Infection Management Summary of changes (Feb-14 to Aug-16)

Infection Management Summary of changes (Feb-14 to Aug-16) Influenza (CAS alert 28 th June-16; noted at TSAPG 10/08/16 & approved PAMM Acute Sore Throat DoH update 28 th June 2016: https://www.cas.dh.gov.uk/viewandacknowledgment/viewalert.aspx?alertid=102 493 GPs and other prescribers working in primary care should no longer prescribe antiviral medicines, for the prophylaxis and treatment of influenza on an FP10 prescription form. This is in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004, commonly known as the Grey List or Selected List Scheme (SLS).This advice stands until we write again to re-commence prescribing and supply of antiviral medicines in primary are. Added: Use FeverPAIN Score; 1 point each: Fever in last 24h (( 36.9 C), Purulent tonsils, patient Attending rapidly ( 3 days), severely Inflamed tonsils, No cough or coryza. Score 0-1: 13-18% streptococci, use NO antibiotic strategy; 2-3: 34-40% streptococci, use 3 day back-up antibiotic; 4-5: 62-65% streptococci, use immediate antibiotic if severe, or 48hr short back-up prescription. Removed: If Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) consider 2 or 3-day delayed or immediate antibiotics. 1 Version: AA Aug-16

Acute Otitis Media (NICE Advice topic March 2016; noted at TSAPG 10/08/16 & approved PAMM Added: Consider Otovent nasal balloon to relieve otitis media with effusion - Initially 3 inflations per day for each affected nostri; Lasts 2-3 weeks (each latex balloon may be inflated 20 times before needing replacement) Community-acquired pneumonia - treatment in the community - Doxycycline placed as first line to cover for possible Mycoplasma pneumoniae presentations. - Added: If CRB65=1, 2 & AT HOME Clinically assess need for dual therapy for atypicals UTI in men & women (no fever or flank pain) (launch of new cost-effective product; noted at TSAPG 10/08/16 & approved PAMM UTI in pregnancy Changed from: - Changed from: CRB65=0: use 5 days. Review at 3 days & extend to 7-10 days if poor response To CRB65=0: use 5 days. Consider extending the antibiotic course to a total of 7-10 days as a possible management strategy for patients with low-severity CAP whose symptoms do not improve as expected after 3 days. Changed from: Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology - to be prescribed in primary care as licensed Fosfomycin 3g granules produced by Lexon UK Ltd. To: Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology - to be prescribed as licensed product Monurol. 2 Version: AA Aug-16

UTI in children (suggested by microbiologist BB; noted at TSAPG 10/08/16 & approved PAMM Oral candidiasis BNF; noted at TSAPG 10/08/16 & approved PAMM Giardiasis (requested by microbiologist SH; noted at TSAPG 10/08/16 & approved PAMM Epididymitis First line: Nitrofurantoin or Trimethoprim Give folic acid if first trimester Second line: if susceptible, Amoxicillin Third line: Cefalexin To: First line: Nitrofurantoin Second line: Trimethoprim (Give folic acid if first trimester) or if susceptible, Amoxicillin Third line: Cefalexin Added: - Pivmecillinam as 2 nd line in lower UTI if 40kg - Fluconazole dose (50mg QDS) in previous PHE guidance changed to 50mg OD - Changed from: For extensive/severe candidiasis or HIV or immunosuppression use oral fluconazole. To: Fluconazole if extensive/severe candidiasis; if HIV or immunosuppression use 100mg. New topic Now a stand-alone item (previously with Chlamydia trachomatis/ urethritis). 3 Version: AA Aug-16

