Guia para Prescripcion de Antibioticos

NHS Wiltshire CCG,
BaNES CCG & Swindon CCG

Guidelines for
Antibiotic Prescribing
in the Community
2013-15
Produced in collaboration with:
Dr Susan Murray, Consultant Microbiologist, Royal United Hospital
Bath NHS Trust,
Dr Susan Dawson, Consultant Microbiologist, Great Western Hospitals
NHS Foundation Trust,
Dr Stephen Cotterill, Consultant Microbiologist, Salisbury NHS
Foundation Trust,
Dr Rachel Hobson, Formulary Pharmacist, Wiltshire CCG,
Emma Taylor, Specialist Antibiotic Pharmacist, Salisbury NHS
Foundation Trust,
Sally Tipping, Specialist Antibiotic Pharmacist, Great Western Hospitals
NHS Foundation Trust,
Wendy Lloyd, Specialist Antibiotic Pharmacist, Royal United Hospital
Bath NHS Trust,
Dr Michael Moore, GP Three Swans Surgery, Salisbury,
Dr Elizabeth Tully, GP Northlands Surgery, Calne,
Cathy Dewdney, Specialist Paediatric pharmacist, Great Western
Hospitals NHS Foundation Trust,
Denise Reeves, Specialist HIV pharmacist, Great Western Hospitals
NHS Foundation Trust.
Thanks also to colleagues who commented on the guidance:
Dr Natasha Zurick, Consultant Paediatrician RUH,
Dr Tracey Farnon, Consultant Paediatrician SFT,
Louise Pitman, Paediatric pharmacist, SFT,
Dr Guy Rooney, Consultant in Genito-Urinary Medicine GWH,
Dr Sophie Forsyth, Consultant in Genito-Urinary Medicine GWH,
Dr Arnold Fernandes, Consultant in Genito-Urinary Medicine RUH,
Dr Angus Waddell, ENT Consultant, GWH,
Dr Tim Bates, Consultant Urologist, RUH.
Any comments, please contact: prescribingwiltshire@nhs.net
The format of these guidelines are based on those produced by
NHS Hampshire.
Preparation date: Feb 2013. Review Date: February 2015. Prepared by: Rachel Hobson.
Purpose of these guidelines
1. To provide clear authoritative advice on the empirical antibiotic treatment of common infections
2. To promote the judicious use of antibiotics
3. To minimize the emergence of bacterial resistance.
Decision to prescribe
The decision to prescribe an antimicrobial should always be clinically justified and the reason(s) should be recorded in
the patient’s medical record. It is important not to prescribe antimicrobials on a ‘just in case’ basis.
Severe infection: This guide is not intended for use in severe infection when use of IV antibiotics is likely to be
necessary. Antimicrobials prescribed empirically in life-threatening situations where inpatient admission is necessary
should be administered within ONE HOUR of presentation and reviewed early in the light of microbiological results
and clinical progress and if appropriate changed following bacterial sensitivities. On community inpatient units, in
cases of severe infection, it may be more appropriate to follow hospital antibiotic treatment guidelines. All inpatient
prescriptions should have a documented indication and duration to review on the inpatient medicine chart.
Antibiotics should be discontinued only when clinically appropriate after a clinical review.
Plasma level monitoring: Certain IV antibiotics require plasma level monitoring eg Gentamicin,Vancomycin or
Teicoplanin. Please look at your local hospital intranet/formulary webpages for advice.
Individual patient and drug-specific factors Grading of guidance recommendations
to consider before prescribing antibiotics in (as per HPA guidance)
all cases include: The strength of each recommendation is qualified by a
• Previous antimicrobial history letter in superscript.
• Allergies (which can be severe and life threatening) Recommendation
Study design
and side-effects grade
• Previous infection with multi-resistant organisms Good recent systematic review of studies A+
• Availability of and absorption by oral route. One or more rigorous studies, not combined A-
• Risk of development of healthcare associated One or more prospective studies B+
infections such as MRSA or C difficile infection One or more retrospective studies B-
• Drug interactions Formal combination of expert opinion C
• Pregnancy and breast-feeding Informal opinion, other information D
• Recent travel history including any travel to malarious
areas in the past 2 years.
N.B. If a patient needs admitting to hospital, it is useful for the referral letter
to contain information about recent use (past 6/12) of antibiotics.
page 3
Principles of antibiotic use 13. Prevention of secondary case of meningitis: Only prescribe
following advice from Public Health Doctor.
1. This guidance is based on the best available evidence
• South West (North) Health Protection Unit, Rivergate
available at the time of review and is intended for EMPIRICAL
use of antibiotics. Its application must be modified by House, 2 Rivergate, Bristol BS1. Contact number 0845
professional judgement and patients should be involved in 504 8668 (option 1) and ask for Wiltshire/Swindon/Avon
treatment decisions. locality Team (or leave a message).
2. A dose and duration of treatment is suggested but may need 14. Where a ‘best guess’ therapy has failed or special
modification for age, weight, renal function, liver function, circumstances exist, microbiological advice can be obtained
concomitant drugs and co-pathologies. In severe or recurrent from the duty microbiologist at the following telephone
cases consider a larger dose or longer course with regular numbers according to which hospital you refer to (see below):
review. Great Western Hospitals NHS Foundation Trust
3. Have a lower threshold for antibiotic use in Microbiology Department: 01793 604800.
immunocompromised patients or those with multiple Microbiology Handbook: http://www.gwh.nhs.uk/wards-and-
morbidities; consider culture and seek microbiological advice
services-a-z/a-to-z/pathology/further-information
if appropriate.
4. Prescribe an antibiotic only when there is likely to be a clear Royal United Hospitals NHS Trust Microbiology Department:
clinical benefit. 01225 825428. Microbiology Handbook: http://www.ruh.nhs.
5. Consult the BNF for Children for children’s doses of uk/For_Clinicians/departments_ruh/Pathology/documents/
antibiotics. Bristol_HPA_User_Manual.pdf
6. Consider a no, or delayed, antibiotic strategy for acute sore Salisbury Hospital NHS Foundation Trust Microbiology
throat, common cold, otitis media, acute cough, acute Department: Lab results: 01722 336262 ext 4099 OR direct:
sinusitis and conjunctivitis (see appendix 2 (p70) for the 01722 429099; Clinical discussions (Monday to Friday 9am to
delayed antibiotic strategy patient information leaflet which 5pm): 01722 336262* ext 4105 OR direct: 01722 429105 *You
may be given to patients in consultations.).
can also ask switchboard to page duty consultant microbiologist
7. Limit prescribing over the telephone to exceptional cases.
bleep 1967 Clinical discussions (after 5pm M-F/ weekends/ bank
8. Use targeted antibiotics if possible. Avoid broad spectrum holidays): Out-of-hours: 01722 336262. Ask switchboard to contact
antibiotics (eg co-amoxiclav, quinolones and cephalosporins)
duty Consultant Microbiologist on-call.
when narrow spectrum antibiotics remain effective, as they
increase risk of Clostridium difficile, MRSA and resistant UTIs. For non-urgent clinical questions or advice GPs can also use our
9. Penicillin allergy- patients with a history of anaphylaxis, e-mail enquiry box at: shc-tr.microenquiries@nhs.net
urticarial rash or a rash immediately after penicillin Microbiology Handbook: http://nww.icid.salisbury.nhs.
administration (type 1 allergy) should not receive a penicillin, uk/icid/diagnostics/pathology/pathologyhandbook/
cephalosporin or other beta-lactam antibiotic. Check before pathlabhandbookv32september2009.pdf
prescribing if you are unsure which class an antibiotic
For advice on Infection Control issues for Wiltshire CCG, see
belongs to. Discuss alternative antibiotic treatment with a
microbiologist if a suitable alternative is not given in this infection control resources:
document. Also see the penicillin allergy appendix 4, p.85-86 http://nww.wiltshire.nhs.uk/policiesandprocedures/
for further information on which antibiotics are safe to use. infectioncontrolpolicyandprocedurebath/index.htm
10. Avoid widespread use of topical antibiotics (especially those For advice on Infection Control issues for Swindon CCG, the
agents also available as systemic preparations, (e.g. fusidic SEQOL IP & C team for SEQOL services can be contacted on
acid). 01793 465509. The infection prevention and control policy and
11. In pregnancy AVOID tetracyclines, aminoglycosides, procedures are the same for SwICC and community and are
quinolones, high dose metronidazole. Short-term use of available from: http://seqol.org/
nitrofurantoin (avoiding use at term, theoretical risk of
neonatal haemolysis) is unlikely to cause problems to the Decontamination
foetus. Contact your local hospital medicines information for It is important that the guidance given by NHS Wiltshire
specialist advice. and Swindon is followed to ensure that there is effective
12. We recommend clarithromycin as it is generally better decontamination of the working environment. See:
tolerated than erythromycin, patients are more likely to http://nww.wiltshire.nhs.uk/policiesandprocedures/
comply with treatment as taken twice rather than four times infectioncontrolpolicyandprocedurebath/2.0_
daily and generic tablets are similar cost. Decontamination_v1.pdf
page 4
Index
Paediatric Section Adult section Skin & Soft Tissue Infections
Impetigo 55
Ear, Nose & Throat Infections Ear, Nose & Throat Infections Eczema 56
Acute Sore Throat 8-9 Acute Sore Throat 25-26 Cellulitis 57
Acute Otitis Media 10-11 Acute Otitis Externa 27 Leg Ulcers 58
Acute sinusitis 28 MRSA 59
Respiratory Tract Infections
Influenza & other Respiratory Tract Infections Animal Bites 60
respiratory infections 12 Note about bronchiectasis NEW Human Bites 61
Community Acquired Influenza 29 Conjunctivitis 62
Pneumonia 13-14 Acute bronchitis 30 Scabies 63
COPD acute exacerbation 31 Dermatophyte infection of
Central nervous System
Community Acquired finger or toenails 64
Meningitis or suspected
Pneumonia 32 Dermatophyte infection of skin 65
meningococcal disease 15
Central Nervous System Varicella Zoster & Herpes Zoster 66
Urinary Tract Infections Meningitis or suspected Mastitis NEW 67-68
UTI 16-17 meningococcal disease 33 Dental Infections
Gastro-Intestinal Infections Urinary Tract Infections Dental Infections NEW 69
Giardiasis 18 Uncomplicated UTI 35-36
Appendices
Threadworms 19 UTI in pregnancy 37
Appendix 1
Acute pyelonephritis 38
Skin & Soft tissue Infections Best practice in antimicrobial
Cathether associated UTI 39
Eczema 20 drug prescribing 70-71
Recurrent UTI 40
Impetigo 21 Appendix 2 NEW
Animal Bites 22 Gastro-Intestinal Infections Probiotics in the prevention of
Human Bites 23 Helicobacter pylori 41 antibiotic-associated diarrhoea
Balanitis NEW 24 Infectious Diarrhoea 42 and clostridium difficle infection 72
Giardiasis 43 Appendix 3
Clostridium difficile 44 Delayed antibiotic
Threadworms 45 prescription strategy PIL 73-77
Diverticultis NEW 46 Appendix 4 NEW
Genito-Urinary Infections Penicillin Allergy Chart 78-79
Introduction 47 Appendix 5 NEW
Vulvo vaginal Candidiasis 48 Fosfomycin Info 80-81
Bacterial Vaginosis 49 Appendix 6 NEW
Chlamydia Trachomatis 50 Educational Info. 82
Trichomoniasis 51
Pelvic Inflammatory Disease 52
Acute prostatitis 53
Epididymo-orchitis NEW 54
page 5
Paediatric
Section
Paediatric
prescribing guidelines:
• Ear Nose and Throat Conditions
• Respiratory Tract Infections
• Central Nervous System infections
• Urinary Tract Infections
• Gastro-Intestinal tract infections
• Skin & soft tissue infections
All prescribers are advised to follow

the NICE CG47 (May 2007) Feverish
illness in children – Assessment &
initial management in children
younger than 5 years.
See: http://guidance.nice.org.uk/CG47
REMEMBER:
• Don’t prescribe antibiotics
unless there is a focus
• Don’t prescribe just because
there is a fever
In order to be able to distinguish

between the very sick and the less
unwell child please refer to the table
on the following page:
Table 1. Traffic light system for identifying likelihood of serious illness
Green – low risk Amber – intermediate risk Red – high risk
Colour • N
ormal colour of skin, lips and • Pallor reported by parent/carer • Pale/mottled/ashen/blue
tongue
Activity • Responds normally to social cues • Not responding normally to social • No response to social cues
• Content/smiles cues • Appears ill to a healthcare
• Stays awake or awakens quickly • Wakes only with prolonged professional
• Strong normal cry/not crying stimulation • Unable to rouse or if roused does not
• Decreased activity stay awake
• No smile • Weak, high-pitched or continuous cry
Respiratory • Nasal flaring • Grunting
• Tachypnoea: • Tachypnoea:
– RR > 50 breaths/minute – RR > 60 breaths/minute
age 6-12 months • Moderate or severe chest indrawing
– RR > 40 breaths/minute
age > 12 months
• Oxygen saturation ≤ 95% in air
• Crackles
Hydration • Normal skin and eyes • Dry mucous membranes • Reduced skin turgor
• Moist mucous membranes • Poor feeding in infants
• CRT ≥ 3 seconds
• Reduced urine output
Other • N
one of the amber or red symptoms • Fever for ≥ 5 days • A ge 0-3 months,
or signs • Swelling of a limb or joint temperature ≥ 38ºC
• Non-weight bearing/not using an • Age 3-6 months,
extremity temperature ≥ 39ºC
• A new lump > 2 cm • Non-blanching rash
• Bulging fontanelle
• Neck stiffness
• Status emilepticus
• Focus neurological signs
• Focal seizures
• Bile-stained vomiting
CRT: capillry refill time
RR: respiratory rate
Table 1: Reproduced from NICE CG47 (May 2007) Feverish illness in children – Assessment & initial management
in children younger than 5 years. http://guidance.nice.org.uk/CG47
page 7
PAEDIATRICS
Ear Nose and Throat Infections – Acute Sore Throat (page 1 of 2)
Consider a delayed antibiotic strategy (see appendix 3, p.73)
When to treat The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a 2 or 3 day
delayed strategy or immediate antibiotics depending on the clinical situation.1, A+ 90% of cases resolve in 7 days without
antibiotics & pain is only reduced by 16 hours.2A+ Also consider infectious mononucleosis.
A low centor score (0-2) has a high predictive value (80%) and indicates low chance of Group A Beta Haemolytic
Streptococci (GABHS). The likelihood of GABHS infection increases with increasing score and is between 25-86% with
a score of 4 and 2-23% with a score of 1, depending on age, local prevalence and seasonal variation. If a patient is
unwell with a centor score of 3-4 then the chance of developing Quinsy is 1:60. For patients with 3 or 4 centor criteria or
history of otitis media consider a 2 or 3-day delayed prescription or immediate antibiotics. The centor clinical prediction
score should be used to assist the decision on whether to prescribe an antibiotic, but cannot be relied upon for a precise
diagnosis. GABHS infection is most likely in the 5-15 year old age group and gets progressively less likely in younger or
older patients.
Centor Criteria (N.B. The score is NOT validated for use in children under 3 yrs)
Presence of each clinical feature scores 1 point:
• History of fever • Tender anterior cervical lymphadenopathy
• Absence of cough • Tonsillar exudates
When to refer NB Children under the age of three months with a temperature of 38˚C or higher and children aged 3-6
months with a temperature of 39˚C or higher should be recognised as being in a high-risk group for
serious illness (see table 1, page 7). Refer to a paediatrician first to exclude more significant pathology
and to assess whether more intensive treatment is required.
When considering whether a patient needs to be referred for consideration of tonsillectomy, please ensure that you
consult the commissioning intentions of NHS Wiltshire (p27):
http://www.wiltshire.nhs.uk/Downloads/Policies/Corporate/Commissioning/055b_Clinical_Priorities_Policy_
Clinical_Content.pdf
or NHS Swindon as appropriate:
http://www.swindon.nhs.uk/Library/Publications/Policies/Clinical_Commissioning/Effective_Clinical_
Commissioning_Polices_List_October_2012.pdf
General advice on when it is appropriate to refer can be found in the SIGN guidance referenced below.
When to Throat swabs should not be carried out routinely in the investigation of acute sore throat.
investigate
General Advice Adequate analgesia & fluids will usually be all that is required. In children with sore throat, an adequate dose of par-
acetamol should be used as first line treatment for pain relief. Ibuprofen may be used as an alternative to paracetamol
but should not be given routinely to children with or at risk of dehydration.
Continued overleaf
page 8
PAEDIATRICS
Treatment First line: If allergic to penicillin:
choices PHENOXYMETHYLPENICILLIN po CLARITHROMYCIN po
Child 0-6 months: Refer for specialist assessment Child 0-6 months: Refer for specialist assessment
Child 6 months - 1 year: 62.5mg QDS Child 6 months-12 years:
Child 1-6 years: 125mg QDS Under 8kg: 7.5mg/kg BD
Child 6-12 years: 250mg QDS 8-11kg: 62.5mg BD
Child 12-18 years: 500mg QDS 12-19kg: 125mg BD
For 10 days. 20-29kg: 187.5mg BD
Dose can be increased as per cBNF in severe infection if 30-40kg: 250mg BD
necessary. CHILD 12-18yrs (and over 40kg): 500mg BD.
Available as 125mg/5ml or 250mg/5ml oral solution For 5 days.
Available as 125mg/5ml or 250mg/5ml suspension
N.B Check for drug interactions!
Cautions Ampicillin-based antibiotics, including co-amoxiclav virtually always cause maculopapular rashes in people with
glandular fever, and should therefore not be used for ‘blind’ treatment of a sore throat (people who develop rashes
may mistakenly be labelled as penicillin allergic).
Evidence The Altamimi meta-analysis shows that short-course (including 5 days clarithromycin) broad-spectrum antibiotics
are as efficacious as 10 day penicillin for sore throat symptom treatment and GABHS eradication. However, 10 day
phenoxymethylpenicillin remains the treatment of choice. 5 day clarithromycin should be reserved for those with true
penicillin allergy. Antibiotics other than phenoxymethylpenicillin and clarithromycin are no more effective and are more
expensive.
Antibiotics to prevent Quinsy NNT >40004B-
Antibiotics to prevent Otitis Media NNT= 2002A+.
References Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation.
March-October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summary Sore throat-acute www.cks.library.nhs.uk
SIGN (2010) Management of sore throat and indications for tonsillectomy: a national clinical guideline. Scottish
Intercollegiate Guidelines Network www.sign.ac.uk
NICE Clinical Guideline 69. Respiratory Tract Infections-antibiotic prescribing. July 2008. www.nice.org.uk
Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short-term late generation antibiotics versus
longer term penicillin for acute streptococcal pharyngitis in children. Cochrane database of systematic reviews 2012.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004872.pub3/abstract
page 9
PAEDIATRICS
Ear Nose and Throat Infections – Acute Otitis Media (AOM) (page 1 of 2)
When to treat Many are viral. The HPA states that you should avoid antibiotics as 60% are better in 24hrs without: they only reduce
pain at 2 days (NNT=15) and do not prevent deafness.4A+ The HPA suggest that you consider a 2 or 3-day
delayed1A+ or immediate antibiotics for pain relief if:
• <2 yrs with bilateral AOM NNT=4 or bulging membrane and ≥4 marked symptoms 5-7+
• All ages with otorrhoea NNT=3 8A+
However, local consensus suggests that Otitis media should not be treated with ‘no antibiotic’ but with a delayed
prescription and with clear instruction to start the antibiotics after 3 days if the symptoms have not improved or earlier
with worsening symptoms. Rare, serious complications can occur if there is a prolonged delay in patients receiving
antibiotics.
When to refer Admit for immediate specialist assessment:
• Children under the age of three months with a temperature of 38˚C or higher and children aged 3-6
months with a temperature of 39˚C or higher should be recognised as being in a high-risk group for
serious illness (see table 1 on page 7). Refer to exclude more significant pathology and to assess
whether more intensive treatment is required.
• Children with suspected acute complications of acute otitis media (AOM), such as meningitis, mastoiditis, facial
paralysis or who are systemically unwell.
Consider admitting: Children who are more unwell than might be expected.
Elective referral if: Persistent effusion or discharge, perforation not healed after 6 weeks, four or more episodes of
AOM in 6 months or impaired hearing after 3-6 months.
When to No investigations are indicated for a first episode.
investigate
General Advice Use NSAID or paracetamol for pain relief.A Inform the parent/carer that the average total duration of illness for untreated
acute otitis media, before and after seeing a healthcare professional, is 4 days. Offer reassurance that antibiotics are
not usually needed because they are likely to make little difference to symptoms, may have adverse effects (for example,
diarrhoea, vomiting, and rash), and can contribute to antibiotic resistance. Advise the person to re-consult if the condition
worsens or if symptoms are not starting to settle within 3 days of the onset of the illness.
Continued overleaf
page 10
PAEDIATRICS
Ear Nose and Throat Infections – Acute Otitis Media (AOM) (page 2 of 2)
Treatment First Line If allergic to penicillin: Second line
choices Amoxicillin po Clarithromycin po Co-amoxiclav po:
Child 0-6 months: Refer for specialist Child 0-6 months: Refer for Child 0-6 months: Refer for
assessment specialist assessment specialist assessment
Child 6 months-1 year Child 6 months-12 years: 6 months-1yr: 0.25ml/kg of 125/31
125mg TDS Under 8kg: 7.5mg/kg BD suspension TDS
Child 1-5 years 8-11kg: 62.5mg BD 1-6 yrs: 5ml of 125/31 suspension TDS
250mg TDS 12-19kg: 125mg BD 6-12 yrs: 5ml of 250/62 suspension
Child 5-18 years 20-29kg: 187.5mg BD TDS
500mg TDS 30-40kg: 250mg BD N.B. Above doses may be doubled in
For 5 days. CHILD 12-18yrs (and over severe infection
Available as 125mg/5ml or 250mg/5ml 40kg): 500mg BD 12-18 yrs: One 250/125 strength
suspension For 5 days. tablet TDS; increased in severe infection
Please note these doses are Available as 125mg/5ml or to one 500/125 strength tablet TDS.
higher than those used for other 250mg/5ml suspension For 5 days.
conditions, in line with BNF and HPA N.B Check for drug interactions! If patient is penicillin allergic,
recommendations. Mg per kg dosing has please seek specialist advice.
been dose banded for ease of use. If child
is markedly underweight use a 40mg/kg
dosage in three divided doses.
Cautions Admission or immediate referral if: Sudden dizziness with nystagmus, severe hearing loss (except simple
perforation), signs of meningitis, progression to mastoiditis. Elective referral if: Persistent effusion or discharge,
perforation not healed after 6 weeks, 4 or more episodes in 6 months or impaired hearing after 3 to 6 months Note:
children with serious craniofacial abnormalities or immune deficiencies that are not responding to primary care
management are at high risk of developing head and neck complications.
Evidence Amoxicillin is as effective as other antibiotics in the treatment of AOM in RCTs, provided there has been no recent
treatment with amoxicillin.
Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, are less effective
treatment. There is no advantage in using an antibiotic to cover beta-lactamase producing organisms
(e.g. co-amoxiclav) in the initial treatment of AOM. Antibiotics to prevent mastoiditis NNT> 4000 9B-
References NHS Clinical Knowledge Summary Otitis Media www.cks.library.nhs.uk
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation.
NICE CG47 (May 2007) Feverish illness in children –Assessment and initial management in children younger than 5
years. http://guidance.nice.org.uk/CG47
page 11
PAEDIATRICS
Respiratory Tract Infections – Influenza HPA Influenza
For treatment of patients under the age of 13 please see the HPA influenza link for the most up to date information:
http://www.hpa.org.uk/infections/topics_az/influenza/seasonal/pdfs/Treatmentflowchart.pdf
For guidance on the treatment of the following respiratory conditions in children please refer to the websites as
per below:
PAEDIATRICS
Other Respiratory Infections
Asthma British Thoracic Society Guidelines. British Guideline on the management of asthma May 2008 (Revised June 2009):
http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
Clinical Knowledge Summaries http://www.cks.nhs.uk/asthma
Bronchiolitis Scottish Intercollegiate Guidelines Network (SIGN) 91 Bronchiolitis in children.
http://www.sign.ac.uk/pdf/sign91.pdf
Croup Clinical Knowledge Summaries. http://www.cks.nhs.uk/croup
Additional guidance that is of relevance:

