Antimicrobial prescribing guidance for primary care

NHS Barking and Dagenham CCG NHS Havering CCG NHS Redbridge CCG NHS Waltham Forest CCG In association with North East London NHS Foundation Trust Barking Havering and Redbridge Hospitals University NHS Trust Barts Health NHS Trust Antimicrobial prescribing guidance for primary care Date of publication: November 2008 Date of 5 th review: February 2015 Date of expiry: February 2017 2 nd review: November 2010 3 rd review: June 2011 4 th review: June 2013 1

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Antibiotic Guideline Review Group: Dr. Sandra Lacey Consultant microbiologist, Barking, Havering & Redbridge University Hospitals NHS Trust Gladys Xavier Dr. Gavin Dabrera Oge Chesa Sarfaraz Ameen Kamaljit Tahkar Hassan Serghini Iyetunde Bello Deputy Director of Public Health, London Borough of Redbridge Public Health Registrar, London Borough of Redbridge Deputy Chief Pharmacist, Barking and Dagenham, Havering & Redbridge (BHR) CCGs Anti-Microbial Pharmacist, Barts Health NHS Trust Deputy Chief Pharmacist, Community Health Services, NELFT Prescribing Adviser, (Waltham Forest) NEL CSU Dental Practice Adviser, North East London Area Team Matthew Henry Rubina Ahmed Information Analyst, BHR CCGs In attendance: Maninder Singh Senior Prescribing Adviser, Newham CCG For further information please contact a member of the medicines management team. Approved by BHR Area Prescribing sub-committees May 2015 3

Contents Policy Statement 5 Background 5 Aims and Objectives of the Guidance... 6 Principles of treatment... 6 Section 1: Antibiotic formulary Eye infections.. 7 Dental infections. 7 Respiratory tract infections upper..... 9 Respiratory tract infections lower.. 10 Gastro-intestinal tract infections... 12 Urinary tract infections....14 Genital tract infections. 16 Meningitis......17 Skin infections..17 Section 2: Information for patients Useful links...22 Section 3: Notification of infectious diseases..23 References....24 4

Antimicrobial Prescribing Guidance for Primary Care Policy Statement These guidelines are to be read in conjunction with current NICE and PHE guidance, BASHH, CKS and RCGP Target Toolkit. Evidence-based antimicrobial prescribing will address the challenge posed by the increase of antibiotic-resistant bacteria, and the rise in health care acquired infections. The Health and Social Care Act 2008 (updated 2011) introduces the Code of Practice for the Prevention and Control of HealthCare Associated Infections, also known as the Hygiene Code. This Code requires all health care organisations to have a policy in place on antimicrobial prescribing, in order to reduce the incidence and prevalence of Health Care Associated Infections (HCAI). Background The increase in antibiotic resistance has led to the more effective use of antibiotics becoming a national priority. The Standing Medical Committee has recommended the following for primary care: - No prescribing of antibiotics for simple coughs and colds For sore throats, antibiotics should generally be avoided, unless sufficient clinical criteria that might indicate a more serious infection are met, when specific antibiotics may be used Bladder infection (cystitis) - the guidance recommends that uncomplicated cystitis in otherwise fit women aged 16 to 64 years old, short courses (3 days) of antibiotics can be prescribed, rather than a 7 day course Otitis media - the guidance recommends specific antibiotics can be prescribed if there are signs of severe infection To limit prescribing of antibiotics over the telephone to exceptional cases. See Section 2 for Treating your infection document to support the issuing of back up prescriptions. Common infective ailments account for a large proportion of the acute workload seen in general practice and cause considerable patient distress. The prescriber is sometimes put under pressure to prescribe by anxious patients who think antibiotics will provide a quick resolution, particularly if they are under pressure to return to work. However, the evidence to support antibiotic intervention is often weak or lacking and certain illnesses can be self-limiting. Good communication between the prescriber and patient, with adequate time given to the consultation, is known to bring about more selective and appropriate prescribing. 5