Gonorrhoea Pelvic Inflammatory Disease MRSA Epidermoid and pilar cysts ( sebaceous cysts) (requested locally; noted at TSAPG 10/08/16 & approved PAMM Boils and carbuncles (requested locally; noted at TSAPG 10/08/16 & approved PAMM Bites Blepharitis (requested locally; noted at TSAPG 10/08/16 & approved PAMM Chalazion (Meibomian cyst) (requested locally; noted at TSAPG 10/08/16 & approved PAMM Stye (requested locally; noted at TSAPG 10/08/16 & New entry: Antibiotic resistance is now very high. Use IM ceftriaxone plus azithromycin and refer to GUM. Doxycycline added as an option: Low risk only Metronidazole PLUS First line: Ofloxacin OR Second line: Doxycycline Topic removed (note: local MRSA decolonisation policy currently under review) New topic New topic Human bites dose change for Co-amoxiclav from 625mg to 375-625mg New topic New topic New topic 4 Version: AA Aug-16

approved PAMM Dental Infections Appendix 1 Guidelines for the management of cellulitis in adults in Somerset ( Appendix 5 - General Practice Sepsis Screening & Action Tools (updated tools from UK Sepsis Trust July 2016; Appendix 2 - Methicillin Resistant Staphylococcus Aureus (MRSA) Decolonisation Policy (approved by TSAPG 24/02/16 & PAMM Erythema chronicum migrans Lyme disease (clarification requested by GPs in West Somerset; approved by TSAPG 24/02/16 & PAMM Dental Infections topic updated and extended to include: - Mucal ulceration and inflammation (simple gingivitis) - Acute necrotising gingivitis - Pericoronitis - Dental abscess Alternative to Retapamulin provided due to ongoing stock supply issues: (if unavailable the recommended (unlicensed) alternative is Sulfadiazine cream (Flamazine ) TDS 5-7days) Added primary care flowcharts: - Sepsis Tool for under 5's - Sepsis Tool for 5-11 year olds - Sepsis Tool for adults & young people - Sepsis Tool for women in pregnancy Aligned with NHS Somerset CCG Infection Control MRSA decolonisation update GPs to discuss cases with Infection Control Team or Consultant Microbiologist after three unsuccessful decolonisation attempts. Octenisan 500ml bottle is the most cost-effective Chlorhexidine-based body wash (removed Skinsan ). Title change to Lyme disease and added clinical comments: If history of a recent tick bite but otherwise well: -Prophylactic antibiotics should not be routinely prescribed. -Advise to seek immediate medical advice if develop symptoms of Lyme disease. -Erythema migrans at the site of a tick bite is diagnostic of Lyme and should be treated with antibiotics without blood tests. Laboratory tests should only be performed where these is evidence of neurological, cardiac or joint involvement. Microbiology will advise on positive results. Specialist advice should be sought when: -Despite antibiotic treatment, symptoms are persisting and getting worse -Erythema migrans not present but has symptoms suggestive of Lyme disease 5 Version: AA Aug-16

Bites (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM Impetigo (approved by TSAPG 24/02/16 & PAMM Acute prostatitis (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM Pelvic Inflammatory Disease - high risk or likely gonorrhoea (as per DoH letter 18/12/15; approved by TSAPG 24/02/16 & PAMM and a recent history of a tick bite or possible exposure to ticks -There is neurological, cardiac involvement, or arthritis; severe symptoms i.e. syncope, breathlessness, or chest pain consider admission -There are any other persistent symptoms. (Note: Cefuroxime is a cephalosporin which is not recommended locally due to poor oral absorption) Prophylaxis or treatment: If penicillin allergic: Metronidazole PLUS Doxycycline (cat/dog/human) NEW: or Metronidazole PLUS Clarithromycin (human bite) Useful in children or intolerance to Doxycycline. Alternative to Retapamulin provided due to ongoing stock supply issues: If Retapamulin stock is unavailable the recommended (unlicensed) alternative is Sulfadiazine cream (Flamazine ) TDS 5-7days. Topical Fusidic Acid is not recommended due to local high resistance levels. Added option in line with PHE guidance: 1st line: Ciprofloxacin 500mg BD or Ofloxacin 200mg BD 28 days Ceftriaxone regimen change to national recommendation in place since 2011: From: Ceftriaxone 500mg IM stat PLUS Metronidazole 400mg BD x 14days PLUS Doxycycline 100mg BD x 14 days To: Ceftriaxone 500mg IM stat PLUS Azithromycin 1g (2x500mg tabs) stat Added option in line with PHE guidance: Epididymitis - low STI risk: Doxycycline 100mg BD 14 days Chlamydia trachomatis/ urethritis (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM Acute pyelonephritis Co-amoxiclav treatment reduced from 14 days to 7 days in line with PHE 6 Version: AA Aug-16

