Guideline for Management of Infection in Primary Care (based on the PHE Management of Infection Guidance for Primary Care 2014)

Guideline for Management of Infection in Primary Care (based on the PHE Management of Infection Guidance for Primary Care 2014) Ratified by: Prescribing & Medicines Management Group Date ratified: Name of originator / author: Name of responsible committee / individual: Atisha Sharma Medicines Management Group/Medicines Management Team Date issued: May 2015 Review date: December 2016 Target audience: Keyword Search Version Control The policy is to be used by all staff involved in the care of patients in primary care. Antibiotic, Infection, Management Version Date Author Status Comment 1 11/11/2014 Atisha Sharma Draft First Draft 2 13/11/2014 Tabassum Khan Draft Comments incorporated 3 14/11/2014 Sangeeta Sharma Draft Comments incorporated 4 05/01/2014 Sandra Chung Draft Comments incorporated 5 6 7 8 9 Contents Note: Doses and recommendations are oral and for adults unless otherwise stated. Please refer to the current BNF or BNFC for further Date reviewed: February 2015 Next Review Date: December 2016 Page 1 of 19

Section Page 1 Introduction 3 2 Purpose 3 3 Scope 3 4 Duties 4 5 Definitions 4 6 Guidance for Management of Infections 4 7 References 19 Note: Doses and recommendations are oral and for adults unless otherwise stated. Please refer to the current BNF or BNFC for further Date reviewed: February 2015 Next Review Date: December 2016 Page 2 of 19

Data Protection Act 1998 Data Protection issues have been considered with regard to this policy. Adherence to this policy will therefore ensure compliance with the Data Protection Act 1998 and internal Data Protection Policies. Diversity Policies Equality issues have been considered with regard to this policy. Adherence with this policy will therefore ensure compliance with Equal Opportunity legislation and internal Equal Opportunity policies. Freedom of Information Act 2000 Freedom of Information issues have been considered with regard to this policy. Adherence with this policy will therefore ensure compliance with the Freedom of Information Act 2000 and internal Freedom of Information Policies. Health and Safety Act 1974 Health and Safety issues have been considered with regard to this policy. Adherence with this policy will therefore ensure compliance with Health and Safety legislation and internal Health and Safety policies. Human Rights Act 1998 The Human Rights Act 1998 has been considered with regard to this policy. Proportionality has been identified as the key to Human Rights compliance. This means striking a fair balance between the rights of the individual and those of the rest of the community. There must be a reasonable relationship between the aim to be achieved and the means used. 1 Introduction This document has been drawn up to guide staff on the management of infection in a primary care environment and is based on the guidance document from the Public Health England (Management of Infection Guidance for Primary Care for Consultation and Local Adpatation October 2014) This guideline should be read in conjunction with the current BNF, BNFC (where necessary) and the relevant NICE and Department of Health guidelines. 2 Purpose To provide a simple, empirical approach to the treatment of common infections. To promote the safe, effective and economical use of antibiotics. To minimise the emergence of bacterial resistance in the community. 3 Scope This guideline is to be used by all primary care staff involved in the care of patients in primary care. Note: Doses and recommendations are oral and for adults unless otherwise stated. Please refer to the current BNF or BNFC for further Date reviewed: February 2015 Next Review Date: December 2016 Page 3 of 19

4 Duties within the organisation 4.1 Responsible Committee The Hounslow CCG Medicines Management Group is responsible for this guideline approval. 4.2 All Staff The policy is to be used by all primary care staff involved in the care of patients in primary care. 5 Definitions BNF British National Formulary BNFC British National Formulary for Children DH Department of Health PHE Public Health England NICE National Institute of Clinical Excellence CCG- Clinical Commissioning Group WMUH West Middlesex University Hospital Further abbreviations used within the guidance are listed at the end of the tabular section. 6 Guidance for management if infection Principles of treatment This guidance is based on the best available evidence but professional judgement should be used and patients should be involved in the decision. It is important to initiate antibiotics as soon as possible in severe infection. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. In severe or recurrent cases consider a larger dose or longer course. Please refer to BNF for further dosing and interaction if needed and please check hypersensitivity. Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. Consider a NO, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections and mild UTI symptoms. Use simple generic antibiotics first wherever possible. Avoid broad-spectrum antibiotics (e.g. co-amoxiclav, quinolones( e.g. Ciprofloxacin) and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs. Do not prescribe an antibiotic for viral sore throat or simple coughs and colds. Note: Doses and recommendations are oral and for adults unless otherwise stated. Please refer to the current BNF or BNFC for further Date reviewed: February 2015 Next Review Date: December 2016 Page 4 of 19

