Antimicrobial Prescribing Guidelines for Primary Care 2017

Antimicrobial Prescribing Guidelines for Primary Care 2017 TABLE OF CONTENTS PRINCIPLES OF TREATMENT 3 SUMMARY OF UPDATES TO GUIDELINES 4 UPPER RESPIRATORY TRACT INFECTIONS Influenza 6 Pharyngitis / Sore Throat / Tonsillitis 7 Otitis Media 8 Otitis Externa 8 Acute Sinusitis 10 Chronic Bacterial Sinusitis 11 Dental Abscess 11 Conjunctivitis 12 LOWER RESPIRATORY TRACT INFECTIONS Acute Cough / Bronchitis 13 Acute Exacerbation of COPD 13 Community Acquired Pneumonia 14 Tuberculosis 15 Bronchiectasis 15 Whooping Cough 15 MENINGITIS Meningitis 16 URINARY TRACT INFECTIONS Algorithm for diagnosis of UTI in Adults 17 Lower UTI / Cystitis 18 Complicated UTI 19 UTI in Pregnancy 19 UTI in Children 21 Acute Pyelonephritis in Adults 23 Recurrent UTI in Women 23 GASTRO-INTESTINAL TRACT INFECTIONS Oral Candidiasis 24 Eradication of Helicobacter pylori 24 Infectious Diarrhoea 25 Clostridium difficile 25 Acute Diverticulitis 28 Traveller s Diarrhoea 28 Threadworms 28 Amoebiasis 29 Giardiasis 29 Cryptosporidiosis 29 GENITAL TRACT INFECTIONS Vaginal Candidiasis 30 Bacterial Vaginosis 30 Neisseria gonorrhoeae 31 Chlamydia trachomatis 31 Trichomoniasis 32 Pelvic Inflammatory Disease 32 1

Vaginal Discharge in a Child 33 Acute Prostatitis 33 Epididymitis +/- Orchitis 33 SKIN / SOFT TISSUE INFECTIONS Panton-Valentine Leukocidin (PVL) toxin producing S.aureus infection 34 Impetigo 34 Eczema 35 Cellulitis 35 Leg Ulcers and Pressure Sores 36 Diabetic Foot Ulcers 37 Osteomyelitis 37 Animal Bite 37 Human Bite 37 Boils 38 Wound Infection 39 MRSA 39 Mastitis and breast abscess 41 Acne 41 Headlice 42 Scabies 43 Crab Lice 43 Dermatophyte Infection of the Proximal Finger or Toe Nail 44 Mould Infections of the Nail 44 Dermatophyte Infection of the Skin 45 Dermatophyte Infection of the Scalp 45 Cutaneous Candidiasis 45 Pityriasis Versicolor 46 Varicella Zoster / Chicken Pox / Herpes Zoster / Shingles 46 Herpes Simplex Virus 46 SPLENECTOMISED PATIENTS AND THOSE WITH AFUNCTIONAL SPLEEN Splenectomised Patients and those with an afunctional Spleen 48 APPENDICES Appendix 1 Prescribing in Pregnancy and Breastfeeding 50 Appendix 2 References and Guidelines 51 Appendix 3 Consultees 52 Appendix 4 Delayed Prescription Service 52 Appendix 5 Antimicrobial Quick Reference Guide 52 or here Authors: Dr Amelia Joseph, Microbiology Specialty Registrar, Nottingham University Hospitals; Dr Vivienne Weston, Consultant Microbiologist, Nottingham University Hospitals; Laura Catt, Prescribing Interface Pharmacist, Mansfield and Ashfield CCG. Updated: December 2017. Next Review: December 2020. 2

Antimicrobial Prescribing Guidelines for Primary Care The electronic versions of this full guideline, its appendices and the quick reference guide can be accessed via: www.nottsapc.nhs.uk Principles of Treatment 1. This guidance has been adapted from national guidelines, including the Public Health England (PHE) guidelines, NICE clinical knowledge summaries (NICE CKS) and those produced by specialist associations. It is based on the best available evidence but its application must be modified by professional judgement and by involving patients in management decisions. 2. A dose and duration of treatment is suggested, but may need modification for age, weight and renal function. In severe or recurrent cases consider a larger dose or longer course. 3. Children s doses are quoted from the age of 1 month. For neonatal doses please consult the British National Formulary for children. 4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 5. Consider a no, or back-up/delayed, antibiotic strategy for self-limiting upper respiratory tract infections and mild UTI symptoms. 6. Limit prescribing over the telephone to exceptional cases. 7. In severe, persistent, recurrent or unusual infections, have a high index of suspicion for immunosuppressive illness and consider investigation e.g. Full Blood Count, HIV testing. 8. Use simple generic antibiotics first whenever possible. Avoid broad spectrum antibiotics particularly quinolones, co-amoxiclav and cephalosporins, when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs from multiresistant coliforms. Empirical use of these agents may be warranted where recommended in the guideline below 9. Avoid use (including empirical use) of quinolones in patients with previous MRSA or Clostridium difficile unless discussed with Microbiology 10. Avoid widespread use of topical antibiotics especially those agents also available as systemic preparations e.g. topical fusidic acid. 11. Prescribing in pregnancy and breastfeeding see appendix 1. 12. If a patient is unable to take amoxicillin capsules due to dietary or religious reasons, consider prescribing amoxicillin liquid as an alternative. If a patient is unable to take doxycycline capsules due to dietary or religious reasons, consider doxycycline dispersible tablets. In other cases or if in doubt, contact your community pharmacy or primary care pharmacist to discuss options. 13. Patients reporting an adverse reaction to antibiotics is relatively common. It is important to record what reaction the patient has experienced in the drug sensitivities section of the electronic record. In some cases it will be a common adverse drug reaction e.g. gastric upset rather than true allergy e.g. rash, angio-oedema or anaphylaxis. It is important to accurately document and communicate this distinction and the nature of the reaction to the patient and other healthcare professionals so it is clear if true allergy or an adverse reaction. Patients with a true allergy to penicillins will be allergic to all penicillins. They may also have a cross over allergy to other ß-lactams, risk is quoted as between 0.5 and 6.5% for cephalosporins. For further advice on antibiotic choice in allergy please contact a Medical Microbiologist. 14. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from either the Microbiology Department at Nottingham University Hospitals on 0115 9249924 ext 61163 or Sherwood Forest Hospitals on 01623 622515 ext 3616/3635. 3