NICE CG47 (May 2007) Feverish illness in children –Assessment and initial management in children younger than
5 years. http://guidance.nice.org.uk/CG47
page 12
PAEDIATRICS
Respiratory Tract Infections – Community Acquired Pneumonia (CAP) (page 1 of 2)
When to treat It is important to consider that significant numbers of CAP cases in children will be of viral origin. However, bacterial and
viral pneumonia cannot be reliably distinguished from each other and so all children with a clear clinical diagnosis of
pneumonia should receive antibiotics.
When to refer Arrange admission for a child with any high risk features from the assessment (table 1, page 7). Arrange urgent
admission if there are episodes of apnoea or if it is judged that the child is in severe respiratory distress.
For a child with any intermediate risk features, the need for hospital assessment will depend on clinical judgement, but
the threshold for arranging this should be low. Arrange hospital assessment if:
• The carers are unable to cope well with the ill child.
• There is uncertainty about the diagnosis.
• A complication is suspected, such as a secondary bacterial infection in a child with viral wheeze or a foreign body.
• The child is unresponsive to treatment, or there is any deterioration in the condition of the child after starting treatment.
• The child has significant health problems such as chronic respiratory disease, congenital heart disease or is
immunocompromised.
• The child does not improve after 48 hours of treatment.
• Children who have oxygen saturations <92% should be referred to hospital for assessment and management.
• Auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia
complicated by effusion.
Bacterial pneumonia should be considered in children up to 3 years of age when there is fever >38.5ºC together with
chest recession, nasal flaring and a respiratory rate >50. If wheeze is present in a pre-school child, primary bacterial
pneumonia is unlikely.
NB. Children under the age of three months with a temperature of 38ºC or higher and children aged 3-6
months with a temperature of 39ºC or higher should be recognised as being in a high-risk group for serious
illness (see table 1, page 7). Refer to exclude more significant pathology and to assess whether more
intensive treatment is required.
When to There is no indication for microbiological investigation of a child with pneumonia in the community that is being treated.
investigate Chest radiography should not be considered a routine investigation in children thought to have CAP.
General Advice Treat a child who is feeling miserable with fever with either paracetamol or ibuprofen.
Encourage the child to take fluids regularly. For infants that are breastfed, continue breastfeeding as normal. Check on the
child regularly, including through the night and seek medical advice if the child deteriorates or the carers are unable to cope.
Continued overleaf
page 13
PAEDIATRICS
Respiratory Tract Infections – Community Acquired Pneumonia (page 2 of 2)
Treatment Children 3 months-5 years: Amoxicillin first-line, clarithromycin for penicillin allergic children or if atypicals suspected.
choices Children 5-18 years: Amoxicillin can be used if S. pneumoniae is the suspected pathogen, but a macrolide may be used if an
atypical causative organism is suspected or known to be circulating in the community (see evidence section below).
Amoxicillin po OR Clarithromycin po
Child 0-3 months: Refer for specialist assessment Child 0-3 months: Refer for specialist assessment
Child 3 months-1 year Child 3 months-12 years:
125mg TDS Under 8kg: 7.5mg/kg BD
Child 1-5 years 8-11kg: 62.5mg BD
250mg TDS 12-19kg: 125mg BD
Child 5-18 years 20-29kg: 187.5mg BD
500mg TDS 30-40kg: 250mg BD
For 7 days. CHILD 12-18yrs (and over 40kg): 500mg BD
Available as 125mg/5ml or 250mg/5ml suspension For 7 days.
(std strengths). Available as 125mg/5ml or 250mg/5ml suspension
Cautions If staphylococci suspected, e.g. in pneumonia following viral respiratory tract infections e.g. influenza use co-amoxiclav
instead of amoxicillin and treat for 7 days.
Where Streptococcus pneumonia is known to be penicillin resistant or the patient is penicillin allergic, please discuss with
the microbiologist to determine the optimal antibiotic therapy.
Evidence For children under 5 years of age:
Amoxicillin is the preferred first-line choice in children under 5 years of age because it is effective against the majority of
pathogens which cause community-acquired pneumonia in this group, is well tolerated, and is inexpensive.
A macrolide is considered an appropriate alternative if the child has an allergy to penicillin, because it covers a similar
spectrum of pathogens. However, amoxicillin is preferred for children that can tolerate it because there is significantly more
resistance of Streptococcus pneumoniae to macrolides. In addition macrolides are generally less well tolerated compared with
amoxicillin.
For children over 5 years of age:
Streptococcus pneumoniae is the most common pathogen causing pneumonia, but a significant proportion of pneumonias in
children over 5 years of age are caused by atypical infections. A macrolide is favoured when atypical infections are known to
be circulating in the community, because macrolides are more effective against these infections.
References BNF for Children 2012-13 www.bnfc.org
NHS Clinical Knowledge Summaries. Cough acute with chest signs in children.
http://www.cks.nhs.uk/cough_acute_with_chest_signs_in_children
British Thoracic Society. Guidelines for the management of Community Acquired Pneumonia in Childhood. Thorax 2011;
66: (Suppl 2) http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAP%20
children%20October%202011.pdf
British Thoracic Society. Recommendations for the Assessment and Management of Cough in Children. Thorax 2008, 63; 1-15.
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Cough/Guidelines/cough_in_children.pdf
Kabra, S.K., Lodha, R. and Pandey, R.M. (2010) Antibiotics for community acquired pneumonia in children (Cochrane
Review). The Cochrane Library. Issue 3. John Wiley and Sons, Ltd. http://onlinelibrary.wiley.com/doi/10.1002/14651858.
CD004874.pub3/abstract;jsessionid=ADBA43EA2C752108CEB4018BD22B8435.d03t01
page 14
PAEDIATRICS
Central Nervous System Infections – Meningitis or suspected meningococcal disease
NICE Bacterial meningitis and meningococcal septicaemia CG102
http://guidance.nice.org.uk/CG102/NICEGuidance/pdf/English
(NICE fever guidelines) www.nice.org.uk/cg047
When to treat Suspected bacterial meningitis without non-blanching rash
Transfer children and young people with suspected bacterial meningitis without a purpuric rash directly to secondary care
without giving parenteral antibiotics. (See table 1, pages 12 & 13 of NICE CG102 (link provided above) for symptoms and
signs of meningitis and meningococcal septicaemia).
If urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), administer
antibiotics to children and young people with suspected bacterial meningitis.
Suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia)
Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, either in primary or
secondary care, but do not delay urgent transfer to hospital to give the parenteral antibiotics.
Treatment First line: If history of penicillin allergy
choices Benzyl Penicillin (NOT anaphylaxis):
Children <1yr: 300 mg Cefotaxime
Children 1-9 yr: 600 mg Neonates: 50mg/kg
Children 10 yr and over: 1200mg Children 1 month-12yrs:
– Ideally IV but IM if a vein cannot be found. 50mg/kg (max 1g)
Child over 12yrs: 1g
– Give as IV bolus or IM if vein cannot be found
Cautions Benzylpenicillin can be given unless history of anaphylaxis,B- a history of a rash following penicillin is not a
contraindication. Anaphylaxis is more likely if there is a history of immediate allergic reactions (such as difficulty in
breathing, collapse, generalised itchy rash) after previous penicillin administration A
Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia. This is a
legal requirement under the Health Protection (Notification) Regulations 2010.
(see HPA: http://www.hpa.org.uk/servlet/Satellite?c=Pageandchildpagename=HPAweb%2FPage%2FHPA
webAutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper)
Close contacts of meningococcal disease will require chemoprophylaxis following discussion with the HPU.
Evidence Early treatment of suspected cases with benzyl penicillin is recommended in the UK to reduce case fatality B
References SIGN 102 Management of invasive meningococcal disease in children and young people, May 2008
www.sign.ac.uk/pdf/sign102.pdf
BNF for children 2012-13. www.bnfc.org
Health Protection Agency Meningococcus Forum with Public Health Medicine Environmental Group, the Scottish Centre
for Infection and Environmental Health, CDSC Wales, CDSC Northern Ireland, the Association of Medical Microbiologists,
and the Community Infection Control Nurses Network. Guidelines for public health management of meningococcal
disease in the UK. Updated February 2011.
http://www.hpa.org.uk/infections/topics_az/meningo/meningococcalguidelines.pdf
NICE Bacterial meningitis and meningococcal septicaemia. CG102. (June 2010) http://guidance.nice.org.uk/CG102
page 15
PAEDIATRICS
Urinary Tract Infections (page 1 of 2)
NICE Urinary tract infection in children CG54
When to treat The most common presentation in infants is an undiagnosed fever. Assess the risk of serious illness in line with ‘Feverish
illness in children’ (NICE CG47; link in reference section). UTIs in children require prompt treatment to minimise the risk of
renal scarring.
All infants younger than 3 months with suspected UTI should be referred to paediatric specialist care and a urine sample
should be sent for urgent culture. These infants should be managed in accordance with NICE CG47.
Treat mildly unwell children over 3 months of age with oral therapy. Infants and children presenting with unexplained
fever of 38°C or higher should have a urine sample tested as soon as possible, before antibiotics are initiated. For
symptoms and signs please refer to table1 in NICE CG54 (link in reference section).
Clinical differentiation between acute pyelonephritis/upper urinary tract infection and cystitis/lower
urinary tract infection:
• Infants and children who have bacteriuria and fever of 38°C or higher should be considered to have acute
pyelonephritis/upper urinary tract infection.
• Infants and children presenting with fever lower than 38°C with loin pain/tenderness and bacteriuria should also be
considered to have acute pyelonephritis/upper urinary tract infection.
• All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have
cystitis/lower urinary tract infection.
If an infant or child is receiving prophylactic medication and develops an infection, treatment should be with a different
antibiotic, not a higher dose of the same antibiotic.
Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI.
Refer urgently for assessment seriously unwell child over 3 months of age for intravenous therapy. Also send a urine
sample for urgent culture. Refer to NICE CG54 (link in reference section) quick reference guide for the patient flow
pathway.
When to Use a urine dipstick on all patients and refer to NICECG54 (table 3 and 4) for urine testing strategy. Only refer children
investigate aged < 6 months or those with recurrent or atypical UTIs for imaging- see NICE CG54 for details (link in reference
section).
Urgent culture is the preferred method for diagnosing UTI in children >3/12 and <3 years; this should be used where
possible. Empirical antibiotics should be started as soon as the sample has been taken in children with specific urinary
symptoms.
For urine testing strategies and guidance on interpretation of microscopy results see NICE guidance CG54 (link in
reference section). See page 18 for which groups of patients need to have a urine sample sent for culture.
How to respond If urine culture yields a high concentration of a single species a diagnosis of UTI is likely. If culture yields multiple
to a positive lab species or low concentrations suspect contamination.
report
General advice The parents or carers should be advised to bring the infant or child for reassessment if the infant or child is still unwell
after 24-48 hours. Children who have had a UTI should be encouraged to drink an adequate amount. Emphasize the
importance of not delaying voiding.
Continued overleaf
page 16
PAEDIATRICS
Urinary Tract Infections (page 2 of 2)
NICE Urinary tract infection in children CG54
Treatment Trimethoprim po Or Cefalexin po
choices 3-6 months: 25mg BD 3 months-1 year: 125mg BD
N.B. Antibiotic 6 months-6 years: 50mg BD 1-5 years: 125mg TDS
choice should be 5-12 years: 250mg TDS
6-12 years: 100mg BD
guided by mid- 12-18 years: 500mg BD-TDS
stream culture and 12-18 years: 200mg BD
For 3 days – if cystitis/uncomplicated lower UTI
sensitivities results For 3 days – if cystitis/uncomplicated lower UTI
125mg & 250mg/5ml suspension or syrup are available.
past and present as 50mg/5ml suspension is available.
different antibiotics If known to be susceptible by culture results, amoxicillin
may be necessary can be used.
to those presented N.B. Admit/consider referral if child is showing signs of acute pyelonephritis or upper UTI as may need
here. IV antibiotics-(treatment duration for 7-10 days).
National collaborating centre for women’s and children’s health. Clinical guideline. Urinary tract infection in children.
Diagnosis, treatment and long-term management. NICE CG54 Urinary tract infections in children (August 2007)
http://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdf
NICE CG47 (May 2007) Feverish illness in children –Assessment and initial management in children younger than 5
years. http://guidance.nice.org.uk/CG47
Other reference UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720
sources ESBLs: www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942126367/
Clinical Knowledge Summary for UTI-children: www.cks.nhs.uk/urinary_tract_infection_children
Urine samples should be sent for culture:

