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES (continued) Bacterial vaginosis Investigations: Not routinely required, diagnosis can be based on symptoms, ph and signs (BASHH 10 ). A 7-day course of oral metronidazole is slightly more effective than 2 g stat. metronidazole or metronidazole 0.75% vaginal gel or 400 mg BD or 2 g 5 g applicatorful at night stat dose 5 days Avoid 2 g stat dose in pregnancy/ breastfeeding. Topical treatment gives similar cure rates but is more expensive. clindamycin 2% cream according to patient choice In pregnancy: metronidazole or clindamycin 2% cream 5 g applicatorful at night 400 mg BD 5 g applicatorful at night Trichomoniasis Refer to GUM. Treat partners simultaneously. Pregnancy Topical clotrimazole gives symptomatic relief (not cure). metronidazole metronidazole or 400 mg BD or 2 g in single dose stat dose 400 mg BD clotrimazole 100 mg pessary OD 6 days North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 16

GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES (continued) Pelvic Inflammatory Disease (PID) Investigations: Send samples for chlamydia (urine or endocervical swab), gonorrhoea (endocervical swab), bacterial vaginosis (high vaginal swab). Exclude pregnancy, appendicitis and ovarian cysts. Delay in diagnosis and effective treatment for PID can increase the risk of tubal damage. Therefore, treatment should start immediately without waiting for swab results. Empirical treatment should be initiated in sexually active young women and others at risk if all the following minimum criteria exist and no other cause for illness: lower abdominal tenderness adnexal tenderness cervical motion tenderness ( cervical excitation ). Refer contacts for specialist sexual health treatment and advice. cefixime PLUS metronidazole PLUS doxycycline If regimen unsuitable, seek specialist advice from GUM or a medical microbiologist 400 mg stat dose 400 mg BD 14 days 100 mg BD 14 days North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 17

GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES (continued) Prostatitis (acute) Severe symptoms, rapid onset of UTI with penile and perineal pain and difficulty voiding (prostatic swelling). Four weeks treatment may prevent chronic infection. trimethoprim or 200 mg BD 28 days ciprofloxacin 500 mg BD 28 days Epididymoorchitis Investigations: Test for chlamydia and N. gonorrhoeae in sexually active young males AND send MSU. doxycycline 100 mg BD 14 days Send MSU for older males and treat as UTI. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 18

GASTRO-INTESTINAL TRACT INFECTIONS Helicobacter pylori (eradication) Eradication is beneficial in proven DU and GU but NOT in GORD. In NUD, 8% of patients benefit. should only be used in those known to be infected with H. pylori through positive results for stool antigen or 13 C urea breath testing. Triple treatment attains >85% eradication. Do not use clarithromycin or metronidazole if used in the past year. Investigations: PPIs and other antisecretory drugs should be stopped 2 weeks prior to testing for H. pylori. In addition, patients should not receive antimicrobials 4 weeks prior to the 13 C urea breath testing or faecal antigen testing. See local acute trust formulary guidance for choices. Gastroenteritis Notes: 1. Fluid replacement is essential. 2. Antimicrobial therapy is rarely appropriate in otherwise healthy individuals for most bacterial pathogens, including Campylobacter species and Salmonella species, as it only reduces diarrhoea by 1-2 days and can cause antimicrobial resistance. 3. of the acute diarrhoeal illness with either antimicrobials or antidiarrhoeal drugs is associated with an increased risk of developing haemolytic uraemic syndrome with E. coli O157. Initiate treatment, on the advice of a medical microbiologist, if the patient is systemically unwell or has prolonged symptoms. 4. Send stool specimens from suspected cases of food poisoning. Notify suspected food poisoning and seek advice on exclusion of patients from a Consultant in Communicable Disease Control: 01904 468900, 9.00am 5.00pm, Monday to Friday. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 19