15. Prescriber s are encouraged to access the range of resources available in the TARGET antibiotics toolkit available here: http://www.rcgp.org.uk/clinical-and-research/toolkits/targetantibiotics-toolkit.aspx and patient information leaflets on the RCGP website: UTI, Treating Your infection and a Get Well Soon Without Antibiotics leaflets. Summary of minor updates December 2017 Scarlet fever New section added Conjunctivitis New section on self-care for non-severe disease Sinusitis Wording changed to reflect new NICE guidance and link added Course length for treatment reduced to 5 days Addition of erythromycin for pregnant penicillin allergic patients Urine section Fosfomycin in men, changed from 3g three days later to 3g stat day 1 plus a further 3g on day three, as per updated PHE guidance Comment regarding the use of nitrofurantoin for lower UTI and egfr 30-45ml/min only if not alternative, with safety netting advice. Summary of the main updates July 2017 Principles of treatment Section 13 reiterates the importance of checking antibiotic allergy history and clear documentation Main guide: Influenza Infection control comment Post exposure prophylaxis doses added Sore throats Change from the Centor to the FeverPAIN score Otitis externa Change to generic gentamicin with hydrocortisone drops Minor wording change regarding aural toilet Dental abscess Addition of metronidazole if spreading infection Addition of gingivitis Meningitis Change to cefotaxime from benzylpenicillin Urine section Fosfomycin now choice for empiric therapy instead of ciprofloxacin. Clearer guidance that need to send urine for culture in >65 year olds (higher risk of resistance) Update to prophylaxis section to reflect full guide and addition of methenamine Catheter UTIs prompt to use of catheter passports to improve decision making and communication regarding urinary catheters. GIT New section added for Candidiasis Removal of piperazine as no longer available 4

H. pylori Options to lengthen the treatments duration to 14 days and a third line combination with levofloxacin added to reflect new European guidance and the updated NUH guidance. Added NICE indications for endoscopy and testing information. Genital Epididymitis/orchitis- change to ofloxacin to be in line with guidance Skin/soft tissue infections Minor change to wording to clarify advice Amorolfine nail lacquer 5% was removed due to limited clinical evidence Appendix 2 Removed as resistance data needs to be monitored and updated more frequently than every 3 years and best communicated in more regular newsletters 5

UPPER RESPIRATORY TRACT INFECTIONS Influenza A and B Treatment for influenza with antiviral agents in the community should only be considered when the Department of Health issue a notification that influenza is circulating in the community. Symptoms of influenza appear abruptly 2-3 days after exposure: Sore throat +/- dry unproductive cough Myalgia and weakness Headache Fever, typically 38-40 o C but may not be present at time of consultation Pain on eye movement, photophobia (rarer) Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals are not recommended. Treat at risk patients only when influenza is circulating in the community, and the patient can start therapy within 48 hours of symptom onset. Note that if the case is in a nursing/residential home other residents in at risk groups may need post-exposure prophylaxis please contact infection control team / local PHE team for advice. At risk: Pregnant women (including up to 2 weeks post-partum) 65 years or over Chronic respiratory disease (including COPD and asthma) Significant cardiovascular disease (not hypertension) Immunocompromised Diabetes mellitus Chronic renal, liver or neurological disease Morbid obesity BMI 40 Influenza Drug Dose Duration Only for at risk groups: Oseltamivir 75mg BD 5 days (10 days OD dosing for prophylaxis) If resistant to oseltamivir or severely immunosuppressed, 10mg BD 5 days (10 days OD dosing for prophylaxis and up to 10 days BD dosing) Pharyngitis / Sore Throat / Tonsillitis use Zanamavir (2 inhalations BD by If suspected or (diskhaler) diskhaler) confirmed oseltamivir resistance Post exposure prophylaxis: At risk groups and those not adequately protected by vaccination may be offered Prophylaxis. For current guidelines see PHE website or contact the local PHE office for guidance on 0344 225 4524. The majority of sore throats are viral but there is clinical overlap between viral and streptococcal infections. Organisms: Viral: Epstein Barr Virus, Enteroviruses, Adenoviruses, Cytomegalovirus. Bacterial: Group A streptococcus (Streptococcus pyogenes) (25-33% of cases), Group C and G streptococcus (role less clear). NB consider diphtheria if recent foreign travel e.g. former USSR/ Africa/ Middle East/South Asia. 6

Sore throat Sore throat is a disease that remits spontaneously and symptoms can be relieved with simple analgesics such as paracetamol and ibuprofen. The fever pain score predicts likelihood of Streptococcus as the causative organism. FeverPAIN is a five-item score based on: Fever, Purulence, Attend rapidly (3 days or less), severely Inflamed tonsils and No cough or coryza; A low FeverPAIN score 0-1: only 13-18% have streptococcus, close to background carriage. NO antibiotic strategy appropriate with discussion A FeverPAIN score 2-3: 34-40% have streptococcus. antibiotic is appropriate with discussion A back-up/ delayed A FeverPAIN score of >4: 62-65% have streptococcus, consider immediate antibiotic if symptoms are severe, or a short delayed prescribing strategy may be appropriate (48 hours) Studies have also shown that antibiotic treatment of a simple sore throat is more likely to result in the patient returning for antibiotic treatment in the future. 90% resolve within 7 days and antibiotics only shorten duration of symptoms by 16 hours. Evidence indicates that penicillin for 10 days is more effective than 3 or 7days. Twice daily higher dose should be used. QDS dosing may be more appropriate if severe. Antibiotics to prevent quinsy NNT >4000 and otitis media NNT 200. First line Child:1mth-1yr: 62.5mg 10 days Phenoxymethylpenicillin QDS 1-6yrs: 125mg QDS 6-12 yrs: 250mg QDS Adult and child >12yrs: 1g BD or 500mg 1g QDS when severe. In penicillin allergy: Clarithromycin Adult and child >12yrs: 5 days 250 mg BD up to 500mg BD if severe. In children, consider 1mth-2yrs: 125mg QDS 5 days Erythromycin syrup: 2-8yrs:250mg QDS Adult and child > 8yrs: 500mg QDS Scarlet fever Notifiable disease. Prompt treatment with appropriate antibiotics significantly reduces complications. Observe immunocompromised individuals (diabetes, women in puerperal period, chickenpox) as they are at increased risk of invasive infection. Treatment: See sore throat antibiotic choices above. 7