• In infants and children who have a diagnosis of acute pyelonephritis/upper urinary tract infection
• In infants and children with a single positive result for leukocyte esterase or nitrite
• In infants and children under 3 years
• In infants and children with a high to intermediate risk of serious illness
• In infants and children with recurrent UTI
• In infants and children with an infection that does not respond to treatment within 24–48 hours,
if no sample has already been sent
• When clinical symptoms and dipstick tests do not correlate.
Reproduced from NICE Urinary tract infections in children CG54 (August 2007)
http://guidance.nice.org.uk/CG54
page 17
PAEDIATRICS
Gastro-intestinal infections – Giardiasis
When to treat Prescribe antibiotic treatment as detailed below for all children with CONFIRMED Giardiasis.
Paediatric doses of metronidazole are usually given as once daily doses for 3 days.
When to Advise the patient to seek medical advice if:
investigate • Their condition doesn’t improve within 48 hrs of treatment
• Symptoms exacerbate or their condition worsens
• Warning signs or symptoms develop (such as severe vomiting or dehydration, persistent fever, abdominal distension,
or frank blood in stools).
General advice Advise parents/carers of the importance of reporting back to the GP if there are ongoing symptoms.
Treatment Metronidazole po:
choices Child 1-3 yrs: 500mg OD
Child 3-7 yrs: 600-800mg OD
Child 7-10 yrs: 1g OD
Child 10-18 yrs: 2g OD
For 3 days
(Alternatively, for child 10-18yrs, 400mg TDS for 5 days).
N.B. 200mg/5ml suspension is available.
Cautions Following up post treatment & 6 weeks later (following a negative sample) is important because a patient may
occasionally need a second course of treatment.
All positive cases of Giardiasis should be notified to the local HPU. See HPA link for further information on notifiable
diseases:
http://www.hpa.org.uk/servlet/Satellite?c=Pageandchildpagename=HPAweb%2FPage%2FHPAweb
AutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper
Gastroenteritis management. NHS Clinical Knowledge Summaries.
http://www.cks.nhs.uk/gastroenteritis/management/quick_answers/scenario_adult/clinical_summary_
confirmed_microbiological_pathogen/giardiasis#
page 18
PAEDIATRICS
Gastro-intestinal Infections – Threadworms
When to treat Treat if threadworms have been seen or their eggs have been detected.
When to investigate If infestation persists after hygiene measures have been continued for the recommended duration and treatment
of household, and if there are frequent recurrences.
How to respond to a Treat all members of the household at the same time (unless contra-indicated) to minimize
positive lab result re-infestation.
General Advice All members of the household must be advised to adhere to strict hygiene measures, including morning showers/
baths and hand hygiene for 2 weeks after treatment. Wear pants at night. Wash sleepwear, bed linen, dust and
vacuum on day 1.
Treatment choices First line: First-line for children aged 3-6 mths,
Mebendazole in all children >6 mths po otherwise second-line if allergy or
100 mg STAT contra-indication to mebendazole:
Repeat in 2 weeks if infestation persists.
Piperazine 4g / senna 15.3mg sachet po
N.B. This is OFF-LABEL for use in children under
Child 3 months-1 year:
2 years of age.
2.5ml spoon STAT in the morning, repeat after 2 weeks
100mg/5ml suspension is available.
Child 1-6 years:
5ml spoonful STAT in the morning, repeat after 2 weeks
Child 6-18 years:
1 sachet STAT in the morning, repeat after 2 weeks
(Make sachet up as per patient information leaflet
with water or milk)
Cautions Treatment with an anthelmintic is contra-indicated in children <3 months. Use hygiene methods
instead for 6 weeks.
Evidence Although it is generally accepted that mebendazole and piperazine have comparable efficacy (90-100% cure-
rate), mebendazole is recommended first line based on expert opinion and its relatively better safety profile and
few contraindications compared with piperazine. It is also the drug of choice for children over the age of 6 months
in the children’s BNF, even though it is unlicensed in children under 2 years.
Neither mebendazole nor piperazine kills eggs, therefore adequate personal and environmental hygiene is
essential to prevent reinfestation from recently swallowed eggs, or eggs already in the environment.
Threadworms. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/threadworm
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local
adaptation. March-October 2012 www.hpa.org.uk
page 19
PAEDIATRICS
Skin & Soft Tissue Infections – Eczema
When to treat Using antibiotics, or adding them to steroids, in eczema encourages resistance and does not improve healing unless
there are visible signs of infection. If there are localized areas of infection a topical antibiotic in combination with
steroid can be considered. In infected eczema, use treatment as in impetigo section overleaf.
CG57 Atopic eczema in children December 2007 http://guidance.nice.org.uk/CG57
Atopic eczema. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/eczema_atopic
page 20
PAEDIATRICS
Skin & Soft Tissue Infections – Impetigo
When to treat For extensive, severe, or bullous impetigo, use oral antibiotics. Initiate empirical first line treatment. Children
less than 1 month of age need to be referred to a paediatric specialist for assessment, hence no
dosage advice given below.
When to investigate Take swabs for culture if first line treatment fails.
How to respond to Alter treatment in response to culture and sensitivity results.
a positive lab result
General advice Educate patient about good hand washing and avoid scratching lesions. Patients should not share towels. Remain
off school for 48 hours after starting treatment. Review if lesions worsening or not improved at end of 7 days
treatment.
Treatment choices: First line: Second line or if Penicillin allergic:
Generalised infection Flucloxacillin po Clarithromycin po
Child 0-1 month: Refer for specialist assessment Child 0-1 month: Refer for specialist assessment
Child 1 month-1 yr: 62.5mg QDS Child <8kg: 7.5mg/kg BD
Child 1-5 yrs: 125mg QDS Child 8-11kg: 62.5mg BD
Child 6-10yrs: 250mg QDS Child 12-19kg: 125mg BD
Child 10-18yrs: 500mg QDS Child 20-29kg: 187.5mg BD
For 7 days. Child 30-40kg: 250mg BD
Available as 125mg/5ml or 250mg/5ml oral solution Child 12-18 yrs (and over 40kg): 500mg BD
Please note that these doses differ from the cBNF For 7 days.
slightly in that we provide more specific doses (rather Available as 125mg/5ml or 250mg/5ml suspension
than a range) according to a narrower age range. N.B Check for drug interactions!
Localised infection Fusidic Acid 2% topically TDS If MRSA isolated:
For 7 days. Mupiricin 2% ointment topically TDS
For 5 days.
Cautions As resistance is increasing reserve topical antibiotics for very localised lesionsC or D
Reserve Mupirocin for MRSA.
Evidence Systematic review indicates topical and oral treatment produces similar results.A+
References Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local
adaptation. March-October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summaries Impetigo. www.cks.library.nhs.uk/impetigo
page 21
PAEDIATRICS
Skin & Soft Tissue Infections – Animal Bites
When to treat If the wound is less than 48 hours old and risk of infection is high. Antibiotics are not generally needed if the wound is
more than 2 days old and there is no sign of local or systemic infection. Children less than 1 month of age need
to be referred to a paediatric specialist for assessment, hence no dosage advice given below. Review at
24 and 48 hours. Surgical toilet most important.
Antibiotic prophylaxis is advised for:
• All cat bites. • Bite involving hand, foot, face, joint, tendon, ligament
• Wounds requiring surgical debridement; • People who are at risk of serious wound infection:
or suspected fractures. - Immunocompromised
• Wounds that have undergone primary closure. - Diabetic
• People with a prosthetic valve or a prosthetic joint. - Cirrhotic
• Puncture wound - or asplenic patients
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles,
tendons, bones, the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds
requiring closure; bites that might need reconstructive surgery; devitalized wounds requiring debridement; bites where
the severity is difficult to assess; bites with severe cellulitis; infections not responding to treatment; people with an
increased risk of infection (see above); children with scalp wounds; bites to poorly vascularised areas.
When to If there is evidence of infection, send pus or deep wound swab for culture before cleaning the wound.
investigate Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.
General advice If the wound has just occurred, encourage it to bleed.
Clean and irrigate the wound thoroughly with warm running water.
Treatment choices: First line: If penicillin allergic:
Co-amoxiclavB po For children under 12 years of age,
Child 1 month-1yr: 0.25ml/kg of 125/31 suspension TDS contact your local microbiologist for advice.
Child 1-6 yrs: 5ml of 125/31 suspension TDS Child 12-18 years (also see page 66):
Child 6-12 yrs: 5ml of 250/62 suspension TDS Metronidazole po
N.B. Above doses may be doubled in severe infection 200-400mg TDS (N.B. 200mg/5ml suspension is available).
Child 12-18 yrs: One 250/125 strength tablet TDS; PLUS
increased in severe infection to one 500/125 strength DOXYCYCLINE po
tablet TDS. 100mg BD
For 7 days. For 7 days. (N.B. Dispersible 100mg tablets are available).
Cautions Assess tetanus and rabies risk. Consider need for tetanus prophylaxis. If it is a primate bite, discuss with virologist.
In the case of unusual animals, please discuss with microbiologist, particularly if persistent infection despite
treatment with co-amoxiclav, or if immunocompromised.
Evidence Co-amoxiclav is effective against most bacteria isolated from domestic animal bites.
NHS Clinical Knowledge Summaries: Animal Bite http://www.cks.nhs.uk/bites_human_and_animal/
management/detailed_answers/managing_an_animal_bite
BNF for Children 2012-13 www.bnfc.org
page 22
PAEDIATRICS
Skin & Soft Tissue Infections – Human Bites
When to treat Antibiotic prophylaxis advised for all wounds less than 72 hours old even if there is no sign of infection. Review at
24 & 48 hours. Thorough irrigation is important. Children less than 1 month of age need to be referred to
a paediatric specialist for assessment, hence no dosage advice given below.
When to The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons,
investigate bones, the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds
requiring closure; bites that might need reconstructive surgery; devitalized wounds requiring debridement; bites where
increased risk of infection (see above); children with scalp wounds; bites to poorly vascularised areas.
If there is evidence of infection, send pus or deep wound swab for culture before cleaning the wound. Admit anyone
who has a severe infection or who is systemically unwell as intravenous antibiotics may be required. Seek immediate
advice from a consultant in microbiology or infectious diseases for anyone considered to be at risk of HIV, hepatitis B or
C. Consider all people to be at risk unless the current status of the biter is known (rare). Consider if tetanus prophylaxis
is required. Tetanus after a human bite is extremely rare.
General advice If the wound has just occurred, encourage it to bleed.
Clean and irrigate the wound thoroughly with warm running water.
Treatment choices: First line: If Penicillin allergic:
Co-amoxiclavB po Metronidazole po
1 month-1yr: 0.25ml/kg of 125/31 suspension TDS 7.5mg/kg (max. 400mg) every 8 hours
Child 1-6 yrs: 5ml of 125/31 suspension TDS (N.B. 200mg/5ml suspension is available).
Child 6-12 yrs: 5ml of 250/62 suspension TDS PLUS
N.B. Above doses may be doubled in severe infection clarithromycin po
Child 12-18 yrs: One 250/125 strength tablet TDS; <8kg: 7.5mg/kg BD
increased in severe infection to one 500/125 strength 8-11kg: 62.5mg BD
tablet TDS. 12-19kg: 125mg BD
For 7 days. 20-29kg: 187.5mg BD
30-40kg: 250mg BD
12-18 yrs: (if over 40kg): 500mg BD
For 7 days.
Available as 125mg/5ml or 250mg/5ml suspension
Cautions Assess HIV, hepatitis B and C risk. Consider need for tetanus prophylaxis.
Evidence Co-amoxiclav is effective against the most commonly isolated organisms from human bites.
Metronidazole covers beta-lactamase-producing anaerobes. 80% of Eikenella corrodens are resistant to macrolides.
If a bite is 72 hours old and there is no sign that it has become infected, the risk of infection is likely to be low and
prophylactic antibiotics are probably not of value.
NHS Clinical Knowledge Summaries Human Bite: http://www.cks.nhs.uk/bites_human_and_animal/
management/detailed_answers/managing_an_animal_bite#-283292
BNF for Children 2012-13 www.bnfc.org
page 23
PAEDIATRICS
Genital Tract Infections – Balanitis NEW
When to treat When infection is suspected or where symptoms are troublesome or do not resolve with good hygiene.
When to A sub-preputial swab is not necessary to make a diagnosis, but can be useful for identifying the underlying cause.
investigate Take a sub-preputial swab if balanitis is severe, recurrent or persists despite treatment.
If balanitis is recurrent and associated with inability to retract the foreskin refer to paediatric urology. If balanitis is
recurrent and no underlying cause can be identified, or balanitis persists despite treatment, refer to paediatric urology.
How to respond to If symptoms are worsening or do not start to improve within 7 days, advise patient to stop topical hydrocortisone
a positive lab result (if prescribed) and in severe cases consider a sub-preputial swab (if not already done) to exclude or confirm a fungal
or bacterial infection and seek specialist advice.
General advice Advise daily cleaning under the foreskin with lukewarm water, followed by gentle drying. Soap or other irritants should
not be used on the genitalia. Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
If the child is still in nappies, ensure that they are changed frequently.
Treatment choices: For suspected non-specific dermatitis, with or without candidal colonization:
Prescribe clotrimazole 1% or miconazole 2% cream BD until symptoms settle.
If inflammation is causing discomfort consider prescribing hydrocortisone 1% cream or ointment for up to 14 days
in addition to treatment.
References 1. British Association of Sexual Health and HIV 2008. UK National Guideline on the management of Balanoposthitis
http://www.bashh.org/guidelines
2. Clinical Knowledge Summaries- Balanitis.
http://www.cks.nhs.uk/balanitis/management/scenario_diagnosis_children/identifying_the_
cause#-448964
page 24
Adult Section
EN&T
Adult
• Ear Nose and Throat Infections
When to treat The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a 2 or 3
day delayed strategy or immediate antibiotics.1, A+ 90% of cases resolve in 7 days without antibiotics and pain is only
reduced by 16 hours.2A+ Suspect glandular fever in a patient with a sore throat that fails to resolve within several days.
Use Centor clinical prediction score to decide whether to prescribe an antibiotic. A low Centor score (0-2) has a high
predictive value (80%) and indicates low chance of Group A Beta -haemolytic Streptococci (GABHS). The likelihood of
GABHS infection increases with Centor score and is between 2-23% with a score of 1, and 25-86% with a score of
4, depending on age, local prevalence and seasonal variation. If a patient is unwell with a Centor score of 3-4 then
the chance of developing Quinsy is 1 in 60. Patients with 3 of 4 Centor criteria or history of otitis media consider a 2
or 3 day delayed prescription or immediate antibiotics.
Centor Criteria (presence of each clinical feature scores 1 point):
• History of fever • Tender anterior cervical lymphadenopathy
• Absence of cough • Tonsillar exudates
When to refer When considering whether a patient needs to be referred for consideration of tonsillectomy, please ensure that you
consult the commissioning intentions of NHS Wiltshire CCG (p27): http://www.wiltshire.nhs.uk/Downloads/
Policies/Corporate/Commissioning/055b_Clinical_Priorities_Policy_Clinical_Content.pdf
or NHS Swindon CCG as appropriate: http://www.swindon.nhs.uk/Library/Publications/Policies/Clinical_
Commissioning/Effective_Clinical_Commissioning_Polices_List_October_2012.pdf
General advice on when it is appropriate to refer can be found in the SIGN guidance referenced below.
When to investigate Throat swabs should not be carried out routinely in the investigation of acute sore throat.
General advice Adequate analgesia and fluids will usually be all that is required. Ibuprofen 400mg three times a day is recommended
for relief of fever, headache and throat pain in adults with sore throat. If the patient is intolerant to ibuprofen or
should avoid NSAIDs, paracetamol 1g four times a day when required is recommended for symptom relief.
Treatment choices First line: If allergic to penicillin:
Phenoxymethylpenicillin (Penicillin V) po Clarithromycin po
500mg QDS 250-500mg BD
For 10 days. For 5 days. N.B Check for drug interactions!
Pregnancy/ In pregnancy or breastfeeding, use phenoxymethylpenicillin (penicillin V) or erythromycin (rather than
Breastfeeding clarithromycin).
Cautions Ampicillin-based antibiotics, including co-amoxiclav virtually always cause maculopapular rashes in people with
glandular fever, and should therefore not be used for ‘blind’ treatment of a sore throat (those who develop rashes
may also mistakenly be labelled as penicillin allergic).
Continued overleaf
page 25
Evidence The Altamimi meta-analysis shows that short-course (including 5 days clarithromycin) broad-spectrum antibiotics
are as efficacious as 10 day penicillin for sore throat symptom treatment and GABHS eradication. However, 10 day
phenoxymethylpenicillin remains the treatment of choice. 5 day clarithromycin should be reserved for those with
true penicillin allergy. Antibiotics other than phenoxymethylpenicillin and clarithromycin are no more effective and
are more expensive.
Antibiotics to prevent Quinsy NNT >40004B-
Antibiotics to prevent Otitis Media NNT= 2002A+
NHS Clinical Knowledge Summary Sore throat-acute http://www.cks.nhs.uk/sore_throat_acute#
SIGN (2010) Management of sore throat and indications for tonsillectomy: a national clinical guideline. Scottish
Intercollegiate Guidelines Network. www.sign.ac.uk
Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short-term late generation antibiotics
versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane database of systematic
reviews 2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004872.pub3/abstract
page 26
Ear Nose and Throat Infections – Acute Otitis Externa
When to Bacterial infection is usually secondary and commonly caused by Staphylococcus aureus or Pseudomonas aeruginosa. Upon
treat presentation symptoms are commonly itchiness of the ear canal and occasionally a painful ear canal. The treatment choices
described below apply to this presentation.
First use aural toilet (if available) and analgesia.
Consider Refer to ENT consultant:
referral: • IMMEDIATELY if patient is systemically unwell and/or if acute complications of otitis media are suspected,
eg. meningitis, mastoiditis or facial paralysis.
• Extensive cellulitis (and consider initiating oral antibiotics: Flucloxacillin 500mg QDS OR Clarithromycin 500mg BD for
1 week)2A+
• Extreme pain, considerable discharge or swelling of the auditory canal and microsuction or ear wick insertion is required
• Recurrent discharging and unexplained treatment failure, especially in diabetics and immunocompromised patients.
Admit urgently if malignant otitis externa is suspected, eg. if pain is more severe than the clinical signs suggest,
there is granulation tissue at the bone-cartilage junction of the ear canal or exposed bone in the ear canal or paralysis
of the facial nerve. Investigations are rarely useful. However if treatment strategy fails or otitis externa recurs frequently,
consider taking an ear swab for bacterial and fungal microscopy and culture. A swab is best taken from the medial aspect
of the ear canal under visualisation to reduce contamination.
How to Interpretation is difficult: Reported bacterial susceptibility may not correlate with clinical outcomes as sensitivities are
respond to a determined for systemic not topical administration which achieves higher concentrations of antibiotic. Culture results do
positive lab not indicate if organisms are causing the disease or are contaminants. Fungal overgrowth is likely after using antibacterial
report drops.
Treatment First line ear drops: Second-line ear drops:
choices Ear-calm spray (acetic acid 2%) is an alternative for mild otitis Otomize ear spray (neomycin 3250 units/ml/
externa and can be purchased OTC for less than a prescription dexamethasone 0.1%)
charge for patients that pay for prescriptions. Instil two to three drops TDS
Instil two to three drops TDS For 7 days (14 days if symptoms persist)
For 7 days.
Pregnancy/ There is inadequate safety evidence of these products in pregnancy and breastfeeding. Use in pregnancy and lactation
Breastfeeding should only occur when it is considered to be essential by the physician, after careful assessment of the potential risks and
benefits. EMC: http://www.medicines.org.uk/emc/
Cautions Aminoglycosides are contra-indicated with perforated eardrum but may be used cautiously by some specialists.
Antibacterial or corticosteroid drops should be used for about a week due to risk of secondary fungal infection or
sensitisation.
Evidence Cure rates are similar at 7 days for topical acetic acid or antibiotic +/- steroid1A+ Recommendations are pragmatic and are
based on expert opinion. Since virtually all of the bacteria recovered are sensitive to the high concentrations of antibiotic
available in topical ear medications it is unnecessary to routinely culture specimens from the ears of people with acute
otitis externa.
March-October 2012 www.hpa.org.uk
NHS Clinical Knowledge Summaries. Otitis Externa. http://www.cks.nhs.uk/otitis_externa
page 27
Ear Nose and Throat infections – Acute Sinusitis
When to treat Many are viral. Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after
7 days NNT=15. 2,3A+ Consider 7-day delayed or immediate antibiotic when purulent nasal discharge (NNT=8 1,2A+),
maxillo-facial pain, fever and/or severe pain.
When to refer Admit to hospital if there is severe systemic infection, or if a complication of sinusitis is suspected:
• Intra-orbital involvement if there is peri-orbital oedema, a displaced globe, double vision, ophthalmoplegia, or reduced
visual acuity.
• Intracranial involvement if there is a severe frontal headache, frontal swelling, symptoms or signs of meningitis, or
focal neurological signs.
• C onsider urgent referral to an ENT department if the person is suspected of having a sinonasal tumour (persistent
unilateral symptoms, such as bloodstained discharge, crusting, non-tender facial pain, facial swelling, or unilateral
nasal polyps).
• C onsider routine referral to ENT department if the person has frequent recurrent episodes of sinusitis which are
troublesome (such as more than three episodes requiring antibiotics in a year).
• Consider referral for unremitting or progressive facial pain or if second line treatment has been ineffective.
• Refer to dentist if suspected dental origin.
When to Routine diagnostic tests are not helpful in the initial assessment of acute sinusitis.
investigate Plain X-rays, blood tests, nasal swabs, sinus puncture, and transillumination of the sinuses are of limited value in primary
care, and are not recommended. Referral for computed tomography is not routinely recommended.
General advice Use adequate analgesia.
Treatment First line: If allergic to Penicillin: Persistent symptoms:
choices AmoxicillinA po Doxycycline po Co-Amoxiclav po
FOR SEVERE 1g TDS 200mg STAT then 100mg OD 625mg tds
CASES ONLY For 7 days. (200mg daily for severe infections) For 7 days.
For 7 days. If penicillin allergic and other options suggested have
been tried, contact microbiology for advice.
Pregnancy/ In pregnancy or breastfeeding, use amoxicillin or erythromycin (if penicillin allergy). Co-amoxiclav is also suitable if
Breastfeeding appropriate. Monitor closely and refer for IV antibiotics if no improvement. BNF http://bnf.org/bnf/index.htm
Cautions = high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients).
Admit if there are suspected complications (e.g. periorbital infection).
Evidence Amoxicillin has similar efficacy to other recommended antibiotics.
Doxycycline has activity similar to amoxicillin. In persistent infection use an agent with additional anti-anaerobic activity,
eg. co-amoxiclav. 6B+ Erythromycin is less effective against Haemophilis influenzae, but recommended in pregnancy/
breastfeeding women due to its safety record.
References NHS Clinical Knowledge Summary Sinusitis www.cks.library.nhs.uk/sinusitis
page 28
Adult Section
RTI
Adult
Respiratory Tract Infections
Bronchiectasis:
For guidance on how to treat
Bronchiectasis, please refer to the BTS
guideline for non-CF Bronchiectasis –
a quick reference guide:
http://www.brit-thoracic.org.uk/
Portals/0/Guidelines/Bronchiectasis/
BronchiectasisQFG_web.pdf
Respiratory Tract Infections – Influenza HPA Influenza
When to treat Annual vaccination is essential for all those at risk of serious complications of influenza. Immunize
between September to early November ideally. For otherwise healthy adults, antivirals are not recommended. Treat ‘at
risk’ patients, only when influenza is circulating in the community or in a care home where influenza is likely, within
36/48 (zanamivir/oseltamivir) hours of onset. For post exposure prophylaxis, please consult most recent HPA guidance:
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131466016
At risk:
• 65 years or over • Chronic neurological disease
• Chronic respiratory disease (including COPD and asthma) • Renal or liver disease
• Chronic cardiovascular disease (not hypertension) • Pregnant (including up to 2 weeks post partum)
• Immunocompromised • Residents in care/nursing homes
• Diabetes mellitus • Household contacts of immunocompromised individuals
• NHS staff dealing face to face with patients
When to Routine follow up in otherwise healthy patients is not necessary, but advise the person they should:
investigate • Return if no improvement after 1 week or they are deteriorating;
• Seek urgent medical attention if they develop shortness of breath, pleuritic chest pain or haemoptysis;
• Have a low threshold for seeking help if they are caring for a young child or baby with influenza, as children cannot
accurately communicate their symptoms.
In at risk groups, consider follow up (particularly in frail people) after 1 week to confirm symptoms are improving and to
exclude the development of secondary complications.
Treatment First line: If there is resistance to oseltamivir or severely
choices Oseltamivir Tablets po: immunocompromised:
Treatment dose: 75mg BD Zanamivir Diskhaler:
For 5 days. Treatment dose: 10mg (2 inhalations) BD
Prophylaxis dose: 75mg OD For 5 days. (10 days if resistance is suspected)
For 10 days (See NICE Influenza). Prophylaxis dose: 10mg (2 inhalations) OD
For 10 days.
Pregnancy/ Oseltamivir and Zanamivir should not be used in pregnancy unless the expected benefit to the mother is thought to
Breastfeeding outweigh any possible risk to the foetus.
In breastfeeding, consider the pathogenicity of the circulating influenza virus strain and the underlying condition of the
lactating woman. Administration of oseltamivir may be considered, where there are clear potential benefits to lactating
mothers. Use of Zanamivir is not recommended in breastfeeding due to there being no information available. See SPC
for further information: EMC http://www.medicines.org.uk/emc/
Cautions Ensure you have looked at the most up to date information via the HPA influenza link provided in this monograph.
Evidence After immunisation, antibody levels may take up to 10 to 14 days to reach protective levels.
In healthy individuals, seasonal influenza is an unpleasant but usually self-limiting disease with recovery in 2-7 days.
Treatment after 48 hours from symptom onset is an off-label use of oseltamivir and clinical judgement should be exercised.
Other reference HPA seasonal influenza:
sources http://www.hpa.org.uk/infections/topics_az/influenza/seasonal/pdfs/Treatmentflowchart.pdf
NICE Influenza (prophylaxis) www.nice.org.uk/guidance/index.jsp?action=byIDando=11736
page 29
Respiratory Tract Infections – Acute Bronchitis
When to treat Consider 7 day delayed antibiotic with symptomatic advice/leaflet. 1,5A- Care should be taken to exclude
a differential diagnosis of pneumonia. Antibiotics are NOT indicated in people who are otherwise well. Routine
follow up is not necessary. However patients should be advised to seek advice if their condition deteriorates
significantly or symptoms persist for longer than 3 weeks.
Consider antibiotics for those with pre-existing conditions that impair their ability to fight infection or are likely to
deteriorate with acute bronchitis.
Consider immediate antibiotics if >80 years of age with one of the following:
• Hospitalisation in the past year • Diabetic
• On oral corticosteroids • CHF
OR >65 years of age with 2 of the above.
When to investigate Not normally necessary. Re-examine if people have deteriorated to exclude pneumonia.
General advice Patients should be advised to use paracetamol or ibuprofen as required, drink plenty of fluids and to stop
smoking. Advise patients that resolution of symptoms can take up to 3 weeks.
Treatment choices First line: Second line if allergic to Penicillin:
Amoxicillin po Doxycycline po
500mg TDS 200mg stat then 100mg OD
For 5 days. For 5 days.
Pregnancy/ Amoxicillin is suitable to use in pregnancy and breastfeeding.
Breastfeeding Contact microbiology if this is not effective or is unsuitable due to penicillin allergy.
Evidence RCT evidence suggests a moderate benefit from antibiotics in acute bronchitis which is a self-limiting condition.A+
This should be considered in the wider context of drug-induced adverse effects, and the likelihood of resistance
developing. There is no evidence from controlled trials to support the use of one antibiotic over another. Choice
should reflect in vitro efficacy against likely pathogens especially S. pneumoniae and H. influenzae. Amoxicillin covers
most bacteria involved in acute bronchitis, including penicillin-intermediate resistant S. pneumoniae. Doxycycline is
active against most of the bacteria that cause bronchitis, including H. influenzae and, less commonly encountered,
Mycoplasma pneumoniae.
Low doses of penicillins are more likely to select for resistance. The quinolones ciprofloxacin and ofloxacin have poor
activity against pneumococci.
Patient leaflets can reduce antibiotic use.B+ There is also more evidence to suggest that delayed prescriptions appear
to be effective in modifying reconsultation behaviour, particularly in those with a prior history of antibiotic prescription
for LRTI.
References National Library for Health Clinical Knowledge Summary Chest infections.
http://www.cks.nhs.uk/chest_infections_adult
Moore M, Little P, Rumsby K, Kelly Jo, Watson L, Warner G, Fahey T, Williamson Ian. Effect of antibiotic prescribing
strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection. Br J
Gen Pract. 59; (567) October 2009 : 728-734(7)
page 30
Respiratory Tract Infections – COPD Acute Exacerbation
When to Origin: 30% viral, 30-50% bacterial, rest undetermined. Treat exacerbations with antibiotics promptly if there is purulent
treat sputum AND increased shortness of breath and/or increased sputum volume. Patients with exacerbations without more
purulent sputum do not need antibiotic therapy unless there is consolidation on a CXR or clinical signs of pneumonia.
Most people do not need follow up during the exacerbation, but if there are signs of deterioration reassess to see if
admission to hospital is appropriate. Routine follow up in less severe exacerbations (if needed) could be via telephone.
When to Sending sputum samples for culture in primary care is of very limited value and not routinely recommended because
investigate empirical therapy is effective and should be prescribed promptly if the sputum is purulent. Pulse oximetry is of value if
there are clinical features of a severe exacerbation. Consider hospital admission if oxygen saturation <90%.
Treatment First line: Second line or if allergic If allergic to penicillin If clinical failure to first line
choices Amoxicillin po to penicillin: & tetracyclines antibiotics or if resistant risk
500mg TDS Doxycycline po contra-indicated: factors (see evidence section):
For 5 days. 200mg stat then 100mg OD Clarithromycin po Co-Amoxiclav po
(200mg OD for severe 500mg BD 625mg tds
infections) For 5 days. For 5 days.
For 5 days. N.B Check for drug = high risk for causing C. Difficile
interactions! infection (see page 70 (appendix 1) for
information on high-risk patients).
Pregnancy/ In pregnancy or breastfeeding, use amoxicillin or erythromycin (rather than clarithromycin). Co-amoxiclav is also suitable if
Breastfeeding appropriate. BNF http://bnf.org/bnf/index.htm
Cautions Assess severity of exacerbation. Measure blood pressure, respiratory rate, and oxygen saturation (by pulse oximetry), and
assess the need for hospital admission based on the clinical findings and social circumstances. The following physical signs
are features of a severe exacerbation (consider hospitalisation): marked dyspnoea and tachypnoea; pursed-lip breathing;
use of accessory muscles at rest; acute confusion; new-onset cyanosis or peripheral oedema; marked reduction in activities
of daily living.
Evidence A meta-analysis of 21 double-blind RCTs involving 10,698 patients, concluded that a short course (≤5 days) of antibiotic
treatment was as effective as the traditional longer treatment in patients with mild to moderate exacerbations of chronic
bronchitis and COPD (see HPA document below for reference). Risk factors for antibiotic resistant organisms include co-
morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months. Comparative trials have not shown one
antibiotic to be superior to another. Evidence suggests the worse the severity of exacerbation (lung function impairment,
purulence of sputum) then the greater the degree of benefit from antibiotics.
References National Library for Health Clinical Knowledge Summary Chronic Obstructive Pulmonary Disease
http://www.cks.nhs.uk/chronic_obstructive_pulmonary_disease/management/scenario_acute_exacerbation
March- October 2012. www.hpa.org.uk
Chronic Obstructive Pulmonary Disease. National clinical guideline on management of chronic obstructive pulmonary
disease in adults in primary and secondary care Thorax 2004:59 (Suppl. 1);i1-232. www.thorax.bmj.com
Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care (partial update).
NICE Clinical Guideline CG101 June 2010. http://www.nice.org.uk/nicemedia/live/13029/49397/49397.pdf
Global Initiative for Chronic Obstructive Lung Disease. Guidelines for COPD.
http://www.goldcopd.org/Guidelines/guidelines-resources.html
page 31
Respiratory Tract Infections – Community Acquired Pneumonia BTS BTSpdf
When to treat Assess CRB-65 score: Score 3-4 admit urgently
Each scores 1: Score 1-2 arrange same day secondary care assessment or admission
• Confusion (AMT <8) Score 0 likely to be able to treat at home but use clinical judgement
• Respiratory rate ≥30 breaths/min Start antibiotics immediately.B If no response in 48 hours consider admission or
• BP systolic ≤ 90mmHg or diastolic add clarithromycin to amoxicillin.
≤ 60mmHg Give immediate IM benzylpenicillin 1.2g or 1g amoxicillin poD if delayed
• Age ≥65 yrs admission/life threatening. If patient is penicillin allergic, IM cefotaxime can be
given if non-severe penicillin allergy.
N.B. If aspiration is suspected, add metronidazole to antibiotic regimen.
When to Routine microbiological investigations are not recommended. Examination of sputum for M. tuberculosis should be
investigate considered for patients with a persistent productive cough, especially if malaise, weight loss or night sweats, or risk
factors for tuberculosis (e.g. ethnic origin, social deprivation, the elderly) are present. Send sputum sample if possible,
PRE-treatment. If atypical cause is suspected consider doing serology (acute AND convalescent 10-14 days later) OR
urinary antigen testing (e.g. legionella/pneumococcal) for example during epidemic mycoplasma years, or when there is a
particular clinical or epidemiological reason (mycoplasma and Q fever).
Treatment IF CRB65=0:
choices AMOXICILLINA+ po OR CLARITHROMYCINA- po OR Doxycycline D po
500mg-1g TDS 500mg BD 200mg stat then 100mg OD
For 7 days. For 7 days. For 7 days.
IF CRB65=1 and AT HOME:
AMOXICILLIN AND CLARITHROMYCIN OR Doxycycline alone
500mg-1g TDS 500mg BD 200mg stat then 100mg OD
For 7-10 days. For 7-10 days. For 7-10 days.
Pregnancy/ In pregnancy or breastfeeding, use amoxicillin and/or erythromycin (according to CRB-65 score).
Breastfeeding BNF http://bnf.org/bnf/index.htm
Cautions In elderly patients, the classic symptoms and signs of pneumonia are less likely, and non-specific features – especially confusion
– are more likely. In addition, absence of fever is more common compared to younger patients with CAP. Aspiration pneumonia is
more common in elderly patients, particularly nursing home residents or those in long term care facilities.
Evidence Amoxicillin has a broad spectrum of activity and most common pathogens involved are still susceptible to it. Atypical
pathogens will need treatment with a macrolide or doxycycline, but these tend to be rare causes of CAP, and will often
illicit symptoms severe enough for referral or admission. Macrolides have a similar spectrum of activity to amoxicillin.
Mycoplasma infection is rare in the over 65s.
References NHS Clinical Knowledge Summary Community Acquired Pneumonia:
http://www.cks.nhs.uk/chest_infections_adult/management/scenario_community_acquired_pneumonia
July 2010. www.hpa.org.uk
BTS Guidelines for the Management of Community Acquired Pneumonia in Adults: update 2009 Guidelines (pdf) Thorax
Oct 2009;64: (suppl. III) http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/
Guidelines/CAPGuideline-full.pdf
page 32
Adult Section
Adult
CNS
Central Nervous System
Central Nervous System Infections – Meningitis or Suspected Meningococcal Disease
When to treat Transfer all patients to hospital immediately. Administer single dose parenteral antibiotics prior to admission if
there is time. Give IV benzylpenicillin or cefotaxime unless hypersensitive i.e. history of difficulty breathing, collapse, loss
of conciousness or rash.1B-
Treatment First line: If history of penicillin allergy (NOT anaphylaxis):
choices Benzyl Penicillin Cefotaxime
1.2g 1g
IV or IM. IV or IM.
Pregnancy/ Benzylpenicillin & Cefotaxime can be used in pregnancy and breastfeeding.
Breastfeeding BNF: http://bnf.org/bnf/index.htm
Cautions Benzylpenicillin can be given unless history of anaphylaxis- a history of delayed rash following penicillin is NOT a
contraindication.
Anaphylaxis is more likely if there is a history of immediate allergic reactions (such as difficulty in breathing, collapse,
generalised itchy rash) after previous penicillin administration.A
Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia.
This is a legal requirement under the Health Protection (Notification) Regulations 2010. (see HPA:
AutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper)
Close contacts of meningococcal disease will require chemoprophylaxis following discussion with the HPU.
Evidence Early treatment of suspected cases with benzyl penicillin is recommended in the UK to reduce case fatality.B
References SIGN 102 Management of invasive meningococcal disease in children and young people, May 2008
www.sign.ac.uk/pdf/sign102.pdf
NICE Bacterial meningitis and meningococcal septicaemia (for children younger than 16 years). CG102. (June 2010)
Health Protection Agency Meningococcus Forum with Public Health Medicine Environmental Group, the Scottish Centre
for Infection and Environmental Health, CDSC Wales, CDSC Northern Ireland, the Association of Medical Microbiologists,
and the Community Infection Control Nurses Network. Guidelines for public health management of meningococcal
disease in the UK. Updated August 2006
http://www.hpa.org.uk/infections/topics_az/meningo/meningococcalguidelines.pdf
The meningitis research foundation’s website has some very useful information. See the following algorithm on
“Early management of suspected bacterial meningitis and meningococcal septicaemia in immunocompetent adults”:
http://www.meningitis.org/assets/x/51738 and “Meningococcal meningitis and septicaemia guidance notes”
(endorsed by the BMA) 2011: http://www.meningitis.org/assets/x/50631
page 33
Adult
Urinary Tract Infections
Adult Section
UTI
Urinary Tract Infections – Uncomplicated UTI in men and (non-pregnant) women, no fever or flank pain.
(page 1 of 2) HPA UTI quick reference guide ESBLs CKS UTI
When to Patients with asymptomatic bacteriuria should not be treated with an antibiotic as it is not associated with increased morbidity.
treat Women with symptomatic UTI should receive empirical antibiotics. Women with severe/≥ 3 symptoms (frequency, urgency, dysuria,
polyuria, suprapubic tenderness, haematuria): treat.1,2C Women with mild/ ≤ 2 symptoms: use dipstick on cloudy urine to guide
treatment (morning specimen most reliable). Prescribers should be aware of local resistance patterns when prescribing antibiotics.
Use urine dipstick to guide treatment. Nitrite and blood/leucocytes has 92% positive predictive value; -ve nitrite, leucocytes and
blood has a 76% negative predictive value.3A- Although the probability of UTI is reduced to less than 20% by a negative dipstick
test, the evidence suggests that women still derive symptomatic benefit from antibiotics (NNT=4). If negative nitrite and positive
leucocyte; treat if symptoms severe or consider delayed antibiotic prescription.
Men: consider prostatitis, chlamydial infection and epididymitis as differential diagnosis. In elderly men (over 65yrs of age),
treatment of asymptomatic bacteriuria does not reduce mortality or significantly reduce symptomatic episodes. Antibiotic
treatment significantly increases the risk of adverse events, such as rashes and gastrointestinal symptoms (NNH=3).
When to Do not routinely culture for urinary symptoms in adult women <65 yrs. In sexually active young women, consider
investigate Chlamydia trachomatis. Do not send urine for culture in asymptomatic elderly with positive dipsticks; only send urine for
culture if two or more signs of infection, especially dysuria, fever >38ºC or new incontinence. Perform culture (mid-stream
urine) if failed antibiotic treatment or persistent symptoms or recurrent infections.
Men: UTI in men is generally regarded as complicated (it results from an anatomic or functional abnormality).
Send pre-treatment MSU for culture in all symptomatic men.1,4C OR if symptoms mild/non-specific, use -ve nitrite and
leucocytes to exclude UTI. 5C
Consider further investigation for men who have:
• Features of urinary obstruction (e.g. in older men, enlarged prostate) • A history of pyelonephritis, calculi, or
• Failed to respond to appropriate antibiotic therapy previous genitourinary tract surgery
• Recurrent UTI (e.g. two or more episodes within one or two years) • Persistent haematuria
How to Single organism ≥ 104 CFU/ml or ≥ 105 mixed growth with one predominant organism indicates UTI. If suprapubic any growth is
respond to a significant Modify empirical treatment if necessary. If culture yields multiple species or low concentrations suspect contamination.
positive lab If culture yields multiple species or low concentrations suspect contamination. In adults ‘no white cells present’ indicates no
report inflammation & reduces culture significance. Epithelial cells/mixed growth indicates perineal contamination, reducing significance
of culture. Consider excluding chlamydia infection in a sexually active man with urinary symptoms, especially if he has sterile
pyuria, or the dipstick test is negative for nitrite and positive for leukocyte esterase. Follow up after 48hrs (or according to the
clinical situation) to check response to treatment and the urine culture results in men.
Treatment First line: Second line:
choices NitrofurantoinA- po OR Trimethoprim B+ po Perform culture in all treatment failures.1B Further
50-100mg QDS OR 100mg M/R BD 200mg BD treatment should be based on culture results. If further
For 3 days in women.B+ For 3 days in women.B+ empirical treatment is necessary consider nitrofurantoin
For 7 days in men. For 7 days in men. (if failed on trimethoprim) If failed on nitrofurantoin
consider an oral first generation cephalosporin such as
CEFALEXIN (most cost-effective) or if a cephalosporin is
not suitable, co-amoxiclav.
Pregnancy/ See UTI in pregnancy monograph overleaf. In breastfeeding, short-term use of trimethoprim is not known to be harmful.
Breastfeeding Co-amoxiclav would also be suitable as a second-line alternative if no penicillin allergy is present.
BNF http://bnf.org/bnf/index.htm
Continued overleaf
page 35
Urinary Tract Infections – Uncomplicated UTI in men and (non-pregnant) women, no fever or flank pain.
(page 2 of 2) HPA UTI quick reference guide ESBLs CKS UTI
Cautions Nitrofurantoin should not be used in patients with a history of, or suspected renal failure (GFR <60ml/min).
Do not advise alkalinising agents (e.g. potassium citrate) in combination with nitrofurantoin. Community multi-resistant
E. coli with Extended-spectrum Beta-lactamase (ESBL) enzymes are increasing so perform culture in all treatment failures.
ESBLs are multi-resistant but many remain sensitive to nitrofurantoin. If patient has had recent MSU culture positive for
ESBL, check sensitivities and if sensitive use nitrofurantoin 50-100mg qds for 7 days and await repeat culture results.
Fosfomycin (unlicensed) 3g stat in women, 2nd 3g dose in men 3 days later, can alternatively be used ONLY on the advice of a
microbiologist – see appendix 5, (p.87) for further information. Quinolones should not be used for first line empiric treatment
of uncomplicated UTI. In recurrent UTI or febrile UTI in men, there is a high risk of prostate involvement which may lead to
complications such as prostatic abscess or prostatitis. Suggest 14 days of ciprofloxacin in such cases.
Trimethoprim is not recommended in men if they have used it in the past 12 months because use of trimethoprim up to
1 year previously is associated with increased risk of infection with a resistant organism.
At least 50% of men with recurrent UTI and over 90% of men with febrile UTI have prostate involvement, which may lead to
complications such as prostatic abscess or chronic bacterial prostatitis. Suggest 14 days of CIPROFLOXACIN in such cases.
= high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients).
Evidence If dysuria and frequency are present the probability of UTI is > 90%. No high quality evidence for treatment of bacterial
UTI has been identified in men..
HPA UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947330877
ESBLs: www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942126367/
CKS UTI: www.cks.nhs.uk/urinary_tract_infection_lower_women www.cks.nhs.uk/uti_lower_men
SIGN guidance 88. Management of suspected bacterial urinary tract infection in adults. A national clinical guideline.
Updated July 2012. http://www.sign.ac.uk/pdf/sign88.pdf
Notes on sending appropriate information to microbiology labs with urine samples:

Dipstick strip results are NOT appropriate clinical details when sending any urine sample for culture, they are simply an indicator
to support suspicion of a non-catheter UTI. Please ensure that requesters provide relevant clinical symptoms, signs or suspected
diagnosis (e.g. pyelonephritis) as well as any antibiotics that have been prescribed as this may be important in how the laboratory
interprets results and which sensitivities are reported.
Please state clearly if the patient has a catheter in situ (see guidance for treatment of Catheter Associated UTI on page 42).
page 36
Urinary Tract Infections – UTI in pregnancy
When to treat Symptomatic bacteriuria occurs in 17-20% of pregnancies. Pregnant women with mild to moderate symptomatic UTI
should be treated with an antibiotic. Asymptomatic bacteriuria detected in pregnancy should also be treated with an
antibiotic (3-7 days), asymptomatic bacteriuria is associated with pyelonephritis and premature delivery. If the patient is
pregnant and pyrexial, admit her to hospital.
When to MSU should be performed routinely at the first antenatal visit. If bacteriuria is reported it should be confirmed with a
investigate second MSU. Send MSU for culture before starting antibiotics. Dipstick testing is not sufficiently sensitive to be used
for screening for bacteriuria in pregnant women. Send MSU for culture before starting antibiotics. Given the risks of
asymptomatic and symptomatic bacteriuria in pregnancy, a urine culture should be performed 7 days after completion of
antibiotic treatment as a test of cure.
How to Single organism ≥ 104 colony forming units (CFU)/mL or ≥ 105 mixed growth with one predominant organism in a
respond to a symptomatic patient a diagnosis of UTI is likely. Modify empirical treatment if necessary. If culture yields multiple species or
positive lab low concentrations suspect contamination. In adults ‘no white cells present’ indicates no inflammation and reduces culture
report significance. Epithelial cells/mixed growth indicates perineal contamination, reducing significance of culture.
Women with bacteriuria confirmed by a second urine culture should be treated and have a repeat urine culture at each
antenatal visit until delivery.
Treatment First line: Second line OR upper tract symptoms:
choices Nitrofurantoin po Cefalexin po
50mg qds OR 100mg M/R BD 500mg BD OR 250mg QDS
N.B. AVOID at term- may produce neonatal haemolysis. If upper tract/systemic symptoms treat for 10-14 days.
Use cefalexin instead.
Cautions Nitrofurantoin should not be used in patients with a history of, or suspected renal failure (GFR<60ml/min).
Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus.B+ But do not use at term
(see note in treatment choices section). If none of these antibiotics are suitable, please contact your local microbiology
department. Consider the possibility of pyelonephritis as a differential diagnosis.
If patient has had recent MSU culture positive for ESBL, check sensitivities and if sensitive use nitrofurantoin
50-100mg qds for 7 days and await repeat culture results. = high risk for causing C. Difficile infection (see page 70
(appendix 1) for information on high-risk patients).
Evidence Untreated upper UTI in pregnancy carries an increased risk of morbidity and rarely mortality. A systematic review concluded that
antibiotic treatment of asymptomatic bacteriuria in pregnancy reduces the risk of upper UTI and low birth weight babies. There is
no clear evidence that any particular antibiotic regimen has any advantage over others.
Nitrofurantoin has been associated with haemolysis in people with G6PD deficiency. However, the risk seems very small because
placental transfer is so low. There is only one reported case of haemolytic anaemia in a newborn whose mother was treated
at term with nitrofurantoin. The efficacy and safety profiles of nitrofurantoin are supported in a recent large multicentre study
undertaken by the World Health Organization in which 778 pregnant women with asymptomatic bacteriuria were treated with
nitrofurantoin [Lumbiganon et al, 2009]. A cure rate of 86% was achieved with a 7-day course.
References Management of suspected bacterial urinary tract infection in adults. SIGN Guidelines Updated July 2012.
Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database of Systematic
Reviews 2011, Issue 1.
http://summaries.cochrane.org/CD002256/treatments-for-symptomatic-urinary-tract-infections-during-pregnancy
Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria. Cochrane Database of Systematic Reviews 2007 issue 2
http://apps.who.int/rhl/reviews/CD000490.pdf
Clinical Knowledge Summaries; Urinary Tract Infection lower women: UTI in pregnancy. http://www.cks.nhs.uk/urinary_
tract_infection_lower_women/evidence/supporting_evidence/uti_during_pregnancy
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation. March-
October 2012. www.hpa.org.uk
page 37
Urinary Tract Infections – Acute Pyelonephritis
When to treat Upper urinary tract infection is defined as: evidence of urinary tract infection with symptoms suggestive of
pyelonephritis (loin pain, flank tenderness, fever, rigors or other manifestations of systemic inflammatory response).
Upper urinary tract infection can be accompanied by bacteraemia, making it a life threatening infection.
Admit to hospital people who:
• Are significantly dehydrated or who are unable to take oral fluids and medications.
• Have signs of sepsis, including:
• A temperature greater than 38°C or less than 36°C, and
• Marked signs of illness (such as impaired level of consciousness, perfuse sweating, rigors, pallor, significantly
reduced mobility), or
• Significant tachycardia, hypotension, or breathlessness.
• Are pregnant and pyrexial.
• Are frail, elderly residents in care homes who have recently been hospitalised or who have had recurrent UTI.
• Fail to improve significantly within 24 hours of starting antibiotics.
When to Dipstick test the urine for leucocyte esterase and nitrite for evidence of a UTI.
investigate • If the nitrite test is positive, with or without a positive leucocyte esterase test, a UTI is highly (90%) likely.
• If the leucocyte esterase test alone is positive, a UTI is moderately (50%) likely.
• If both dipstick tests are negative, a UTI is unlikely (5%). Consider and exclude other causes of loin pain and/or
fever including: pelvic inflammatory disease; appendicitis; renal calculi.
If hospital admission not needed, send MSU for culture and sensitivities and start antibiotics.
How to respond Modify empirical treatment if necessary.
to a positive lab If no response within 24 hours admit.
report
Treatment First line Second line if penicillin allergic:
choices Co-Amoxiclav po Ciprofloxacin A po
625mg TDS 500mg BD
Cautions Increasing bacterial resistance means that no antibiotic is sufficiently reliable for empiric treatment of upper UTI
(upper urinary tract infections). Nitrofurantoin is ineffective in upper UTI as it does not achieve effective concentrations
in blood. = high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk
patients).
Evidence RCT shows 7 days ciprofloxacin is as effective as 14 days of co-trimoxazole.A-
Evidence about the effectiveness of less than 2 weeks treatment with co-amoxiclav is lacking.
Management of suspected bacterial urinary tract infection in adults. SIGN Guidelines Updated July 2012
NHS Clinical Knowledge Summaries. Acute pyelonephritis. http://www.cks.nhs.uk/pyelonephritis_acute#-367791
page 38
Urinary Tract Infections – Catheter associated UTI *SYMPTOMATIC PATIENTS ONLY*
When to treat Between 2-7% of patients with indwelling catheters acquire bacteriuria each day, even with the application of best practice
for insertion and care of the catheter. All patients with a long-term indwelling catheter are bacteriuric, often with two or
more organisms. In the presence of a catheter antibiotics will not eradicate bacteriuria. Do not routinely prescribe antibiotic
prophylaxis to prevent symptomatic UTI in patients with catheters. Treatment of asymptomatic bacteriuria does not reduce
mortality or prevent symptomatic episodes and causes harms: increased short-term frequency of symptomatic infection and
re-infection with antimicrobial-resistant organisms.
One of the following symptoms should prompt initiation of antibiotic therapy:
• Loin pain • New-onset delirium
• Rigors • Fever> 37.9°C or 1.5°C above baseline on two occasions during 12 hours
Change catheter during course of antibiotic treatment. Asymptomatic patients should NOT be treated.
Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI3B
Investigations Symptomatic catheter-associated UTI (CA-UTI) cannot be differentiated from asymptomatic bacteriuria on the basis of urine
analysis with dipstick tests. Dipstick testing should not be used to diagnose UTI in catheterised patients. Urine
samples should only be sent for laboratory culture if the patient has clinical sepsis, not because the appearance or smell of the
urine suggests that bacteriuria is present.
A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed CA-UTI because of the
wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance.
• If an indwelling catheter has been in place for >2 weeks at the onset of CA-UTI and is still indicated, the catheter should
be replaced to hasten resolution of symptoms and to reduce the risk of subsequent CA-UTI. The urine for culture should be
obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy.
• In patients with short-term catheterisation, it is recommended that specimens be obtained by sampling through the
catheter port using aseptic technique or, if a port is not present, puncturing the catheter tubing with a needle and syringe.
Culture specimens should not be obtained from the drainage bag.
How to If urine culture shows that the organism is resistant to the current antibiotic, and:
respond to a • If symptoms have not resolved, change to an antibiotic that the organism is sensitive to.
positive lab • If symptoms have resolved, consider continuing with the current antibiotic.
report • If symptoms recur, start treatment with an antibiotic shown in the culture to cover the infecting organism.
Treatment Presumed Upper Tract Infection or If known previous MRSA Recent MSU with
choices Presumed Bacteraemia: Bacteriuria: previous multi-resistant
Co-Amoxiclav Trimethoprim bacteriuria:
625mg TDS po 200mg BD po Consult a microbiologist.
OR For 7 days.
Ciprofloxacin N.B. If used empirically, check actual
500mg BD po sensitivities and confirm that the
OR – If sensitivity has been shown previously: infection is trimethoprim sensitive.
Trimethoprim Do NOT use co-amoxiclav or
200mg BD po quinolones due to resistance.
For 7-14 days.
Evidence When changing catheters in patients with a long-term indwelling urinary catheter: do not offer antibiotic prophylaxis
routinely. Consider antibiotic prophylaxis for patients with a history of symptomatic UTI after catheter change or who
experience trauma during catheterisation. = high risk for causing C. Difficile infection (see page 70 (appendix 1) for
information on high-risk patients).
References Management of suspected bacterial urinary tract infection in adults. SIGN Guidelines Updated July 2012
HPA UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947330877
page 39
Urinary Tract Infections – PROVEN Recurrent UTI in non-pregnant Women ≥3/yr
When to Continuous or postcoital antimicrobial prophylaxis should be considered to prevent recurrent uncomplicated cystitis in
treat women in whom non-antimicrobial measures have been unsuccessful. Ensure that the need for antibiotic prophylaxis
is reviewed at 6 months as the evidence base only supports patient benefit when used for up to 6 months
duration.
In appropriate women with recurrent uncomplicated cystitis, self-diagnosis and self-treatment with a short course
‘stand-by’ regimen of an antimicrobial agent should be considered.
When to Positive urine culture is needed to confirm a microbial cause for at least one episode of urinary tract infection (before
investigate commencing long-term prophylactic treatment). Urine culture and sensitivity tests are helpful to manage breakthrough
infections.
How to Modify empirical treatment if necessary. If culture yields multiple species or low concentrations suspect contamination.
respond to Send an MSU if a patient with recurrent UTIs has an acute infection. Discuss the case with a urologist and/or microbiologist
a positive BEFORE prescribing prophylaxis in case the woman needs investigating to exclude an underlying cause. Base prophylactic
lab report drug choice on previous MSU results. Eradication of a previous UTI should be confirmed by a negative urine culture 1-2
weeks after treatment.
General If cystitis is related to sexual intercourse, advise: Using a different contraceptive method if a diaphragm is being used;
advice voiding soon after intercourse; using a lubricant if symptoms could be due to mild trauma rather than infection.
Treatment Prophylactic for 6 month trial: OR
choices Nitrofurantoin po Trimethoprim po
50mg-100mg ON OR STAT post-coital dose to be taken 100mg ON OR STAT post-coital dose to be taken within 2hrs
within 2hrs of intercourse (off-label use) of intercourse (off-label use)
Cautions Monitor patients on long term nitrofurantoin for signs of pulmonary fibrosis. Avoid nitrofurantoin if GFR<60ml/min; risk of
peripheral neuropathy; ineffective due to inadequate urine concentrations. Review need to continue prophylaxis every six
months, if ineffective, treatment choices will need review in the light of latest sensitivity of pathogens. Length of antibiotic
treatment has been found to be a risk factor for development of C.difficile infection.
Evidence Post coital prophylaxis is as effective as prophylaxis taken nightly. If treatment is given nightly, although it reduces UTIs there
is greater risk of adverse effects1A+ and the development of resistance. Nightly prophylaxis: pooled data from 10 RCTs of
poor methodological quality calculated a Relative Risk of having one microbiological recurrence was 0.21 (95% CI 0.13 to
0.34), favouring antibiotic and the NNT was 1.85 over 6–12 months. But adverse effects do occur and 30% of women did
not adhere to treatment. The evidence that the benefit of cranberry juice for preventing UTI is small, and therefore it cannot
currently be recommended for the prevention of UTIs.
Jepson RG, Williams G and Craig JC, Cranberries for preventing urinary tract infection. Cochrane Database of Systematic
Reviews Oct 2012 Issue 1. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001321.pub5/abstract
National Library for Health Clinical Knowledge Summary UTI (lower) women
www.cks.nhs.uk/urinary_tract_infection_lower_women
European Association of Urology. Guidelines on Urological Infections 2011.
http://www.uroweb.org/guidelines/online-guidelines/
page 40
Adult
Gastro-Intestinal Infections
Adult Section
GII
Gastro-intestinal infections – Eradication of Helicobacter pylori
When to The presence of H. pylori should be confirmed before starting eradication therapy.
treat Eradication is beneficial in Duodenal Ulcer (DU), Gastric Ulcer (GU) and low grade MALT lymphoma, but NOT in Gastro-Oesophageal
Reflux Disease (GORD).A For Non-Ulcer Dyspepsia (NUD), the Numbers Needed to Treat (NNT) is 14 for symptom relief.3A+
In chronic NSAID user without ulcer history, Helicobacter pylori (HP) eradication will reduce peptic ulcers and/or bleeding but will
not remove all risk. Urgently refer patients >55 years with new, unexplained and persistent recent-onset dyspepsia for endoscopy.
Who to • P atients with uncomplicated dyspepsia unresponsive to lifestyle change, antacids, H2 receptor antagonists or 1 month Proton
investigate Pump Inhibitor (PPI) and without alarm symptoms
• Patients with a past history of GU or DU who have not previously been tested.
Test eligible patients using a urea breath test, a stool antigen test or lab serology testing. The urea breath test is preferred
in patients who have undergone previous H. pylori eradication therapy. Stop PPI use 14 days prior to breath or stool testing.
Withhold breath/stool testing for 28 days after antibiotic treatment. DU/GU relapse: retest for H. pylori using breath or stool test
OR consider endoscopy for culture and susceptibility.
NUD relapse: Do not retest, offer PPI or H2RA.
Patients with complicated peptic ulcer or MALT lymphoma should be retested (using breath test) 4 weeks after treatment.
Refer for endoscopy culture and sensitivity testing:
• Patients who have had metronidazole and clarithromycin for any infection and are allergic to amoxicillin or tetracycline;
• Patients who have received two courses of eradication and still test positive.
Seek microbiology or gastroenterology advice for third line options
Routine testing is not recommended in patients with GORD.A
Treatment First lineA+ cheapest option:
choices N.B. Do not use clarithromycin or metronidazole if already used in the past year for any infection.C
Lansoprazole po 30mg BD
PLUS
Clarithromycin po 250mg BD if with metronidazole, 500mg BD if with amoxicillin
AND
Metronidazole po 400mg BD
Or Amoxicillin po 1g BD
For 7 days.
(14 days for maltoma) N.B Check for drug interactions if clarithromycin is used!
Cautions There is usually no need to continue PPI/H2RA unless large ulcer, haemorrhage or perforation- continue for 3 weeks.
For alternative treatment regimens see the BNF.
Evidence Helicobacter test and treat strategies will benefit patients with ulcer disease, 8% of patients with functional dyspepsia, and
reduce future risk of ulcer disease, gastric cancer and risks of long-term PPIs.
References SIGN Dyspepsia guideline (68) 2003. Available at http://www.sign.ac.uk/guidelines/fulltext/68/index.html
NICE dyspepsia guidance. August 2004. Available at: http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline.pdf
March to October 2012. www.hpa.org.uk
Clinical Knowledge Summaries: dyspepsia. http://www.cks.nhs.uk/dyspepsia_unidentified_cause
HPA Diagnosis of H Pylori in dyspepsia document. Quick reference guide for primary care (updated Sept 2012):
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947347671
page 41
Gastro-intestinal infections – Infectious Diarrhoea
When to treat Definition of acute diarrhoea: 3 or more episodes a day, <14d and sample takes shape of pot. Empirical treatment for
patients well enough to be managed in primary care is not usually recommended because the majority of illnesses seen in
the community do not have an identifiable bacterial cause.
For Campylobacter, Salmonella and Shigella, antibiotic treatment is not normally indicated. If the patient is systemically
unwell and of clinical concern, discuss with a microbiologist. Treatment of E.coli 157 with antibiotics is positively contra-
indicated.
Bear in mind that diarrhoea may not reflect enteritis and may be a symptom of other conditions. Consider other
differential diagnoses especially in patients returning from abroad.
Urgently refer all previously healthy children with acute painful, bloody diarrhoea or confirmed E.coli O157.
When to Send a stool specimen for culture and sensitivity if:
investigate • Systemically unwell; blood or pus in the stool;
• Immunocompromised;
• Recent antibiotics or hospitalisation (also request C. difficile test);
• Diarrhoea occurs after high risk foreign travel (also request tests for ova, cysts, and parasites);
• Diarrhoea is persistent (e.g. >1week).
If the diarrhoea has stopped, culture is rarely indicated, as recovery of the pathogen is unlikely. Consult local HPU if:
Suspected public health hazard; outbreaks of diarrhoea in the family or community; infected with certain organisms
(e.g. E. coli O157) where there may be serious clinical sequelae to an infection.
How to Most patients in whom pathogens are detected will NOT require specific treatment unless systemically unwell or
respond to a treatment is advised by a microbiologist or consultant in communicable disease control.
positive lab Campylobacter: Antibiotic therapy has little effect on duration of symptoms unless given very early in illness course.
report Giardia lamblia and Entamoeba histolytica should be treated according to sensitivity results.
Unless symptoms persist, Blastocystis and Dientamoeba fragilis do not usually require treatment if otherwise healthy.
C.difficile – see recommendations on p48.
Treatment Fluid replacement. Do not treat with antibiotics without discussing case with a microbiologist first of all.
choices
Cautions Notify and seek advice on exclusion of patients from Public Health Doctor/Health Protection.
Evidence There are no routine methods for detecting enterotoxigenic E. coli, the commonest cause of traveller’s diarrhoea.
Quinolones are not recommended because there is increasing resistance in Campylobacter to quinolones.
Infectious Diarrhoea: The Role of Microbiological Examination of Faeces Quick Reference Guide for Primary Care for
consultation and local adaptation (July 2010):
CKS Gastroenteritis: http://www.cks.nhs.uk/gastroenteritis#-392747
page 42
Gastro-intestinal infections – Giardiasis
When to treat Prescribe antibiotic treatment as detailed below for all people with confirmed giardiasis.
When to Advise the patient to seek medical advice if:
investigate • Their condition doesn’t improve within 48 hrs of treatment
• Symptoms exacerbate or their condition worsens
• Warning signs or symptoms develop (such as severe vomiting or dehydration, persistent fever,
abdominal distension, or frank blood in stools).
General Advice Advise patients/carers of the importance of reporting back to the GP if there are ongoing symptoms.
Treatment First line options: OR
choices Metronidazole po Tinidazole po
2g OD for 3 days 2g STAT
OR
400mg tds for 5 days
Pregnancy/ In pregnancy do not use tinidazole, instead use metronidazole at the lower dose (400mg tds). The lower dose
Breastfeeding metronidazole can also be used during breastfeeding.
Cautions Following up post treatment and 6 weeks later (following a negative sample) is important because a patient may
occasionally need a second course of treatment.
All positive cases of Giardiasis should be notified to the local HPU. See HPA link for further information on notifiable
diseases:
AutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper
NHS Clinical Knowledge Summaries. Gastroenteritis management: Giardiasis.
http://www.cks.nhs.uk/gastroenteritis/management/scenario_adult/confirmed_microbiological_
pathogen/giardiasis#
page 43
Gastro-intestinal infections – Clostridium difficile See appendix 1 (p70) for further information
When to When patient is symptomatic and has a positive C. difficile test from a stool sample.
treat If a patient has severe symptoms and is causing concern, discuss with microbiology and consider admission if clinically unwell.
Mild: No increased white cell count (WCC) and typically associated with <3 episodes of loose stools/day.
Moderate: Increased WCC (but <15 x 109/L) and typically associated with 3-5 loose stools per day.
Severe: WCC >15 x 109/L, or an acutely increased serum creatinine concentration (>50% above baseline), or a temperature
>38.5°C, or evidence of severe colitis. The number of stools may be a less reliable indicator of severity.
Life-threatening: Signs and symptoms include hypotension, partial or complete ileus, or toxic megacolon.
When to • One episode of diarrhoea in an at-risk patient not attributable to any other cause including medicines.
investigate • Patient has diarrhoea conforming to types 5-7 on the Bristol Stool Chart
• Sample takes the shape of the container used to sample it
• A
t-risk patient: older patient (>65yrs) + recent antibiotic treatment (2 months) + recent exposure to patients infected
with or environment contaminated with C. difficile.
Document the following details on the stool sample request form: Clinical features, recent antibiotic or proton pump inhibitor,
or hospital admission, contact with other affected individuals or outbreak, state if the test was requested by the HPU or a
Consultant in Communicable Disease Control. Do not send a repeat sample within 28 days if initial test is positive.
How to • Initiate treatment as below and isolate the patient if in a care/nursing home.
respond to a • Discontinue therapy with the inciting antibiotic(s) as soon as possible, as this may influence the risk of recurrence. Review
positive lab need for continuing antibiotics, if still required consider changing to another antibiotic which is less likely to cause C. difficile
result (see appendix 1, page 77).
• Review the need for PPIs and stop where it is felt safe to do so.
• Stop any laxatives.
• Stop any anti-motility drugs (e.g. codeine and loperamide) due to risk of ileus and toxic megacolon.
• Initiate treatment as below and isolate the patient if in a care/nursing home.
• Review patients regularly for fluid resuscitation, electrolyte replacement and nutrition as necessary and monitor for signs of
increasing disease severity.
Treatment First and second episode: Third episode or severe symptoms:
choices Metronidazole po Vancomycin po
400mg tds 125mg QDS
For 10-14 days. For 10-14 days.
Pregnancy/ Refer/seek specialist advice.
Breastfeeding
Cautions Mild cases don’t necessarily need antibiotic treatment. Cessation of other antibiotics the patient is taking may be adequate. If
unsure, discuss with a microbiologist.
Evidence 70% respond to metronidazole in 5 days; 92% in 14 days.
If severe, use vancomycin due to relatively high failure rates with metronidazole.
Recurrences: the majority or recurrences are due to re-infection rather than relapse and the same antibiotic that has been used
initially can be used to treat a first recurrence.
References Health Protection Agency. Management of Infection Guidance for Primary Care for consultation and local adaptation.
DH C. difficile – How to deal with the problem 2009
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093218.pdf
Other HPA/ Department of Health: C. Difficile infection: How to deal with the problem:
reference http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093220
sources CKS: Diarrhoea- antibiotic associated. www.cks.nhs.uk/diarrhoea_antibiotic_associated
UKMI Clostridium difficile infection- which antimicrobials are implicated? Medicines QandAs. Nov 2012.
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Clostridium-difficile-infection--which-
antimicrobials-are-implicated/
page 44
Gastro-intestinal Infections – Threadworms
When to treat Treat if threadworms have been seen or their eggs have been detected.
When to If infestation persists after hygiene measures have been continued for the recommended duration and treatment of
investigate household, and if there are frequent recurrences.
How to respond to Treat all members of the household at the same time (unless contra-indicated) to minimize re-infestation.
General Advice All members of the household must be advised to adhere to strict hygiene measures, including morning showers/
baths and hand hygiene for 2 weeks after treatment. Wear pants at night. Wash sleepwear, bed linen, dust and
vacuum on day 1.
Treatment choices First line:
Mebendazole po
100 mg STAT
Repeat in 2 weeks if infestation persists.
Pregnancy/ Treatment with an anthelmintic is contra-indicated in women in the first trimester of pregnancy. During pregnancy,
Breastfeeding hygiene methods alone are preferred for 6 weeks.
If drug treatment is considered necessary in the second or third trimester give mebendazole (off-licence indication).
See CKS link below for further information.
During breastfeeding, hygiene methods are generally preferred.
Evidence Neither mebendazole nor piperazine kills eggs, therefore adequate personal and environmental hygiene is essential
to prevent reinfestation from recently swallowed eggs, or eggs already in the environment.
It is generally accepted that mebendazole and piperazine have comparable efficacy (90–100% cure-rate),
however mebendazole has few contraindications and post-marketing surveillance has revealed no serious safety
concerns. Therefore piperazine should only be used in patients who cannot take mebendazole (see BNF for dosage
instructions).
References Threadworms. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/threadworm
page 45
Gastro-intestinal infections – Diverticulitis NEW
When to treat Antibiotic treatment is recommended for the routine management of diverticulitis, either at home or as an inpatient.
People with mild, uncomplicated diverticulitis can be managed at home with paracetamol, clear fluids and antibiotics.
Arrange admission for people with diverticulitis when:
• Pain cannot be managed with paracetamol
• Hydration cannot be easily maintained with oral fluids
• Oral antibiotics cannot be tolerated
• The person is frail or has a significant co morbidity that is likely to complicate their recovery (particularly if
immunocompromised)
• The person has any of the following suspected complications: rectal bleeding that may require transfusion, perforation
and peritonitis, intra-abdominal abscess, fistula.
When to If symptoms persist after 48hrs despite conservative management at home. Admit patient to hospital.
investigate
General advice Review within 48hrs or sooner if symptoms deteriorate. Arrange admission if symptoms persist or deteriorate. Prescribe
paracetamol for pain. Recommend clear liquids only. Gradually reintroduce solid food as symptoms improve over 2-3 days.
Treatment First line Second-line or if allergic to penicillins:
choices Co-Amoxiclav po METRONIDAZOLE po
625mg TDS 400mg TDS For 7 days
For 7 days. PLUS
Ciprofloxacin A po
500mg BD For 7 days.
Pregnancy/ In pregnancy or breastfeeding, seek specialist advice. Co-amoxiclav is suitable to use if appropriate. Seek advice from
Breastfeeding microbiologist if the patient is allergic to penicillins.
Evidence A recent Cochrane review2 has found that the most recent evidence from one RCT says there is no significant difference
between antibiotics versus no antibiotics in the treatment of uncomplicated diverticulitis. Previous RCTs have only
suggested non-inferiority between different antibiotic regimes and treatment lengths. This new evidence needs
confirmation from more RCTs before it can be implicated safely in clinical guidelines. Ongoing RCTs will be published in
the years to come and more are needed. The role of antibiotics in the treatment of complicated diverticulitis has not been
investigated yet.
Non-steroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics have been identified as risk factors for diverticular
perforation and are probably best avoided in the management of people with acute diverticulitis.
References NHS Clinical Knowledge Summaries. Acute Diverticulitis.
http://www.cks.nhs.uk/diverticular_disease/management/scenario_acute_diverticulitis#-319655
Shabanzadeh DM, Wille-Jørgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database of Systematic Reviews
2012, Issue 11. Art. No.: CD009092. Published 28/11/12.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009092.pub2/pdf
page 46
Adult
Genito-Urinary Infections
Adult Section
GUI
Genital Tract Infections – Criteria for Referring Patients to Specialist Care
Patient risk Refer patients with risk factors for STIs to Sexual Health Services or General Practices with level 2 or 3 expertise in Sexual
factors Health Services: 1,2
• <25yrs
• no condom use or inconsistent use
• recent (<12mth) or frequent change of sexual partner.
• previous STI
• symptomatic partner
• high risk sexual practices e.g. gay or bisexual men, IV drug users and their partners and patients with confirmed STIs.
If your patient has symptoms suggestive of any STI, refer to the sexual health clinic. Guidance on treatment of these
conditions can be found at the BASHH website (see link in reference section).
Diseases • Syphilis- always refer to Sexual Health Services
• Gonorrhoea- always refer to Sexual Health Services (N.B. The previous treatment monograph on this condition in older
versions of this guidance has been removed as this should always be treated by specialist sexual health services).
• Genital Herpes- Treat on suspicion (as per http://www.bashh.org/documents/115/115.pdf)
and refer to Sexual Health Services
Evidence See HPA and British Infection Association Quick Reference Guide to Management and Laboratory Diagnosis of
Abdominal Vaginal Discharge for useful flowchart.3
References 1. BASHH Clinical Effectiveness Group Guidelines (updated 7th Dec 2012) http://www.bashh.org/guidelines
2. National Chlamydia Screening Programme http://www.chlamydiascreening.nhs.uk/ps/index.asp
3. H
PA/BIA: Quick Reference Guide for primary Care Management of Abnormal Vaginal Discharge in Women
(amended 26.09.11) http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947408846
page 47
Genital Tract Infections – Vulvo Vaginal Candidiasis
When to treat Symptoms suggestive of episodic vulvovaginal candidiasis include external dysuria, vulval pruritus, swelling or
redness. Signs include vulval oedema, fissures, excoriation, or thick curdy discharge. The vaginal pH is usually normal
(<4.5). Treatment on the basis of symptoms alone is common clinical practice but results in the over-treatment of
a large number of women. There is no evidence to support the treatment of asymptomatic male sexual partners in
either episodic or recurrent vulvo vaginal candidiasis (VVC).
When to investigate Testing is recommended for episodic VVC whenever possibleB and for complicated VVC. This includes; severe episodic
VVC infection, recurrent VVC (> 4 attacks per yr) and those with underlying host abnormality,
e.g. pregnancy, HIV infection and diabetes.C If a patient has failed treatment with appropriate anti-fungals discuss
options with microbiology.
How to respond to a The possibility of Candida being an ‘innocent bystander’ needs to be considered.C Isolation of Candida is common in
positive lab report asymptomatic women. Treatment is not indicated in the absence of symptoms.B
General Advice Advise the woman to return if symptoms have not resolved within 7-14 days. Refer, or seek specialist advice, if:
symptoms are not improving and treatment failure is unexplained; treatment fails again; if diagnosis is unclear.
Recommend routine use of vulval moisturizers (e.g. aqueous cream or epaderm ointment) as soap substitute and
regular skin conditioner (instruct the patient that this does not constitute ‘internal use’).
Avoid tight fitting synthetic clothing. Avoid local irritants e.g. perfumed products.
Treatment choices First line choices OR OR
Clotrimazole pv Clotrimazole pv Fluconazole po
10% vaginal cream (5g) STAT 500mg pessary STAT (nocte) 150mg po STAT
N.B. Check for drug interactions!
Pregnancy/ In pregnancy avoid oral azole.B Pregnant women need a longer duration of treatment to clear the infection. Use
Breastfeeding intravaginal treatment for 7 days3A+, 2,4 B-
During pregnancy extra care should be taken when using the applicators with the clotrimazole100mg pessaries
or miconazole 2% vaginal cream (5g BD pv for 7 days) to prevent the possibility of mechanical trauma. Pregnant
women may wish to insert the pessary or cream without using the applicator.
http://www.medicines.org.uk/emc/
Cautions Women with chronic symptoms need a careful history and examination. Pay particular attention to alternative
diagnoses, most commonly vulval eczema/dermatitis. Other possibilities include other causes of vaginal discharge
e.g. recurrent bacterial vaginosis, recurrent herpes, vulval vestibulitis syndrome and other vulvar dermatoses.B More
than one condition may occur and this may vary with time e.g. the patient may cycle between bacterial vaginosis
and VVC. A general skin examination can be helpful.C Topical azoles can cause vulvovaginal irritation – consider if
symptoms worsen or persist.
Evidence All topical and oral azoles give 75% cure.1A+
References United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis (2007) Clinical Effectiveness
Group.
British Association of Sexual Health and HIV. http://www.bashh.org/guidelines
Clinical Knowledge Summaries, Candida, female genital, management:
http://www.cks.nhs.uk/candida_female_genital/management/scenario_uncomplicated_infection/
treating_vulvovaginal_candidiasis
page 48
Genital Tract Infections – Bacterial Vaginosis
When to treat Treatment is indicated for: symptomatic women (offensive fishy-smelling vaginal discharge, not associated with soreness,
itching, or irritation); women undergoing some surgical procedures; and some pregnant women. Symptomatic pregnant
women should be treated in the usual way and asymptomatic pregnant women may be considered for treatment.
Routine screening and treatment of male partners is not indicated.
When to Examination and further tests may be omitted and empirical If empirical treatment is not
investigate treatment for bacterial vaginosis (BV) started in women with considered appropriate, or if the
characteristic symptoms of BV if all of the following apply: diagnosis is uncertain:
• The woman is not at high risk of a sexually transmitted infection (STI). • Perform a speculum examination.
• The woman does not have symptoms of other conditions causing vaginal • If pH paper is available, test the
discharge (e.g. itch, abdominal pain, abnormal bleeding, dyspareunia, fever). pH of the vaginal fluid (pH > 4.5 is
• The woman is not pregnant, post-natal, post-miscarriage, or post-termination. consistent with a diagnosis of BV).
• Symptoms have not developed after a gynaecological procedure. • Take a high vaginal swab (or use a
• Symptoms have not recurred soon after treatment for BV or persisted following self-taken low vaginal swab) for Gram
treatment for BV staining and to exclude other causes
of vaginal discharge.
General Advice Advise patients to avoid vaginal douching, use of shower gel, and use of antiseptic agents or shampoo in the bath. C
Treatment First line treatment: Topical treatments:
choices MetronidazoleA+ po MetronidazoleA+ pv
400mg BD 0.75% vaginal gel 5g applicatorful ON
For 5-7 days (preferred dose regime in terms For 5 days.
of efficacy. Use this dose in pregnancy.) OR
OR ClindamycinA+ pv 2% vaginal cream, 5g applicatorful ON
METRONIDAZOLEA+ po For 7 days.
2g STAT (N.B. Product weakens condoms – advise against use during treatment)
(AVOID 2g dose in pregnancy/breastfeeding)
For 7 days.
Consider suspension formulation at night
for better tolerability compared to tablets.
Pregnancy/ Oral Metronidazole at the 400mg bd dose regimen is recommended during pregnancy and breastfeeding.
Breastfeeding BNF: www.bnf.org/bnf/current/index.htm EMC: www.emc.medicines.org.uk
Evidence All treatments have been shown to have cure rates of 70-80%. A 7 day course of oral metronidazole is slightly more
effective than 2 g stat.3A+ Topical treatment gives similar cure rates1A+ but is more expensive. Treating partners does not
reduce relapse.5B+
References National Guideline For The Management Of Bacterial Vaginosis (2012) Clinical Effectiveness Group
British Association for Sexual Health and HIV www.bashh.org/guidelines
Clinical Knowledge Summaries. Bacterial Vaginosis – management.
http://www.cks.nhs.uk/bacterial_vaginosis
page 49
Genital Tract Infections – Chlamydia trachomatis
When to treat In people with signs or symptoms strongly suggestive of Chlamydia, start treatment without waiting for laboratory
confirmation (after testing for other sexually transmitted infections as appropriate) Sexual partners should be offered treatment
and referred to sexual health services. The patient and partner should be advised to abstain from sex for the next 7 days.
Partners must be treated even if they have a negative test result. In the absence of treatment, 10-40% of infected
women will develop pelvic inflammatory disease (PID).
N.B. Azithromycin (Clamelle®) is available to buy over-the-counter (OTC) from pharmacies without a prescription, post positive
sample.
When to Offer all positive patients and contacts a full STI screen by referral to Sexual Health Services clinic. If a patient refuses to/can’t
investigate attend or the GP has specialist training in Sexual Health medicine, ensure that contact tracing is done via the GP practice.
Opportunistically screen all aged 15-25 yrs.
How to Treat if there is a positive confirmed reactive nucleic acid amplification technique (NAAT) test. Note: In high-risk populations,
respond to a tests are not confirmed with culture. Beware of false positive test results in low risk populations. Patients with reactive
positive unconfirmed NAAT tests should also be offered treatment. Encourage all patients diagnosed with C. trachomatis to have
lab report screening for other STIs, including an HIV test and, where indicated hepatitis B screening and vaccination.
General Abstain from genital, oral or anal sex, even with condom, until both index patient and partner(s) have completed treatment.
advice Abstain for one week after treatment with Azithromycin.
Treatment First line: OR
choices Doxycycline po Azithromycin po
100mg BD 1g STAT
For 7 days. (1hr before or 2hrs after food) N.B Check for drug interactions!
Pregnant or breastfeeding: (Also see advice in pregnancy/breastfeeding section below)
Most effective option is OR OR
AZITHROMYCIN but it is OFF-LABEL Erythromycin po AMOXICILLIN po
use – (dose as stated above). 500mg BD 500mg TDS
N.B Check for drug interactions! For 14 days. For 7 days.
Retest after 6 weeks. Retest after 5/52 as less effective. Retest after 5/52 as less effective.
Pregnancy/ Refer all pregnant patients to Sexual Health Services. However, if the patient won’t/can’t attend, advice on what
Breastfeeding antibiotic to prescribe is given above. Advice should also be sought from the local Sexual Health Service. In pregnancy or
breastfeeding: azithromycin can be used but is ‘off label’. It is recommended by WHO and USA CDC and is more effective than
erythromycin and amoxicillin. The BNF however, recommends its use only if no alternative is available.
Due to more frequent positive Chlamydia tests after treatment in pregnancy, attributed to either less efficacious treatment
regime, non compliance or re-infection, it is recommended that pregnant women must have a test of cure 6/52 after
completing therapy with azithromycin. If erythromycin or amoxicillin is used, retest after 5 weeks.
Erythromycin or amoxicillin should ONLY be used to treat special groups such as in pregnancy as they are
less effective.
Evidence Comparative studies of doxycycline and azithromycin have shown similar efficacy at 2-5 week follow-up, with >95% being
Chlamydia-negative retesting. However, there is evidence to suggest that with longer follow-up >10% will be positive on
retesting. NAATs may remain positive for up to 5 weeks, even if treatment has been successful.
References UK National Guideline for the Management of Genital Tract Infection with Chlamydia trachomatis) Clinical Effectiveness Group
British Association for Sexual Health and HIV 2006 www.bashh.org/guidelines
Clinical Knowledge Summaries. Chlamydia -uncomplicated genital: http://www.cks.nhs.uk/chlamydia_uncomplicated_
genital/management/scenario_diagnosis/screening_for_chlamydia
page 50
Genital Tract Infections – Trichomoniasis
When to treat Refer to Sexual Health Services. Treat partners simultaneously. Laboratory confirmed diagnosis, or may be
diagnosed in sexual health clinic on a wet preparation.
When to investigate All symptomatic patients: Yellow, green frothy discharge. Fishy/offensive odour +/- pruritis, vaginitis, dysuria.
Screening of asymptomatic patients is not recommended
How to respond to a Screening for coexistent sexually transmitted infections should be undertaken in both men and women.
positive lab report
General advice Sexual partner(s) should be treated simultaneously. Patients should be advised to avoid sexual intercourse
(including oral sex) until they and their partner(s) have completed treatment and follow-up.
Treatment choices First line: OR
MetronidazoleA- po MetronidazoleA- po
400mg BD 2g STAT
For 5-7 days. (AVOID 2g dose in pregnancy/breastfeeding)
Consider suspension formulation at night for better tolerability compared to tablets.
Pregnancy/ In pregnancy or breastfeeding: avoid 2g single dose metronidazole. Consider clotrimazole (100mg pessaries ON for
Breastfeeding 6 days) for symptom relief (not cure) if metronidazole declined.
Cautions The single dose has the advantage of improved compliance and being cheaper; however there is some evidence to
suggest that the failure rate is higher, especially if partners are not treated concurrently.
Evidence Most strains of T. vaginalis are highly susceptible to metronidazole and related drugs (approx. 95% cure rate).
There is a spontaneous cure rate in the order of 20-25%. Treating partners does not decrease relapse.
References United Kingdom National Guideline on the Management of Trichomonas vaginalis (2007) Clinical Effectiveness
Group, British Association of Sexual Health and HIV www.bashh.org/guidelines
page 51
Genital Tract Infections – Pelvic Inflammatory Disease (PID)
When to treat Signs include: Lower abdominal tenderness which is usually bilateral; adnexal tenderness on bimanual vaginal examination;
cervical motion tenderness on bimanual vaginal examination; fever (>38°C). Delaying treatment may increase the risk
of long term sequelae such as ectopic pregnancy, infertility and pelvic pain. Because of this, and the lack of definitive
diagnostic criteria, a low threshold for empiric treatment of PID is recommended. Start treatment and refer patient
and contacts to Sexual Health Service clinic. If gonorrhoea (GC) likely use ceftriaxone treatment regime via sexual
health service referral.
High risk for GC:
• Has had GC in the past • Severe PID/ severe clinical symptoms
• Partner has GC • Sex abroad
When to ALWAYS test for Gonorrhoea and Chlamydia as positive result supports PID diagnosis. However, a negative result does not
investigate exclude PID. Elevated ESR or C reactive protein also supports diagnosis.
How to respond All patients should be offered a pregnancy test to help exclude an ectopic pregnancy and screening for sexually transmitted
to a positive lab infections. Refer contacts to GUM/Sexual Health Services clinic.
report
General advice Rest is advised for those with severe disease.C Appropriate analgesia should be provided. Patients should be advised to
avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up.C Useful patient
information leaflet from BASHH can be found here: http://www.bashh.org/guidelines
Treatment If low risk of Gonococcal infection: If high risk of GC (endemic risk)
choices Metronidazole po OR – (see when to treat section above for defn):
400mg BD CEFTRIAXONE IM 500mg STAT (this is given at the sexual health
+ clinic, therefore any pts at risk of GC must be referred)
DOXYCYCLINE +
po 100mg BD Metronidazole po 400mg BD
OR +
Ofloxacin po Doxycycline po 100mg BD
400mg BD For 14 days.
For 14 days.
Pregnancy/ If it is known or suspected that the patient is pregnant, they should be referred urgently to a sexual health specialist.
Breastfeeding Management of the patient depends upon gestation and clinical severity and hence each patient will need to be dealt with
individually on a case by case basis.
Cautions In both regimens metronidazole is included to improve coverage for anaerobic bacteria. Anaerobes are of relatively greater
importance in patients with severe PID and metronidazole may be discontinued in those patients with mild or moderate
PID who are unable to tolerate it. Ofloxacin should be avoided in patients who are at high risk of gonococcal PID because
of increasing quinolone resistance in the UK ~28% of gonorrhoea isolates now resistant to quinolones, therefore get
advice from Sexual Health Specialist.3B+ If you have a patient where you are unsure as to whether they have GC and
the sexual health clinic is closed, a NAAT test can be undertaken (along with other necessary tests) PRIOR to starting
antibiotics and you can specify that you wish for GC to be tested. Oral treatment should be initiated and the patient
referred to sexual health clinic where IM Ceftriaxone can be administered if necessary and screening undertaken.
References United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease (2011) Clinical Effectiveness
Group, British Association of Sexual Health and HIV www.bashh.org/guidelines
page 52
Genital Tract Infections – Acute Prostatitis (where STI not suspected)
When to treat Acute prostatitis should be suspected in a man who presents with a feverish illness of sudden onset; irritative urinary
voiding symptoms or acute urinary retention; perineal or suprapubic pain; exquisitely tender prostate on rectal
examination. Empirical treatment should be started immediately after urine cultures have been obtained. Treatment
should be selected according to the clinical condition of the patient. Most prostatitis is caused by urinary tract
pathogens – not STIs.
When to All patients >35 years need mid-stream urine sample for dipstick testing and culture for bacteria and antibiotic
investigate sensitivity. Blood culture for bacteria and antibiotic sensitivity. First catch urine sample for NAATs. An STI is much more
likely in men <35 years.
Admit to hospital if the man is unable to take oral antibiotics, has acute urinary retention or is severely ill. Refer
urgently if the man has a pre-existing urological condition and consider urgent referral if the man has diabetes or is
immunocompromised.
How to respond to Reassess after 24-48 hours: Review the culture results and ensure that an appropriate antibiotic is being used.
a positive lab result However cultures are often negative. If there is deterioration or failure to respond to oral therapy, urgent admission
and parenteral therapy should be arranged; prostatic abscess may need to be excluded or treated.
There is no need to treat partners unless a positive STI is diagnosed. Refer to sexual health clinic if STI is suspected.
General advice Adequate hydration should be maintained, rest and use of analgesics encouraged.
Most men treated appropriately for acute prostatitis will recover completely within 2 weeks (but treatment should be
continued for at least a further 2 weeks). Following recovery, refer for investigation to exclude structural abnormality of
the urinary tract.
Treatment choices First line: Second line or if allergic or intolerant to quinolones:
Ciprofloxacin po TrimethoprimC po
500mg BD 200mg BD
OR For 28 days.
Ofloxacin C po
200mg BD
For 28 days.
Cautions If there is deterioration or failure to respond to therapy urgent admission to hospital should be arranged.
Evidence Quinolones are more effective, as they have greater penetration into prostate.2 4 weeks treatment may prevent
chronicity.
References United Kingdom National guideline for the management of prostatitis (2008) Clinical Effectiveness Group
British Association of Sexual Health and HIV www.bashh.org/guidelines
page 53