Aims and Objectives of the Guidance The guidance is presented in three parts: - Section 1 Section 2 Section 3 Provides an antibiotic formulary for the North East London geography that is recommended by the local Microbiologists, and Public Health England. Lists information for patients. Lists conditions for which notification of infectious diseases is required. The aims are to: Support the rational, safe and cost-effective use of antibiotics by selecting the best approach to managing common infections from the evidence available. Promote the selective use of antibiotics to reduce the emergence of antimicrobial resistance in the community. Empower patients with information and support mechanisms so they can cope with illness. The objectives are to: Assist prescribers in managing the case by providing clear information on the likely clinical outcome with or without treatment and to indicate possible risk. Help the prescriber decide whether treatment is indicated and which antibiotic may be appropriate. Principles of treatment Considerations Prescribe antibiotic only when there is likely to be a clear clinical benefit Use tried and tested, simple, cheap, narrow spectrum antibiotics first Save new, more expensive, broader spectrum antibiotics for non-responding or resistant infections. Prescribe clarithromycin or azithromycin if there is a personal history of intolerance to erythromycin. Adverse effects from benzylpenicillin are unusual. Anaphylactic reactions are rare, occurring in one in 7,000 to one in 25,000 treated patients. Anaphylaxis is more likely to occur if there is a history of immediate allergic reactions (such as difficulty in breathing, collapse, generalised itchy rash) after previous penicillin administration although most people with a history of penicillin allergy do not have a true hypersensitivity Offer a deferred prescription to equivocal cases so that patient is asked to await developments. Avoid Do not prescribe an antibiotic for a simple cold or viral sore throat Avoid repeated use of topical antibiotics, as they select for resistant organisms. Avoid certain antibiotics in pregnancy, e.g. tetracyclines, quinolones, metronidazole, trimethoprim (in first trimester), nitrofurantoin (at term), minoglycosides. Where a best guess therapy has failed or special circumstances exist, microbiological advice can be obtained from BHRuT via the Queens Hospital/ King George Hospital switchboard on 01708 435000 or Whipps Cross Pathology on 0208 535 6455. The Guidance should only be applied to individual cases with clinical judgement. The recommendations apply in the absence of contra-indications. Please refer to the latest BNF or SmPC for further information. 6

Conjunctivitis EYE INFECTIONS Treat only if severe, as most viral or self-limiting. If severe: Bacterial conjunctivitis is usually unilateral and also self-limiting; it is characterised by red eye with mucopurulent, not watery, discharge; chloramphenicol 0.5% drop and 1% ointment Second line: fusidic acid 1% gel 2 hourly for 2 days, then 4 hourly (whilst awake) at night Twice a day Continue all for 48 hours after resolution DENTAL INFECTIONS This guidance is not designed to be a definitive guide to oral conditions. It is for GPs for the management of acute oral conditions pending being seen by a dentist or dental specialist. GPs should not routinely be involved in dental treatment and, if possible, advice should be sought from the patient s dentist, who should have an answer-phone message with details of how to access treatment out-of-hours, or telephone 111. Local measures should be attempted first, hence refer to dentist. However if patients present with significant swelling and there may be a delay in getting a dental appointment, only then should antimicrobials be prescribed. Temporary pain and swelling relief can be attained with saline mouthwash Simple saline mouthwash ½ tsp salt dissolved in glass warm water Always spit out after use. Use antiseptic mouthwash: Chlorhexidine 0.12-0.2% (Do not use within Rinse mouth for 1 minute BD with 5 ml diluted with 5-10 ml water. Mucosal ulceration and inflammation (simple gingivitis) Acute necrotising ulcerative gingivitis If more severe and pain limits oral hygiene to treat or prevent secondary infection. The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes simplex infection, oral cancer) needs to be evaluated and treated. N.B the presence of white/red patches should be referred to local maxillo-facial department as well as minor/major apthous ulcers that do not heal after two weeks. Commence metronidazole and refer to dentist for scaling and oral hygiene advice Use in combination with antiseptic mouthwash if pain limits oral hygiene 30 mins of toothpaste) Hydrogen peroxide 6% - (spit out after use) Rinse mouth for 2 mins TDS with 15ml diluted in ½ glass warm water Use until lesions resolve or less pain allows oral hygiene Metronidazole 200mg TDS 3 days Chlorhexidine or hydrogen peroxide See above dosing in mucosal ulceration Until oral hygiene possible 7