GASTRO-INTESTINAL TRACT INFECTIONS (continued) Traveller s diarrhoea Only consider standby antimicrobials for remote areas or people at high risk of severe illness with traveller s diarrhoea. If standby treatment appropriate give: ciprofloxacin 500 mg BD for 3 days by private prescription. If quinolone resistance high (e.g. south Asia): consider bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment. Giardiasis National Travel Health Network and Centre 12 Diarrhoea associated with Giardia lamblia is generally higher in people returning from resource-poor countries (e.g. many countries of Africa, Asia and South and Central America), where access to clean water and basic sanitation is lacking. metronidazole 2 g OD 3 days or 400 mg TDS 5 days Threadworms Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower) PLUS wash sleepwear, bed linen, dust and vacuum on day one. Use piperazine in children under 2 years. Avoid treatment in pregnancy. mebendazole or >2 years: 100 mg stat dose piperazine >6 years: 1 sachet 1-6 years: 5 ml 3-12 months: 2.5 ml stat dose, repeat after 2 weeks North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 20

GASTRO-INTESTINAL TRACT INFECTIONS (continued) Clostridium difficile infection (CDI) Investigations: Stool sample in all suspected cases. Include any risk factors for Clostridium difficile on the request form, e.g. >65 years, prior hospitalisation, previous antimicrobials. Stop unnecessary antimicrobials and/or PPIs (see below). Admit if severe: temperature of >38.5 o C; or WCC >15 x 10 9 /L, or rising creatinine (i.e. >50% increase above baseline), or signs/ symptoms of severe colitis. 13 Review progress daily. metronidazole 1st/2nd episodes oral vancomycin 3rd episode/severe 400 mg TDS 125 mg QDS 10-14 days 10-14 days CDI Notes: 1. If the patient is still receiving an antimicrobial(s) at the time CDI is suspected/confirmed, consider whether these can be stopped. If they cannot, identify whether an agent with a narrower spectrum of activity can be substituted. 2. Ensure that patient is well hydrated and that their nutritional needs continue to be met. Do NOT use anti-motility agents. 3. Relapsing infection may occur if shorter than recommended courses of metronidazole/vancomycin are administered and compliance with therapy should be encouraged. Relapses should be treated with the same agent used to treat the first episode unless the relapse is severe in a patient initially treated with metronidazole. Contact a medical microbiologist for advice on management of patients with more than one relapse. 4. Alcohol handrub does not inactivate spores of C. difficile, thus hand hygiene using liquid soap and warm water (which physically remove the spores) should be practised when attending to patients known/suspected to have CDI. 5. Use of acid suppressive therapy, particularly PPIs, is associated with an increased risk of community acquired C. difficile 14. PPI use in patients being treated for C. difficile was associated with a 42% increased risk of recurrence 15. 6. The background to the development of C. difficile is likely to be multi-factorial and precise mechanisms are unknown. Consider that patients who have been in hospital in the previous 3 months and who have received antimicrobials, may have C. difficile as a cause of their gastroenteritis. C. difficile should also be suspected in care home residents who have recently received a course of antimicrobials. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 21

SKIN / SOFT TISSUE INFECTIONS Impetigo Systematic review indicates topical and oral treatment produces similar results. mupirocin 2% ointment for localised infection flucloxacillin for treatment failure or more extensive lesions clarithromycin if hypersensitive to penicillin Topically TDS Oral 500 mg QDS Oral 250-500 mg BD 5-10 days (max 10 days) Eczema Using antimicrobials, or adding them to steroids, in eczema does not improve healing unless there are visible signs of infection. If infection is suspected, swab and treat according to the results, use treatment as per impetigo. Cellulitis If patient afebrile and healthy other than cellulitis, use flucloxacillin alone. If febrile and ill, admit for IV treatment. If river or sea water exposure, discuss with a medical microbiologist. Facial cellulitis (if severe - refer to a medical microbiologist). Infections are more frequently streptococcal than staphylococcal. mild: flucloxacillin 500 mg QDS 7-14 days clarithromycin if hypersensitive to penicillin 250-500 mg BD 7-14 days amoxicillin 500 mg TDS 7-14 days clarithromycin if hypersensitive to penicillin 500 mg BD 7-14 days North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 22