Otitis Media Organisms: Many are viral Respiratory viruses in 50% of cases, Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes (group A strep), Moraxella catarrhalis and Staphylococcus aureus. 60% resolve in 24 hours without antibiotics. Optimise analgesia using NSAID or paracetamol. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness. In patients who are not acutely unwell, delayed prescription approach could be used with the delay being 2-3 days. Antibiotics should be used in an acutely ill child fever, vomiting, pain for >48 hours and a discharging ear. Consider a 2-3 day delayed or immediate prescription, if <2yrs with bilateral AOM or any age with otorrhoea. First line: Neonate 7 28 days 5 days Amoxicillin 30mg/kg TDS Child 1mth-1yr: 125mg TDS 1-5yrs: 250mg TDS 5-18yrs: 500mg TDS Adult: 500mg TDS In penicillin allergy: Adult and child >12yrs: 5 days Clarithromycin 250mg BD up to 500mg BD if severe In children, consider 1mth-2yrs: 125mg QDS 5 days Erythromycin syrup: 2-8yrs:250mg QDS Adult and child > 8yrs: 500mg QDS Otitis Externa Second line if first line Child 1mth-1yr: 5 days treatment failure (send samples for culture if 0.25mls/kg of 125/31mg suspension TDS purulent discharge): Co-amoxiclav (only if not allergic to 1-6 yrs: 5mls of penicillins) 125/31mg suspension If allergic to penicillin TDS consult microbiology 6-12 yrs: 5mls of 250/62mg suspension TDS Adult and child >12yrs: 625mg TDS Organisms (usually present as secondary colonisers): Pseudomonas aeruginosa Staphylococcus aureus Group A streptococcus (especially if inflamed) Aspergillus spp. + other fungi 8

Otitis Externa continued Treatment: If severe or unable to get drops into the ear canal, then refer to ENT for aural toilet. Acetic acid 2% spray (EarCalm Spray ) is as effective as topical antibiotic in mild otitis externa for the first 7 days. In more severe cases, a topical antibiotic plus steroid ear drops may be considered as first line. Topical application of a ribbon gauze dressing soaked with corticosteroid ear drops may be beneficial where swelling is to the extent that drops will not readily penetrate. Aminoglycoside ear drops are potentially toxic and should not be given in the presence of a perforation with a discharge for more than 10 days without being reassessed. An underlying perforation is likely, and should be excluded if there is a mucoid discharge. In many cases of otitis externa there is no underlying perforation and ear drops can be given for longer. If there is a history of recurrent discharge an underlying cholesteatoma should be excluded. Diabetic and immunocompromised patients are particularly susceptible to aggressive destruction of cartilage caused by Pseudomonas aeruginosa ( Malignant Otitis Externa ). If suspected, the patient should be referred urgently to an ENT specialist. Otitis externa not responding to treatment and with persistent pain after 5-7 days should be referred urgently to an ENT specialist. Systemic antibiotics are only indicated when there is evidence of spreading cellulitis. Choice of antibiotics depends on likely organisms: Staphylococcus aureus (folliculitis or pustular lesions) or Group A Streptococcus flucloxacillin Pseudomonas aeruginosa use topical applications as suggested above. If severe infection, discuss with an ENT specialist. Candida 1% clotrimazole ear drops. Aspergillus Discuss treatment with an ENT specialist. Drug Dose (adult) Duration of TX First line: Acetic acid 2% spray 1 spray at least TDS (maximum 2-3 hourly) 7 days Second line choices: Gentamicin with 2-4 drops QDS 7 days hydrocortionse drops (not if perforation) Locorten-Vioform drops 2-3 drops BD 7 days Otomize spray 1 spray TDS 7 days Sofradex drops 2-3 drops TDS QDS 7 days Clotrimazole 1% ear 3 drops BD-TDS For at least 14 days Drops after resolution of symptoms Only if spreading cellulitis Flucloxacillin 500mg QDS 5 days In penicillin allergy use: Clarithromycin. 500 mg BD 5 days 9