Pericoronitis Refer to dentist for irrigation & debridement. If persistent swelling or systemic symptoms use metronidazole. Use antiseptic mouthwash if pain and trismus limit oral hygiene Dental infections continued Amoxicillin or 500mg TDS 3 days Metronidazole 400mg TDS 3 days Chlorhexidine or hydrogen peroxide see above dosing in mucosal ulceration Until oral hygiene possible Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscess are not appropriate; Repeated antibiotics alone, without drainage are ineffective in preventing spread of infection. Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications. Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction, Ludwigs angina requires urgent referral for surgical intervention/management. Refer urgently for admission to protect airway, achieve surgical drainage and IV antibiotics Dental abscess The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients and should only be used if no response to first line drugs when referral is the preferred option. If pus drain by incision, tooth extraction or via root canal. Send pus for microbiology. Amoxicillin or Phenoxymethylpenic illin 500mg TDS - 500mg 1g QDS Up to 5 days review at 3days If spreading infection (lymph node involvement, or systemic signs i.e. fever or malaise) ADD metronidazole Severe infection & allergy Metronidazole 400mg TDS 5 days True penicillin allergy: use clarithromycin or clindamycin if severe. If severe Clindamycin True penicillin allergy: Clarithromycin 300mg QDS 500mg BD 5 days Up to 5 days review at 3d 8

UPPER RESPIRATORY TRACT INFECTIONS Pharyngitis/Sore Throat/Tonsilitis Avoid antibiotics as 90% resolve in without, and pain only reduced by 16 hours. Antibiotics may be indicated for patients with more severe symptoms or a history of otitis media, where streptococcal tonsillitis infection is suspected. E.g. fever, Lymphadenopathy, scarlet fever. A degree of clinical judgement is necessary, which should be led by the evidence. Antibiotics are not indicated for glandular fever. For recurrent, more severe sore throat consult the Microbiologist for advice. Twice daily, higher dose can also be used. QDS may be more appropriate if severe. First line: Penicillin V If allergic to penicillin, clarithromycin 500mg QDS 1g BD 250-500mg BD 10 days 5 days Acute Otitis Media (AOM) (child doses) Acute Otitis Externa AOM resolves without antibiotics in 60% of cases. Consider treatment 2 year, bulging membrane or systemically unwell. Antibiotics do not reduce pain in the first 24 hours, prevent subsequent attacks or deafness. Antibiotics may be indicated for severe or persistent symptoms or when the patient is systemically unwell. Use NSAID or paracetamol to treat symptoms First use aural toilet (if available) and analgesia Cure rates similar at for topical acetic acid or antibiotic +/- steroid If cellulitis or disease extending outside ear canal, start oral antibiotics and refer First Line: Amoxicillin If allergic to penicillin, erythromycin First Line: acetic acid 2% Second Line: neomycin sulphate with corticosteroid * Ciprofloxacin (risk assess C diff) if unable to take ciprofloxacin consult microbiologist. Child doses Neonate 7-28 days 30mg/kg TDS 1 month-1 yr: 125mg TDS 1-5 years: 250mg TDS 5-18 years: 500mg TDS 2 years 125 mg QDS 2-8 years 250mg QDS 8-18 years 250-500mg QDS 1 spray TDS 3 drops TDS 500mg BD 5 days min to 14 days max * if a prescription of ciprofloxacin is being considered a risk assessment 1 for c.diff acquisition should be undertaken Relapse at 10 days is higher with a 3 day course in otitis media but long-term outcome is similar 1 A risk assessment is to try and identify those most at risk of developing C diff. The particularly at risk group are those>80years of age, those who have had multiple recent hospital admissions and those who have had multiple previous courses of antibiotics. If it is felt that the patient is at high risk then they might like to consider discussing treatment with their friendly local microbiologist to see if any alternatives may be more appropriate. 9

