Aims

q       to provide a simple, best guess approach to the treatment of common infections

q       to promote the safe, effective and economic use of antibiotics

q       to minimise the emergence of bacterial resistance in the community

Principles of Treatment

1.        This guidance is based on the best available evidence but its application must be modified by professional judgement.

2.        Prescribe an antibiotic only when there is likely to be a clear clinical benefit

3.        Do not prescribe an antibiotic for viral sore throat, simple coughs and colds.

4.        Limit prescribing over the telephone to exceptional cases.

5.        Use simple generic antibiotics first whenever possible.

6.        The use of new and more expensive antibiotics (eg quinolones, clarithromycin) is inappropriate when standard and less expensive antibiotics remain effective

7.        Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).

8.        In pregnancy AVOID tetracyclines, 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, theoretical risk of neonatal haemolysis) or cefalexin is unlikely to cause problems to the foetus.

9.        Clarithromycin is an acceptable alternative in those who are unable to tolerate erythromycin because of side effects.

10.     Sensitivity of bacteria is often unpredictable particularly when the patient is exposed recent courses of therapy or has had recent hospitalisation. It is recommended that already available recent culture results are considered while selecting an empirical regimen and appropriate specimens taken for culture.

11.     Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from:

Dr R. E. Stansfield, Consultant ( NTGH ext 4067, Bleep #6141               

Dr J Sellers, Consultant (WGH ext 3702, NTGH ext 4531, Bleep #6219

Dr J Sarma, Consultant ( NTGH ext 4533, Bleep #6220

Dr B Marshall, Consultant ( NTGH   ext 4545, Bleep #6245       

Registrar (NTGH ext 4578, Bleep #6276

ILLNESS

COMMENTS

DRUG

DOSE

Adults unless otherwise stated.  Please refer to BNF for further information 

DURATION OF Tx

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.A-(J Fam Pract 2002:51:324-8)

Influenza

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, only when influenza is circulating in the community, within 48 hours of start of symptoms, ie those aged 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus and chronic renal disease. Patients over 12 years use oseltamivir 75 mg oral capsule BD or zanamivir 10 mg (2 inhalations by diskhaler) BD for 5 days.

Pharyngitis /

sore throat / tonsillitis

The majority of sore throats are viral; most patients do not benefit from antibiotics. Patients with 3 of 4 centor criteria (history of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from antibiotics. A-Antibiotics only shorten duration of symptoms by 8 hours.A+ You need to treat 30 children or 145 adults to prevent one case of otitis media.A+ Seven days treatment gives less relapse than three days.B+

Recent evidence indicates that penicillin 500 mg TDS for 7 days is more effective than 3 days.^B+  Twice daily higher dose can also be used.^A- QDS may be more appropriate if severe.^D

first line

phenoxymethylpenicillin

500 mg QDS

7-10 days

erythromycin

if allergic to penicillin

500 mg BD or

250 mg QDS

(QDS less side-effects)

5-10 days

Otitis media

(child doses)

Many are viral. 80% resolve without antibiotics.^A+ Poor outcome unlikely if no vomiting or temp <38.5^oC.^A- Use paracetamol.^B+ Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.^A+ Need to treat 20 children >2y and seven 6-24m old to get pain relief in one at 2-7 days.^A+B+  Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, are less effective treatment.

amoxicillin

first line

 1 mo-1 yr: 125 mg TDS

1-10 yrs : 250 mg TDS

>10 yrs : 500 mg TDS

5 days*

5 days*

erythromycin

if allergic to penicillin

2^nd line

co-amoxiclav

1 mo-2 yrs: 125 mg QDS

2-8 yrs  250 mg QDS

Other:  250-500 mg QDS

1-6 yrs   156 mg TDS

6-12 yrs 312 mg TDS

5 days*

5 days*

5 days*

Rhinosinusitis

acute or chronic

Many are viral. Symptomatic benefit of antibiotics is small - 69% resolve without antibiotics; 84% resolve with antibiotics.^A+  Reserve for severe^B+ or persistent symptoms (>10 days).

Cochrane review concludes that phenoxymethylpenicillin  has similar efficacy.

phenoxymethylpenicillin ^A+

amoxicillin ^A+

or oxytetracycline

or erythromycin

or doxycycline

500 mg TDS

500 mg TDS

250 mg QDS

250 mg QDS/500 mg BD

200 mg stat/100 mg OD

3 days*

3 days*

3 days*

3 days*

3 days*

Second line antibiotics

co-amoxiclav

ciprofloxacin plus

metronidazole

625 mg TDS

250 – 500 mg BD

400 mg BD

7 days

7 days

7 days

* Standing Medical Advisory Committee guidelines suggest 3 days. In otitis media, relapse rate is slightly higher at 10 days with a 3 day course but long-term outcomes are similar.^A+.