SKIN / SOFT TISSUE INFECTIONS (continued) Leg ulcers Bite (animal) Ulcers are always colonised. Antimicrobials do not improve healing unless signs of active infection (inflammation/redness/cellulitis, increased pain, rapid deterioration of ulcer or pyrexia). Purulent exudate, slough and odour are not reliable indicators of infection. Investigations: Only investigate if active infection. Sampling for culture requires wound cleaning with saline then vigorous curettage and aspiration or a swab taken from the leading edge of the infected area. Swabs from the open surface of an unclean ulcer are usually unhelpful and are costly (approx. 20.00 each). Some patients may benefit from antibacterial dressings contact Tissue Viability Nurse. Diabetic leg ulcer. Refer for specialist opinion if severe infection. (Refer diabetic foot ulcers for specialist podiatry opinion.) Surgical toilet is most important. Assess tetanus and rabies risk. Antimicrobial prophylaxis advised for: puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised; diabetics; elderly; asplenic. flucloxacillin clarithromycin if hypersensitive to penicillin treatment failure or severe infection: refer/admit 500 mg QDS and review 500 mg BD and review Prophylaxis or treatment co-amoxiclav 625 mg TDS metronidazole if hypersensitive to penicillin PLUS doxycycline or oxytetracycline 200-400 mg TDS 100 mg BD or 250-500 mg QDS North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 23

SKIN / SOFT TISSUE INFECTIONS (continued) Bite (human) Antimicrobial prophylaxis advised. Discuss the need for hepatitis B vaccination +/- tests for other bloodborne viruses, e.g. HIV, hepatitis C, with a medical microbiologist/ccdc (contact details on pages 2 and 19). prophylaxis and treatment co-amoxiclav 625 mg TDS metronidazole if hypersensitive to penicillin 200-400 mg TDS PLUS clarithromycin review at 24 and 48 hours 250-500 mg BD Scabies Treat whole body including scalp, neck, ears, under nails and web spaces of fingers and toes. Treat all household and sexual contacts at the same time. failures may result from insufficient quantities being prescribed. permethrin 5% cream if atopic: malathion 0.5% aqueous liquid stat An average sized adult will require a total of 3 x 30 g tubes to cover 2 applications 1 application followed 7 days later by a second application North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 24

SKIN / SOFT TISSUE INFECTIONS (continued) Fungal infection of the proximal fingernail or toenail Fungal infection of the skin Investigations: surfaces must be cleaned with alcohol swab before sampling to remove bacteria. Softened material collected from nail bed under nail plate or deep shavings from nail after removal of surface nail. Mycology specimens are transported in special black transport envelopes. This is a disease of the nail bed rather than the nail plate. Nail appearance will not return to normal for about 12 months after treatment. Not all infections respond to treatment. Investigations: Surface must be cleaned with alcohol swab before sampling to remove surface bacteria. Take skin scrapings from leading edge of affected area of skin. Mycology specimens are transported in special black transport envelopes. : 1 week terbinafine is as effective as 4 weeks azole. If intractable consider oral itraconazole. Discuss scalp infections with specialist. Start therapy only if infection is confirmed by laboratory. For children seek advice. terbinafine clotrimazole 1% cream 250 mg OD fingers 6-12 weeks (max 12 weeks) toes 3-6 months (max 6 months) North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 25 or Apply BD 4-6 weeks terbinafine 1% cream Apply BD 1-2 weeks

SKIN / SOFT TISSUE INFECTIONS (continued) Varicella zoster/ chicken pox and herpes zoster/ shingles Pregnant/immunocompromised/neonate: seek urgent specialist advice. Chicken pox: consider aciclovir if started <24 hours of onset of rash and >14 years or severe pain or dense rash or secondary household case or steroids or smoker. If indicated aciclovir 800 mg five times daily Child doses see BNF for Children Shingles: treat if >50 years and within 72 hours of rash (PHN rare if <50 years) or if active ophthalmic or Ramsey Hunt or eczema. Cold sores Cold sores resolve after 7-10 days without treatment. Topical antivirals applied prodromally reduce by 12-24 hours. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 26

EYE INFECTIONS Conjunctivitis Investigations: Eye swabs are not necessary except in neonates. Most cases of acute infective conjunctivitis in children resolve spontaneously and do not need antimicrobials. Most bacterial infections are self-limiting (64% resolve on placebo). They are usually unilateral with yellow-white mucopurulent discharge. If severe chloramphenicol 0.5% drops PLUS 1% ointment fusidic acid second line 2 hourly reducing to QDS as infection is controlled Ointment at night 1% gel BD All for 48 hours after resolution North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 27