Acute Rhinosinustis Upper respiratory tract infections continued Avoid antibiotics as 80% resolve in 14 days without; they only offer marginal benefit after 7days Use adequate analgesia Consider 7-day delayed or immediate antibiotic when purulent nasal discharge In persistent infection use an agent with anti-anaerobic amoxicillin or doxycycline 500mg TDS 1g if severe 200mg stat then100mg OD 7days * or phenoxymethyl penicillin 500mg QDS 7days* For persistent symptoms: co-amoxiclav 625mg TDS 7days* activity e.g. co-amoxiclav * Standing Medical Advisory Committee guidelines suggest 3 days but longer courses of may be needed to prevent relapse Note: Doses are for adults unless otherwise stated. Please refer to BNF for information LOWER RESPIRATORY TRACT INFECTIONS Note: Low doses of penicillins are more likely to select out resistance, we recommend 500mg of amoxicillin., Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. Acute cough, bronchitis In primary care, antibiotics have marginal benefits otherwise healthy adults. Patients leaflets can reduce antibiotic use. Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones, **ciprofloxacin and ofloxacin have poor activity against pneumococci Antibiotics NOT normally required ** if a prescription of ciprofloxacin is being considered a risk assessment 2 for c.diff acquisition should be undertaken 2 For the meaning of risk assessment in this context see entry on page 9 10

Acute exacerbation of COPD Lower respiratory tract infections continued 500mg TDS Amoxicillin or doxycycline Many cases are viral-consider whether antibiotics are needed Note: in acute bronchitis and COPD consider co-amoxiclav 625mg TDS only if failure to respond to first line treatment. Use CRB65 score to help guide and review: Each scores 1: Confusion (AMT<8); Respiratory rate >30/min; age >65; BP systolic <90 or diastolic 60; Score 0: suitable for home treatment; If patients MRSA status is known or allergic to penicillin or doxycycline then use clarithromycin IF CRB65=0: amoxicillin 200mg stat then 100mg OD 500mg BD 500mg TDS 5 days 5 days 5 days Community acquired pneumoniatreatment in the community Score 1-2: hospital assessment or admission or NELFT Community Treatment Team (CTT) Score 3-4: urgent hospital admission Mycoplasma infection is rare in over 65s or clarithromycin 500mg BD or doxycyclin If CRB65=1 and AT HOME 200mg stat/100mg OD amoxicillin AND clarithromycin or doxycycline alone 500mg TDS 500mg BD 200mg stat/100mg OD 7-10 days 7-10 days Note: Avoid tetracyclines in pregnancy. The quinolones, ciprofloxacin and ofloxacin have poor activity against pneumococci and should not normally be used 11

Eradication of helicobacter pylori GASTRO-INTESTINAL TRACT INFECTIONS Treat all positives in known DU, GU or low grade MALToma. In Non-Ulcer NNT is 14 Do not offer eradication for GORD Do not use clarithromycin, metronidazole or quinolone if used in past year for any infection Penicillin allergy: use PPI plus clarithromycin & MTZ; If previous clarithromycin use PPI + bismuthate + metrondiazole + tetracycline. In relapse see NICE Relapse and previous MTZ & clari: use PPI PLUS amoxicillin, PLUS either tetracycline or levofloxacin Always use PPI First and second line PPI WITH amoxicillin PLUS either clarithromycin OR metronidazole TWICE DAILY 1g BD 500mg BD 400mg BD All for Retest for H. pylori post DU/GU or relapse after second line therapy: using breath test OR consider endoscopy for culture and susceptibility Penicillin allergy & previous MTZ + clari: PPI WITH bismuthate (De-nol tab) PLUS metronidazole PLUS tetracycline hydrochloride 240mg BD 400mg BD 500mg QDS Relapse & previous MTZ +clari: PPI WITH amoxicillin PLUS tetracycline hydrochloride OR levofloxacin 1 1g BD 500mg QDS 250mg BD 14 days Infectious diarrhoea Fluid and electrolyte replacement is essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days can aggravate the disease and can lead to resistance. Initiate treatment on the advice of the microbiologist. If the patient remains systemically unwell initiate stool investigation for severe, prolonged or recurrent diarrhoea, food poisoning or for travellers diarrhoea. Always consider referral to hospital if the patient is systemically unwell e.g. with fever, dehydration, jaundice, abdominal pain, is on antibiotics or has had chemotherapy. Please notify suspected cases of food poisoning to the Public Health England North East and North Central London Health Protection Team (NENCLHPT) 020 3837 7084. Send stool samples early in these cases. 12