Genital Tract Infections – Epididymo-Orchitis NEW
When to treat1 Most common causes are chlamydia and GC in under 35s and E.coli in over 35s. Have a very low threshold for admitting
immediately to exclude testicular torsion. If symptoms are severe or the man or boy is very unwell, consider admitting to hospital,
particularly if he has diabetes or is immunocompromised. Refer for same-day or next-day assessment by a sexual-health
specialist. If this is not possible: Obtain a mid-stream urine for dipstick, microscopy, and culture and test for sexually-transmitted
infections. Urine should be tested for chlamydia & GC NAAT. After test samples are taken, Empirical therapy should be
given to all patients with epididymo-orchitis before laboratory results are available.2 Consider other (rare) causes,
such as mumps orchitis (may be parotid swelling), Bechet’s syndrome (if recurrent epididymitis), tuberculosis, and amiodarone.
When to All patients with sexually transmitted epididymo-orchitis should be screened for other sexually transmitted infections.2 If a urinary
investigate tract infection is confirmed, refer to a urologist to investigate for an underlying structural abnormality or urinary tract obstruction.1
How to respond Tailor treatment according to culture and sensitivity results. If lab tests have been ordered in primary care and the patient
to a positive lab was gonorrhoea positive, ensure patient is referred to sexual health services. A test of cure should be performed at least 72
result hrs after completion of antibiotics.2
General advice1 Bed rest, scrotal elevation (such as supportive underwear) and analgesia. If symptoms worsen, or do not begin to improve
within 3 days, return for assessment. BASHH pt info leaflet on epididymo-orchitis can be found here:
Treatment First line: If allergic to tetracyclines:
choices DOXYCYCLINE po OFLOXACIN po
100mg BD For 10-14 days 200mg BD For 14 days
Cautions Epididymo-Orchitis related to a sexually transmitted infection (generally under 35s):
If you suspect the patient is at high risk for gonorrhoea (previous gonorrhoea infection, known contact of a person with
gonorrhoea, purulent urethral discharge, men who have sex with men, black ethnicity) then the patient MUST be referred to
sexual health services in order to be given Ceftriaxone 500mg STAT IM.
If you have a patient where you are unsure as to whether they have GC and the sexual health clinic is closed, a NAAT test
can be undertaken (along with other necessary tests) PRIOR to starting antibiotics and you can specify that GC is to be
tested for. Oral treatment should be initiated and the patient referred to sexual health clinic where IM Ceftriaxone can be
administered if necessary.
If it is suspected that the cause of the epididymo-orchitis is related to a sexually transmitted organism (most likely in
patients who are less than 35yrs of age, >1 sexual partner in the past 12 months, any urethral discharge) the patient should
be instructed that there should be no intercourse until review. Notify Partner (sexual health services can do contact tracing
once patient is referred).1
If a patient has GC identified as the causative organism, a GC test of cure is recommended at least 2 weeks after a positive
NAAT (or 72hrs for culture). Ensure that patients go back to their sexual health clinic to have this done.
Epididymo-orchitis related to an enteric organism (generally over 35s):
If it is suspected that the patient’s epididymo-orchitis is related to an enteric organism (low risk sexual history, age>35yrs,
history of penetrative anal intercourse, recent urological instrumentation or catheterization) such as E. coli, Ciprofloxacin
500mg bd for 10 days OR Ofloxacin 200mg BD for 14 days is recommended.3 If a quinolone is contraindicated, treat
with Co-amoxiclav 500/125 mg three times daily for 10 days.1
= high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients). Avoid
quinolones in people with a history of tendon disorders related to quinolones, or a history of seizures or conditions that
predispose to seizures.1
References 1. C KS- scrotal swellings- management http://www.cks.nhs.uk/scrotal_swellings/management/scenario_
diagnosis/identifying_the_cause/causes_of_scrotal_swelling_clinical_features#-404534
2. British Association of Sexual Health and HIV 2010. United Kingdom national guideline for the management of epididymo-
orchitis. http://www.bashh.org/guidelines
3. B ritish Association of Sexual Health and HIV 2011. Clinical care pathway for management of epididymo-orchitis.
4. B ritish Association of Sexual Health and HIV 2011. UK National Guideline for the management of Gonorrhoea in Adults.
page 54
Adult
Skin and Soft Tissue Infections
Adult Section
SSTI
Skin & Soft Tissue Infections – Impetigo
When to treat Although usually self-limiting, treatment is recommended for all cases, as untreated impetigo is highly contagious
and there is a risk it may become generalised. Topical antibiotics should be reserved for very localised lesions and
oral antibiotics used for extensive, severe or bullous impetigo.
Non-bullous impetigo is the most common form. Lesions begin as vesicles or pustules, which rapidly burst and evolve
into gold-crusted plaques. The area around the mouth and nose is most commonly affected.
Bullous impetigo, which commonly affects neonates, presents with flaccid, fluid-filled vesicles and blisters. These
easily burst leaving raw skin, and eventually form thin, flat, brown-to-golden crusts. Tends to involve the axillae, neck
folds, and nappy area. Lesions are usually painful, are often multiple and spread rapidly.
When to investigate Skin swabs are not necessary to diagnose impetigo. Take a swab (for bacterial identification and sensitivity) if the
infection is: very extensive or severe; recurrent (consider nasal swab for staphylococcal carriage); suspected as being
a community outbreak; suspected as being caused by MRSA. Advise the person to attend a follow-up appointment if
there is no significant improvement after 7 days..
How to respond to a Alter treatment in response to culture and sensitivity results.
positive lab result
General advice Educate patient about good hand washing technique and to avoid scratching lesions. Advise that hygiene measures
are important to aid healing and stop the infection spreading to other sites on the body and to other people.
Treatment choices: First line: Second line or if penicillin allergic:
Generalised infection Flucloxacillin po Clarithromycin po
500mg QDS 250-500mg BD
N.B. Check for drug interactions!
Localised infection Fusidic Acid 2% topically TDS If MRSA isolated:
For 7 days. Mupiricin 2% ointment topically TDS
For 5 days.
Cautions As resistance is increasing, reserve topical antibiotics for very localised lesions. Reserve Mupirocin for MRSA.
Evidence Systematic review indicates topical and oral treatment produces similar results.
Koning S et al. Interventions for impetigo. Cochrane Database of Systematic Reviews 2012, Issue 1.
http://summaries.cochrane.org/CD003261/interventions-for-the-skin-infection-impetigo
NHS Clinical Knowledge Summaries. Impetigo. www.cks.library.nhs.uk/impetigo
page 55
Skin & Soft Tissue Infections – Eczema
When to treat Using antibiotics, or adding them to steroids, in eczema encourages resistance and does not improve healing
unless there are visible signs of infection. If there are localized areas of infection a topical antibiotic in
combination with steroid can be considered for no longer than two weeks.
In more generalised infected eczema, use treatment as in impetigo (i.e. first line flucloxacillin)
Refer immediately (same day) to hospital if eczema herpeticum is suspected.
Signs of eczema herpeticum are:
• areas of rapidly worsening, painful eczema;
• clustered blisters consistent with early-stage cold sores;
• punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter that are uniform in
appearance (these may coalesce to form larger areas of erosion with crusting);
• possible fever, lethargy, or distress.
Refer urgently (within 2 weeks) to a dermatologist if infected eczema has not responded to treatment.
Atopic eczema. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/eczema_atopic
page 56
Skin & Soft Tissue Infections – Cellulitis
When to treat Cellulitis presents with an acute onset of red, painful, hot, swollen, and tender skin, with possible blister formation. Fever,
malaise, nausea, shivering and rigors may also occur. Differential diagnoses include DVT and varicose eczema. Most
cases are attributed to an infective cause. Initiate empirical first line treatment. If patient has risk factors for colonisation
with MRSA (e.g. recurrent abscesses, contact with military personnel, engages in contact sports, healthcare worker,
recent admission to hospital) consider doxycycline. If cellulitis is in a diabetic patient or associated with recent abdominal
surgery, gram negatives and even anaerobes may be involved and a broader spectrum antibiotic may be needed. In such
cases, discuss with a microbiologist and/or diabetologist for further advice.
When to Swabs from intact skin are of no value as they are frequently contaminated and provide a poor yield of pathogens.
investigate Swabs of broken skin or of an obvious portal for microbial entry may help guide antibiotic choice if empirical treatment
fails. Swabs should be taken before commencing treatment. The yield is often poor, however, with pathogens isolated
from only 25% of swabs in some studies. Consider a wide range of non-infective causes in cases of treatment failure.
Consider admission for patients with severe or rapidly deteriorating cellulitis; an uncertain diagnosis with sinister signs or
symptoms (e.g. possible necrotizing fasciitis); severe systemic illness; comorbidities that may complicate or delay healing;
facial or periorbital cellulitis; lymphoedema; or for the very young, elderly or frail people.
How to respond to Alter treatment in response to culture and sensitivity results of potential pathogens. Refer people who fail to respond to
a positive lab result oral antibiotics or have frequent recurrence of cellulitis, for example more than two episodes at the same site.
General advice Before treatment, draw around the extent of the infection with a permanent marker pen for future comparison.
Elevation of the affected area speeds improvement by promoting gravity drainage of the oedema/inflammatory substances.
Treatment choices First line: If penicillin allergic:
Flucloxacillin po Clarithromycin po N.B Check for drug interactions!
500mg QDS 500mg BD
For 7 days. OR
If there is continuing clinical response but Clindamycin po
incomplete resolution continue for a further 300mg-450mg QDS (higher dose if severe)
7 days or longer 1C For 7 days.
N.B. STOP clindamycin if diarrhoea occurs and send a stool
sample for C. Difficile testing.
If there is continuing clinical response but incomplete resolution
continue for a further 7 days or longer1C
Facial Cellulitis Co-Amoxiclav po This is required to cover organisms from mouth and sinuses. If pen allergic, discuss with microbiology.
625mg TDS For 7-14 days.
Pregnancy/ In pregnancy or breastfeeding, use flucloxacillin or erythromycin instead of clarithromycin. Clindamycin is not known
Breastfeeding to be harmful in pregnancy. In breastfeeding, the amount of clindamycin absorbed is probably too small to be
harmful but bloody diarrhea reported in 1 infant (BNF Sept 2012).
Cautions = high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients).If
patient afebrile and healthy other than cellulitis, flucloxacillin or clarithromycin may be used as single drug treatment.
If exposure to river or sea water, discuss with microbiologist to consider causes such as aeromonas, atypical
mycobacteria, etc. If febrile and ill, admit for IV treatment. For pre-existing wound or leg ulcer see next monograph
overleaf.
Evidence There is little evidence to guide the choice of antibiotic. Most trials comparing antibiotics have been small,
inconclusive and often hospital-based. Topical antibiotics should not be prescribed. There is no published evidence to
support their use and widespread use is likely to increase antibiotic resistance.
NHS Clinical Knowledge Summaries Cellulitis http://www.cks.nhs.uk/cellulitis_acute
page 57
Skin & Soft Tissue Infections – Leg Ulcers
When to treat Venous leg ulcers affect 1.7% of those ≥ 65 years. All venous leg ulcers contain bacteria; most are colonisers, but some
cause clinical infection. Antibiotics are only indicated if there is evidence of clinical infection such as cellulitis,
increased pain, enlarging ulcer or pyrexia. If ulcer is in a diabetic patient gram negatives and even anaerobes may be
involved and a broader spectrum antibiotic may be needed. In such cases, discuss with a microbiologist and /or diabetologist
for further advice. Also see local guidance on diabetic footcare pathways:
SFT: http://www.icid.salisbury.nhs.uk/ClinicalManagement/Diabetes/Pages/DiabeticFootcareICP.aspx
RUH: http://www.bathdiabetes.org/index2.php?section_id=225andredirect=654
GWH: www.sdpreview.co.uk –this diabetes website is being developed and diabetic foot ulcer info will be added to it
shortly.
When to Microbiology investigations should only be undertaken when there are clinical signs of infection. Tissue biopsy is the gold
investigate standard, but wound swabs are easier. Take swabs before starting antibiotics. Use a swab with transport medium and
charcoal, to aid survival of fastidious organisms. Cleanse the wound with tap water or saline to remove surface contaminants.
Slough and necrotic tissue should also be removed. Swab viable tissue displaying signs of infection. Rotate the swab. Review
antibiotics after culture results. Refer for specialist opinion if severe infection. Arterial or mixed venous/arterial ulcer: refer
people to a specialist tissue viability or leg ulcer nurse for further assessment. Take a swab for all infected venous leg ulcers
before prescribing an antibiotic.
How to Swab results determine organisms present and antimicrobial susceptibilities-they do not determine the presence of infection.
respond to a Significance of organisms depends on presence of clinical criteria for infection. Group A beta-haemolytic streptococci can be
positive lab associated with significant infection and delay healing. Other bacterial contamination is not considered to adversely affect
result healing. Inclusion of antibiotic susceptibilities does not necessarily mean an organism is significant or that it requires antibiotic
treatment. Seek microbiological advice if colonised with MRSA.
General Advise patients to keep mobile, elevate legs when immobile, avoid trauma and wear appropriate footwear, use an
advice emollient frequently even after the ulcer has healed, examine legs regularly for deterioration and wear compression
bandages or stockings as advised. The use of a topical antiseptic, for example an iodine-based product, may be used as an
adjunct to systemic treatment.
Treatment If active infection (cellulitis/increased pain/pyrexia/ If anaerobes are suspected
choices purulent exudates/odour)2C: ADD-IN:
FLUCLOXACILLIN po OR CLARITHROMYCIN po METRONIDAZOLE po
500mg QDS 500mg BD 400mg TDS
For 7 days. For 7 days. For 7 days.
N.B Check for drug interactions if clarithromycin chosen!
If there is continuing clinical response but incomplete resolution continue for a further 7 days or longer1C
Pregnancy/ Flucloxacillin is suitable to use in pregnancy and breastfeeding. If penicillin allergic, use erythromycin (rather than
Breastfeeding clarithromycin) Metronidazole at the suggested dosage is suitable for use as well if necessary.
References Health Protection Agency Venous Leg Ulcers: Infection Diagnosis and Microbiology Investigation Quick Reference Guide for Primary
Care 2009 http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/#VLegUlcers
NHS Clinical Knowledge Summaries: Leg Ulcers
http://www.cks.nhs.uk/leg_ulcer_venous/management/quick_answers/scenario_infected_venous_leg_ulcer#-316797
O’Meara S, Al-Khurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic
Reviews. 2010. Issue 1. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003557/frame.html
page 58
Skin & Soft Tissue Infections – Methicillin-Resistant Staphylococcus aureus (MRSA) (active treatment)
For screening & suppression, see HPA MRSA quick reference guide
When to treat For active MRSA infection: Use antibiotic sensitivities to guide treatment.
More complex infections such as worsening chest infection or associated with an infected prosthetic infection may require
combination therapy (seek advice from microbiologist) or referral to hospital for assessment. If there is no response to
monotherapy after 24-48 hours, seek advice from microbiologist.
Monitor for signs of sepsis, cellulitis, pneumonia, urinary infection, and osteomyelitis (such as fever, spreading infection).
Do not give systemic antibiotics to patients with minor skin and soft tissue infections or small abscesses (<5 cm). Incise and
drain small abscesses without cellulitis and do not give antibiotic therapy.
MRSA infections most commonly affect the skin presenting as boils; abscesses; styes; carbuncles; cellulitis; impetigo; wound
infections. If MRSA enters the blood stream it can affect almost any part of the body.
Diagnosing active infection: Swab for pathogens including MRSA, or obtain a specimen if appropriate, if the person has
an active infection and one or more of the following risk factors: elderly or debilitated people with critical or chronic illness;
surgical wounds, open ulcers, intravenous lines, or catheter lines; infected pressure sore; history of MRSA colonisation or
infection; recent surgery; recent hospital discharge; regular nursing home contact or a nursing home resident; recent antibiotic
use (especially cephalosporins, fluoroquinolones, and macrolides); dialysis; permanent urinary catheter.
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus. It can rarely cause severe
invasive infections in healthy people. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or
sport; poor hygiene.
If active infection, MRSA confirmed by lab results, infection not severe and admission not required then
treat as below. 1,2B+
When to refer • C onsider admitting people who are MRSA positive if they have worsening signs of infection (for example, sepsis, worsening
cellulitis, fever, or tachycardia), particularly if they are likely to require parenteral antibiotic therapy and/or surgical drainage.
• Do not refer people who are MRSA positive if they do not have an active infection (that is they are colonized with MRSA),
or another reason for admission.
General advice • R eassure that infection with meticillin-resistant Staphylococcus aureus (MRSA) does not present a risk to healthy people in
the community.
• Advise the person or their carer to:
• Keep wounds, cuts, and abrasions covered until they are healed and dry.
• Wear disposable gloves when changing dressings (and to dispose of them safely, and not to re-use them).
Dispose of dressings carefully so that the risk of infection is reduced.
• Wash their hands regularly, especially before and after wound care, even if gloves are worn.
Treatment ENSURE SENSITIVITIES ARE CHECKED BEFORE INITATING TREATMENT!
choices CLINDAMYCIN po
DOXYCYCLINE po OR
100mg BD 300mg-450mg QDS
N.B. STOP clindamycin if diarrhoea occurs and send a stool sample for C. Difficile testing.
Pregnancy/ Check sensitivities first. Seek advice from microbiologist.
Breastfeeding
References Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation. March-
October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summaries. MRSA:
http://www.cks.nhs.uk/mrsa_in_primary_care/management/scenario_diagnosis#344309006
page 59
Skin & Soft Tissue Infections – Animal Bites
When to treat If the wound is less than 48 hours old and risk of infection is high. Antibiotics are not generally needed if the wound is more
than 2 days old and there is no sign of local or systemic infection. Review at 24 and 48 hours. Thorough irrigation is most
important.
Antibiotic prophylaxis is advised for:
• All cat bites.
• Wounds requiring surgical debridement; or suspected fractures.
• Wounds that have undergone primary closure.
• People with a prosthetic valve or a prosthetic joint.
• Puncture wound
• Bite involving hand, foot, face, joint, tendon, ligament
• People who are at risk of serious wound infection: • Immunocompromised • Cirrhotic
• Diabetic • Asplenic patients
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons, bones,
the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds requiring closure;
bites that might need reconstructive surgery; devitalized wounds requiring debridement; bites where the severity is difficult
to assess; bites with severe cellulitis; infections not responding to treatment; people with an increased risk of infection (see
above); children with scalp wounds; bites to poorly vascularised areas.
When to If there is evidence of infection, send pus or deep wound swab for culture before cleaning the wound.
investigate Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.
How to respond Alter treatment in response to culture and sensitivity results.
to a positive lab
result
General advice If the wound has just occurred, encourage it to bleed. Clean and irrigate the wound.
Treatment First line: If penicillin allergic:
choices Co-Amoxiclav po Metronidazole po
625mg TDS 200-400mg TDS
For 7 days. PLUS
Doxycycline po
100mg BD
For 7 days.
Assess tetanus and rabies risk. If any risk of rabies contact the HPA (tel: 020 8327 6017).
Consider need for tetanus prophylaxis.
Pregnancy/ Co-amoxiclav is suitable to use in pregnancy & breastfeeding. If penicillin allergic, contact microbiology for advice.
Breastfeeding
Cautions = high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients). Regarding
tetanus and rabies risk, if it is a primate bite, discuss with virologist. In the case of unusual animals, please discuss with
microbiologist, particularly if persistent infection despite treatment with co-amoxiclav, or if immunocompromised.
Evidence Non-human bites that are low risk and that do not involve the hand have infection rates <2%. Macrolides are not recommended
for animal bites because they do not adequately cover Pasteurella. Co-amoxiclav is effective against most bacteria isolated from
domestic animal bites. Metronidazole (in addition to tetracyclines) covers beta-lactamase-producing anaerobes.
NHS Clinical Knowledge Summaries: Animal Bite http://www.cks.nhs.uk/bites_human_and_animal/management/
quick_answers/scenario_managing_a_cat_or_dog_bite
page 60
Skin & Soft Tissue Infections – Human Bites
When to treat Antibiotic prophylaxis advised for all wounds less than 72 hours old even if there is no sign of infection. Thorough
irrigation of the wound is important. Review at 24 and 48 hours.
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons,
bones, the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds
requiring closure; bites that might need reconstructive surgery; devitalised wounds requiring debridement; bites where
increased risk of infection (e.g. diabetic, cirrhotic, immunosuppressed, asplenic); bites to poorly vascularised areas.
When to Where infection suspected, send a pus or deep wound swab for culture before cleaning the wound and starting
investigate antibiotics. Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.
Seek immediate advice from a consultant in microbiology or infectious diseases for anyone considered to be at risk of
HIV, hepatitis B or C. Consider all people to be at risk unless the current status of the biter is known (rare). Consider if
tetanus prophylaxis is required. Tetanus after a human bite is extremely rare.
How to respond Alter treatment in response to culture and sensitivity results.
to a positive lab
result
General advice If the wound has just occurred, encourage it to bleed. Clean and irrigate the wound thoroughly with warm running water.
Treatment First line (prophylaxis or treatment): If penicillin allergic (prophylaxis or treatment):
choices CO-AMOXICLAV po Metronidazole po
625mg TDS 200-400mg TDS
For 7 days. Plus
Doxycycline po Or Clarithromycin po
100mg BD 250-500mg BD
For 7 days. For 7 days. N.B Check for drug interactions!
Pregnancy/ Co-amoxiclav is suitable to use in pregnancy & breastfeeding. If penicillin allergic, contact microbiology for advice.
Breastfeeding
Assess HIV, hepatitis B and C risk. Antiseptic cleansers are not necessary and there is some concern that they damage
tissue and delay wound healing.
Evidence Co-amoxiclav is effective against the most commonly isolated organisms from human bites. Doxycycline, but not
clarithromycin is active against Eikenella species, which is commonly isolated from human mouths. Metronidazole
covers beta-lactamase-producing anaerobes. 80% of Eikenella corrodens are resistant to macrolides. If a bite is 72
hours old and there is no sign that it has become infected, the risk of infection is likely to be low and prophylactic
antibiotics are probably not of value.
NHS Clinical Knowledge Summaries Human Bite: http://www.cks.nhs.uk/bites_human_and_animal/
management/quick_answers/scenario_managing_a_cat_or_dog_bite#-282212
page 61
Skin & Soft Tissue Infections – Conjunctivitis
When to Only treat if severe, as most infections are viral or self-limiting. Bacterial conjunctivitis is usually unilateral and also self-
treat limiting; therefore a wait and see or delayed prescription approach is likely to be most appropriate. Consider starting treatment if
no improvement after 3 days.
Conjunctivitis is characterised by red eye with mucopurulent, not watery, discharge.
Consider offering a topical ocular antibiotic to a person with infective conjunctivitis when:
• Infective conjunctivitis is severe, or likely to become severe, providing serious causes of a red eye can be confidently excluded.
• Schools and childcare organizations require treatment before allowing a child to return.
• They understand the limitations of treatment but still prefer treatment.
When a topical ocular antibiotic is prescribed because of the person’s preference for treatment, consider advising them to delay
starting treatment for 3 days to see if the condition will resolve spontaneously.
N.B. Chloramphenicol 0.5% eye drops and 1% ointment can now be bought over-the-counter at pharmacies for adults and
children over the age of 2 years.
When to If any of the following symptoms are present, refer the patient for specialist same-day assessment to exclude acute glaucoma,
investigate keratitis, iritis or orbital cellulitis: Significant photophobia; reduced visual acuity; pain deep in the eye; recent eye surgery;
absent or sluggish pupil response; irregular pupils; corneal damage or opacity on fluorescein staining; restricted or painful eye
movements; history of head/eye trauma.
Swab the eye to identify the infective cause when infective conjunctivitis is hyper-acute or persistent. This is not usually
considered useful for people with acute infective conjunctivitis.
Patients should be advised to seek medical advice if symptoms do not settle within 7 days, or if there is visual disturbance,
significant eyelid swelling, photophobia or pain in the eye. In cases where conjunctivitis persists for >2 weeks, take swabs for
bacteria and chlamydia.
General Warn patient to not wear contact lenses whilst having this treatment and for 24hrs after finishing treatment. Patients should
Advice be advised to wash hands regularly, particularly after touching infected secretions, and avoid sharing pillows and towels.
Treatment If Severe, First line: Second-line, for Staphylococcus-aureus eye infections Only:
choices Chloramphenicol Fusidic Acid
0.5% eye-drops 1% topical gel
2hrly for 2 days, then reducing to four hourly (whilst awake) BD
Plus and for 48hrs after resolution of symptoms.
1% eye ointment
AT NIGHT and for 48hrs after resolution of symptoms
Pregnancy Fusidic acid is the treatment of choice during pregnancy. See CKS
Cautions Consider the differential diagnoses of blepharitis.
Evidence 65% of infections resolve on placebo by day five. Fusidic acid has less Gram-negative activity. Hence use for Staphylococcus
aureus eye infections ONLY. A double-blind placebo-controlled RCT in children showed, at day 7, 83% clinical cure with placebo
compared with 86% with chloramphenicol.
Delayed prescribing of antibiotics appears to reduce antibiotic use (almost 50%) with similar symptom control to immediate prescribing.
March-October 2012 www.hpa.org.uk
NHS Clinical Knowledge Summaries http://www.cks.nhs.uk/conjunctivitis_infective#
Management of acute infective conjunctivitis. Drug and Therapeutics Bulletin 2011; 49(7): 78-80
Rose PW et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care. The Lancet 2005;
366(8479): 37-43
Everitt H, Little P, Smith P. A randomised controlled trial of management strategies for acute infective conjunctivitis in general
practice. BMJ 2006; 333(7563): 32
page 62
Skin & Soft Tissue Infections – Scabies
When to The main symptom is generalised itch – especially at night. Characteristic silvery lines may be seen in the skin where mites
treat have burrowed. Erythematous papular or vesicular lesions are often associated with the burrows. Typical sites include the
interdigital folds, wrists, elbows and around the nipples in women.
Treat whole body from chin and ears downwards, including under the nails. People who are immunosuppressed, the very
young and elderly should apply the insecticide to the whole body including the face and scalp. Treat all household, close
contacts and sexual contacts even in the absence of symptoms within 24hrs. Scabies persists indefinitely if not treated.
When to Finding the mite or its products confirms, but is not necessary for making a diagnosis of scabies. Consider referral to a
investigate dermatologist if the diagnosis is in doubt, or after continued treatment failure (e.g. if two courses of an insecticide have failed).
Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies.
Admission may be required.
Consider referral to a genito-urinary medicine clinic for specialist advice, diagnostic services, partner notification, and contact
tracing if there is a history of risk behaviour for sexually transmitted infections: Contact tracing of partners from the previous 2
months should be undertaken.
Refer institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes, and prisons) to the Health Protection
Agency, as control measures are necessary to deal with all residents, staff and healthcare workers.
Review if symptoms have not cleared within 6 weeks after the first application of treatment.
Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is
required for this age group.
General Consider symptomatic treatment for itching (e.g. topical crotamiton). Consider a sedating antihistamine at night-time if
Advice itching is particularly problematic. Machine wash (at 50°C or above) clothes, towels, and bed linen, on the day of application
of the first treatment. Advise to avoid close body contact with others until their partners and close contacts have been treated.
Apply the treatment to cool dry skin (i.e. not after a hot bath). Allow the lotion or cream to dry before dressing.
Wash the treatment off after prolonged contact with the skin: Permethrin: 8 to 12 hours. Malathion: 24 hours.
Reapply treatment if it is washed off during the treatment period (e.g. after hand washing). Advise the patient that the itching
may take several weeks to resolve.
Treatment First line: If allergic to Permethrin:
choices PermethrinA+ Malathion
5% topical cream 0.5% aqueous liquid topically
2 applications one week apart 2 applications one week apart
Pregnancy/ The first choice treatment is permethrin in pregnancy or breastfeeding (due to there being more evidence of safety) but if the
Breastfeeding patient is allergic to permethrin, malathion can be used. Both products are poorly absorbed following topical application and
are widely recommended for use during pregnancy. Neither malathion nor permethrin are specifically licensed for use during
pregnancy or breastfeeding, however there is no indication that either product poses any risk to the fetus or child.
Breastfeeding mothers should remove the liquid or cream from the nipples before breastfeeding, and reapply treatment
afterwards.
Evidence There is more evidence for the effectiveness of permethrin than malathion. Expert opinion is that two treatment sessions are
needed to treat scabies effectively (HPA). The SPC states that: Approximately 90% of individuals are cured with a single application
of cream. If necessary, a second application may be given not less than 7 days after the initial application, if there are no signs of
the original lesions healing or if new lesions are present.
NHS Clinical Knowledge Summaries. Scabies. http://www.cks.nhs.uk/scabies
BASHH. United Kingdom National Guideline on the Management of Scabies infestation (2007)
http://www.bashh.org/documents/27/27.pdf
page 63
Skin & Soft Tissue Infections – Dermatophyte infection of the proximal fingernail or toenail
When to treat Take nail clippings: Start therapy only if infection is confirmed by laboratory. Self care alone may be appropriate for people who
are not bothered by the infected nail or who wish to avoid the possible adverse effects of drug treatment. For children with
such infections, seek specialist advice.
Consider drug treatment if:
• Walking is uncomfortable.
• Abnormal-looking nails are causing significant psychological distress.
• The person has diabetes, vascular disease, or a connective tissue disorder (because of a higher risk for secondary bacterial
infections and cellulitis).
• The nail infection is thought to be the source of fungal skin infection.
• The person is, or is likely to become, severely immunocompromised (for example with haematological malignancy or its treatment).
When to • If the diagnosis is uncertain
investigate • If treatment is unsuccessful
• If the person is immunocompromised, refer to dermatology.
False-negative rates are high (about 30%). Therefore repeat the test if the result is negative, and there is high clinical suspicion
that the nail is infected.
General Advise the person to avoid or minimize exposure to situations which predispose to, or aggravate, fungal nail infection, for example:
Advice • Prolonged or frequent exposure to warm, damp conditions.
• Occlusive footwear.
• Damaging the nails.
• Keep nails trimmed short and filed down.
• Wear well fitting shoes.
• Consider seeing a podiatrist if the nails are causing discomfort when walking.
Treatment Treatment options: OR If candida or non-dermatophyte
choices Amorolfine nail lacquerB- 5% TerbinafineA- po infection is CONFIRMED use:
1-2x/week 250mg OD ITRACONAZOLE po
Fingernails: 6 months treatment Fingernails: 6-12 weeks 200mg BD for 7 days, subsequent courses
Toenails: 12 months treatment Toenails: 3-6 months repeated after 21 day interval.
Most suitable if infection is mild and superficial Fingernails: 2 courses
Toenails: 3 courses
Pregnancy/ None of these treatments are recommended to be used during pregnancy and breastfeeding.
Breastfeeding
Cautions Idiosyncratic liver reactions occur rarely with terbinafine. It is more effective than the azoles. Itraconazole is also active
against yeasts. In non-dermatophyte moulds use itraconazole.C Unpleasant adverse effects can occur. These include headache,
itching, loss of the sense of taste, gastrointestinal symptoms, rash, and fatigue. Although abnormal liver function tests are not
uncommon, liver failure and other serious adverse effects are rare.
Evidence Treatment does not always cure the infection. Cure rates range between approximately 60–80%. Treatment that eradicates the
infection sometimes does not restore the nail’s appearance to normal. The HPA Mycology Reference Laboratory recommends
itraconazole for non-dermatophyte infections because although some of the infecting organisms are not particularly
susceptible to this agent in vitro, it does reach high concentrations in nail tissue. It can be given as a pulse therapy regimen
rather than continuous treatment.
HPA Fungal skin and nail infections. Quick Reference Guide.2011.
NHS Clinical Knowledge Summaries. Fungal nail infection.
http://www.cks.nhs.uk/fungal_nail_infection/drugs_in_this_topic/scenario_fungal_nail_infection#-378744
page 64
Skin & Soft Tissue Infections – Dermatophyte infection of the skin (body and groin)
When to treat The rash typically presents as one or more red or pink, flat or slightly raised, patches of skin which enlarge to become
ring-shaped lesions with red, scaly borders with a clear central area.
If candida possible, use imidazole. If intractable: send skin scrapings. If infection confirmed, use oral terbinafine/
itraconazole.
Scalp: discuss with specialist
When to Refer patient to a dermatologist if they are immunocompromised.
investigate Take samples for microscopy and culture if:
• The diagnosis is unclear
• The infection has not responded to standard topical antifungals
• Oral antifungals are being considered.
Samples are not needed for uncomplicated athlete’s foot, mild infections of the groin or mild skin ringworm.
If samples are needed, scrape skin from the advancing edge of lesion. Use a blunt scalpel blade or similar. 5mm of skin
flakes are needed for microscopy and culture. Do not refrigerate.
How to Treat if positive lab cultures. Susceptibility testing of dermatophytes is not required, as antifungal resistance is unusual
respond to a and there is no known correlation between antifungal susceptibilities and outcome. For non-dermatophyte moulds other
positive lab than Candida sp, seek the advice of a microbiologist or dermatologist.
result
General Advise the person to:
Advice • Wash the affected skin daily and dry thoroughly afterwards; particularly in the skin folds
• Wash clothes and bed linen frequently to eradicate the fungus.
• Not share towels and to wash them frequently
• Wear loose fitting clothes made of cotton or similar material.
Treatment First-line options: OR For athlete’s foot only:
choices TerbinafineA+ IMIDAZOLE (Topical) 4A+ UNDECANOATE (Topical) 4B+
1% topical cream BD Paint
BD For 1-2 weeks after healing BD
For 1-2 weeks.4A+ (i.e. total duration of 4-6 wks). For 1-2 weeks after healing (i.e. total duration of 4-6 wks).
Pregnancy/ In pregnancy and breastfeeding a topical azole can be used.
Breastfeeding
Evidence Terbinafine is fungicidal, so treatment time shorter than with fungistatic imidazoles. A Cochrane review found little
difference between terbinafine and azoles in standard courses at 2 weeks after baseline however at 6 weeks, treatment
failure was lower with terbinafine.
NHS Clinical Knowledge Summaries. Fungal skin infection.
http://www.cks.nhs.uk/fungal_skin_infection_body_and_groin
HPA Fungal skin and nail infections. Quick Reference Guide.2011.
Cochrane Summaries. Crawford F, Hollis S Creams, lotions and gels (topical treatments) for fungal infections of the skin
and nails of the foot. July 2009.
http://summaries.cochrane.org/CD001434/creams-lotions-and-gels-topical-treatments-for-fungal-
infections-of-the-skin-and-nails-of-the-foot
page 65
Skin & Soft Tissue Infections – Varicella Zoster (chickenpox) and Herpes Zoster (shingles)
When to treat Chickenpox: Consider prescribing aciclovir if they present within 24 hours of the onset of the rash and >14yrs or severe pain
or dense/oral rash or secondary household case or steroids or smoker.2-4
Shingles: Start an anti-viral drug within 72 hours of rash onset for anyone over the age of 50, those with non-truncal
involvement or moderate or severe pain or rash. If the person presents up to 1 week after rash onset, consider prescribing
treatment if they are at higher risk of severe shingles or complications.
Always treat if active ophthalmic, and Ramsey Hunt syndrome or eczema. Post-Herpetic Neuralgia rare if <50yrs7B-
Cold sores resolve after 7–10 days without treatment. Topical antivirals applied prodomally reduce duration by 12-24hrs 1,2,3B+,4
When to Chickenpox: Admit to hospital if serious complications are suspected (pneumonia, encephalitis).
investigate Chickenpox and Shingles: If the patient is immunocompromised seek specialist advice.
Shingles: Patients who have had 2 episodes of shingles or if there is a diagnostic uncertainty or if there is ophthalmic
involvement, seek specialist advice/refer.
General Chickenpox: Offer paracetamol or ibuprofen for pain and fever. To relieve itch consider topical calamine lotion or oral
Advice chlorphenamine. Encourage adequate fluid intake.
The most infectious period is 1-2 days before the rash appears, but infectivity continues until all the lesions have crusted
over (~5-6 days after onset).
Shingles: Only people who have not had chickenpox or varicella vaccine can catch chickenpox from someone with shingles.
Shingles can only be passed on by direct skin contact with the affected area. Offer paracetamol and /or ibuprofen for pain.
Patients with chickenpox or shingles should be advised to avoid contact with the immuncompromised,
pregnant women and neonates.
Treatment First line:
choices ACICLOVIR po
800mg 5x /day
For 7 days.
Pregnancy/ In pregnancy seek specialist advice.
Breastfeeding In breastfeeding seek specialist advice regarding whether the mother should continue to breastfeed if she has chickenpox.
Consider prescribing aciclovir if the woman presents within 24 hours of the onset of rash (particularly if severe chickenpox
or risk of complications).
Evidence Chicken pox: In immunocompetent value of antivirals minimal unless severe pain, or adult, or on steroids, or secondary
household case AND treatment started <24h of onset of rash.A-
Non-ophthalmic shingles: Treat >50 yrsA+ if <72h of onset of rash, as post-herpetic neuralgia rare in <50 yrs but
occurs in 20% >50 yrsA+. In a review in children and adolescents, aciclovir within 24h of rash onset shortened fever by
approximately one day and reduced the maximum number of lesions but did not reduce the complication rate.
March to October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summaries: Chickenpox. http://www.cks.nhs.uk/chickenpox#-308226
NHS Clinical Knowledge Summaries: Shingles and postherpetic neuralgia. http://www.cks.nhs.uk/post_herpetic_neuralgia
page 66
Skin & Soft Tissue Infections – Mastitis NEW (page 1 of 2)
When to treat Clinical features of mastitis include: a painful breast, fever, general malaise and a tender, red, swollen and hard area of the
breast, usually in a wedge-shaped distribution.
It is not possible to distinguish clinically between non-infectious mastitis and infectious mastitis. Suspect and treat
infectious mastitis if:
• Symptoms do not improve or are worsening after 12-24 hours despite effective milk removal.
• The woman has a nipple fissure that is infected.
• Bacterial culture is positive (if done: see ‘when to investigate’ section)
Be aware and rule out other differential diagnoses before treatment.
When to refer If you suspect there is a breast abscess, refer urgently to a general surgeon to confirm the diagnosis and treat. Suspect a
breast abscess if the woman has:
• A history of recent mastitis
• A painful swollen lump in the breast with redness, heat and swelling of the overlying skin
• Fever and malaise (may have subsided if the woman has taken antibiotics)
• On examination, the lump may be fluctuant with skin discolouration
Refer if there is an underlying mass, or ductal cancer or if inflammatory breast cancer (a rapid onset of warmth of the
breast, diffuse redness (varies from a faint blush to bright red) and oedema causing an orange skin [peau d’orange]
appearance) is suspected. Arrange urgent investigation or referral.
It is unlikely that the infant will become unwell but, if staphylococcal or streptococcal infection is confirmed, observe the
infant for signs of infection and seek the advice of a paediatrician if the child becomes unwell.
When to Investigations are not routinely required. Culture the breast milk when:
investigate • Antibiotic have been prescribed and there has been no response after 48 hours.
• Mastitis is severe before any antibiotics prescribed.
• History of recurrent mastitis.
• Hospital-acquired infection is likely.
• The patient is unable to take standard antibiotics (such as flucloxacillin and erythromycin).
• There is severe deep ‘burning’ breast pain (indicative of ductal infection).
To collect a sample of breast milk into a sterile container, clean the nipple of the affected breast, express a small amount
of milk by hand and discard it (to avoid skin decontamination) and express milk into a sterile container, avoiding touching
the inside of the container with the nipple or hands.
General To relieve pain and discomfort, offer paracetamol. Also advise the patient to place a warm compress on the breast, or bathe or
Advice shower in warm water (to relieve pain and help milk flow). Rest (if possible) and do not wear a bra (especially at night).
Advise to continue to breastfeed, refer to a breastfeeding specialist if necessary. If the affected breast is not completely
empty after feeding advise to express the remaining milk by hand or pump until breastfeeding can be resumed. Encourage
to drink plenty of fluids.
Advise to contact a healthcare professional if symptoms worsen, antibiotics have not been prescribed and symptoms have
not settled within 12-24 hours or if symptoms fail to settle after 48 hours of antibiotic treatment.
The following patient information leaflet from the Breastfeeding Network may be of use:
http://www.breastfeedingnetwork.org.uk/pdfs/BFN_Mastitis.pdf
page 67
Skin & Soft Tissue Infections – Mastitis NEW (page 2 of 2)
Treatment First line: If allergic to penicillin:
choices FLUCLOXACILLIN ERYTHROMYCIN
500mg QDS For 14 days. 250-500MG QDS For 14 days.
If the results of breast milk culture are available, prescribe an antibiotic according to the sensitivities of the organism that
has been identified.
Pregnancy/ Antibiotics are only excreted in milk in very small amounts. Usually the infant is not affected, but occasionally stools may
Breastfeeding be looser or more frequent than usual or the infant may be more irritable.
Cautions If symptoms fail to settle after 48 hours of antibiotic treatment, ensure compliance with medication, send a sample of
the milk for culture and change the antibiotic to co-amoxiclav 500/125mg TDS. Seek specialist advice if the patient
is penicillin allergic. Review antibiotic choice once culture results are available. = high risk for causing C. Difficile
infection (see page 70 (appendix 1) for information on high-risk patients).
Evidence Expert opinion is that relapse is more common with shorter courses of treatment.2,3
References 1. \Mastitis and breast abscess. Clinical Knowledge Summary.
www.cks.nhs.uk/mastitis_and_breast_abscess#417587006
2. WHO (2000) Mastitis. Causes and management. World Health Organisation. www.who.int (Free full-text)
3. Academy of Breastfeeding Medicine (2008) ABM Clinical protocol #4: mastitis. Revision, May 2008. Breastfeeding
Medicine 3(3), 117-180.
page 68
Adult
Dental Infections
Adult Section
DI
Emergency Treatment of Dental Infections NEW
(derived from the Scottish Dental Clinical Effectiveness Programme 2011 SDCEP Guidelines)
Dental infections are always best treated by a dentist. This guidance is not designed to be a definitive guide to oral conditions.
It is for GPs for the management of acute oral conditions pending being seen by a dentist or dental specialist. GPs should not routinely be
involved in dental treatment and, if possible, advice should be sought from the patient’s dentist, who should have an answer-phone message
with details of how to access treatment out-of-hours, or NHS Direct on 0845 4657.
Illness Comments Drug Adult Duration of TX
Mucosal • Temporary pain and swelling relief can be attained Simple saline mouthwash1C ½ tsp salt dissolved in
ulceration with saline mouthwash1C (spit out after use) glass warm water.
and • Use antiseptic mouthwash: Chlorhexidine 0.2%2-6A+ Rinse mouth for 1 minute
inflammation If more severe and pain limits oral hygiene to treat (Do not use within 30 mins of BD with 5 ml diluted with Use until lesions
(simple or prevent secondary infection.2-8C toothpaste, spit out after use) 5-10 ml water. resolve or less pain
gingivitis) • The primary cause for mucosal ulceration or allows oral hygiene
inflammation (aphthous ulcers, oral lichen planus, Hydrogen peroxide 6%6-8A- Dilute 15ml in ½ glass of
herpes simplex infection, oral cancer) needs to be (spit out after use) warm water and rinse in
evaluated and treated. mouth for 2 minutes.
Acute Commence metronidazole1-7 and refer to dentist for Metronidazole1-7C 400 mg TDS 3 days
necrotising scaling and oral hygiene advice.C
ulcerative Use in combination with antiseptic mouthwash if Chlorhexidine or hydrogen see above dosing in Until oral hygiene
gingivitisC pain limits oral hygiene. peroxide mucosal ulceration possible
Pericoronitis1B Refer to dentist for irrigation and debridement.1C Amoxicillin 500 mg6 TDS 3 days
If persistent swelling or systemic symptoms use
metronidazole.1-5A Metronidazole1-7C 400 mg TDS 3 days
Use antiseptic mouthwash if pain and trismus limit Chlorhexidine or hydrogen see above dosing in Until oral hygiene
oral hygiene. peroxide mucosal ulceration possible
Dental • Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscess
abscessB are not appropriate;1 Repeated antibiotics alone, without drainage are ineffective in preventing spread of infection.
• Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications.2,3
• S evere odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction,
Ludwigs angina. Refer urgently for admission to protect airway, achieve surgical drainage and IV antibiotics
• T he empirical use of cephalosporins,9 co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage
for most dental patients and should only be used if no response to first line drugs when referral is the preferred
option.6,12C
If pus drain by incision, tooth extraction or via root Amoxicillin2 or 500 mg2 TDS
canal.4-7B Send pus for microbiology. Phenoxymethylpenicillin2 500 mg2 - 1g QDS Up to 5 days review
True penicillin allergy: use clarithromycin or True penicillin allergy: at 3d11
clindamycinC if severe. Clarithromycin 500 mg BD
If spreading infection (lymph node involvement,
or systemic signs ie fever or malaise) ADD Severe infection add
metronidazole8-10C Metronidazole8-10 or if allergy 400 mg TDS 5 days
Clindamycin 3,8-11 300mg QDS 5 days11
N.B. STOP Clindamycin if diarrhoea occurs and send a stool sample for C. Diff testing.
page 69
Appendix 1
Best practice in antimicrobial drug prescribing
Clostridium difficile infection (CDI) is associated with antimicrobial use.
Prescribing antimicrobials wisely can reduce the incidence.
Clostridium difficile infection (CDI) Antimicrobials to avoid where possible