MENINGITIS Meningococcal disease 1 (suspected) Transfer all patients to hospital immediately. Administer benzylpenicillin or cefotaxime prior to admission, unless history of anaphylaxis, ideally IV but IM if a vein cannot be found. In special cases where there is likely to be a delay, e.g. rural areas, doctors may stock chloramphenicol in emergency bags for administration to those with true documented penicillin anaphylaxis or allergy to cephalosporins. Prevention of secondary case of meningitis Adults and children: IV or IM benzylpenicillin or IV or IM cefotaxime Only prescribe following advice from Consultant in Communicable Disease Control: 01904 468900, 9.00am 5.00pm, Monday to Friday. 10 yrs & over: 1200 mg Children 1-9 yrs: 600 mg Children <1 yr: 300 mg 12 yrs & over: 1 g Child<12yrs: 50 mg/kg Out of hours - contact on-call Public Health Doctor for North Yorkshire via Yorkshire Ambulance Service switchboard: 01924 584957. stat stat North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 28

APPENDIX 1: MANAGEMENT OF SUSPECTED TYPE I PENICILLIN HYPERSENSITIVITY Suspected penicillin hypersensitivity Take a history of hypersensitivity to establish the nature. Type I (IgE mediated) anaphylaxis occurs immediately or within 72 hours. Immediate symptoms of anaphylaxis include diffuse erythema, pruritus, urticaria, angio-oedema, bronchospasm, laryngeal oedema, hyperperistalsis hypotension or cardiac arrhythmias, alone or in combination. Patients reporting such immediate reactions must NOT be given a beta-lactam antimicrobial (cephalosporins and penicillin). Other IgE mediated reactions occurring from 1 to 72 hours after administration may be manifested by urticaria, angio-oedema, laryngeal oedema and wheezing. Beta-lactam antimicrobials should not be given to patients who report such symptoms without immunological investigations. In patients who have a type I penicillin hypersensitivity, if the infection can be adequately treated with a nonbeta-lactam antimicrobial, e.g. erythromycin, the safest and easiest option is to use the alternative. Always consult with a medical microbiologist if there is any doubt of the suitability of a recommended antimicrobial. If it is likely a patient with type I penicillin hypersensitivity should need further courses of antimicrobials to treat severe infections (e.g. associated with neutropenia), establish the nature of the hypersensitivity and possible future treatment options. Patients with a history of type I penicillin hypersensitivity must NOT be given a cephalosporin. It is probably safe to give a cephalosporin only if the reported rash was strictly maculopapular, and there are no signs of a history of a true type I reaction. Diarrhoea, nausea or vomiting do not signify penicillin hypersensitivity. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 29

APPENDIX 1: MANAGEMENT OF SUSPECTED TYPE I PENICILLIN HYPERSENSITIVITY (continued) The risks of giving a penicillin antimicrobial to a patient with a true history of penicillin allergy are well known. However, most of us recognise that decisions regarding the treatment of infections in patients who report a history of penicillin hypersensitivity are not always as straightforward as we would like. The decision may be easy when the causative bacterium is susceptible to a non-beta-lactam antimicrobial, but not so easy when the drug of choice is either a penicillin or cephalosporin. Too often, side effects are reported incorrectly as hypersensitivity and, therefore, may preclude its use unintentionally. This appendix aims to give guidance on determining whether or not a patient has a true type I hypersensitivity to penicillin and which antimicrobials are safe to use in patients with type I penicillin hypersensitivity. Documenting hypersensitivities Drug hypersensitivities must be fully documented in the patient s notes (computerised and paper) and on any relevant prescription chart in the allergy/drug susceptibility box. Beta-lactam antimicrobials The molecular structures of penicillins, cephalosporins, carbapenems (imipenem, meropenem) and monobactams (aztreonam) contain a beta-lactam ring. The risk of anaphylaxis to antimicrobials containing a beta-lactam ring (with the possible exception of aztreonam) is greater in patients who are hypersensitive to penicillin. The risk of a hypersensitive reaction to cephalosporins in patients with a history of hypersensitivity to penicillin has been estimated as 8 times as high as the risk in those with no history of hypersensitivity to penicillin. This is the basis for recommendations that patients who have a type I hypersensitivity to penicillin should not receive another antimicrobial containing a beta-lactam ring. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 30