ILLNESS

COMMENTS

DRUG

DOSE

DURATION OF Tx

LOWER RESPIRATORY TRACT INFECTIONS

Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones ciprofloxacin and ofloxacin have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections. Levofloxacin has some anti-Gram-positive activity but should not be needed as first line treatment.

Acute bronchitis

Systematic reviews indicate antibiotics have marginal benefits in otherwise healthy adults.A+ Patient leaflets can reduce antibiotic use.B+

amoxicillin or oxytetracycline or doxycycline

500 mg TDS

 250–500 mg QDS

200 mg stat/100 mg OD

5 days

5 days

5 days

Acute exacerbation of COPD

Antibiotics not indicated in absence of purulent/mucopurulent sputum. B+ Most valuable if increased dyspnoea and increased purulent sputum.B+

If clinical failure to first line antibiotics

amoxicillin or oxytetracycline or doxycycline

erythromycin

 co-amoxiclav

500 mg TDS

 250 mg QDS

200 mg stat/100 mg OD 250-500mg QDS

625mg TDS

5-10 days

5-10 days

5-10 days

5-10 days

5-10 days

Community-acquired pneumonia -treatment in the community

Start antibiotics immediately. B-If no response in 48 hours consider admission or add erythromycin first line or a tetracyclineC to cover Mycoplasma infection. Mycoplasma is rare in over 65s. In severely ill give parenteral benzylpenicillin before admissionC and seek risk factors for Legionella and Staph. aureus infection. D

amoxicillin or

erythromycin

500 mg - 1g TDS

500 mg QDS

Up to 10 days

Up to 10 days

oxytetracycline or doxycycline

250-500 mg QDS

 200 mg stat 100 mg OD

Up to 10 days

Up to 10 days

MENINGITIS

Suspected meningococcal disease

Transfer all patients to hospital immediately.  Administer benzylpenicillin prior to admission, unless history of anaphylaxis,^B- NOT allergy.  Ideally IV but IM if a vein cannot be found. 

IV or IM benzylpenicillin

Adults and children

10 yr and over: 1200 mg

Children 1 - 9 yr: 600 mg

Children <1 yr:    300 mg

Prevention of secondary case of meningitis

Only prescribe following advice from Northumberland, Tyne & Wear Health Protection Unit

9 am – 5 pm:       ( 0191 2733584

Out of hours:            0191 2336161

UTI quick reference guide  (www.hpa.org.uk/infections/topics_az/primary_care_guidance/uti.guide_290404.rtf)

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

Uncomplicated UTI ie no fever or flank pain 

Use urine dipstick to exclude UTI -ve nitrite and leucocyte 95% negative predictive value. Perform culture and susceptibility only in treatment failure.

Nitrofurantoin

or                   

cefalexin

50-100 mg QDS

or 100mg BD of m/r form

250 mg TDS

Non-pregnant  otherwise healthy women 3 days; Elderly 3-7 days [1]

2nd line - depends on susceptibility of organism isolated e.g. trimethoprim, amoxicillin, cefalexin, co-amoxiclav, quinolone

Recurrent UTI women ≥ 3/yr

Post-coital prophylaxis is as effective as prophylaxis taken nightly.

nitrofurantoin or

cefalexin

50 mg

250 mg

Stat post coital or od at night

UTI in pregnancy and men

Suggest MSU for susceptibility testing. Short-term use of cefalexin  or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. B+

nitrofurantoin or

cefalexin

2nd line - depends on susceptibility of organism isolated e.g. trimethoprim, amoxicillin, cefalexin, co-amoxiclav

50 – 100 mg QDS   

250 mg TDS  

7 days

7 days

Children

Send MSU for culture and susceptibility.

 Nitrofurantoin or cefalexin

 If susceptible, amoxicillin

See BNF for dosage

7 daysA+

Acute pyelonephritis

A recent RCT showed 7 days ciprofloxacin was as good as 14 days co-trimoxazole.A-If no response within 48 hours admit.

ciprofloxacinA-or co-amoxiclav.