Limit prescribing over the telephone to exceptional cases. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations e.g. fusidic acid). In pregnancy take specimens to inform treatment; AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole (2g). Shortterm use of nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is not expected to cause problems to the foetus. Trimethoprim also unlikely to cause problems unless poor dietary folate intake or taking another folate antagonist such as antiepileptic. Where empirical therapy has failed or special circumstances exist, microbiology advice can be obtained from Speciality Name Contact details email Microbiology Dr Prasanna 01895 279290 Prasanna.kumari@thh.nhs.uk Consultant Kumari Microbiology Dr Arup Ghose 01895 279115 Arup.ghose@thh.nhs.uk Consultant Pathology service 01895 279285 Microbiology Consultant (WMUH) Dr Farhana Butt 020 8321 6882 Farhana.Butt@wmuh.nhs.uk If patients are being treated by West Middlesex University Hospital please use the following contacts:- Microbiologist Registrar or consultant doing clinical work: 020 8321 5858 or 020 8560 2121 (switchboard) and bleep 316.. Note: Doses and recommendations are oral and for adults unless otherwise stated. Please refer to the current BNF or BNFC for further Date reviewed: February 2015 Next Review Date: December 2016 Page 5 of 19

Tables separated into therapeutic areas: UPPER RESPIRATY TRACT INFECTIONS: consider deferred (post-dated) antibiotic prescriptions ILLNESS DRUG DOSE DURATION Influenza Acute sore throat OF COMMENTS TREAMENT Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults the use of antivirals is not recommended. 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 and morbid obesity (BMI>=40). Use treatment with oseltamivir 75mg BD or if there is resistance to oseltamivir or severe immunosuppression use zanamivir 10mg BD (2 inhalations by diskhaler for up to 10 days) and seek advice. For prophylaxis, see NICE. (NICE Influenza). See PHE Influenza guidance for treatment of patients under 13 years or in severe immunosuppression (and seek advice) 1 st line: Phenoxymethylpenicillin 500mg QDS 1g QDS when severe 10 days Avoid antibiotics as 90% resolve in without, and pain only reduced by 16 hours. Penicillin Allergy: Clarithromycin For doses in children see BNFC 250-500mg BD The Centor score helps delineate management of a child or adult with potential Group A streptococcus (GAS). There are four parts to the score, and each receives one point: 1. Fever (greater than 100.4 F or 38 C) 2. Exudates or swelling of tonsils 3. Tender lymphadenopathy of anterior cervical nodes 4. Lack of cough If Centor score 3 or 4:(Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) consider 2 or 3-day delayed or immediate antibiotics or rapid antigen test. Date reviewed: February 2015 Next Review Date: December 2016 Page 6 of 19

Acute Otitis media (child dose) Amoxicillin Penicillin Allergy: Erythromycin Child doses Neonate 7-28 days: 30mg/kg (max 125mg) TDS 1mth-1 year: 125mg TDS 1-5 yrs: 250mg TDS 5-18 yrs: 500mg TDS 1mth to 2yrs:125mg QDS 2-8yrs: 250mg QDS 8-18yrs: 250-500mg QDS Acute Otitis media (AOM) resolves in 60% in 24hrs without antibiotics, which only reduce pain at 2 days and does not prevent deafness Optimise analgesia and target antibiotics. Consider 2 or 3-day delayed or immediate antibiotics for pain relief if: <2 years AND bilateral acute AOM or bulging membrane and 4 marked symptoms All ages with otorrhoea ILLNESS DRUG DOSE DURATIO Acute Rhinosinusitis Amoxicillin Doxycycline Phenoxymethylpenicillin For persistant symptoms: Co-amoxiclav 500mg TDS 1g TDS if severe 200mg stat then 100mg OD 500mg QDS 625mg TDS N OF TX COMMENTS Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after Use adequate analgesia Consider 7-day delayed or immediate antibiotic when purulent nasal discharge In persistent infection use an agent with anti-anaerobic activity eg. co-amoxiclav Date reviewed: February 2015 Next Review Date: December 2016 Page 7 of 19