• C. difficile is a bacterium present in the gut flora in The antimicrobials most strongly associated with CDI are:
some people. • Second and third generation cephalosporins: cefaclor,
• Antimicrobials disturb the balance of the gut flora, cefuroxime, cefixime and cefpodoxime are examples
allowing C. difficile to multiply and cause infection. for oral use
• Symptoms of CDI can vary from mild diarrhoea to fatal • Clindamycin
bowel inflammation. • Quinolones (associated with the virulent 027 strain of
• C. difficile spores are shed in the faeces. The spores C. difficile): ciprofloxacin, levofloxacin, moxifloxacin,
ofloxacin, norfloxacin.
can survive for long periods in the environment.
If ingested, they can transmit infection to others. • Long courses of amoxicillin, ampicillin, co-amoxiclav or
co-fluampicil.
Prudent antimicrobial prescribing
Antimicrobials to choose
• Only prescribe antimicrobials when indicated by
• All antimicrobials are associated with CDI, but
the clinical condition of the patient or the results of
those with lower risk are trimethoprim, penicillin V,
microbiological investigation.
tetracyclines and aminoglycosides.
• Do not prescribe antimicrobials for sore throat, coughs
• If antimicrobials are required, prescribe a short course
and colds in patients at low risk of complications. and follow the local formulary.
• Consider delayed prescriptions in case symptoms • Where therapy has failed or there are special
worsen or become prolonged. circumstances, obtain advice from a local
• If an antimicrobial is required, follow local guidelines. microbiologist.
• Choose a narrow-spectrum agent where possible and CDI and primary care
prescribe a short course.
• CDI has commonly been associated with hospital stay but
• Generally, no more than 5-7 days’ treatment is it is being recognised that many cases originate in the
required. community, due to indiscriminate use of antibiotics.
• Three-day courses are appropriate in some cases. • Patients most at risk are the elderly, particularly if
• Broad-spectrum antimicrobials should be reserved for they have medical conditions and are in close contact
the treatment of serious infections when the pathogen with others, e.g. in a care home, residential treatment
is not known. centre or hospital.
Reference: Clostridium difficile infection- which antimicrobials are implicated? Medicines Q and As UKMI. Nov 2012.
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Clostridium-difficile-infection--which-
antimicrobials-are-implicated/
page 70
How we use antimicrobials affects the whole community
Which patients are most at risk of CDI? When can broad-spectrum antibiotics be
Patients are more at risk of CDI if they are: recommended?
• Elderly There are few indications for broad-spectrum
• Suffering from severe underlying diseases cephalosporins or quinolones in primary care.
• Immunocompromised The following situations are the only indications for their
• In an environment where they are in close contact first-line use.
with one another (e.g. in a care home), particularly
if hygiene is lacking. Co-amoxiclav or
Acute pyelonephritis
Ciprofloxacin
• Have been in hospital in the previous 6 months.
• Have finished a course of antibiotics in the previous 30 Acute prostatitis Ciprofloxacin or ofloxacin
days.
Animal bite or human bite Co-amoxiclav
Other factors that increase the risk of CDI are:
Suspected meningitis in
• Long duration of antimicrobial treatment, use of multiple Cefotaxime
penicillin-allergic patient
courses and use of combinations of antimicrobials.
• Recent gastrointestinal procedures When using broad spectrum antimicrobials, counsel
• Presence of a nasogastric tube patients at risk to be alert for signs of CDI and to stop
The use of proton pump inhibitors (PPIs) might their antimicrobial and seek medical help if diarrhoea
increase the risk of CDI. Only prescribe PPIs when develops.
indicated and review. If prescribing antimicrobials to patients with a history of
CDI, refer to the CCG’s Clostridium difficile guidelines.
Reducing the risk of CDI
Prudent antimicrobial prescribing Bottom line
• Broad-spectrum antimicrobials are strongly
associated with CDI. Clindamycin and broad spectrum antimicrobials are
associated with CDI.
Isolating infected patients
• Isolating patients with CDI reduces the spread of Don’t prescribe antimicrobials when they’re not
infection in care homes and other places where people needed.
are in close contact with one another. If antimicrobial is indicated, prescribe a short course
Good hygiene of a narrow-spectrum agent at the appropriate dose,
• Everyone should wash their hands with soap and water as outlined in this guidance.
before and after each contact with a CDI-infected
patient, including at home
• Alcohol gel is effective against MRSA but not
against C. difficile spores
• The National Patient Safety Agency’s ‘Clean Your
Hands’ campaign has been rolled out to primary care –
see www.npsa.nhs.uk/cleanyourhands
• Carers of CDI-infected patients should wear gloves
and aprons.
page 71
Appendix 2 Probiotics in the prevention of antibiotic-associated
NEW diarrhoea and clostridium difficle infection.
Probiotics have been advocated in the prevention and as yet unknown and may vary between strains of bacteria.
treatment of antibiotic associated diarrhoea (AAD). A recent Data indicate that Lactobacillus strains in particular seem to
systematic review and meta-analysis1 has found that using be effective; however the largest body of evidence is for the
probiotics as an adjunct therapy reduces the risk of antibiotic yeast S. boulardii and also for L. rhamnosus.4
associated diarrhoea, with a relative risk of 0.58. The A recent Cochrane review5 of the use of probiotics to prevent
treatment effect equates to an NNT of 13. Another recent AAD in children states that S. boulardii and L. rhamnosus at a
systematic review and meta-analysis investigated the use of high dosage of 5-40 billion CFU/day may prevent the onset of
probiotics for the prevention of clostridium difficile associated AAD, with no serious side-effects, however this benefit needs
diarrhoea (CDAD).2 Probiotics reduced the incidence of CDAD to be confirmed in a large randomised study.
by 66%. The results indicate that in a population with a 5% Therefore there is a growing evidence base to suggest that
incidence of antibiotic-associated CDAD, probiotic prophylaxis the use of probiotics to prevent AAD is efficacious in terms
would prevent 33 episodes per 1000 persons with the of reducing the risk of AAD occurring. However, significant
evidence being rated as moderate quality. heterogeneity and low quality trials require conduct of
An earlier meta-analysis also found that administration of further well-designed randomized trials that directly compare
probiotics led to a statistically significant relative risk reduction probiotics.
of 44% for AAD and 71% for CDAD.3 Meanwhile, until further evidence is available, for
AAD can occur up to 2-3 weeks following cessation of high risk patients (see appendix 1, p77) it might be
antibiotic therapy rather than during treatment. Clostridium- useful to suggest that they buy their own supply of
difficile associated diarrhoea (CDAD) is responsible for 10- probiotics (especially those containing S. boulardii or L.
20% of all cases of AAD and it can occur up to 8 weeks after rhamnosus, if available) to take whilst having courses
antibiotic therapy.4 of antibiotics.
Researchers have proposed that probiotics may prevent Lactobacillus casei is contained in both Yakult & Actimel
diarrhoea by interrupting either of the potential mechanisms; (Danone) and both are widely available and should
by maintaining the flora of the gut and on-going be taken twice a day. Various internet suppliers can
carbohydrate fermentation; and/or by competitively inhibiting specifically supply oral versions of S. boulardii or L.
the growth of pathogens. The exact mechanism of action is rhamnosus.
Reference:
1. Hempel S et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhoea.
A systematic review and meta-analysis. JAMA May 9th, 2012; 307:18; 1959-1969
http://ods.od.nih.gov/pubs/ebrp.probiotics_for_the_prevention_and_treatment_of_antibiotic-associated_diarrhea.pdf
2. Johnston BC et al. Probiotics for the prevention of clostridium difficile-associated diarrhoea: A systematic review and meta-
analysis. Ann Intern Med. 18th Dec 2012; 157 (12):878-888. https://annals.org/article.aspx?articleid=1390418
3. Avadhani, A and Miley H. Probiotics for prevention of antibiotic-associated diarrhoea and clostridium difficile associated disease
in hospitalized adults – a meta analysis. J of Am Acad of Nurse Prac 23 (2011) 269-274.
http://www.ncbi.nlm.nih.gov/pubmed/21649768
4. Hickson M. Probiotics in the prevention of antibiotic-associated diarrhoea and clostridium difficile infection. Ther Adv
Gastroenterol (2011) 4(3) 185-197 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3105609/
5. Johnston BC, Goldenberg JZ, Vandvik PO, Sun X and Guyatt GH. Probiotics for the prevention of paediatric antibiotic-associated
diarrhoea (AAD). Cochrane Summaries. Nov 9th 2011. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004827.pub3/pdf
Further reading:
Canadian Agency for Drugs and Technologies in Health. Rapid Response Report: Summary with critical appraisal. Probiotics for
antibiotic-associated diarrhoea, Clostridium difficile infection and irritable bowel syndrome: A review of clinical evidence and safety.
17th Jan 2013: http://www.cadth.ca/en/products/rapid-response/publication/3635
page 72
Appendix 3
page 73
Notes for prescribers1 Care pathway for respiratory tract infections
At the first face-to-face contact in primary care, including walk-in centres and emergency
departments, offer a critical assessment including:
• history (presenting symptoms, use of over-the-counter or self medication, previous medical history,
relevant risk factors, relevant comorbidities).
• examination as needed to establish diagnosis.
Address patients’ or parents’/carers’ concerns’ and expectations when agreeing the use of
the three antibiotic strategies (no prescribing, delayed prescribing and immediate prescribing).
Agree a no antibiotic or delayed antibiotic prescribing However, also consider