 If susceptible, trimethoprim

500 mg BD

 500/125 mg TDS

 200 mg BD

7 daysA--14 days

14 days

ILLNESS

COMMENTS

DRUG

DOSE

DURATION OF Tx

GASTRO-INTESTINAL TRACT INFECTIONS

Eradication of Helicobacter pylori

Eradication is beneficial in DU, GU and low grade MALTOMA, but NOT in GORD.^A In NUD, 8% of patients benefit.

Triple treatment attains >85% eradication.^A. Do not use clari or mtz if used for any infection in the past year.^C

In treatment failure consider endoscopy for culture & sensitivities.^C Substitute oxytetracycline for clarithromycin or metronidazole and add bismuth salt.^A-

First line:

lansoprazole 

amoxicillin             

clarithromycin

Second line( or for penicillin sensitive patients):

lansoprazole

clarithromycin

metronidazole

30 mg BD

1 g BD

500 mg BD

30 mg BD

500 mg BD

400 mg BD

7 days course

Note: The preferred test for HP eradication is a ¹³C-Urea breath test. If eradication has failed, a second course of eradication therapy should be given.

Gastroenteritis

Fluid replacement essential.  Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days^B+ and can cause resistance.^B+  Initiate treatment, on advice of microbiologist, if the patient is systemically unwell. Please notify suspected cases of food poisoning to, and seek advice on exclusion of patients from, the Health Protection Unit ( 0191 2733584

Send stool samples in these cases.

Traveller’s diarrhoea

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

GENITAL TRACT INFECTIONS – UK NATIONAL GUIDELINES http://www.phls.co.uk/topics_az/vaginal/vag_dis_guidelines.doc        http://www.phls.co.uk/topics_az/primary_care/chlam_guidelines.doc

Vaginal candidiasis

All topical and oral azoles give 80-95% cure.^A-

In pregnancy avoid oral azole^.B

clotrimazole  10%

or clotrimazole

or fluconazole

5 g vaginal cream

500 mg pessary

150 mg orally

stat

stat

stat

Bacterial vaginosis

A 7 day course of oral metronidazole is slightly  more effective than 2 g stat.^A+

Avoid 2g stat dose in pregnancy.

Topical treatment gives similar cure rates^A+ but is more expensive.

metronidazole^A+

or

metronidazole

0.75% vag gel^A+

or

clindamycin 2% cream^A+

400 mg BD

5 g applicatorful at night

5 g applicatorful at night

7 days

5 days

7 days

Chlamydia trachomatis

Tetracyclines are contra-indicated in

pregnancy.

Erythromycin and ciprofloxacin are less efficacious than doxycycline.

Treat partners

Refer contacts to GUM clinic

doxycycline^A+ or

oxytetracycline^A-

erythromycin ^A-

azithromycin^A+

100 mg BD

500 mg QDS

500 mg BD

or 500 mg QDS

1 g  stat

7 days

7 days

14 days

7 days

1 hr before or

2 hrs after food  

Trichomoniasis

Treat partners simultaneously.

In pregnancy avoid 2G single dose metronidazole.  Topical clotrimazole gives symptomatic relief (not cure).

metronidazole^A-

clotrimazole

400 mg BD

or 2 g in single dose

100 mg pessary

5-7 days

6 days

Pelvic Inflammatory Disease

(PID)

Test for Chlamydia & N. gonorrhoea

Microbiological and clinical cure are

greater with ofloxacin than with doxycycline.^A+

Refer contacts to GUM clinic

metronidazole +

ofloxacin^B

or

metronidazole +

doxycycline^B

400 mg BD

400 mg BD

400 mg BD

100 mg BD

14 days

14 days

14 days

14 days

Acute prostatitis

4 weeks treatment may prevent chronic infection.

Quinolones are more effective.

ofloxacin^C or

norfloxacin or

ciprofloxacin or

trimethoprim^C

200 mg BD

400 mg BD

500 mg BD

200 mg BD

28 days

28 days

28 days

28 days

Note: Refer patients with STDs, including trichomoniasis, to GUM clinic for contact tracing.

PARASITIC INFECTIONS

Threadworm

Treat household contacts. Advise morning shower/baths and hand hygiene.