Gastro-Intestinal tract infections continued Stop unnecessary antibiotics and/or PPIs 70% respond to MTZ in 5 days; 92% in 14 days 1 st and non severe episode Antibiotic related diarrhoea e.g. clostridium difficile If severe (sever = 4 or more bowel movements for 2 or more days) symptoms or signs (below) should treat with oral vancomycin, review progress closely and/or consider hospital referral. Admit if severe: T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis metronidazole 400mg or 500mg TDS 10-14 days 2 nd episode/severe oral vancomycin 125mg QDS 10-14 days Travellers Diarrhoea Threadworm Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers diarrhoea If standby treatment appropriate give: *ciprofloxacin 500mg twice a day for 3 days (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 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 >6 months: mebendazole (offlabel if <2yrs) 3-6 mths: (contact microbiology) 100mg stat < 3mths: 6 weeks hygiene *If a prescription of ciprofloxacin is being considered, a risk assessment 3 for c. diff acquisition should be undertaken 3 For the meaning of risk assessment in this context see entry on page 9 13

URINARY TRACT INFECTIONS Short course advisable Trimethoprim Or 200mg BD 3 days Uncomplicated UTI in adult men and women i.e. no fever or flank pain Community acquired UTI caused by E coli with extendedsepectrum Betadactamane Enzymes (ESBL) Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly ( 65 years), do not treat asymptomatic bacteriuria. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or peylonephritis Community UTI caused by ESBL is increasing. So perform culture in all treatment failures. ESBL s are multi resistant but remain sensitive to nitrofurantoin Nitrofurantoin 100mg m/r BD Women all ages 3 days Men Treatment failure Co-amoxiclav until results become available (please send sample) Nitrofurantoin Or Trimethoprim (if flow risk) Second line depends on susceptibility of organism isolated Positive nitrites on dipstick increases likelihood of UTI (not reliable in pregnancy) 375mg TDS 100mg m/r BD 200mg BD Women all ages 3 days Men 3 days Second line depends on sensitivity of MS and microbiology advice The September 2014 Drug Safety Update highlights that new evidence indicates Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (egfr) less than 45ml/min/1.73m 2 (previously 60 ml/min/1.73m 2 ). However, a short course (3 to ) may be used with caution in certain patients with an egfr of 30 to 44 ml/min/1.73m 2. Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity Note: Asymptomatic bacteruria occurs in 25% of women and 10% of men 65 years and should not be treated except in pregnancy. UTI in catheterised patients catheterised patients who develop UTI may require removal of the catheter to clear infection. Antibiotics cannot clear infection in the presence of foreign material but usually indicate invasive infection 14

Acute prostatitis UTI in men 4 weeks treatment may prevent chronic infection. Quinolones are more effective as they have greater penetration into prostate. MSU for sensitivities. Investigation of cause. Send MSU for culture and start antibiotics Urinary tract infections continued First line: ciprofloxacin* Or Second line: trimethoprim 500mg BD 200mg BD 28 days 28 days Nitrofurantoin 100 mg m/r BD Or Trimethoprim 200mg BD First line: cefalexin 500mg BD UTI in pregnancy Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus Avoid trimethoprim if low folate status or on folate antagonist (e.g. antiepileptic or proguanil) Second line: 1 st trimester is nitrofurantoin. 2 nd trimester is trimethoprim or nitrofurantoin 100mg m/r BD 200mg BD 100mg m/r BD 3 rd trimester is trimethoprim 200mg BD UTI in children Acute pyelonephritis Recurrent UTI in nonpregnant women 3 UTI s/year Refer children <3 months: to specialist. MSU for sensitivities. If 3 months, use positive nitrite to start antibiotics upper UTI Send MSU for culture. If no response within 24 hours admit To reduce recurrence first advise simple measures including hydration, cranberry products. Then standby or post-coital antibiotics. Nightly prophylaxis reduces UTIs but adverse effects and long term compliance poor. Trimethoprim Or Nitrofurantoin If susceptible, amoxicillin See BNF for dosage Lower UTI 3 days Co-amoxiclav Upper UTI 7-10 days co-amoxiclav tablets 500/125mg TDS if allergic ciprofloxacin* nitrofurantoin or trimethoprim 500mg BD 50 100mg 100mg Post coital stat (offlabel) Prophylaxis OD at night review at 6 months *If a prescription of ciprofloxacin is being considered, a risk assessment 4 for c. diff acquisition should be undertaken Note: doses for adults unless otherwise stated. Please refer to BNF for information 4 For the meaning of risk assessment in this context see entry on page 9 15

