Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group Community Hospitals Urgent Care Centres and Out of Hours Care Antimicrobial Policy Prescribers should ensure 1. Prudent antibiotic prescribing by following the appropriate antibiotic guidelines and recommended durations to reduce the emergence of bacterial resistance in the community. 2. The use of antibiotic is appropriate and the clinical benefit of prescribing outweighs any potential risks (e.g. Clostridium difficile-associated diarrhoea). 3. The patient s medical records state the indications for all prescribed antibiotics. 4. The course duration is stated on primary care prescriptions and the prescription chart when prescribing antibiotics for patients in community hospitals 5. Any antibiotic allergy is documented in the patient s clinical record and state the nature of allergy to differentiate side effects from true hypersensitivity so that antibiotic treatment is not withheld for serious infection. 6. If samples are collected and sent for microbiological investigation, antibiotic choice is reviewed on the availability of the results. Use narrow spectrum agents when possible. 7. For difficult or complicated cases or for further advice on antibiotic management beyond that given in the antibiotic guidelines, a microbiologist is contacted. 8. If advice is required from a microbiologist, ensure essential clinical information is readily available, such as patient identification details, recent clinical history and current and recent antimicrobial therapy. 9. Antibiotic prescribing is regularly monitored to ensure prudent prescribing and compliance to antibiotic guidelines. 10. Department of Health s Standing Medical Advisory Committee (SMAC) advice is followed: No prescribing of antibiotics for simple coughs and colds No prescribing of antibiotics for viral sore throats Uncomplicated cystitis in otherwise fit women limit course to 3 Limit prescribing of antibiotics over the telephone to exceptional cases 11. Advocate patient education regarding the benefits and disadvantages of antimicrobial agent.
Antimicrobial Guidance -Principles of Treatment 1. This guidance is based on the best available evidence but its application must be modified by professional judgement. 2. Where a best guess therapy has failed or special circumstances exist, GPs can obtain microbiological advice from 0116 2586544 between 9am-11am, 12noon-1pm and 3pm-5pm (outside of these times the doctors are on ward rounds etc.) However, if your call is urgent ring the LRI switchboard and ask to speak to the microbiology registrar on call who will take your call at any time between 9am-5pm. There is always a microbiologist on call out of hours (via LRI switch board) that you can speak to for clinical advice. 3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. SECOND LINE IF RESPIRATY TRACT INFECTIONS: A. UPPER RESPIRATY TRACT INFECTIONS: Pharyngitis / Sore throat / Tonsillitis Avoid antibiotics as 90% resolve in 7 without antibiotics. Consider an antibiotic if patient has Centor score of 3 or 4 (Centor score predicts likelihood of Streptococcus pyogenes as the causative organism. 1 point each for Lymphadenopathy; No cough; Fever; Tonsillar exudate) Phenoxymethylpenicillin (Penicillin V) 500mg QDS. Erythromycin 250mg QDS Otitis media (child doses) Otitis externa Sinusitis (acute and chronic) Many cases are viral Avoid antibiotics as 60% are better in 24 hours without antibiotics; they only reduce pain at 2 and do not prevent deafness. Optimise analgesia. Note: Otitis Media is rare in adults and does not require treatment Children with otorrhoea, or < 2 years with bilateral acute otitis media have greater benefit, but are still eligible for delayed prescribing. Cure rates similar at 7 for topical acetic acid or antibiotic + / - steroid. If cellulitis or disease extending outside ear canal observed, start oral antibiotics and refer. Amoxicillin (children) 1 month 1 year 125 mg TDS 1 5 years 250 mg TDS 5 12 years 500 mg TDS 12 18 years 500 mg TDS First use aural toilet (if available) & analgesia. Acetic acid 2% 1 spray TDS (Available as EarCalm spray ) Erythromycin (children) <2 years 125mg QDS 2-8 years 250mg QDS >8 years 250-500mg QDS Neomycin sulphate with corticosteroid 3 drops TDS for min 7 to max 14 Caused by a virus in more than 98% of people, and resolve in 14. Use adequate analgesia. Avoid antibiotics as only likely to help when there are features indicative of bacterial infection Acute sinusitis Amoxicillin 500mg TDS Doxycycline 200mg OD Chronic sinusitis Co-amoxiclav 625mg TDS