LOWER RESPIRATY TRACT INFECTIONS ILLNESS DRUG DOSE DURATION COMMENTS OF TX 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 Amoxicillin Doxycycline 500mg TDS 200mg stat then 100mg OD Antibiotic little benefit if no co-morbidity. Symptom resolution can take 3 weeks. Consider 7day delayed antibiotic with advice Consider immediate antibiotics if >80yr and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure >65yrs with 2 of above. Acute exacerbation of COPD Community acquired pneumonia treatment in the community Amoxicillin Doxycycline Clarithromycin If resistance: Co-amoxiclav IF CRB65=0: Amoxicillin Clarithromycin Doxycycline If CRB65=1 and AT HOME Amoxicillin AND Clarithromycin 500 mg TDS 200 mg stat then 100 mg OD 500 mg BD 625 mg TDS 500mg TDS 500mg BD 200mg stat then 100mg OD 500mg TDS 500mg BD 7-10 days. Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume. Risk factors for antibiotic resistant organisms include comorbid disease, severe COPD, frequent exacerbations and antibiotics in last 3 months. Use CRB65 score or CRP to help guide and review: Each scores 1: Confusion (abbreviated mental test score <8); Respiratory rate >30/min; BP systolic <90 or diastolic 60; Age >65; Score 0: suitable for home treatment; Score 1-2: hospital assessment or admission Score 3-4: urgent hospital admissionmycoplasma infection is rare in over 65s doxycycline alone 200mg stat then 100mg OD 7-10 days Date reviewed: February 2015 Next Review Date: December 2016 Page 8 of 19

MENINGITIS ILLNESS DRUG DOSE DURATION Suspected meningococcal disease (Transfer all patients to hospital immediately) Prevention of secondary case of meningitis Benzylpenicillin IV or IM Cefotaxime IM or IV Children <1 yr: 300 mg Children 1-9 yr: 600 mg Age 10+ years: 1200 mg Child < 12 yrs: 50mg/kg Age 12+ years: 1gram OF TX (give IM if vein cannot be found) COMMENTS 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 Only prescribe following advice from HPA consultant in communicable diseases 9am 5pm: 020 8327 7181 Out of hours contact on-call Public Health duty doctor via Hillingdon Switchboard: 01895 238282 URINARY TRACT INFECTIONS ILLNESS DRUG DOSE DURATION COMMENTS OF TX People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma. Date reviewed: February 2015 Next Review Date: December 2016 Page 9 of 19

UTI in adults (no fever or flank pain) UTI in pregnancy Nitrofurantoin (First line: nitrofurantoin if GFR over 45ml/min) Trimethoprim Pivmecillinam If organism susceptible: Amoxicillin 50mg QDS 200mg BD 400mg STAT then 200mg TDS 500mg TDS Women all ages 3 days Men Treatment Failure: perform culture in all. Always safety net Community multi-resistant ESBL are increasing. Use nitrofurantoin first line. If GFR <45ml/min consider pivemecillinam. Risk factors for increased resistance include: care home resident, recurrent UTI, hospitalisation >7days in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones. If resistance risk send culture for susceptibility testing and give safety net advice. 1st 2 nd Trimester: Cefalexin 500mg BD or nitrofurantoin 100mg Modified Release BD GFR 30-45ml/min: only use if resistance & no alternative Treat women with severe/or 3 symptoms Women mild/or 2 symptoms AND a)urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors for infection. b) If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% positive predictive value ; nitrite, leucocytes, and blood all negative has a 76% negative predictive value c) Consider a back-up/ delayed antibiotic option Men: Consider prostatitis and send pre-treatment MSU if symptoms mild/non-specific, use negative dipstick to exclude UTI Send MSU for culture & sensitivity and start empirical antibiotics even if asymptomatic. Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. 3 rd trimester :Cefalexin or Trimethoprim 500mg BD 200mg BD (off label) Avoid trimethoprim if low folate status or on folate antagonist (eg antiepileptic or proguanil) Date reviewed: February 2015 Next Review Date: December 2016 Page 10 of 19