GENITAL TRACT INFECTIONS (Contact UKTIS for information on foetal risks if patient is pregnant) People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. STI screening Refer individual and partners to GUM service. Risk factors: <25yr, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner, area of high HIV. 1 hour before Note: Chlamydia screening Azithromycin tablets 1g stat or 2 hours programme. after food Refer patients and contacts to Sexual Health Clinic and other sexual health service providers Or Doxycycline capsules 100 mg BD Chlamydia Trachomatis Tetracyclines are contraindicated in pregnancy and should be avoided in breast feeding Opportunistically screen all aged 15-24 years Treat partners and refer to GUM service Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment For suspected epididymitis in men over 35 years with low risk of STI (High risk, refer GUM) Pregnant or breastfeeding: azithromycin 1g (off-label use) stat or erythromycin 500mg QDS or amoxicillin 500mg TDS Epididymitis: low STI risk: ofloxacin 200mg BD 14 days or doxycycline 100mg BD 14 days All topical and oral azoles give 75% cure clotrimazole 500mg pess or 10% cream stat Vaginal Candidiasis Bacterial Vaginosis In pregnancy: avoid oral azoles and use intravaginal treatment for Oral metronidazole (MTZ) is as effective as topical treatment but is cheaper. Less relapse with 7 day than 2g stat at 4 weeks Pregnant/breastfeeding: avoid 2g stat Treating partners does not reduce relapse or oral fluconazole 150mg orally stat Pregnant: clotrimazole or miconazole 2% cream oral metronidazole (MTZ) or MTZ 0.75% vag gel or clindamycin 2% crm 100mg pessary at night 5g intravaginally BD 400mg BD or 2g 5g applicatorful at night 5g applicatorful at night 6 nights stat 5 nights 7 nights 16

Trichomoniasis Treat partners and refer to GUM service In pregnancy or breastfeeding: avoid 2g single dose MTZ. Consider clotrimazole for symptom relief (not cure) if MTZ declined Genital tract infections continued metronidazole (MTZ) clotrimazole 400mg BD or 2g 100mg pessary at night 5- stat 6 nights Pelvic Inflammatory Disease (PID) Test for chlamydia and N. gonorrhoea. Refer contacts to Sexual Health Clinic. Avoid doxycycline in pregnancy. Doxycycline capsules plus metronidazole Or Metronidazole plus levofloxacin 100mg BD 400mg BD 400mg BD 500mg OD 14 days 14 days 14 days 14 days MENINGITIS IV or IM benzylpenicillin Age 10+ years: 1200mg Suspected meningococcal disease Transfer all patients to hospital immediately. If time before hospital admission, and non-blanching rash, give IV benzylpenicillin or cefotaxime, unless definite history of hypersensitivity 1B- Children 1-9 yr: Children <1 yr: 600mg 300mg IV or IM cefotaxime Age 12+ years: 1gram Child < 12 yrs: 50mg/kg Note: if there is a history of penicillin allergy, transfer to hospital immediately. If available, give cefotaxime 2g or ceftriaxone 2g stat for adults, 50mg/kg to 2g stat for children, subject to risk assessment Prevention of secondary care meningitis: Only prescribe antibiotics following advice from NENCLHPT: 9am - 5pm Tel: 02038377084; Out of hours: Contact on-call doctor on Tel: 07623541417 Impetigo Topical and oral treatment produces similar results. As resistance is increasing reserve topical antibiotics for very localised lesions. Reserve Mupirocin for MRSA advise good infection control precautions SKIN INFECTIONS Flucloxacillin or if penicillin allergic, clarithromycin tablets. 500mg QDS 250 500mg BD Fusidic acid 2% cream or ointment. Mupirocin Note: doses for adults unless otherwise stated. Please refer to BNF for information Topically TDS Topically TDS 5 days 5 days 17

