RECOMMENDATION FOR THE USE OF ANTIBIOTICS FOR THE TREATMENT OF INFECTION Aims

to provide a simple, best guess approach to the treatment of common infections, based on known sensitivity and resistance patterns in Cumbria

to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance i n the community

Principles of Treatment 1. This guidance is based on the best available evidence but its application must be modified by professional judgement in the l ight of

co-existing diseases and other drug therapy. 2. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 3. Limit prescribing over the telephone to exceptional cases. 4. Use simple generic antibiotics first whenever possible. 5. The use of new and more expensive antibiotics (e.g., quinolones and cephalosporins) is inappr opriate when standard and less

expensive antibiotics remain effective. Antibiotics are listed in order of preference. 6. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations). 7. In pregnancy AVOID tetracyc lines, aminoglycosides, quinolones, high dose metronidazole. Short - term use of trimethoprim

(theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretica l risk of neonatal haemolysis) is unlik ely to cause problems to the foetus.

8. Doses quoted are intended for otherwise fit adults. Doses may need to be changed in children and those with renal impairment . The duration of therapy will vary by individual patient, disease severity and speed of resolu tion.

9. ltant Microbiologists at:

West Cumberland Hospital 01946 693181 Cumberland Infirmary 01228 814641 Furness General Hospital 01229 491022

This guidance has been produced in consultation with the consultant microbiologists and the Cumbria Medicines Management team .

Published: December 2012 , Review date: November 2014

Condition Comments Drug and dose

(listed in order of preference) Duration

(days)

UPPER RESPIRATORY TRACT/ENT

Delayed prescriptions are a useful strategy as most upper respiratory tract infections are viral, self - limiting and improve without antibiotics. Regular use of analgesics such as paracetamol and ibuprofen should be encouraged.

Influenza Annual vaccination is essential for all those at risk of influenza . For otherwise healthy adults antivirals not recommended. Treat at risk patients, ONLY within 48 hours of onset and when influenza is circulating in the community or in a care home where influenza is likely. At risk:

pregnant 65 years or over chronic respiratory disease (including COPD and

asthma) significant cardiovascular disease (n ot

hypertension) immunocompromised diabetes mellitus chronic neurological renal or liver disease

OSELTAMIVIR 75mg BD or , if there is resistance to oseltamivir

ZANAMIVIR 10mg BD (2 inhalations by diskhaler)

For prophylaxis, see NICE. (NICE Influenza) . Patients under 13 years see HPA Influenza link.

5

Tonsillitis/pharyngitis/sore throat

AVOID ANTIBIOTICS as 90% resolve in 7 days without and pain only reduced by 1 6 hours. If Centor score 3 to 4:

lymphadenopathy history of fever tonsillar exudate no cough

consider 2 or 3 -day delayed antibiotics or immediate antibiotics .

Antibiotics to prevent q uinsy , NNT >4000 Antibiotics to prevent otitis m edia , NNT 200

ANTIBIOTIC TREATMENT NOT

ROUTINELY RECOMMENDED

If antibiotic is required, PHENOXYMETHYLPENICILLIN 500mg QDS (severe) , or

CLARITHROMYCIN 250 -500 mg BD

10 5

Acute rhino sinusitis AVOID ANTIBIOTICS as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days (NNT 15)

Use adequate analgesia Consider 7 -day delayed or immediate antibiotic when purulent nasal discharge (NNT 8)

In persistent infection use an agent with anti -anaerobic activity e.g., co -amoxiclav

ANTIBIOTIC TREATMENT NOT ROUTINELY RECOMMENDED

If antibiotic is required, AMOXICILLIN 50 0mg TDS, or DOXYCYCLINE 200mg stat , then 100mg daily , or

CLARITHROMYCIN 250mg BD 2 nd line CO-AMOXICLAV 625mg TDS

5 5 5 5

http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11736http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11736http://www.hpa.org.uk/infections/topics_az/influenza/seasonal/pdfs/Treatmentflowchart.pdf

Condition Comments Drug and dose

(listed in order of preference) Duration

(days)

Otitis externa (acute) First use aural toilet and analgesia. Cure rates similar for topical acetic acid or antibiotic

steroid

ACETIC ACID spray (EarCalm ) 1 spray TDS , or

PREDNISOLONE + NEOMYCIN ear drops 3 drops TDS

5

Otitis media (acute) child doses

Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness. Use paracetamol or NSAID.