Acute sinusitis (NICE guideline NG79 Sinusitis- 2017) Organisms: Respiratory viruses e.g. RSV, rhinovirus; Rarely bacterial: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Nearly all are viral 90% of patients with colds have x-ray evidence of sinus disease which usually resolves spontaneously within 2 to 3 weeks. Acute sinusitis (also known as rhinosinusitis) is self-limiting and usually triggered by a viral infection of the upper respiratory tract (for example, a common cold), with only about 2% of cases complicated by bacterial infection. Symptoms can last for 2 to 3 weeks most people will get better within this time without treatment, regardless of cause (bacteria or virus). So antibiotics are not needed for most people. The number of people improving with antibiotics is similar to the number getting adverse effects, such as diarrhoea. Complications of acute sinusitis are rare (about 2.5 to 4.3 per million people per year). Withholding antibiotics is unlikely to lead to complications. Previous antibiotic use may lead to resistant organisms if the same antibiotic is used again. Reserve antibiotics (consider delayed if non severe) only for severe or symptoms >10 days. Refer people to hospital if they have symptoms and signs of acute sinusitis associated with any of the following: a severe systemic infection (see NICE guideline on sepsis) intraorbital or periorbital complications, including periorbital oedema or cellulitis, a displaced eyeball, double vision, ophthalmoplegia, or newly reduced visual acuity. Intracranial complications, including swelling over the frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs. For those with symptoms <10days and not severe, give advice about: the usual course of acute sinusitis (2 to 3 weeks) an antibiotic not being needed managing symptoms, including fever, with self-care seeking medical help if symptoms worsen rapidly or significantly, do not improve after 3 weeks, or they become systemically very unwell. Reassess if symptoms worsen rapidly or significantly, taking account of: - alternative diagnoses such as dental infection - any symptoms or signs suggesting a more serious illness or condition. First line: Phenoxymethylpenicillin 500mg QDS or Doxycycline 200mg stat / 100mg OD If pregnant and penicillin allergic Erythromycin 500mg BD 5 days Second line with additional anaerobic activity if first line fails: Co-amoxiclav 625mg TDS 10

Chronic bacterial sinusitis Chronic sinusitis is diagnosed by the presence of nasal blockage or discharge (anterior/posterior nasal drip) with facial pain or pressure, and/or reduction or loss of the sense of smell, lasting for longer than 12 weeks. Treatment: Chronic purulent rhinosinusitis may need additional activity against anaerobes and ß-lactamase producing organisms with co-amoxiclav 625mg TDS for 14 days coupled with topical nasal steroids. Patients should be warned about increased risk of Candida infection with these broader spectrum agents and topical steroids. Co-amoxiclav 625mg TDS 14 days In penicillin allergy: Doxycycline 200mg OD 14 days of both and Metronidazole 400mg TDS Dental abscess (see PHE recommendation for gingivitis here, on page 10) Organisms Viridans streptococci Anaerobes Treatment: NHS 111 may be contacted to find an emergency dentist, if the patient is not currently registered at a dental practice. Surgical drainage is the most important treatment if there is a pointing abscess. If there is obvious facial swelling/cellulitis referral to a maxillo-facial surgeon is advised. Antibiotics are not indicated in otherwise healthy patients when there are no signs of spreading infection. Consider antibiotics when evidence of spreading infection, or in those at high risk of complications e.g. immunocompromised. Repeated courses of antibiotics are not appropriate. Amoxicillin Or In true penicillin allergy Clarithromycin 500mg 1g in severe infections TDS 500mg BD 5 days (review at 3 days) Plus if spreading infection or systemic signs Metronidazole 200mg-400mg TDS 5 days 11

Conjunctivitis Organisms: Staphylococcus aureus Streptococcus pneumoniae Haemophilus influenzae Neisseria gonorrhoeae (neonates) Chlamydia trachomatis (neonates) Viruses e.g. adenovirus Most bacterial infections are self-limiting. Mild cases should not need treating. They are usually unilateral with yellow-white mucopurulent discharge 65% resolve on placebo by day 5 Viral infections may be associated with other upper respiratory symptoms such as pharyngitis and fever. Discharge may be more watery than bacterial. Refer cases of severe contact lens conjunctivitis to an ophthalmologist to exclude the possibility of acanthamoeba. For more severe infections or if spontaneous resolution is not occurring after 4-5 days, antimicrobials should be given until 48 hours after clinical resolution. Delayed or post-dated prescriptions should be considered. Neonatal conjunctivitis: Urgently refer all neonates with suspected ophthalmia for specialist assessment. Simple sticky eye (no signs of conjunctival inflammation) does not need referral. Antibiotics: Chloramphenicol has broad spectrum antimicrobial activity, is well-tolerated, and the recommendation that it should be avoided even in eye drop/ointment form because of an increased risk of aplastic anaemia or Grey Baby Syndrome is not well founded and should not stop use as a first line agent. Gentamicin drops should only be used for Pseudomonas. Refer if not responding. Fusidic acid drops have inferior Gram negative cover to chloramphenicol and thus should be reserved for second line use. For dacryocystitis, systemic antimicrobials should be used. If gonococcal infection or orbital cellulitis is suspected, arrange urgent admission to hospital for intravenous therapy. PHE recommends that it should not normally be necessary to stay off work or school if suffering from acute bacterial conjunctivitis and that it should not be necessary for a school or nursery to exclude a child until the infection has cleared. Drug Dose Duration First line treatment if non-severe is self-care: bath/clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water, to remove crusting. If severe First line: Chloramphenicol 0.5% 2 hrly reducing to QDS For 48 hrs after drops resolution Or Chloramphenicol TDS-QDS For 48 hrs after 1% eye ointment resolution Second line: Fusidic Acid 1% eye Twice daily For 48 hrs after drops resolution Chlamydial conjunctivitis: (if pregnant use Azithromycin 1g stat) Adults: Doxycycline 100mg BD 7 days 12