(approved by TSAPG 24/02/16 & PAMM UTI in men & women (no fever or flank pain) (approved by TSAPG 24/02/16 & PAMM Eradication of Helicobacter pylori (following UK discontinuation of De-Noltab (tripotassium di-citrato bismuthate 120mg in December 2015; approved by TSAPG 24/02/16 & PAMM Community-acquired pneumonia - treatment in the community (updated in line PHE guideline July 2015; approved by TSAPG 24/02/16 & PAMM Acute Otitis Externa (cost-effectiveness review to align options in Somerset healthcare community as highlighted by SOMPAR 08/01/16; (approved by TSAPG 24/02/16 & PAMM Influenza (added webpage links to PHE January 2016 communications approved by TSAPG 24/02/16 & PAMM Introduction Principles of treatment (approved by TSAPG 24/02/16 & PAMM guidance. Nitrofurantoin alternative formulation provided due to ongoing stock supply issues: If Nitrofurantoin MR 100mg capsules stock is unavailable the next most costeffective alternative is Nitrofurantoin 50mg tablets (1 QDS). Entries for Bismuthate (De-nol tab ) 240mg BD changed to Bismuth subsalicylate (Pepto-Bismol chew tab ) off-label 2x262.5mg QDS IF CRB65=0: Changed from 7 days treatment to: Use 5 days. Review at 3 days & extend to 7-10 days if poor response Second line option changed from: Neomycin sulphate with corticosteroid To: Betnesol-N drops (Betamethasone 0.1% Neomycin 0.5%) - 2-3 drops TDS- QDS (can be given to babies and small children; take clinical precautions*) OR Otomize spray (Neomycin Sulphate 0.5% Dexamethasone 0.1% Glacial Acetic Acid 2.0%) - 1 spray TDS (adults and children aged 2 years) Removed previous information and added link to PHE online January 2016 resources letter to GPs and guidance on prescribing antivirals. Added link to electronic version of No Antibiotic/Back-up prescribing patient leaflet Treating your infection 7 Version: AA Aug-16

August 2015 August 2015 Appendix 5 The UK Sepsis Trust General Practice Sepsis Screening & Action Tool (as suggested by Sepsis case study review group 09/07/15) Acute Diverticulitis (new topic agreed by TSAPG 12/08/15 & PAMM 08/09/15) New appendix containing guidance for screening of sepsis in primary care. There is no robust evidence to support the use antibiotics for treating diverticulitis in primary care. Prescribers are therefore advised to exercise careful clinical judgment and keep the use of antibiotics to the necessary minimum. Contact microbiology if pregnant or breastfeeding. This local guidance takes into account safety, cost-effectiveness and antimicrobial resistance, and stratifies treatment based on episode severity: -Mild - symptoms of diverticulitis with no inflammatory response; no antibiotics required; advise fluid intake and analgesia if required -Mild to moderate - symptoms of diverticulitis with evidence of inflammatory response = 2 or more SIRS criteria: Temp 38.3ºC or 36.0ºC, Pulse 90/min, RR 20/min, New confusion/drowsy, Glucose 7.7mmol/L (non-diabetic patient), WBC 12 or 4x10 9 /L -Moderate to severe acute hospital assessment/ admission August 2015 April 2015 UTI in men & women (no fever or flank pain) (new licensed product approved by PAMM 15/07/15) Eradication of Helicobacter pylori (typo identified by Vicky MM team Apri-15) In some circumstances it may be appropriate to treat mild to moderate episodes: Doxycycline 200mg STAT then 100mg OD for 7days PLUS Metronidazole 400mg TDS for 7days (Review within 48 hours) Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology - to be prescribed in primary care as licensed Fosfomycin 3g granules produced by Lexon UK Ltd. First line option with penicillin allergy incorrectly stated Amoxicillin instead of Metronidazole (main guidance document only not quick reference guide) 8 Version: AA Aug-16