Otitis media resolves in 60% of patients in 24 hours without antibiotics. Antibiotics reduce pain at 2 days (NNT 15)

Consider antibiotics (2 to 3 days) if:

< 2 years AND bilateral otitis media (NNT 4) or

All ages with otorrhea (NNT 3) Immediate prescribing may be appropriate for the following groups:

otorrhoea

Condition Comments Drug and dose

(listed in order of preference) Duration

(days)

Corneal abrasions If corneal u lcer - Urgent ophthalmic referral is necessary .

CHLORAMPHENICOL eye ointment BD

5

ORAL

Mucosal ulceration and inflammation

Temporary pain and swelling relief can be attained with saline mouthwash (tsp in glass of warm water)

CHLORHEXIDINE 0.2% mouthwash, rinse mouth for 1 minute BD with 5ml diluted with equal volume of water, or

HYDROGEN PEROXIDE 6%, 15mls in glass of warm water TDS

Until lesion resolves of less pain allows oral hygiene

Dental abscess Advise urgent dental consultation, as repeated courses of antibiotics f or abscess are not appropriate. Antibiotics are only recommended if there are:

signs of severe infection systemic symptoms high risk of complications

Otherwise, regular analgesia should be first option until a dentist can be seen.

AMOXICILLIN 500 mg TDS , or PHENOXYMETHYLPENICILLIN 500mg -1 gram QDS

If penicillin allergic, or in severe infection

METRONIDAZOLE 200mg TDS

5 5 5

Oral thrush NYSTATIN 100,000 units QDS , or MICONAZOLE gel, 5mL QDS (mi conazole interacts with statins and

anticoagulants )

If immunosuppressed, consider fluconazole 50 -100 mg OD for 7 to 14 days

7 7

Acute necrotising ulcerative gingivitis

Refer to dentist for scaling and oral hygiene advice, after starting antibiotic

METRONIDAZOLE 200mg TDS 3

Pericoronitis Refer to dentist for irrigation and debridement. If persistent swelling or systemic symptoms, use metronidazole

METRONIDAZOLE 200mg TDS 3

GASTRO- INTESTINAL INFECTIONS

H.pylori infection Tetracycline 500mg four times a day may be used instead of amoxicillin in penicillin -allergic patients.

Resistance to clarithromycin or to metronidazole is much more common than to amoxicillin and can develop during treatment. Do not use clarithromycin or metronidazole if used for any infection in the past year.

Triple - therapy: LANSOPRAZOLE 30mg BD plus AMOXICILLIN 1 gram BD plus either

CLARITHROMYCIN 500mg BD, or METRONIDAZOLE 400mg BD

7

Giardiasis Recurrence is high even with optimal treatment, therefore follow -up with a stool sample is advised.

METRONIDAZOLE 20 0mg TDS for 7 days is the most tolerable and effective doses; 400mg TDS for 5 days or 2 grams daily for 3 days

3-7 depending on the doses

Threadworms 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 .

MEBENDAZOLE 100mg (mebendazole is not licensed for children under 2 years, use piperazine instead)

One dose repeat in two weeks

Acute gastroenteritis Antibiotics not usually indicated. Discuss any intended treatment with microbiologist.

Antibiotic treatment not routinely recommended

Fluid replacement essential

Travellers diarrhoea Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 500mg single dose, unlicensed indication ) to people travelling to remote areas in whom an e pisode of infective diarrhoea could be dangerous.

C.difficile infection Stop unnecessary antibiotics and/or PPIs. 70% respond to metronidazole in 5 days, 92% in 14 days.

Admit if severe: Temperature >38.5 C WCC >15 Rising creatinine Signs/symptoms of severe colitis

METRONIDAZOLE 400mg TDS for 1 st and 2 nd episodes

VANCOMYCIN 125mg QDS for 3 rd episode/severe or type 027

10 -14 10 -14

URINARY TRACT

Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (> 65 years), do not treat asymptomatic bacter iuria: it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelo nephritis likely.