B. LOWER RESPIRATY TRACT INFECTIONS: Acute bronchitis SECOND LINE IF Antibiotics not indicated in absence of purulent muco-purulent sputum. Cough can be prolonged (up to 3 weeks (NICE 2008). Antibiotics most valuable if increased dyspnoea and increased purulent sputum. Amoxicillin 500mg TDS Doxycycline 200mg OD for 5 Acute exacerbation of COPD Community-acquired pneumonia - Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breathe and / or increased sputum volume. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in the last 3 months Start antibiotics immediately Amoxicillin 500mg TDS If resistance Co-amoxiclav 625 mg TDS Amoxicillin 500mg TDS If atypical pneumonia likely consider adding Doxycycline 200mg OD Doxycycline 200mg OD Doxycycline 200mg OD for 5 As single agent for both penicillin allergy and atypical pneumonia Additional clinical review maybe required in unresponsive patients. Pertussis For management of patients with pertussis please see the guidance on the UHL Antimicrobial website under tab A-Z index > alphabet P > Pertussis. http://insite.xuhl-tr.nhs.uk/antibiotic/ Bronchiectasis Unless advised otherwise by secondary care Amoxicillin 500mg TDS for 10 Erythromycin 500mg QDS Clarithromycin 500mg BD Doxycycline 200mg stat then 100mg OD for 10
SECOND LINE IF URINARY TRACT INFECTIONS: In the elderly (>65 yrs), do not treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter, do not treat if systemically well. If multi-resistant coliform (e.g. ESBL) previously isolated (in last 3 months) send urine for C&S and follow Primary care guidance via the following link http://www.lmsg.nhs.uk/wp- content/uploads/2015/09/extended-spectrum-beta-lactamase-esbl-urinary-tract-infection-uti- Guidance-in-Primary-Care.pdf Note new reference for nitrofurantoin contraindication: Contraindicated in patients with an estimated glomerular filtration rate (egfr) of less than 45 ml/min (previously 60ml/min). However, a short course (3 to 7 ) may be used with caution in certain patients with egfr of 30 to 44 ml/min with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects after discussion with microbiologist. Uncomplicated UTI Complicated UTI UTI in pregnancy UTI in children Acute pyelonephritis Young-middle aged nonpregnant females with symptoms of lower urinary tract infections Trimethoprim 200mg BD for 3 Nitrofurantoin 50mg QDS for 3 If non response send urine for culture and sensitivity test Males, older women, abnormal renal tract, immunocompromised patients, or history of recurrent UTI's Trimethoprim 200mg BD Nitrofurantoin 50mg QDS Treatment based on culture results if allergic or resistant to first line agents Special consideration: If organism is found to be resistant to Trimethoprim consider Nitrofurantoin 50mg QDS for 5 if renal function allows. Alternative co-amoxiclav 625mg TDS In catheterised patients follow the antimicrobial guidance for management of catheterised patients in community via LMSG link http://www.lmsg.nhs.uk/wpcontent/uploads/2015/06/catheter-uti-guidance-may-2013.pdf Send MSU for culture. Use urine culture and sensitivity results, when available, to review antibiotic choice. May need specialist input. Child <3 months: refer urgently for assessment. Child 3 months: Send pretreatment MSU for all. Use positive nitrite to start antibiotics. Send MSU for culture. Review microbiological sensitivity results and change antibiotic if needed First Trimester: Nitrofurantoin 50mg QDS Cefalexin 500mg BD Second Trimester: Nitrofurantoin 50mg QDS Trimethoprim 200mg BD Third Trimester: Trimethoprim 200mg BD Cefalexin 500mg TDS For lower UTIs: Trimethoprim for 3 Or Nitrofurantoin for 3 (see BNF for doses) For upper UTIs: Co-amoxiclav for 7-10 (see BNF for doses) In penicillin allergy, please confirm child has true allergy and not side effect -Cefalexin for 7-10 (see BNF for doses) Co-amoxiclav 625mg TDS for 14 Ciprofloxacin 500mg BD for 7