APPENDIX 1: MANAGEMENT OF SUSPECTED TYPE I PENICILLIN HYPERSENSITIVITY (continued) Diagnosis of penicillin hypersensitivity Reactions which are IgE mediated are commonly classed as type I reactions. Only 10-20% of patients reporting a history of penicillin hypersensitivity are truly hypersensitive when tested. Alternative antimicrobials may be less effective or associated with more adverse effects. It is important that steps are taken to establish the nature of the hypersensitivity before a decision about what to prescribe is taken. Taking a clinical history of penicillin hypersensitivity: What to ask to establish the nature of the hypersensitivity What was the patient s age at the time of the reaction? Anaphylactic reactions are most commonly seen in adults aged between 20 and 49 years. These reactions are IgE mediated. How long after beginning penicillin did the reaction begin? IgE mediated reactions occur either immediately or between 1 and 72 hours. Immediate reactions to penicillin administration are often associated with symptoms of anaphylaxis such as diffuse erythema, pruritus, urticaria, angio-oedema, bronchospasm, laryngeal oedema, hyperperistalsis, hypotension or cardiac arrhythmias, either alone or in combination. Patients reporting such immediate reactions must NOT be given a beta-lactam antimicrobial. Other IgE medicated reactions to penicillin can occur from 1 to 72 hours after administration and may be manifested by urticaria, angio-oedema, laryngeal oedema and wheezing. Beta-lactam antimicrobials should not be given to patients who report such symptoms without immunological investigations. Reactions to penicillin occurring after 72 hours of drug administration are unlikely to be IgE mediated. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 31

APPENDIX 1: MANAGEMENT OF SUSPECTED TYPE I PENICILLIN HYPERSENSITIVITY (continued) What were the characteristics of the reaction? See above for symptoms of type I penicillin hypersensitivity. Drug-independent rashes are common in patients with viral infections which may have been mistreated with an antimicrobial, and infections with bacteria can also be associated with a rash. Many patients taking penicillin may also be taking other medications that can cause rashes. Hence, patients with infections who develop a rash while taking a penicillin antimicrobial should not be automatically labelled as penicillin hypersensitive, rather rash with antimicrobials. If a detailed history and clinical risk assessment of a patient s reaction to penicillin indicates that the rash was strictly maculopapular, with no signs of a type I reaction, and if a non-betalactam antimicrobial is not appropriate, then it is probably safe to give a cephalosporin. Does the patient recall the reaction? If not, who informed them of it? What was the route of administration? Why was the patient taking penicillin? What other medications was the patient taking? Why and when were they prescribed? What happened when the penicillin was discontinued? Has the patient taken antimicrobials similar to penicillin (for example, amoxicillin, ampicillin, cephalosporins) before or after the reaction? If yes, what was the result? North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 32

ABBREVIATIONS AMT Abbreviated Mental Test IgE Immunoglobulin E AOM Acute otitis media IM Intramuscular BASHH British Association for Sexual Health and HIV IV Intravenous BNF British National Formulary MRSA Meticillin-resistant Staphylococcus aureus CAP Community acquired pneumonia MSU Mid-stream urine CCDC Consultant in Communicable Disease Control NICE National Institute for Health and Clinical Excellence CDI Clostridium difficile infection NUD Non-ulcer dyspepsia COPD Chronic obstructive pulmonary disease PHN Postherpetic neuralgia DBP Diastolic blood pressure PID Pelvic inflammatory disease DU Duodenal ulcer PPI Proton pump inhibitor ENT Ear, nose and throat SBP Systolic blood pressure GORD Gastro-Oesophageal Reflux Disease STI Sexually transmitted infection GU Gastric ulcer UTI Urinary tract infection GUM Genito-urinary medicine WCC White cell count HPA Health Protection Agency North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 33