LOWER RESPIRATORY TRACT INFECTIONS Acute cough, bronchitis (NICE CG 69 RTI-2008) Acute exacerbation of COPD-NICE CG101 COPD 2010 In previously healthy patients most cases of acute bronchitis are associated with viral infection. Additional bacterial pathogens to consider - Streptococcus pneumoniae, Mycoplasma pneumoniae and Chlamydophilia pneumoniae. Numerous randomised controlled trials have shown little or no benefit from the use of antibiotics for acute bronchitis in otherwise healthy adults in primary care. Advise patients that a cough may persist for up to 3 weeks even if treatment is given. Discoloured sputum does not necessarily indicate infection as it may be due to non-infective inflammatory conditions. Reassurance that it is not serious and patient information leaflets informing previously well patients about the natural history of LRTI symptoms are an effective strategy for reducing re-consultations and antibiotic use. A delayed prescription approach could be used with the delay being 7 days as per NICE guidance. Consider immediate antibiotics if >80 years old and one of: episode of hospitalisation in the past year, oral steroids, diabetic, congestive heart failure. OR >65 years with two of the above.consider POC CRP test if antibiotic being considered. If CRP <20mg/L no antibiotics, 20-100mg/L delayed antibiotics, CRP>100mg/L immediate antibiotics. Doxycycline 200mg stat /100mg OD 5 days Or Amoxicillin 500mg TDS 5 days Organisms: Respiratory viruses (30%), bacterial (30-50%) Streptococcus pneumoniae, Haemophilus influenzae (amoxicillin sensitive and resistant strains), Moraxella catarrhalis, and atypical pathogens such as Mycoplasma pneumoniae and Chlamydophilia pneumoniae. Check results of previous sputum cultures and send sputum sample if possible, before prescribing antibiotics. Viral infections may cause acute exacerbations, but if purulent sputum is being produced bacterial infection is possible. Antibiotics are most valuable in patients with purulent sputum and increased shortness of breath and/or increased sputum volume. NICE recommend as part of self-management that patients are given a course of antibiotics and oral corticosteroids to keep at home and commence if their sputum becomes purulent (see Nottinghamshire guidance for prescribers on COPD Exacerbation Rescue Medication Pack) Risk factors for antibiotic resistant organisms include: Severe COPD Co-morbid disease Frequent exacerbations and/or hospital admissions Multiple courses of antibiotics, or antibiotics within last 3 months Previous resistant organisms in sputum culture 13

Acute exacerbation of COPD-NICE CG101 COPD 2010 Communityacquired pneumonia (CAP) Doxycycline 200mg stat then 100mg OD 5 days Or Amoxicillin 500mg TDS 5 days Or if penicillin allergy and where doxycycline contraindicated: Clarithromycin If resistance factors present, or failure of first line: Co-amoxiclav 500mg BD 625mg TDS 5 days 5 days Bacterial causes: Streptococcus pneumoniae (very common in all age groups). Haemophilus influenzae (uncommon). Mycoplasma pneumoniae (particularly in young adults, usually in 3-4 yearly peaks that last for 12-15 months, rare in >65yr olds. Chlamydophila pneumoniae (probably common). Chlamydophila psittaci (uncommon, history of pet birds). Legionella pneumophila (uncommon, may be a history of recent travel). CAP is defined as the presence of the following symptoms and signs, which cannot otherwise be explained: Acute lower respiratory tract symptoms i.e. cough and one or more other symptoms. Focal chest signs of recent onset. Systemic symptoms or signs: Pyrexia >38 o C. Sweating. Shivers (rigors). Aches and pains. Confirmation of diagnosis with a chest X-ray is helpful where available. A 5 day course for low-severity pneumonia treated in the community should be sufficient, longer courses may be necessary in hospitalised patients or those with more severe pneumonia. If symptoms do not improve as expected after 3 days, consider extending the course for longer than 5 days. Assessment of patients using the CRB-65 score helps to determine the management of CAP for patients in the community. CRB-65 score for mortality risk = score 1 point for each of the following features present: Confusion (AMT <8 or new disorientation in person, place or time). Respiratory rate > 30/min. Blood pressure (SBP <90mmHg or DBP < 60mmHg). > 65 years. A score of 0 (low risk) indicates that the patient is likely to be suitable for home treatment. A score of 1-2 (intermediate risk) indicates a need to consider hospital referral and antibiotics should include cover for atypical organisms. Patients with a score of 3 or 4 (high risk) require urgent hospital admission. 14

Consider immediate antibiotic administration for patients being referred to hospital if CAP is thought to be life threatening or there is likely to be a delay >2 hours to admission. Also seek risk factors for Legionella and Staphylococcus aureus infection. For Legionella these may include: exposure to air conditioning systems, recent travel, cooling towers, spa pools and other artificial water systems. For S. aureus these may include: recent influenza, nursing home residents, aspiration, and chronically ill or debilitated patients. If CRB-65=0: Amoxicillin Or Clarithromycin Or Doxycycline If CRB-65=1 & at home: Amoxicillin AND Clarithromycin 500mg TDS 500mg BD 200mg stat / 100mg OD 500mg 1g TDS 500mg BD 5 days (review at 3 days and extend to 7-10 days slow/poor response) 7-10 days or Doxycycline alone 200mg stat/100mg OD 7-10 days Tuberculosis (TB) Bronchiectasis Whooping Cough Notifiable Disease. Suspected and confirmed cases should be notified to PHE. Incidence of tuberculosis has risen over the last decade and should be considered as a cause of persistent productive cough (i.e. over 3 weeks) or lack of response to usual antibiotics. Sputum samples are not routinely examined for TB, and a specific request for TB microscopy and culture needs to be included on the request card if this is possible diagnosis. If in North Nottinghamshire, the referral should be made to Dr Nabeel Ali at King s Mill Hospital on 01623 622515. All other suspected or confirmed cases need to be referred directly to the TB specialist nurses based at Nottingham City Hospital on 01159 628051, who will arrange appointments with the most appropriate physician. Notify Public Health England on 03442254524. Bronchiectasis patients may be on long-term or rotational courses of antibiotics under the care of Respiratory Medicine. In cases of suspected bronchiectasis, refer to a Respiratory Physician for investigation and management. Organism: Bordetella pertussis. Typical symptoms e.g paroxysmal cough, whooping and post-tussive vomiting may not be present in older children and adults. Pertussis should be considered as a cause of a chronic episodic cough in older age groups. Treatment: Treatment aim is to eradicate carriage from cases and prevent secondary transmission. Antibiotics have limited effect on symptoms and therefore antibiotic treatment for the case is only recommended within 3 weeks of onset. Prophylaxis: Given the limited benefit of chemoprophylaxis, antibiotics should only be offered to close contacts (e.g. household) when onset of illness in the index case is within the preceding 3 weeks AND there is a close contact who belongs to a priority group. Full guidance for treatment, prophylaxis and vaccination is on the Public Health England website (https://www.gov.uk/government/publications/pertussisguidelines-for-public-health-management). 15