SECOND LINE IF GASTRO-INTESTINAL TRACT INFECTIONS: Clostridium difficileassociated diarrhoea Gastroenteritis Traveller s diarrhoea Acute Diverticulitis Follow LLR Primary care guidelines according to severity of disease, use the following link on the LMSG website http://www.lmsg.nhs.uk/wpcontent/uploads/2015/06/communitycdifficilepathwayawpratifiednov2014-lmsglogo.pdf Antibiotics not usually indicated. In the case of E coli: 0157 in children, antibiotics may increase the likelihood of HUS (haemolytic uraemic syndrome) Routine prescribing of antibiotic not advised. Avoid inappropriate sampling for Clostridium difficile Infection where traveller s diarrhoea is likely, as Clostridium difficile may be present but not the cause of current symptoms. This has previously led to inaccurate high report rates of Clostridium difficile Infection Routine use of antibiotics in uncomplicated diverticulitis is not of value as the evidence is sparse, of low quality, and conflicting Restrict antibiotics to patients with signs of systemic infection Co-Amoxiclav 375mg TDS Ciprofloxacin 500mg BD GENITAL TRACT INFECTIONS: Refer patients with risk factors for STIs (<25yrs, no condom use, recent (<12mth) or frequent change of sexual partner, previous STI, symptomatic partner) to GUM clinic or general practices with level 2 or 3 expertise in GUM. Vaginal candidiasis In pregnancy avoid oral azole. Clotrimazole 10% 5g vaginal cream single dose Clotrimazole 500mg pessary single dose Fluconazole 150mg orally single dose Bacterial vaginosis (notably Gardnerella vaginalis infections) Avoid 2g single dose oral metronidazole in pregnancy and breast feeding Metronidazole 0.75% vaginal gel 5g applicatorful at night Clindamycin 2% cream 5g applicatorful at night If adherence to treatment is an issue, a single oral dose of Metronidazole - 2 g (associated with a higher relapse rate).
Chlamydia Refer contacts to GUM Azithromycin 1g STAT 1 trachomatis clinic. hour before or 2 hours Endometritis Trichomoniasis Pelvic Inflammatory Disease (PID) First line combination recommended in breast feeding Refer to GUM. Treat partners simultaneously. In pregnancy and breast feeding avoid 2g single dose metronidazole after food Cefalexin 500mg TDS Metronidazole 2g single dose SECOND LINE IF Doxycycline 100mg BD If allergic to first line choice Ciprofloxacin 500 mg BD Clindamycin 300 mg QDS for 5 Refer woman and contacts to GUM clinic. If gonorrhoea likely (e.g. previous N. gonorrhoea infection, when the patient s partner has gonorrhoea, in clinically severe disease, following sexual contact abroad, recent change of sexual partner) use ceftriaxone regimen A regimen of metronidazole and doxycycline without ceftriaxone IM is not recommended. Ceftriaxone IM is to maximise tissue levels and overcome low level resistance therefore do not replace with oral cephalosporins Ceftriaxone IM 500mg stat for 14 Doxycycline 100mg BD for 14 If gonorrhoea likely use first line ceftriaxone regimen as 28% of gonorrhoea isolates now resistant to quinolones Ofloxacin 400mg twice daily Metronidazole 400mg twice daily for 14 Postnatal perineal wound infections Balanitis (adults) Prostatitis Inspect perineum and clinical indication for antibiotic Take swab for culture and sensitivity Review in 48 hours If no improvement refer to Maternity Admission Unit Suspected or confirmed streptococcal balanitis Acute Send MSU for culture and start antibiotics. 4 week course may prevent chronic prostatitis Chronic Refer to urology & consider prescribing antibiotics if there is history of UTI (or an episode of acute prostatitis) within the last 12 months Flucloxacillin 1gm QDS First line combination recommended in breast feeding Flucloxacillin 500mg QDS Trimethoprim 200mg BD for 28 Trimethoprim 200mg BD for 28 then reassess Clindamycin 300mg QDS Erythromycin 500mg QDS Clarithromycin 500mg BD Ofloxacin 200mg BD for 28 Ciprofloxacin 500mg BD Ofloxacin 200mg BD for 28 then reassess