Use piperazine in children under 2. 

mebendazole  or

piperazine

100 mg

1-6 yrs      5ml spoon

3-12mths   2.5ml spoon

stat

stat, repeat after 2 weeks

ILLNESS

COMMENTS

DRUG

DOSE

DURATION OF Tx

SKIN / SOFT TISSUE INFECTIONS

Impetigo

Systematic review indicates topical and oral treatment produces similar resultsA+

As resistance is increasing reserve topical antibiotics for very localised lesionsC or D

Reserve Mupirocin for MRSA.

flucloxacillin    

or erythromycin   First line

 fusidic acid

mupirocin

Oral 500 mg QDS

 Oral 500 mg QDS

Topically QDS

Topically QDS

7 days

7 days

5 days

5 days

Eczema

Routinely adding antibiotic to steroid in eczema does not improve response.

Leg ulcers

Culture swabs and antibiotics are only indicated if cellulitis is present.

Animal bite

Human bite

Surgical toilet most important.

Assess tetanus and rabies risk.

Antibiotic prophylaxis advised for – puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic

Antibiotic prophylaxis advised.

Assess HIV/hepatitis B & C risk

First line animal & human

prophylaxis and treatment

co-amoxiclav^B-

If penicillin allergic:

metronidazole plus

oxytetracycline (animal)

or erythromycin (human)

and review at 24 & 48 hrs

375-625 mg TDS

200-400 mg TDS

250-500 mg QDS

250-500 mg QDS

7 days

7 days

7 days

7 days

Conjunctivitis

Most bacterial infections are self-limiting (64% resolve on placeboA+). They are usually unilateral with yellow-white mucopurulent discharge. Fusidic acid has less Gram-negative activity

chloramphenicol 0.5% drops + 1% ointment

fusidic acid

2 hrly reducing to QDS

 at night

 1% gel BD

All for 48 hours after resolution

Scabies

Treat whole body including scalp, face, ears and under nails. Treat household contacts.

permethrin^A+

5% cream

2 applications one week apart

Dermatophyte infection of the proximal fingernail or toenail For children seek advice

Take nail clippings: Start therapy only if infection is confirmed by laboratory. Idiosyncratic liver reactions occur rarely with terbinafine.

5% amorolfine nail lacquerB

terbinafineA-

1-2x/weekly fingers

 toes

250 mg OD fingers

 toes

6 months

12 months

 6 – 12 weeks

3 – 6 months

Pulsed itraconazole monthly is recommended for infections with yeasts and non-dermatophyte moulds. C

itraconazole

200 mg BD fingers

                    toes

7 days monthly

 2 courses

7 days monthly

3 courses

Dermatophyte infection of the skin

Take skin scrapings for culture.

Treatment: 1 week terbinafine is as effective as 4 weeks azole. A-If intractable consider oral itraconazole. Discuss scalp infections with specialist.

Topical 1% terbinafine A+

Topical undecenoic acid or 1% azoleA+

OD –BD

 1-2x/daily

1 weekA+

4 – 6 weeksA+

MRSA infection

Chronic ulcer such as pressure sores may be colonised with MRSA which does not require systemic treatment unless signs of infection. Similarly, MRSA often colonises throat, so sputum growing MRSA may reflect colonisation rather than infection. Seek advice for deep and severe MRSA infection.

Tetracycline (e.g., doxycycline or oxytetracycline) ± Sodium Fusidate (use fusidic acid if required in suspension form)

Doxycycline: 200mg Stat the 100 mg OD

Oxytetracycline: 500mg QDS

Sodium Fusidate (tablet): 500mg TDS

Fusidic acid (suspension): 750mg TDS

7-10 days depending on the severity

Eradication of MRSA colonisation

Eradication is always successful. The aim is not necessarily to eradicate but to reduce the load so that the risk is reduced Should be attempted in special circumstances e.g., before elective surgery. Discuss with a microbiologist if in doubt.

1. A small amount of 2% Mupirocin applied with a cotton wool swab to each nostril TDS.

2. Antiseptic detergent Triclosan used as a body wash daily applied to the moistened skin prior to washing off in bath or shower. Special attention should be paid to known carriage sites, using disposable cloth/ clean flannel.

5 days

VIRAL INFECTIONS

Varicella zoster

(chicken pox)

&

Herpes zoster (shingles)

If pregnant seek advice.

Chicken pox: Clinical value of antivirals minimal unless immunocompromised, on steroids, secondary household case or severe pain, AND if treatment started < 24h of onset of rash.^A- 

Shingles: Treatment indicated if: ophthalmic or predictors of post-herpetic neuralgia: >60 y^A+, severe pain,^A+  severe skin rash, prolonged prodromal pain^B+ AND <72h of onset of rash.

Aciclovir

or

valaciclovir

800 mg 5x/day

1 g TDS

Child doses – see BNF

7 days

7 days