April 2015 Community-acquired pneumonia - treatment in the community (feedback from North Sedgemoor Federation Mar-15) February 2015 UTI in men & women (no fever or flank pain) (agreed with BB at PAMM Feb-15) January 2015 January 2015 January 2015 Mastitis (reviewed in line with CKS guidance & local staph sensitivities; noted in PAMM Feb-15) Diabetic Foot Infections (04/02/15 in line with MPH & YDH guidance; noted in PAMM Feb-15) MRSA (as per PHE update Nov-14; noted in PAMM Feb-15) Hyperlink to NICE guidance made clearer to improve access to CRB65 definition Further to risk stratification approval in Jan-15, Pivmecillinam has been added as first option if previous history of Trimethoprim resistance. Pivmecillinam is first option for community multi-resistant Extended-spectrum Beta-lactamase E. coli and Fosfomycin (women: 3g stat; men: 3g stat plus 2 nd 3g dose 72 hours later) may be an option on advice of microbiology. Flucloxacillin 500mg-1G QDS (was 500mg only) If allergic to penicillin Clarithromycin 500mg BD (if not breastfeeding) Doxycycline 200mg STAT then 100mg OD (2 nd option was Erythromycin) Treatment duration 14 days as per CKS recommendation (changed from 7 days). Treatment options updated to: Flucloxacillin 500g 1G QDS If allergic to penicillin Doxycycline 200mg STAT followed by 100mg OD (2 nd option was Clarithromycin) New topic Flucloxacillin 1g QDS (reduce to 500mg QDS if intolerant); if allergic to penicillin: Clarithromycin (500 mg BD; (caution in elderly with heart disease) or Doxycyline (200mg STAT followed by 100mg OD). Facial: Co-amoxiclav 500/125 mg TDS If severe infection or no response to monotherapy after 24-48 hours, seek advice from microbiologist. January 2015 Acute prostatitis (review local guidance as differs from PHE update Nov-14; agreed with BB 28/01/15; noted 1st line Ciprofloxacin 2nd line Trimethoprim (removed doxycycline as only recommended for chlamydial infections) in PAMM Feb-15) January 2015 Chlamydia trachomatis/ urethritis New info 9 Version: AA Aug-16

January 2015 (as per PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) Acute pyelonephritis (review local guidance as differs from PHE update Nov-14; agreed with BB 04/02/15; noted in PAMM Feb-15) January 2015 Community-acquired pneumonia - treatment in the community (NICE CG191 Dec-14 has been considered and local guidance differs ; options agreed with BB 28/01/15; noted in PAMM Feb-15) January 2015 Acute exacerbation of COPD (review local guidance as differs from PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) January 2015 Acute cough, bronchitis (as per PHE update Nov-14; agreed with BB 28/01/15; noted in PAMM Feb-15) County wide Cellulitis guideline (Appendix 1) (as agreed in SPF & TSAPG Nov-14) Genital Tract Infections (as per PHE update Nov-14) Eradication of Helicobacter pylori (following NICE CG184 Sept-14 approved by For suspected epididymitis in men 35 years with low risk of STI (High risk, refer to GUM). Epididymitis: low STI risk: Ofloxacin 200mg BD 14 days New info If previous or current MRGNO/ ESBL discuss with microbiology or consider admission. If ESBL risk and with microbiology advice consider IV antibiotic via outpatients (OPAT). Change in: Score 3-4 - urgent hospital admission Give immediate IM Benzylpenicillin if delayed admission/life threatening, and seek risk factors for Legionella and Staph. aureus infection. Changed to 5-7 days recommended course for all options (was 7days; 14 days for frequent exacerbations) Change in Comments section to: Consider 7 days delayed antibiotic with symptomatic advice/leaflet. Consider immediate antibiotics if > 80yr and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure OR > 65yrs with 2 of above. From: Consider 7-14 day delayed antibiotic with symptomatic advice/leaflet. Removal of SOMPAR logo and references; agreement remains valid between MPH, YDH & CCG. Contact UKTIS (Tel. 0844 892 0909 or use TOXBASE ), for information on foetal risks if patient is pregnant. First line treatment: -Choose the treatment regimen with the lowest acquisition cost, and take into 10 Version: AA Aug-16