UTI in children Lower UTI: Trimethoprim Nitrofurantoin if susceptible, Amoxicillin Second line: Cefalexin See BNFC for dosage Lower UTI 3 days Child <3 mths: refer urgently for assessment Child 3 mths: use positive nitrite to guide start antibiotics also send pre-treatment MSU. Imaging: only refer if child <6 months, recurrent or atypical UTI. Upper UTI: Co-amoxiclav Upper UTI 7-10 days Second line: Cefixime Acute pyelonephritis Co-amoxiclav Ciprofloxacin 625mg TDS 500mg BD 7days If admission not needed, send MSU for culture & susceptibility and start antibiotics If no response within 24 hours, admit Check sensitivities for guidance on choice of antibiotic to use If lab report shows sensitive: trimethoprim 200mg BD 14 days If ESBL risk consult with microbiologist for advice Recurrent UTI in non-pregnant women 3 UTIs/year Nitrofurantoin Trimethoprim GASTRO-INTESTINAL TRACT INFECTIONS 50 100 mg 100 mg Post coital stat (offlabel) Prophylaxis OD at night review at 6 months ILLNESS DRUG DOSE DURATION OF TX 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 COMMENTS Date reviewed: February 2015 Next Review Date: December 2016 Page 11 of 19

Eradication of Helicobacter pylori Infectious diarrhoea Travellers diarrhoea Clostridium difficile diarrhoea Always use PPI Twice dailyfirst line and second line : PPI WITH amoxicillin PLUS Either clarithromycin metronidazole Penicillin allergy & previous Metronidazole +Clarithromycin: PPI with bismuthate (De-nol tab) PLUS metronidazole PLUS tetracycline hydrochloride Relapse &previous Metronidazole & Clarithromycin: PPI with amoxicillin PLUS tetracycline hydrochloride 1g BD 500mg BD 400mg BD 240mg BD 400mg BD 500mg QDS 1g BD 500mg QDS All for MALToma 14 days Treat all positives in known DU, GU or low grade MALToma Do not offer eradication for GD Do not use clarithromycin, metronidazole or quinolone if used in the past year for any infection. Penicillin allergy: use PPI plus clarithromycin and metronidazole; If previous clarithromycin use PPI + bismuthate+ metronidazole +tetracycline. In relapse see NICE. Retest for H.Pylori post DU/GU or relapse after second line therapy: using breath or stool test consider endoscopy for culture & susceptibility. Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection. Antibiotic therapy usually not indicated unless systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin 250 500 mg BD for 5 if treated early (within 3 days). Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers diarrhoea. If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private Rx). If quinolone resistance high (eg south Asia): consider bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment. 1 st episode Metronidazole (MTZ) 2 nd episode/ severe/type 027 oral Vancomycin 400mg TDS 500mg TDS (available as oral liquid) 125mg QDS 10-14 days 10-14 days Stop unnecessary antibiotics and/or PPIs. 70% respond to Metronidazole in 5days; 92% in 14days. If severe symptoms or signs (see below) should treat with oral vancomycin, review progress closely and/or consider hospital referral. Admit if severe: Temperature >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis. Recurrent disease see rationale: Oral vancomycin Seek advice from 125mg QDS, consider taper 10-14 days, or taper Date reviewed: February 2015 Next Review Date: December 2016 Page 12 of 19

microbiologist Threadworms >6 months: mebendazole (offlabel if <2yrs) 3-6 mths: piperazine+senna < 3mths: 6 weeks hygiene 100mg 2.5ml Stat Stat, repeat after 2 weeks 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 GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES ILLNESS DRUG DOSE DURATION STI screening Chlamydia trachomatis/ urethritis COMMENTS OF TX People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. 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 Azithromycin 1g stat Opportunistically screen all aged 15-25yrs Treat partners and refer to GUM service. Doxycycline 100mg BD Pregnancy or breastfeeding: Azithromycin Erythromycin Amoxicillin Epididymitis: low STI risk: Ofloxacin (specialist initiation only) 1g (off-label use) 500 mg QDS 500 mg TDS 200mg BD Stat 14 days Pregnancy or breastfeeding: Azithromycin is the most effective option. Do not use Doxycyline in pregnant or breastfeeding women. Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment. Date reviewed: February 2015 Next Review Date: December 2016 Page 13 of 19