MENINGITIS Meningitis Transfer all patients to hospital as an emergency by telephoning 999 For suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) parenteral antibiotics (IM or IV cefotaxime) should be administered so long as this does not delay transfer to hospital. Meningitis or meningococcal septicaemia should be notified on suspicion to Public Health during daytime hours (03442254524) or on-call Public Health Doctor out-of-hours (01159675099), who will advise which contacts need prophylaxis and whether vaccination is required. Prophylaxis: Is given to household and kissing contacts of the index case. Household and kissing contacts include those who have slept in the same house or dormitory before the onset, boy/girlfriend, childminders, anybody who has performed mouth to mouth resuscitation or intubation of the index case. Choice of antibiotic should be made through discussion with the Public Health Doctor and considering the patient/s requiring prophylaxis. If the disease is due to confirmed serogroup C, and the contact was immunised in infancy or >1year ago, an extra dose of Men C will be offered. If the disease is due to confirmed serogroups A, W or Y, vaccination of close contacts with quadrivalent vaccine may be advised. Chemoprophylaxis agents: Ciprofloxacin (unlicensed) is now recommended by PHE for use in all age groups and in pregnancy, as a single prophylactic dose. Rifampicin interacts with anticoagulants, hormonal contraceptives and other drugs, and stains soft contact lenses and urine. It is licensed for use in prophylaxis. DRUG DOSE DURATION Treatment in suspected meningococcal disease: Cefotaxime IV or IM Child <12yr: 50mg/kg IV (avoid if history of immediate hypersensitivity to penicillin and use with caution if non-severe allergy) Or Adult and child 12yrs If vein cannot be found and over: 1g give IM. Prophylaxis: Recommended for use in all age groups and in pregnancy: Ciprofloxacin Child <5yrs: 30mg/kg Single dose (maximum of 125mg) 5-12yrs: 250mg Adult and child >12yrs: 500mg Or Recommended for use in all age groups: Rifampicin <12 month: 5mg/kg BD 1-12yrs: 10mg/kg BD Adult and child >12yrs: 600mg BD 2 days 16

Quick Reference Guide for the Diagnosis of UTI in Adults in Primary Care Urinary Symptoms in Adult Women <65 years: Do not culture routinely. Severe or 3 symptoms of UTI Dysuria Frequency Suprapubic tenderness Urgency Polyuria Haematuria AND NO vaginal discharge or irritation Give empirical antibiotic treatment Mild or 2 symptoms of UTI (as listed above) Obtain urine specimen Urine NOT cloudy 97% NPV Consider other diagnosis URINE CLOUDY Perform urine dipstick test with nitrite When reading test WAIT for the time recommended by the manufacturer Positive nitrite, and leucocytes and blood 92% PPV or positive nitrite alone Probable UTI Treat with first line agents if uncomplicated UTI Negative nitrite Positive leucocyte UTI or other diagnosis equally likely Review time of specimen (morning is most reliable) Treat if severe symptoms or consider delayed antibiotic prescription and send urine for culture Negative nitrite, leucocytes and blood 76% NPV or negative nitrite and leucocyte positive blood or protein Laboratory microscopy for red cells is less sensitive than dipstick = UTI Unlikely Consider other diagnosis Reassure and give advice on management of symptoms Urine Culture in Men and Women >65 years: Send urine samples prior to antibiotic treatment but don t send urine for culture in asymptomatic elderly patients with positive dipsticks Do not treat asymptomatic bacteriuria as it does not reduce mortality, prevent symptomatic episodes, but does increase side-effects and antibiotic resistance. Only send urine for culture if two or more signs of infection, especially dysuria, temperature>38ºc or new incontinence. Review urine culture result to check that empirical treatment is appropriate. Urine Culture in Men and Women with Catheters: Dipstick tests are not useful in catheterised patients. Only send urine for culture in catheterised patients if there are features of systemic infection. Do not treat asymptomatic bacteriuria in asymptomatic catheterised patients. Do not routinely give antibiotic prophylaxis for catheter changes. Patients should have a catheter passport (ask your local continence team). When else to send a urine sample for culture: Suspected UTI in men (see notes below in lower UTI section) Suspected pyelonephritis (see pyelonephritis section) Failed antibiotic treatment or persistent symptoms Suspected complicated UTI: recurrent UTIs, previous urogenital surgery, urinary tract abnormalities (see complicated UTI section) Pregnancy (see UTI in pregnancy section) Children (see UTI in children section) 17

URINARY TRACT INFECTIONS Lower UTI /cystitis Organisms: i.e. no fever or Escherichia coli, Coliforms, Proteus mirabilis Staphylococcus saprophyticus flank pain, in men Enterococcus spp. and women In patients >65 years, do not treat asymptomatic bacteriuria as it is not associated with increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely (see Complicated UTIs). Women with severe or 3 symptoms: urinalysis is unlikely to be helpful Treat empirically. This is because in people with characteristics, signs and symptoms highly suggestive of a bacterial infection, dipstick tests are not sufficiently accurate to assist diagnosis. If symptoms do not respond to empirical antibiotics within 2-3 days, urine should be sent for culture and sensitivity testing. Consider sexually transmitted infection if does not respond. Women with mild or 2 symptoms: use urine dipstick to guide treatment. Men with severe or highly suggestive symptoms: send pre-treatment MSU and treat empirically. Men with mild or non-specific symptoms: use negative nitrites and leucocytes to exclude UTI, if negative consider alternative cause e.g. sexually transmitted infection, prostatic symptoms. Community multi-resistant E. coli are increasing so perform culture in all treatment failures. Risk factors for increased resistance include: >65yrs Care home resident Recurrent UTI Hospitalisation >7days in the last 6 months Recent travel to country with increased antimicrobial resistance Previously resistant organism in urine Treatment failures Multiresistant isolates are usually resistant to amoxicillin, co-amoxiclav, cephalosporins, and may also be resistant to trimethoprim and quinolones. Often susceptible to nitrofurantoin, pivmecillinam and fosfomycin. Pivmecillinam (a penicillin antibiotic) has been introduced as a second line option for lower UTI. The resistance rate is low and it is less likely to cause C difficile. Amoxicillin resistance is common and there is also an increased risk of Clostridium difficile compared to first line agents, therefore never use for empirical treatment. Trimethoprim resistance has increased locally such that it is no longer recommended for empiric treatment. First line: (avoid if egfr<45ml/min ineffective, if egfr 30-45mls/min only use if no alternative with safety netting advice) Nitrofurantoin 100mg M/R BD Women: 3 days (50mg QDS if MR caps unavailable) Men: 7 days Second line: If <65yrs and no risk factors for resistance: Trimethoprim 200mg BD Second line: If 65yrs or risk factors for resistance: Pivmecillinam 400mg stat then 200 mg TDS 18