Co-amoxiclav is alternative in patients with low GFR . Nitrofurantoin should not be used if GFR is

Condition Comments Drug and dose

(listed in order of preference) Duration

(days)

UTI or confirmed asymptomatic bacter iuria in pregnant women

Screening requires a urine sample to be sent to microbiology for microscopy and culture, dip stick testing alone is not adequate

AMOXICILLIN 500mg TDS, or NITROFURANTOIN MR 100mg BD, or CEFALEXIN 500mg TDS for 7 days , or TRIMETHOPRIM 200mg BD for 7 days (unless folate deficient or taking folate antagonist [e.g. antiepileptic or proguanil])

7 7 7 7

UTI in children < 3 months , immediate paediatric referral > 3 months with acute pyelonephritis/upper UTI , consider referral to paediatric specialist , treat with antibiotics

> 3 months with cystitis/lower UTI , treat. If still unwell after 24 to 48 hours, child should be reassessed

TRIMETHOPRIM 4mg/kg BD (max 200mg) , or

CEFALEXIN 1 mon th -1 year - 125mg BD 1 5 years - 125mg TDS 5 - 12years - 250mg TDS

3 (lower) 7-10 if upper UTI

Pyelonephritis Culture required . CO-AMOXICLAV 625mg TDS, or CIPROFLOXACIN 500mg BD

7-10

Epididymo -orchitis Screen for chlamydia . DOXYCYCLINE 100mg BD Add IM CEFTRIAXONE 500mg stat if there likelihood of sexually transmitted pathogen

10 -14

GENITAL SYSTEM

Vaginal candidiasis Clotrimazole and fluconazole are available over - the -counter .

7 day course recommended during pregnancy . Fluconazole is contra - indicated in pregnancy.

CLOTRIMAZOLE pessaries 500mg , or

200mg FLUCONAZOLE 150mg

1 3 Stat dose

Bacterial vaginosis Usually associated with anaerobes, recurrence is frequent, but is not a sexually transmissible infection (STI).

Do not retest if symptoms resolve . In pregnancy 7 days of clindamycin gel recommended. In pregnancy testing should be repeated after 1 month to ensure cure achieved .

METRONIDAZOLE 400mg BD, or 2 grams stat , or

METRONIDAZOLE vaginal gel, 0.75% daily apply at night

CLINDAMYCIN vaginal gel, 2% daily apply at night

7 5 7

Chlamydia Advise sexual abstinence until the infected woman and her partner(s) have both completed the course of treatment. If treatment w ith single -dose azithromycin is given, then sexual abstinence for the following 7 days is advised.

(Azithromycin has been used for 20 years, during which time a

number of studies have shown that there is no increased risk of adverse effects associated with using the drug during pregnancy. It

is significantly more effective and better tolerated than the

alternative agents (erythromycin and amoxicillin), but its use is

more limited).

Pregnant woman must be retested after 5 weeks after completing the rapy (6 weeks if azithromycin used).

Refer to GUM clinic for contact tracing.

DOXYCYCLINE 100mg BD , or AZITHROMYCIN 1 gram (not licensed for use in pregnancy, see comments)

7 stat

Trichomoniasis Refer to GUM may be associated with other STDs . METRONIDAZOLE 400mg BD 7

Gonorrhoea - uncomplicated Increasing resistance Refer to GUM clinic for contact tracing and screening for other sexually transmitted diseases.

CEFTRIAXONE IM 500mg stat and AZITHROMYCIN 1 gram stat

stat

Pelvic inflammatory disease Refer to GUM. Tests essential for gonococcus and chlamydia.

CEFTRIAXONE IM 500 mg stat followed by DOXYCYCLINE 100mg BD and METRONIDAZOLE 400mg BD or

OFLOXACIN 400mg BD and METRONIDAZOLE 400mg BD

14 14

Acute prostatitis Send MSU for culture and start antibiotics. 2 week course may prevent chronic prostatitis.