Doxycycline 100mg BD 14 days For suspected epididymitis in men over 35 years with low risk of STI High risk, refer GUM Vaginal candidiasis Clotrimazole 500mg pessary or 10% vaginal cream Stat All topical and oral azoles give 75% cure. Fluconazole oral 150mg orally Stat In pregnancy: avoid oral azole and use intravaginal treatment for 7 days Pregnant: clotrimazole pessary Pregnant: 100 mg pessary at night 6 nights Bacterial vaginosis Trichomoniasis miconazole 2% cream Metronidazole oral Metronidazole 0.75% vaginal gel Clindamycin 2% cream Metronidazole Clotrimazole 5g intravaginally BD 400mg BD 2g 5g applicatorful ON 5g applicatorful ON 400mg BD 2g 100mg pessary ON stat 5 nights 7 nights 5- Stat 6 nights Oral metronidazoleis as effective as topical treatment but is cheaper. Less relapse with 7 day than 2g stat at 4 weeks. Pregnant/breastfeeding: avoid 2g stat Metronidazole. Treating partners does not reduce relapse Treat partners and refer to GUM service. In pregnancy or breastfeeding: avoid 2g single dose Metronidazole Consider clotrimazole for symptom relief (not cure) if Metronidazole declined. GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES ILLNESS DRUG DOSE DURATION OF TX COMMENTS Date reviewed: February 2015 Next Review Date: December 2016 Page 14 of 19

Pelvic inflammatory disease (PID) Metronidazole PLUS Ofloxacin (specialist initiation only) 400 mg BD 400 mg BD 14 days 14 days Refer woman and contacts to GUM service. Always culture for gonorrhoea and chlamydia. Acute prostatitis If high risk of gonorrhoea Ceftriaxone PLUS Metronidazole PLUS Doxycycline Ciprofloxacin Ofloxacin (specialist initiation only) 500 mg IM 400 mg BD 100 mg BD 500mg BD 200mg BD Stat 14 days 14 days 28 days 28 days 28% of gonorrhoea isolates now resistant to quinolones. If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM. Send MSU for culture and start antibiotics. 4-week course may prevent chronic prostatitis. Quinolones achieve higher prostate levels. 2 nd line Trimethoprim 200mg BD Genital herpes Treatment: Aciclovir First Episode: 200 mg five times daily or 400mg TDS 28 days Increase the dose to 400 mg five times daily if absorption is impaired in immunocompromised patients. A longer course of treatment may be needed if new lesions appear or healing is incomplete and in immunocompromised patients (7-10 days) SKIN / SOFT TISSUE INFECTIONS ILLNESS DRUG DOSE DURATION OF TX Impetigo oral Flucloxacillin 500 mg QDS COMMENTS For extensive, severe, or bullous impetigo, use oral antibiotics. Eczema If penicillin allergic: oral Clarithromycin topical Fusidic acid MRSA only Mupirocin 250-500 mg BD TDS TDS Reserve topical antibiotics for very localised lesions to reduce the risk of resistance. Reserve mupirocin for MRSA If no visible signs of infection use of antibiotics (alone or with steroids) encourages resistance and does not improve healing. In eczema with visible signs of infection, use treatment as in impetigo. Cellulitis Flucloxacillin If penicillin allergic: 500 mg QDS All. If slow response If patient afebrile and healthy other than cellulitis, use oral Flucloxacillin alone. Date reviewed: February 2015 Next Review Date: December 2016 Page 15 of 19

Clarithromycin Clindamycin 500 mg BD 300 450 mg QDS continue for a further If river or sea water exposure, discuss with microbiologist. If febrile and ill, admit for IV treatment. If facial: Co-amoxiclav 625 mg TDS Stop Clindamycin if diarrhoea occurs. Leg ulcers Active infection if cellulitis/increased pain/pyrexia/purulent exudate /odour. Ulcers always colonized. Antibiotics do not improve healing unless active infection. As for cellulitis If active infection, send pre-treatment swab. If active infection: Flucloxacillin Clarithromycin 500 mg QDS 500 mg BD MRSA Review antibiotics after culture results. Doxycycline alone Trimethoprim 100mg BD 200mg BD For MRSA screening and suppression, see PHE 2014 MRSA Quick Reference Guide Do NOT use clindamycin. For active MRSA infection, confirmed by lab results Use antibiotics sensitivities to guide treatment. Animal bite / Human bite Co-amoxiclav (Prophylaxis or treatment) If penicillin allergic: Metronidazole PLUS Doxycycline (cat/dog/man) Metronidazole PLUS Clarithromycin (human bite) 375-625 mg TDS 400 mg TDS 100 mg BD 200-400 mg TDS 250-500 mg BD All for If severe infection or no response to monotherapy after 24-48 hours, seek advice from microbiologist Thorough irrigation is important. Assess risk of tetanus, HIV, hepatitis B&C. Antibiotic prophylaxis is advised. Assess risk of tetanus and rabies. 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 AND review at 24&48hrs SKIN / SOFT TISSUE INFECTIONS ILLNESS DRUG DOSE DURATION COMMENTS Date reviewed: February 2015 Next Review Date: December 2016 Page 16 of 19