Lower UTI /cystitis continued Third line (empirical use only if first and second line treatments are not suitable): Fosfomycin Women 3g one-off dose Single dose Men 3g stat on day 1 plus a further 3g dose on day 3 (unlicensed, as per PHE guidance) As described Complicated UTI. Complicated UTIs are more likely in the following situations: See also specific Recurrent infection patient groups Treatment failures and conditions Previous urogenital surgery below. Urinary tract abnormalities Urinary or suprapubic catheters Symptoms of renal infection e.g. fever or flank pain (see Acute Pyelonephritis in Adults) Infants and neonates (see UTI in Children) Pregnancy (see UTI in Pregnancy) UTI in pregnancy Organisms: Escherichia coli Proteus sp. Klebsiella sp. Pseudomonas aeruginosa (if recurrent infections) Treatment: Always send a pre-treatment urine sample to guide antibiotic choice. Always review results of urine cultures if available before making choice of antibiotic. A positive catheter specimen urine does not necessarily mean there is a UTI present, a clinical assessment should be made and antibiotics only given if there are signs and symptoms of a UTI. If a patient suffers a repeat infection but had responded to a first line agent on the previous occasion, that same agent should be restarted rather than assuming that an alternative agent will be necessary. Consider a 7 day course of antibiotics. Asymptomatic bacteriuria in pregnancy: isolation of the same organism in a properly collected MSU sample on two separate occasions, with a colony count of >10,000-100,000 organisms/ml. It should be treated in pregnancy because of the higher risk of pyelonephritis and an association with pre-term labour and low birth weight. Treat for 7 days with an antibiotic according to the culture and sensitivity results, treatment options as below. Symptomatic cystitis: send a pre-treatment MSU. Review any previous microbiology results as a guide. Start empiric treatment as below, adjust when the sensitivities of a pre-treatment MSU are available. Upper UTI/pyelonephritis. If symptoms suggest pyelonephritis, the antibiotics below are not suitable and the patient should be referred for IV antibiotics. Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus however should be avoided at term or if delivery is imminent. Avoid trimethoprim in the first trimester, or in women who have a low folate status or on folate antagonists e.g. anti-epileptics or proguanil. 19

UTI in pregnancy continued Quinolones should not be used in pregnancy or women who are trying to become pregnant. Cefalexin is safe in pregnancy but is recommended for third-line use due to the increased risk of C.difficile, and recent reports of serious C.difficile infection in pregnant women. Pivmecillinam is not known to be harmful in pregnancy. Long courses (>7 days) or repeated courses should be avoided as long term use of pivmecillinam is associated with carnitine deficiency (see here). First line: Nitrofurantoin Avoid at term or if delivery is imminent 100mg M/R BD (50mg QDS if MR caps unavailable) Or Pivmecillinam Second line: Trimethoprim (except in first trimester) Third line: Cefalexin 400mg stat then 200 mg TDS 200mg BD 500mg BD All for 7 days 20

UTI in children UTI is associated with a higher risk of underlying congenital renal anomalies, pyelonephritis, acquired renal scarring and recurrent infection. This is particularly so in young children or if the UTI is associated with recurrence or atypical features Diagnosis should be considered in all febrile children or if there are features suggestive of UTI. It requires a carefully collected urine sample (MSU, CSU or Bag Urine) taken prior to antibiotic therapy. A clinical assessment should be made as to the likelihood of a: Lower UTI (cystitis) significant bacteriuria with no systemic features Upper UTI (acute pyelonephritis) significant bacteriuria with fever 38ºC Or significant bacteriuria with fever 38ºC and loin pain/tenderness Particular attention should be paid to the following features, which may warrant paediatric follow-up or referral for further investigation: Poor urine flow, dysfunctional voiding, enlarged bladder or abdominal mass History suggesting previous UTI or confirmed previous UTI Recurrent fever of uncertain origin Antenatally diagnosed renal abnormality Family history of vesicoureteric reflux or renal disease Constipation Evidence of spinal lesion or lower limb neurology Poor growth High blood pressure. Assessment should be made as per NICE CG160 Feverish Illness in Children. Some children will require referral during the acute illness for treatment in hospital. Others can be treated at home but will need referral at the time or afterwards for further investigations (see NICE CG54). Admit to hospital for treatment during the acute illness if: < 3 months of age Severely ill as NICE guideline Atypical feature (unless non-e.coli organism is the only atypical feature): Failure to respond to a suitable antibiotic within 48 hours Seriously ill, suspected or confirmed septicaemia or raised creatinine Poor urine flow +/- palpable bladder or abdominal mass Non-E.coli UTI Refer for further investigation if: <6 months of age Non-E.coli UTI Recurrent UTIs (see NICE CG54 for definition) Children with: Any antenatal urinary tract abnormality Abnormal blood pressure Evidence of spinal lesion and lower limb neurology Abnormal growth / centiles For full guidance on the referral, investigation and follow-up of children with UTI please refer to NICE CG54 Urinary Tract Infection in Children. See below for first line treatments and dosing guidance 21