GLOSSARY Centor criteria CRB65 score Delayed antimicrobial prescribing strategy ESBLs NNT NPV The Centor criteria have been developed to predict bacterial infection in acute sore throat. The four Centor criteria are: presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough. A means of assessing severity of community acquired pneumonia (CAP) in patients seen in the community (CRB65 severity score plus clinical judgement). It is derived from the CURB criteria (includes urea level and is commonly used in hospital) and recommended by the British Thoracic Society for the assessment of pneumonia. The score is an acronym for each of the risk factors measured, each risk factor scores one point for a maximum score of 4. Confusion, Respiratory rate 30/min, Blood pressure (SBP <90 or DBP 60 mmhg), Age 65 years. A strategy employed to reduce antimicrobial prescribing whereby a delayed prescription with instructions can be either given to the patient or left at an agreed location to be collected at a later date. It is used where there is no immediate need for an antimicrobial, but to reduce the need for further consultations if symptoms don t resolve. NICE Clinical Guideline 69 on Respiratory Tract Infections recommends a delayed antimicrobial prescribing strategy may be appropriate for patients with acute otitis media, acute sore throat/pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis, acute cough/bronchitis. Extended Spectrum Beta-Lactamases. Enzymes produced by some bacteria which are responsible for their resistance to beta-lactam antimicrobials such as penicillins, cephalosporins and carbapenems. Number Needed to Treat is a measure used in assessing the effectiveness of an intervention. The NNT is the number of patients who need to be treated to prevent one additional adverse outcome, (i.e. the number of patients that need to be treated for one to benefit compared with a control in a clinical trial). The ideal NNT is 1, where everyone improves with treatment and no one improves with control. The higher the NNT, the less effective is the treatment. Negative Predictive Value. The proportion of patients with negative results who are correctly diagnosed. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 34

REFERENCES 1. Health Protection Agency (March-July 2010). Management of Infection Guidance for Primary Care for consultation and local adaptation. Health Protection Agency and Association of Medical Microbiologists. Available online at www.hpa.org.uk 2. Department of Health (2010). The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. Available online at www.dh.gov.uk 3. National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 69 (July 2008). Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. Available online at www.nice.org.uk 4. British Thoracic Society. Guidelines for the Management of Community Acquired Pneumonia in Adults. Update 2009. Available online at www.brit-thoracic.org.uk 5. Health Protection Agency (April 2011). Diagnosis of UTI. Quick reference guide for Primary Care. Available online at www.hpa.org.uk/infections/topics_az/primary_care_guidance/uti_guide.rtf 6. Health Protection Agency. Extended Spectrum Beta-Lactamases (ESBLs). Topics A-Z. Accessed from HPA website July 2011. Available at www.hpa.org.uk/infections/topics_az/esbl/default.htm 7. Scottish Intercollegiate Guidelines Network (July 2006). Management of suspected bacterial urinary tract infection in adults. Scottish Intercollegiate Guidelines Network. National Guideline number 88. Available online at www.sign.ac.uk/pdf/sign88.pdf 8. Elsevier BV (2006). Myler s Side Effects of Drugs 15th Edition. Nitrofurantoin. 9. Health Protection Agency. Vaginal Discharge quick reference guide. Primary Care Guidance. Topics A-Z. Updated July 2011. Available online at www.hpa.org.uk/infections/topics_az/primary_care_guidance/vaginal_discharge_guide.rtf 10. British Association for Sexual Health and HIV. Clinical Effectiveness Group Guidelines. Last updated 13th July 2011. Available online at www.bashh.org/guidelines 11. Health Protection Agency. Primary Care Guidance. Chlamydia quick reference guide. Topics A-Z. Updated June 2011. Available online at www.hpa.org.uk/infections/topics_az/primary_care_guidance/chlamydia_guide_280406.pdf 12. National Travel Health Network and Centre (October 2007). Travel Health Information Sheet: Giardiasis. Available online at www.nathnac.org/pro/factsheets/giardiasis.htm 13. Department of Health (2009). Clostridium difficile: How to deal with the problem. Available online at hcai.dh.gov.uk/whatdoido/cdi/ 14. Dial et al. Use of Gastric Acid-Suppressive Agents and the risk of Community-Acquired Clostridium difficile-associated disease. JAMA 2005; Vol 294 (no.23) p2989-2995. 15. Linsky et al. Proton pump inhibitors and risk for recurrent clostridium difficile infection. Arch Intern Med 2010; 170(9): 772-778. North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 35

Prescribing and Medicines Management team NHS North Yorkshire and York Tel: 01904 601590 or 01845 573854 www.northyorkshireandyork.nhs.uk Infection Prevention and Control (Community) team Harrogate and District NHS Foundation Trust www/hdft.nhs.uk North Yorkshire Guidance for use of Antimicrobials in Primary Care January 2012 36