PAMM & SPF Jan-15) Recurrent UTI in women 3 UTIs/year (application from MPH approved bypamm & SPF Jan-15) UTI in men & women (no fever or flank pain) (as per PHE update Nov-14; to be reviewed at PAMM & SPF Jan-15) Influenza (as per Public Health England update November 2014) account previous exposure to clarithromycin or metronidazole. -Metronidazole as an option in combination for people who are allergic to penicillin -Tetracycline for people allergic to penicillin and who have had previous exposure to clarithromycin. Second line treatment: - Use Clarithromycin or metronidazole (whichever was not used first-line). - A quinolone or tetracycline (whichever has the lowest acquisition cost) for people who have had previous exposure to clarithromycin and metronidazole. -Levofloxacin for people who are allergic to penicillin (and who have not had previous exposure to a quinolone). - Tetracycline people who are allergic to penicillin and who have had previous exposure to a quinolone. Methenamine hippurate changed from AMBER to GREEN status. Proposed treatment options based on risk stratification according to patient clinical status and drug cost-effectiveness. Allowed on FP10 as SLS (winter season); status change to: Treat at risk patients, when influenza is circulating in the community and ideally within 48 hours of onset (do not wait for lab report) or in a care home where influenza is likely. At risk: pregnant (including up to two weeks post partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease, morbid obesity (BMI>=40). Use 5 days treatment with oseltamivir 75mg bd. If resistance to oseltamivir or severe immunosuppression, use zanamivir 10mg BD (2 inhalations by diskhaler for up to 10 days) and seek advice. See PHE Influenza guidance for 11 Version: AA Aug-16

September 2014 August 2014 August 2014 August 2014 Document Introduction Principles of treatment (as per PHE update Nov-14) Hyperlinks have all been updated mainly due to changes in PHE and CKS websites The main document now contains a new version of the county wide Cellulitis guideline. (the order of the Appendices has changed) (approved by TSAPG, PAMM & SPF) Appendix 1- Methicillin Resistant Staphylococcus Aureus (MRSA) Decolonisation Policy (due to supply problems with Bactroban nasal ointment) Conjunctivitis (guidance review following discontinuation of Fucithalmic and subsequent release of a generic version) Recurrent UTI in women (approved by TSAPG, MPH D&T, YDH D&T, PAMM & SPF) treatment of patients under 13 years or in severe immunosuppression (and seek advice). Minor wording changes: 3. 6. and 11 New: 14. New item: Appendix 1 Guidelines for the management of Cellulitis in Adults in Somerset Added 2 nd line option: - if Mupirocin nasal treatment is unavailable the second line treatment is Neomycin sulphate & chlorhexidine dihydrochloride (Naseptin ) Nasal Cream four times daily for 10 days -This is used for 5 days (if using Naseptin then this nasal cream must be continued for an additional 5 days) then stopped for 2 days and the patient is rescreened on day 8 to determine if the patient is still MRSA positive. Chloramphenicol remains first option. Added wording: Fusidic acid gel eye drops has less Gram-negative activity than Chloramphenicol and is not recommended locally due to rising resistance and in cost. If treatment failure with Chloramphenicol consider referral to specialist. Ofloxacin (Exocin ) is a cost-effective option in severe conjunctivitis only when Chloramphenicol not tolerated. Methenamine hippurate (Hiprex ) has been locally approved has an option on the recommendation of a microbiologist (AMBER drug). Note: patients already taking prophylactic antibiotics should only be switched if failure/ resistance in urinary isolate/ drug intolerance or complication. Dose: 1g BD (may be increased to TDS if catheterised) 12 Version: AA Aug-16