UTI in children continued Drug Dose Duration of Tx Comments Lower UTI (3 months -12 years) Review at 48 hours to check response to treatment, noting trimethoprim resistance rates are over 30% If <15kg or unable to take tablets Trimethoprim Do not use if 3-6 months 25mg BD 3 days Liquid for doses < 100mg trimethoprim 6 months 6 50mg BD resistance or failed years trimethoprim 6 12 years 100mg BD treatment 12-18 years 200mg BD If >15kg and able to take tablets Unsuitable in carnitine Pivmecillinam >15kg and <40kg 200mg TDS 3 days (9 deficiency or patients Avoid if penicillin tablets) taking sodium valproate. allergy Tablets should be swallowed whole with half a glass of water whilst sitting or standing. If known trimethoprim resistance or failed trimethoprim treatment (and unable to take pivmecillinam) Nitrofurantoin 3 months 12yrs 750 micrograms/kg QDS Lower UTI (12-18 years) First line Nitrofurantoin 12-18 years 100mg MR BD Second line Pivmecillinam Avoid if penicillin allergy Third line (50mg QDS if supply problem with MR capsules) 3 days 3 days >15kg and <40kg 200mg TDS 3 days (9 tablets) > 40kg 400mg stat then 200mg TDS 3 days (10 tablets) Fosfomycin 12-18 years 3g one-off Single dose Not suitable in G6PD deficiency or acute porphyria. Liquid is very expensive, but may be clinically necessary Not suitable in G6PD deficiency or acute porphyria N.B. Liquid is very expensive therefore not recommended, use tablets or capsules or consider alternative agent if >15kg and able to take tablets Avoid if penicillin allergy Unsuitable in carnitine deficiency or patients taking sodium valproate As an option when we can t use Nitrofurantoin or Pivmecillinam. Upper UTI 1month-1yr: 125mg BD 1-5 years 125mg TDS Review children at 48 Cefalexin 7-10 days hours to check response 5-12 yrs 250mg TDS to the chosen antibiotic 12-18 yrs 500mg TDS In severe penicillin allergy discuss with Paediatrics or Medical Microbiology 22

Upper UTI/Acute pyelonephritis in adults Recurrent UTI women 3 times/ Year For full guideline click here. Send MSU for culture and sensitivities, and start antibiotics. If no response within 24 hours admit. If multiresistant infection with not suitable oral options consider referral for IV antibiotics as an outpatient (OPAT). First line Ciprofloxacin 500mg BD 7 days Second line Trimethoprim (only if lab 200mg BD 14 days report shows sensitive) or Cefalexin 500mg BD 7 days General hygiene, use of condoms, post coital voiding and good hydration are all important non-pharmacological prophylactic measures to help prevent recurrent UTIs. Antibiotics should be considered as well as rather than instead of these measures. Post coital is equally as effective as nightly prophylaxis if taken in timely fashion. A standby antibiotic may also be considered. Nitrofurantoin should be used with caution in those with anaemia, diabetes, and vitamin B or folate deficiencies. Long-term use requires monitoring of full blood count, liver function tests, for the development of any pulmonary symptoms of peripheral neuropathy, especially in the elderly. Nitrofurantoin Or 50mg Single dose post coital or at night Review at 6 months Trimethoprim Third line: Methenamine hippurate if no renal or hepatic impairment 100mg 1g BD 6 months 23

GASTRO-INTESTINAL TRACT INFECTIONS Oral Candidiasis Eradication of Helicobacter Pylori Topical azoles are more effective than topical nystatin Oral candidiasis is rare in immunocompetent adults: consider undiagnosed risk factors including HIV and diabetes mellitus. Drug Dose Duration of Tx Miconazole oral gel 20mg/g (24mg/ml) If not tolerated: Nystatin oral suspension 100,00units/ml For severe/extensive or unresponsive: Fluconazole oral 2.5ml QDS 1ml QDS 50mg OD (higher doses 100mg OD may be used in HIV/immunosuppressed patients) Treatment should be continued for at least 7 days after lesions have healed or symptoms have cleared For 7 days, and continued for 2 days after symptoms resolve For 7 days, extending further 7 days if persistent. Indications: Helicobacter treatment will benefit patients with H. pylori-induced duodenal or gastric ulceration. 10-15% of patients with non-ulcer dyspepsia will also have resolution of their symptoms. H. pylori treatment does not help gastrooesophageal reflux disease (GORD) In the community, dyspeptic patients without indications for endoscopy (see below) should either be treated with a course of proton pump inhibitors or tested for H. pylori with a non-invasive test (preferably a urea breath test) and treated if positive: if the first strategy does not work the other should be tried. Tests for H. pylori include the urea breath test ((UBT), stool antigen test, serology, and endoscopic biopsy-based tests. Most tests for H. pylori are only reliable if the patient has had no antibiotics or bismuth compounds within 4 weeks and proton pump inhibitors have been stopped for at least two weeks. The exception is serology, but this is less accurate than other tests and often remains positive even after successful treatment; thus it cannot be used to assess treatment success, even in the distant past. Re-testing after treatment: All GU or DU patients should be retested for H. pylori at least 4 weeks after the end of antibiotic treatment and re-treated if still positive. Treated patients who did not have an ulcer (or who did not have an endoscopy) should be re-tested if symptoms recur. A carbon-13 urea breath test (UBT) or a stool antigen test are normally used to retest patients. However, if they are having a further endoscopy for any indication (for example all GU patients have repeat endoscopy to ensure healing and exclude gastric adenocarcinoma) biopsy-based tests can also be used. Note the PPI will need to be stopped at least 2 weeks, and any antibiotics or bismuth compounds at least 4 weeks before H. pylori testing is carried out. 24