Epididymo-orchitis Always important to exclude torsion in suspected epididymoorchitis SECOND LINE IF If gonococcal infection suspected e.g. previous N. gonorrhoea infection; known contact of gonorrhoea; presence of purulent urethral discharge, men who have sex with men and black ethnicity. Refer patient and contacts to GUM clinic (BASHH 2010/11 guidelines usual age differentiation 35 years).check for recent change of sexual partner Probably due to chlamydia or other non-gonococcal organisms (Often <35) Doxycycline 100mg BD for 10-14 Ofloxacin 200mg BD for 14 Probably due to enteric organisms (Often >35 years) Ofloxacin 200mg BD for 14 Ciprofloxacin 500mg BD for 10 SKIN / SOFT TISSUE INFECTIONS: Acne Minocycline is not recommended. Refer to Leistershire Medicines Formulary for guidance in detail http://leicestershire.formulary.co.uk/chapterssubdetails.asp?formularysectionid=1 3&SubSectionRef=13.06&SubSectionID=A100 Impetigo Localized infections. Topical treatment with. Fusidic acid TDS for 7 Resistance may emerge on use during treatment, move to oral Extensive severe infection including systemic symptoms Flucloxacillin 500mg QDS In children: Flucloxacillin <2 yrs 62.5 125mg QDS 2-10yrs 125 250mg QDS >10yrs 250 500mg QDS Erythromycin 500mg QDS for 5 Cellulitis Follow Primary care cellulitis pathway via LMSG http://www.lmsg.nhs.uk/wp-content/uploads/2015/05/cellulitis-pathway-march-2015- FINAL.pdf Leg ulcers Diabetic foot infection Except in the presence of cellulitis antibiotics are not indicated Follow specialist community guidelines according to severity of disease via UHL antimicrobial website http://insite.uhl-tr.nhs.uk/antibiotic/.> A-Z index > alphabet D > Title: Antimicrobial Guidelines for the Empirical Management of Diabetic Foot Infections. There is a multidisciplinary team for diabetic foot infection management and covers a range of severity and risk to limb.
SECOND LINE IF Mastitis Flucloxacillin 500mg QDS for 10 Erythromycin 250mg-500mg QDS for 10 Bites Animal Human Consider Blood Borne Viruses (BBV) risk from human bites. Review at 24-48hrs. Surgical toilet most important Co-amoxiclav 625mg TDS Metronidazole 400mg TDS Doxycycline 200mg OD Metronidazole 400mg TDS Erythromycin 500mg QDS Scabies Treat all home and sexual contacts within 24 hours. Treat whole body from ear/chin downwards and under nails. If <2 yrs or elderly also treat face/scalp. See BNF for cautions and contraindications of treatment. Permethrin 5% - apply over whole body and wash off after 8-12 hrs. Repeat after 7. Malathion 0.5% - apply over whole body and wash off after 24 hrs. Repeat after 7. Boils (carbuncles and furuncles) Repeated episodes of boils maybe associated with the presence of a PVL +ve S.aureus. This may need further investigation, please discuss with microbiology. Note: Hidradenitis suppurativa, would require a referral to a dermatologist For small or multiple small boils: antibiotic treatment not routinely necessary For large boils treatment: incision and drainage Conjunctivitis (purulent) Treat if severe only, as most viral or self-limiting.. Treat if severe only. Most Chloramphenicol 0.5% bacterial conjunctivitis is selflimiting. 65% resolve with reducing to QDS drops apply 2hrly placebo by day five Chloramphenicol 1% ointment apply at night until 48hrs after resolution Fusidic acid 1% eye gel apply BD until 48 hrs. after resolution