CIPROFLOXACIN 500mg BD, or TRIMETHOPRIM 200mg BD

14 14

Genital herpes Screening for low risk patients may be done in practice. Higher risk should be referred to GUM.

ACICLOVIR 200mg five times a day 5

Bartholins gland infection May be associated with STD consider screening . Antibiotics not indicated for uncomplicated disease

Genital warts Screening for co -existent STD indicated . Podophyllotoxin is contra - indicated in pregnancy.

PODOPHYLLOTOXIN applied twice daily for three consecutive days, repeated at weekly intervals if necessary for a total of 4 to 5 courses

Liquid nitrogen if small number of low volume warts or keratinized

WOUND AND SKIN INFECTION

Cellulitis - limb

I f afebrile and well other than cellulitis oral therapy is adequate .

If febrile and unwell admit or arrange for IV antibiotics (flucloxacillin or clarithromycin, as approved under PCT Cellulitis pathway) .

If river or sea water exposure discuss with mi crobiologist .

FLUCLOXACILLIN 500mg QDS, or CLARITHROMYCIN 500 mg BD

5 5

- facial Early referral necessary if not responding to treatment . CO-AMOXICLAV 625 mg TDS 7

Condition Comments Drug and dose

(listed in order of preference) Duration

(days)

Surgical wounds, abscesses, mastitis, wound infection

Abscesses should be drained. FLUCLOXACILLIN 500mg QDS , or CLARITHROMYCIN 500mg BD

5 5

If wound could be contaminated with soil, faeces or bodily fluids or if infection area has poor vascular supply .

CO-AMOXICLAV 625mg TDS , or CLARITHROMYCIN 500mg BD and METRONIDAZOLE 400mg TDS , or

CLINDAMYCIN 300mg QDS

5 5 5

Leg ulcers and pressure sores

Bacteria will always be present. Antibiotics do not improve healing , unless active infection . Culture swabs and antibiotics are only indicated if diabetic or there is evidence of clinical infection such as inflammation/redness/cellulitis, increased pain, purulent exudate, rapid deterioration of ulcer or pyrexia.

Herpes zoster ACICLOVIR 800mg five times a day, started within 72 hours of onset of rash

5

Animal and human bites Human bites should generally be treated with antibiotics if the skin is broken, and consideration given to tetanus, hepatitis B and HIV prophylaxis. If the skin is broken following an animal bite, consider antibiotics if puncture wound, bite to hand, foot, face, joint , tendon, ligament or immunocompromised, diabetic, asplenic or cirrhotic. Cat bites carry a high risk of infection and should be treated.

Consider tetanus, and, if the bite occurred abroad, rabies.

CO-AMOXICLAV 625mg TDS 2nd line Cat, dog and human bites - DOXYCYCLINE 100mg BD and METRONIDAZOLE 400mg TDS

Human bites - CLARITHROMYCIN 250 -500mg BD and METRONIDAZOLE 400mg TDS

5 5 5

Tick bite Lyme disease prophylaxis is indicated if tick is likely to have been attached for >24 hours, or it is obviously engorged.

Prophylaxis not indicated if the bite occurred more than 72 hours ago, or if the patient is continually exposed to ticks.

Treatment of localised erythema migrans: Treatment of later stages of Lyme disease - discuss with Microbiologist.

DOXYCYCLINE 200mg DOXYCYCLINE 100mg BD, or AMOXICILLIN 500mg TDS; children 14 years or severe pain or dense/oral rash or 2 household case or smoker

ACICLOVIR 800mg five times day 7

Shingles: treat if > 50 years and within 72 hours of rash or if active ophthalmic or Ramsey Hunt or eczema.

CENTRAL NERVOUS SYSTEM

Meningitis Urgent hospital transfer is primary consideration. Only contra - indication to benzylpenicillin if true penicillin anaphylaxis; use of alternate antibiotics is not recommended.

BENZYLPENICILLIN, preferably IV, but IM if access difficult

Over 10 years, 1.2 grams 1 to 9 years, 600mg Under 1 year, 300mg

stat