OF TX Conjunctivitis If severe: Chloramphenicol 0.5% drops AND Chloramphenicol 1% ointment 2 hourly for 2 days then 4 hourly (whilst awake) At night All for 48 hours after resolution Treat if severe, as most viral or self-limiting. Bacterial conjunctivitis is usually unilateral and also self-limiting;it is characterised by red eye with mucopurulent, not watery, discharge; 65% resolve on placebo by day five. Scabies Second line: Fusidic acid1% gel Permethrin BD 5% cream Fusidic acid has less Gram-negative activity Treat all home and sexual contacts within 24hrs. Dermatophyte infection skin Dermatophyte Infection nail If allergy: Malathion Topical terbinafine or topical imidazole or (athlete s foot only): topical undecanoates (Mycota ) Superficial only: Amorolfine 5% nail lacquer First line: Terbinafine oral Second line: 0.5% aqueous liquid BD BD BD 1-2x/weekly 250mg OD 2 applications 1 week apart 1-2 weeks for 1-2 wks after healing (i.e. 4-6wks) Fingers:6 months Toes:12 months Fingernails: 6-12 weeks Toenails: 3-6 months Treat whole body from ear/chin downwards and under nails. If under 2yr/elderly, also face/scalp. Terbinafine is fungicidal, so treatment time shorter than with fungistatic imidazoles If candida possible, use imidazole. If intractable: send skin scrapings and if infection confirmed, use oral terbinafine/itraconazole. Scalp: discuss with specialist, oral therapy indicated Topical therapy only be considered if infection is mild and superficial or where systemic therapy is contra-indicated or not tolerated. Take nail clippings: start therapy only if infection is confirmed by laboratory. Terbinafine is more effective than azoles. Liver reactions rare with oral antifungals. If candida or non-dermatophyte infection confirmed, use oral itraconazole. Itraconazole 200mg BD a month For children, seek specialist advice. (course) Fingernails 2 courses Toenails 3 courses Varicella zoster / If indicated: Pregnant/immunocompromised/neonate: seek urgent specialist Date reviewed: February 2015 Next Review Date: December 2016 Page 17 of 19

chicken pox Herpes zoster / shingles Aciclovir (oral) Second line for shingles if compliance a problem, as ten times cost Valaciclovir or Famciclovir 800mg five times a day 1g TDS 500mg TDS or 750mg BD advice Chicken pox: IF onset of rash <24hrs and >14years or severe pain or dense/oral rash or secondary household case or steroids or smoker consider aciclovir. Shingles: treat if >50 years and within 72 hrs of rash (Postherpetic neuralgia is rare if <50yrs); 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 duration by 12-24 hours. Abbreviations used within these tables: BD - Twice a day BNF - British National Formulary BNFC - British National Formulary for Children COPD - Chronic Obstructive Pulmonary Disease DU - Duodenal Ulcer ED - Every Day ESBL - Extended-spectrum Beta-lactamase E. coli GFR - Glomerular Filtration Rate GD- Gastro-Oesophageal Reflux Disease GU - Gastric Ulcer GUM - Genito-Urinary Medicine HIV - Human Immunodeficiency Virus IM - Intra-muscular Date reviewed: February 2015 Next Review Date: December 2016 Page 18 of 19

IV - Intra-venous MALToma- Mucosa Associated Lymphatic Tissue MRSA - Methicillin Resistant Staphylococcus Aureus MSU - Mid Stream Urine NUD - Non Ulcer Dyspepsia OD - Once a day ON - At night PID - Pelvic Inflammatory Disease PPI - Proton Pump Inhibitor PU - Peptic Ulcer QDS - Four times a day STD - Sexually Transmitted Disease TDS - Three times a day Tx - Treatment UTI - Urinary Tract Infection WCC -White Cell Count 7 References 7.1 British National Formulary, No 68. British Medical Association and Royal Pharmaceutical Society of Great Britain. www.medicinescomplete.com 7.2 British National Formulary for Children, November 2014 accessed via www.medicinescomplete,com 7.3 Managing common infections: Guidance for Primary Care. Public Health England, October 2014 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366683/phe_primary_care_guidance_15_1 0_14_pivmecillinam.pdf 7.4 NHS PrescQIPP: Bulletin 55 January 2014v2.0 Topical antifungal nail treatment review Date reviewed: February 2015 Next Review Date: December 2016 Page 19 of 19