SECOND LINE IF Varicella zoster / chicken pox & Herpes zoster / shingles Paronychia Dermatophyte infection of proximal finger or toenail. Confirm diagnosis. SPLENECTOMY Pregnant / immunocompromised / neonate seek urgent specialist advice Shingles: treat if > 50 yrs and within 72 hours of rash; or if active ophthalmic or Ramsey Hunt or eczema. If indicated: Aciclovir 800mg five times a day (Only if compliance a problem as ten times cost) Valaciclovir 1g TDS Famciclovir 250mg TDS for 7 Antibiotics not routinely indicated. Consider incision and drainage or if performed but person has signs of cellulitis refer to cellulitis guidelines Mild and superficial Oral treatment Amorolfine 5% nail laquer (OTC) 6 months for fingernails 9-12 months for toenails Terbinafine 250mg OD 6 weeks-3 months in fingernails 3-6 months for toe nails. (Monitor LFTs) Pulsed itraconazole 200mg BD repeated after 21 ; 2-3 pulsed courses for fingernails 3-4 pulsed courses for toenails. May take longer to treat in older people (Monitor LFTs) Vaccinations also required refer to UHL guidance for details. http://insite.xuhltr.nhs.uk/antibiotic/ -Antimicrobial website link. >A-Z INDEX >splenectomy Phenoxymethylpenicillin Erythromycin 500mg BD (penicillin V) 250mg BD life-long life-long DENTAL ABSCESS MENINGITIS/Meningococcal Disease Advice patient to seek dental treatment with own dentist or Out Of Hour dental Clinic/Services as soon as possible. Antibiotics are generally not indicated for otherwise healthy individuals with no signs of spreading infection Suspected Transfer all patients to meningococcal hospital immediately. IV or IM benzylpenicillin disease Administer benzylpenicillin Adults and children prior to admission, unless history of anaphylaxis, NOT allergy. Ideally IV but IM if a 10 yrs and over: 1200mg Children 1-9 yrs: 600mg Children <1 yr: 300mg vein cannot be found. Prevention of secondary case of meningitis: attending clinician should notify all cases to Public Health Doctor: 9am-5 pm: 0116263 1400 and out of hours on 0115 9296477 when public health will decide if contacts should receive preventative antibiotics.
LAST REVIEW: May 2014 NEXT REVIEW: April 2017 GINATS: Dr D Modha, Dr A Swann, Kate Dawson REVIEWERS: Dr A Swann, Michelle Lord, Nicola Illingworth, Mini Satheesh, Jas Kaur, Tejus Khatau, Dr P Danaher, Dr RS Hurwood APPROVED BY : Leicestershire Medicines Strategy Group RATIFIED BY: Antimicrobial Working Party Review record Date Issue No. Reviewed By Description of change (if any) November 2012 2 Dr D Modha, Joanne Charles, Phyllis Navti May 2014 3 Dr A Swann, Michelle Lord, Nicola Illingworth, Mini Satheesh, Jas Kaur, Tejus Khatau, Dr P Danaher, Dr RS Hurwood Update review Review of Antimicrobial Policy (modification of statement 1 and addition of statement 5, 10, 11 ) Combining the Policy and Guidance into single document. Change of format of antibiotic choice to first line and second line/penicillin allergic columns Addition of Centor score statement under pharyngitis/sore throat/tonsillitis. Addition of Ear calm spray under otitis externa Addition of risk factors for antibiotic resistance and antibiotic to treat this under Acute exacerbation of COPD Change in definition of complicated and uncomplicated UTI,duration of treatment, additional text to second line options Addition of Cefalexin as second line agent in penicillin allergic patients under upper UTI for children Review of bacterial vaginosis and trichomoniasis and addition of metronidazole stat dose to treatment options Addition of second line agents to Pelvic Inflammatory disease Addition of the following new indication with suggested treatment/recommendation- bronchiectasis, traveller s diarrhoea, acute diverticulitis, post natal endometritis, post natal perineal wound infection, adult balanitis, chronic prostatitis,epididymo-orchitis, acne,paronychia,dermatophyte infection of proximal finger and toenail, splenectomy, dental abscess Deletion of treatment option in cellulitis and diabetic foot infection and addition of text and link to specialist community guidance for this indication. Change of treatment course length in mastitis to 10 Deletion of references supporting treatment choice November 2014 4 Dr A Swann, Dr P Danaher, Mini Satheesh Updated nitrofurantoin new reference for contraindication under section urinary tract infection
September 2015 4 Mini Satheesh Updated information and included LMSG website link to new Primary Care ESBL Guidance.