Skin infections continued If no visible signs of infection, use of antibiotics (alone or with steroids) encourages Eczema resistance and does not improve healing In eczema with visible signs of infection, use treatment as in impetigo. Cellulitis Leg Ulcers If patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone If river or sea water exposure, discuss with microbiologist. If febrile and ill, admit for IV treatment Stop clindamycin if diarrhoea occurs. Flucloxacillin If penicillin allergic: clarithromycin or clindamycin If facial: co-amoxiclav 500mg QDS 500mg BD 300 450mg QDS 500/125mg TDS All for. If slow response continue for a further 7 days Diagnosis and management of the underlying condition is important. Routine swabs are not recommended. Antibiotics are only indicated if significant cellulitis present. Selectively investigate patients and treat those that do not resolve (see under cellulitis). Review the management of diabetes in diabetic ulcers. ANTIBIOTICS DO NOT IMPROVE HEALING. If active infection refer for specialist advice if infection is severe GP s may be asked to prescribe eradication protocol for patients who are found to be colonised with MRSA prior to admission to hospital for treatment or surgery. Flucloxacillin Or Clarithromycin Mupirocin 2% (Bactroban nasal ointment) unless resistant in which case contact the relevant hospital. 500mg QDS 500mg BD To both nostrils TDS 5- (repeated for maximum of 2 courses) MRSA colonisation PVL The protocol should continue for 5 days (Barts Health) to 7 days (BHRuT) and then should be discontinued for 2 days before the patient is screened. The patient should be reswabbed and the protocol restarted as above. Further courses of nasal mupiocin should only be on the advice of the hospital microbiologist. If this does not eliminate carriage, please contact the Hospital Infection Control Team for further advice. Octenisan should be applied neat once daily for to wet skin during bathing in place of soap, it is not to be added to water. In Barts Health, Chlorhexidine gluconate 4% cleansing solution is also an option. Bath or shower once a day Hair wash 5- Twice weekly Please seek advice from a microbiologist for use of antibiotics for presumed MRSA infection Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from boils/abscesses. This bacteria can rarely cause severe invasive infections in healthy people; if found suppression therapy should be given. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene. See https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322857/guidance_o n_the_diagnosis_and_management_of_pvl_associated_sa_infections_in_england_2_ed.pdf 18

Topical Benzoyl peroxide remains the first line topical agent. Varying strengths, choice dependent on severity and clinical judgement. It is usual to start with a lower strength and increase gradually. Skin infections continued Benzoyl Peroxide (2.5%, 4%, 5% and 10 %). OD or BD At least 6 months. If the acne does not respond after 2 months then use of topical antibacterial should be considered. Acne Vulgaris Antibiotics may be used in severe acne. Oxytetracycline 500mg BD Maximum improvement usually occurs after 4-6 months but may need to be continued in more severe cases. Topical antibiotics should be reserved for patients who cannot tolerate oral preparations Lymecycline Clindamycin 1% lotion 408mg OD BD For at least 8 weeks 6 months Bites (Human & Animal) Thorough irrigation is important Prophylaxis or treatment: Human Cat or dog Assess risk of tetanus, HIV, hepatitis B&C Antibiotic prophylaxis is advised Assess risk of tetanus and rabies co-amoxiclav If penicillin allergic: metronidazole PLUS doxycycline capsules (cat/dog/man) 375-625mg TDS 400mg TDS 100mg BD All for Give prophylaxis if cat bite/puncture wound; bite to hand, foot, face, joint, tendon, ligament; immunocompromised/diabetic/ asplenic/cirrhotic/ presence of prosthetic valve or prosthetic joint or metronidazole PLUS clarithromycin (human bite) 200-400mg TDS 250-500mg BD AND review at 24&48hrs 19