July 2014 June 2014 June 2014 The main document now includes Appendices with Primary Care guidance for the Management of Clostridium Difficile in community (proposed by Wendy Grey on behalf of the NHS Somerset Clostridium difficile Reduction Task and Finish Group to PAMM 09/07/14 and agreed) UTI in men & women (no fever or flank pain) UTI in pregnancy (as agreed with MPH, YDH & SOMPAR 16/06/14) Recurrent UTI in women (as agreed with MPH, YDH & SOMPAR 16/06/14) Appendix 2 Flow chart for the management of suspected CDI first or second episodes of infection Appendix 3 Flow Chart for the management of recurrent CDI Note: as per June 2014 100mg MR 1xBD is the most cost-effective option for treatment with Nitrofurantoin (subject to review) Note: as per June 2014 100mg (non-mr) 1x nocte is the most cost-effective option for prophylaxis with Nitrofurantoin (subject to review) June 2014 Scarlet Fever Notify your Health Protection Team changed to Devon, Cornwall and Somerset, Public Health England June 2014 Bacterial vaginosis (added topical Lactic Acid as an option following TSAPG & SPF 14/05/14, PAMM 04/06/14 to be presented again to SPF & MPH D&T for final ratification) Lactic Acid Gel as Balance Activ BV used in place of clindamycin (for treatment only; self-care and buy OTC for prophylaxis; one single use tube at night for 7 nights June 2014 May 2014 Cellulitis (as advised by TSAPG 14/0514 & PAMM 04/06/14) Influenza (as per Central Alerting system letter from DoH and NHS England) Doxycyline: 200mg STAT followed by 100mg OD (changed from 100mg BD) GPs should no longer prescribe, at NHS expense, antiviral medicines for the prophylaxis and treatment of influenza, in accordance with NICE guidance and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004, commonly known as the Grey List or Selected List Scheme (SLS). 13 Version: AA Aug-16

April 2014 New topic: Scarlet Fever (As per PHE April 2014 Interim guidelines for the public health management of scarlet fever outbreaks in schools, nurseries and other childcare settings ) This stands until we write again when the use of antivirals is next triggered. First line: Penicillin V (For children who are unable to swallow tablets, or where compliance is a concern, Amoxicillin may be used as an alternative.) April 2014 Acute Otitis Media (following cbnf update) Second line (If penicillin allergy) Azithromycin Neonate & Child Amoxicillin doses 7-28 days 30mg/kg (max. 125mg) TDS 1mth-1yr 125mg TDS 1-5yrs 250mg TDS 5-18yrs 500mg TDS (previously stated 40mg/kg/day in 3 doses (max. 3g daily) ) April 2014 Threadworms < 6months: six weeks hygiene (previously stated < 3months ) March 2014 < 3mths: six weeks hygiene (instead of Pripsen - piperazine+senna) Threadworms (following Pripsen - piperazine+senna discontinuation) February 2014 Fungal infection fingernail or toenail Added info: Topical treatment for most fungal skin and nail infections are low priority and suitable for self-care. February 2014 February 2014 Acute dental-alveolar infections (as per Somerset Partnership guidance) Cellulitis (in line with Guidelines For The Management Of Cellulitis In Adults Presenting To Primary Care In Somerset) Amoxicillin 500mg TDS (instead of 250mg) -Consider referral to Medical Assessment Unit (MAU) patients: a) with significant co-morbidities b) systemically unwell c) who do not improve after 72hours (previously stated If febrile and ill, admit for IV treatment ) - Flucloxacillin: 1g QDS reduce to 500mg QDS if intolerant (changed from 500mg QDS ) - Doxycyline: 100mg BD (changed from 200mg STAT followed by 100mg OD) - Now states refer if no response after 72hours (instead of If slow response continue for a further 7 days ) 14 Version: AA Aug-16

February 2014 Impetigo (as per SPC update) Mupirocin: dose change from TDS to BD Reserved for MRSA only (Note: Retapamulin remains first option for topical treatment) February 2014 Acute exacerbation of COPD Inverted the order of Doxycycline (now first) and Amoxicillin 15 Version: AA Aug-16