Skin infections continued Scabies Treat whole body from ear/chin downwards and under nails. If under 2 or elderly, also face and scalp. Itch can persist for weeks and antiprutitic cream or an oral antihistamine may be indicated. Treat all home and sexual contacts within 24 hours. permethrin If allergy: malathion 5% cream 0.5% aqueous liquid 2 applications 1 week apart Dermatophyte infection - skin. Body, groin, foot and scalp Terbinafine is fungicidal so treatment time shorter than with fungistatic imidazoles Topical terbinafine BD 1-2 weeks If candida possible, use imidazole If intractable: send skin scrapings and if infection confirmed, use oral terbinafine/itraconazole or topical imidazole or (athlete s foot only): topical undecanoates (Mycota ) BD BD for 1-2 wks after healing (i.e. 4-6wks) Scalp: discuss with specialist, oral therapy indicated Dermatophyte infection of the finger nail or toenail Adults take nail clippings 5% amorolfine nail lacquer (for mild or moderate infections) 1-2x/weekly fingers, toes Fingers - 6 months Idiosyncratic liver reactions occur rarely with terbinafine. It is more effective than the azoles. Toes 9-12 months Itraconazole is also active against yeasts. In nondermatophyte moulds use itraconazole. Terbinafine 250mg OD fingers, toes Fingers - 6 12 weeks Toes 3 6 months 20

Skin infections continued Itraconazole (monitoring of liver function is recommended) 200mg BD fingers toes Fingers -7 days monthly (repeat after 21 day interval) 2 courses Toes 7 days monthly (repeat after 21 day interval) 3 courses For children seek advice Herpes zoster/varicella zoster/chicken pox/shingles Pregnant/immunocompromise d/neonate: seek urgent specialist advice If indicated: Chicken pox: IF onset of rash <24hrs & >14 years or severe pain or dense/oral rash or 2 o household case or steroids or smoker consider aciclovir Aciclovir 800mg five times a day https://www.gov.uk/government /publications/viral-rash-inpregnancy 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 Seek advice from NENCLHPT for immunoglobulin advice 020 3837 7084 Out of Hours 020 7191 1860 or e-mail: nel.team@phe.gov.uk Cold sores resolve after 7 10d without treatment. Topical antivirals applied prodromally reduce duration by 12-24hrs 1 21

Section 2: Information for patients 1. Refer to NHS Choices http://www.nhs.uk/pages/homepage.aspx 2. Treating your infection document: http://www.rcgp.org.uk/clinical-and-research/target-antibioticstoolkit/~/media/2e1292605d174b318a5302223b04c175.ashx 3. Get better without using antibiotics https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/2 45826/3-PC-Get-well-soon-without-antibiotics1.pdf 4. Management of respiratory tract infections (coughs, colds, sore throats, and ear aches) in children http://www.whenshouldiworry.com/ 5. Home care is best poster for GP waiting area http://www.selfcareforum.org/wp-content/uploads/2011/07/poster_fin.pdf 6. Cough fact sheet http://dev.selfcareforum.org/wp-content/uploads/2013/04/cough_fin.pdf 7. Ear infection fact sheet http://dev.selfcareforum.org/wp-content/uploads/2013/04/ear_infection_fin.pdf 8. Sore throat fact sheet http://dev.selfcareforum.org/wp-content/uploads/2011/07/sore_throat_fin.pdf 22

Section 3: Notification of Infectious Diseases Registered medical practitioners (RMPs) have a statutory duty to notify suspected cases of certain infectious diseases (listed below). These can be notified via their local health protection team (HPT). For North East London, the relevant HPT is North East and North Central London (Tel: 02038377084, Fax: 020 3837 7086) Acute encephalitis Acute infectious hepatitis Acute meningitis Acute poliomyelitis Anthrax Botulism Brucellosis Cholera Diphtheria Enteric fever (typhoid or paratyphoid fever) Food poisoning Haemolytic uraemic syndrome (HUS) Infectious bloody diarrhoea Invasive group A streptococcal disease Legionnaires disease Leprosy Malaria Measles Meningococcal septicaemia Mumps Plague Rabies Rubella Severe Acute Respiratory Syndrome (SARS) Scarlet fever Smallpox Tetanus Tuberculosis Typhus Viral haemorrhagic fever (VHF) Whooping cough Yellow fever 23

References Public Health England Management of infection guidance for primary care for consultation and local adaptation. Published October 2014- latest review 14 November 2014. Useful Websites Public Health England Main Web Site https://www.gov.uk/government/organisations/public-health-england http://legacytools.hpa.org.uk/aboutthehpa/whattheagencydoes/localservices/nort heastandnorthcentrallondonhpt/ https://www.nice.org.uk/ 24