strategy for patients with acute otitis media, acute an immediate prescribing
sore throat/acute pharyngitis/acute tonsillitis, strategy for the following The patient is at risk of developing complications.
common cold, acute rhinosinusitis or acute cough/ subgroups, depending on
acute bronchitis. the severity of the RTI.
No antibiotic Delayed antibiotic prescribing No antibiotic, delayed Immediate antibiotic prescribing or further
prescribing Offer patients: antibiotic prescribing investigation and/or management
Offer patients: • reassurance that antibiotics are or immediate antibiotic Other immediate antibiotics or further investigation/
• reassurance that not needed immediately because prescribing management for patients who:
antibiotics are not they will make little difference Depending on clinical assessment • are systemically very unwell
needed immediately to symptoms and may have side of severity, also consider an • h ave symptoms and signs suggestive of serious illness
because they will effects, for example, diarrhoea, immediate prescribing strategy for: and/or complications (particularly pneumonia, mastoiditis,
make little difference vomiting and rash • children younger than 2 years peritonsillar abscess, peritonsillar cellulitis, intraorbital or
to symptoms and • advice about using the delayed with bilateral acute otitis media intracranial complications)
may have side prescription if symptoms do not • children with otorrhoea who have • a re at high risk of serious complications because of pre-
effects, for example, settle or get significantly worse acute otitis media existing comorbidity. This includes patients with significant
diarrhoea, vomiting • advice about re-consulting • patients with acute sore throat/ heart, lung, renal, liver or neuromuscular disease,
and rash if symptoms get significantly acute pharyngitis/acute tonsillitis immunosuppression, cystic fibrosis, and young children
• a clinical review if worse despite using the delayed when three or more Centor who were born prematurely.
the RTI worsens or prescription. criteria1 are present. • are older than 65 years with acute cough and two or more
becomes prolonged. The delayed prescription with 1
Centor criteria are: presence of of the following, or older than 80 years with acute cough
instructions can either be given to the tonsillarexudate, tender anterior and one or more of the following:
patient or collected at a later date. cervical lymphadenopathy or - hospitalisation in previous - type 1 or type 2 diabetes
lymphadenitis, history of fever and year
an absence of cough. - history of congestive heart - current use of oral
failure glucocorticoids
Offer all patients:

• advice about the usual natural history of the illness and average • advice about managing symptoms including fever (particularly
total illness length: analgesia and antipyretics). For information about fever in
- acute otitis media: 4 days children younger than 5 years, refer to ‘Feverish illness in
- acute sore throat/acute pharyngitis/acute tonsillitis: 1 week children’ (NICE clinical guideline 47)
- common cold: 1½ weeks
- acute rhinosinusitis: 2½ weeks
- acute cough/acute bronchitis: 3 weeks
Prescribers: if you do need to treat a patient with an antibiotic,

please follow the Wiltshire and Swindon Guidelines for antibiotic prescribing in the community.
nww.wiltshire.nhs.uk/policiesandprocedures/Wiltshire_MedicinesManagementGuidance/CNP017_Antibiotic_guide_Jan_10.pdf
page 74
Delayed Antibiotic Prescriptions
Information for patients
(To be completed by the prescriber) Why should antibiotics only be taken when
they are needed?
Please collect your antibiotic prescription on
• Antibiotics can cause side-effects such as diarrhoea,
sickness and rash.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (dd/mm/yy)
• Antibiotics can upset the natural balance of bacteria
ONLY if your symptoms do not improve.
in your body allowing numbers of other bacteria to
increase. Bacteria such as Clostridium difficile (C. Diff) can
cause severe illness in this way.
Clostridium difficile infection (CDI)
• Bacteria can adapt and find ways to survive the effects of
Delayed or “if needed” prescriptions are written on the an antibiotic. They become ‘antibiotic resistant’ so that
basis that they are not to be used straight away, but the antibiotic no longer works. The more often we use an
can be collected from the surgery a few days later (as antibiotic, the more likely it is that bacteria will become
specified by the health care professional you see) if your resistant to it. Some bacteria that cause infections in
symptoms get worse or have not improved. hospitals and community, such as Methicillin Resistant
Staphylococcus Aureus (MRSA), are resistant to several
Why have I been offered a delayed antibiotics.
prescription?
All colds and most coughs, cases of sinusitis, otitis When should you re-visit the GP practice/
media (earache) and sore throats are caused by viruses. contact NHS Direct?
Antibiotics do not work against infections which are • If your cough or cold is lasting longer than as expected in
caused by viruses. Viral infections are much more the table overleaf and you are getting worse.
common than bacterial infections.
• If your earache is lasting longer than as expected in the
Evidence shows that coughs and colds get better just as table overleaf and you are getting worse.
quickly without antibiotics. If we do not use antibiotics
unnecessarily, they are more likely to work when we do • If you develop chest pain or start coughing up a large
need them. amount of green or yellow phlegm from your lungs.
• If the back of your throat or your tonsils are covered in
lots of white spots.
• If you develop severe headaches, vomiting or unusual
rashes.
page 75
When will I start to feel better? Illness Which could last for (average)
Times may vary depending on age (if for a child) and Ear infection 4 days
the number of symptoms you have:
Sore throat 1 week
Common cold 1½ weeks
Sinusitis 2½ weeks
Cough/bronchitis 3 weeks
Useful tips to help you deal with viral Useful telephone numbers:
illnesses such as common colds, coughs and Out of hours service (Wiltshire Medical Services):
sore throats: 0300 111 5717
• Drink plenty of water-based fluids so that you do not NHS Direct: 0845 4647 www.nhsdirect.nhs.uk
get dehydrated.
• Take paracetamol if you have fever or aches and If you have any comments about this leaflet,
pains. Read the package instructions for dosage please contact:
information. Before taking paracetamol make sure Medicines Management, Southgate House, Pans Lane,
you are not taking any other medicines which Devizes SN10 5EQ
contain paracetamol. Ask your local community Telephone: 01380 733881
pharmacist for advice on this and for other suitable
over-the-counter remedies that you might find E-mail: prescribing@wiltshire.nhs.uk
helpful if necessary.
page 76
Please re-order these leaflet pads from Medicines Management, NHS Wiltshire on:
01380 733881 or prescribing@wiltshire.nhs.uk
If you have any comments please contact the author Rachel.Hobson@wiltshire.nhs.uk
page 77
Appendix 4
Penicillin Allergy
Penicillin and Cephalosporin antibiotics are often the cornerstone of antibiotic prophylaxis. If a patient has
been wrongly attributed with a penicillin allergy, optimal management may be compromised.
Allergic reactions to penicillins occur in 1-10% of exposed individuals; true anaphylactic reactions (which
may be fatal) occur in fewer than 0.05% of treated patients. However patients with a history of atopic
allergy (e.g. asthma, eczema, hay fever) are at a higher risk of anaphylactic reactions to penicillins.
Investigating and Recording Drug Allergies

All available drug sensitivity issues should be recorded. It is important to clarify the nature of the reaction. Check
with the patient and the medical notes prior to all prescribing. Do NOT label a patient as being allergic to an
antibiotic on the basis of side effects of a drug (e.g. nausea, diarrhoea, etc.).
Type 1 reaction – Immediate anaphylaxis (IgE mediated)

Individuals with a history of immediate hypersensitivity following penicillin administration clinically
recognisable by features of urticaria, laryngeal oedema, bronchospasm, hypotension or local swelling within
72 hours of administration should NOT receive a penicillin.
Patients who are allergic to one penicillin will be allergic to all because the hypersensitivity is related to the
basic penicillin structure.
Patients with a history of immediate hypersensitivity to penicillins may also react to the cephalosporins and
other beta-lactam antibiotics. They should not receive these antibiotics.
Type 2 reaction – Delayed reaction (non-IgE mediated)

Individuals with a DEFINITE history of NON-URTICARIAL RASH allergy to penicillin SHOULD NOT receive
a penicillin but the likelihood of serious cross sensitivity with Cephalosporins or Carbapenems is very low, so
other non-penicillin beta-lactam antibiotics can still be used in these individuals.
Other cases
Individuals with a history of a minor rash (i.e. non-confluent, non-pruritic rash restricted to a small area of
the body) or a rash that occurs more than 72 hours after penicillin administration are probably not allergic to
penicillin and in these individuals a penicillin should not be withheld unnecessarily for serious infections; the
possibility of an allergic reaction should, however, be borne in mind. Other beta-lactam antibiotics (including
Cephalosporins) can be used in these patients.
NOTE: T he principal side-effect of the Cephalosporins is hypersensitivity and about 0.5–6.5%

of penicillin-sensitive patients will also be allergic to the Cephalosporins.
page 78
Treating Penicillin-allergic Patients:
These Antibiotic Guidelines contain alternative empirical treatment options for indications
in which Penicillins are the first-line choice. If you are unsure about treatment options in
Penicillin allergy please obtain guidance from the local Consultant Microbiologist.
Amoxicillin
Ampicillin
Co-amoxiclav (Augmentin®)
Flucloxacillin
Contra-Indicated Penicillin G (Benzylpenicillin)

Penicillin V (Phenoxymethyl-penicillin)
Piperacilin
Piperacillin plus tazobactam (PipTazo, Tazocin®)
Ticarcillin
Ticarcillin plus clavulanic acid (Timentin®)
Cefaclor Cefradine NOTE: Risk of allergic reaction is

greater in ß-lactams most similar to
Cefalexin Ceftaroline penicillins in underlying structure.
Caution Cefixime Ceftazidime

Avoid if serious Type 1 penicillin allergy
Cefotaxime Ceftriaxone
(e.g. anaphylaxis / angioedema)
Cefuroxime
Use with caution if non-severe allergy Imipenem plus cilastin (Primaxin®)
(e.g. minor rash only) Meropenem
Aztreonam
Amikacin Gentamicin Rifampicin

Azithromycin Levofloxacin Sodium Fusidate
Chloramphenicol Linezolid Sulfadiazine
Ciprofloxacin Lymecycline Synercid®
Clarithromycin Metronidazole Teicoplanin
Considered Safe Clindamycin Minocycline Tigecycline
Colistin Moxifloxacin Trimethoprim
Co-trimoxazole Nitrofuratoin Tobramycin
Daptomycin Norfloxacin Vancomycin
Doxycycline Ofloxacin
Erythromycin Oxytetracycline
For further information please contact Medicines Management on 01380 733881 or refer to the latest edition of the BNF.
Adapted for use with permission from Great Western Hospital Trust by: Dr Rachel Hobson (Formulary Pharmacist) Date: February 2013 Review date February 2015
page 79
Appendix 5 Fosfomycin Indication and Licensing
NEW
To be used on advice of microbiologist ONLY;
For symptomatic Extended Spectrum Beta-Lactamases (ESBLs) ONLY.
When is Fosfomycin indicated? What is an ESBL?

Lower UTI due to ESBL-producing micro-organisms on ESBLs are bacterial enzymes (usually plasmid-mediated)
recommendation of consultant medical microbiologist. that confer resistance to a broad range of beta-lactam
Fosfomycin is not indicated for the treatment of antibiotics including co-amoxiclav and cephalosporins.
ESBL pyelonephritis or peri-nephric abscess (admit to
hospital for IV antibiotics).
What is Fosfomycin’s licensing status in the UK? Where is Fosfomycin licensed?

Fosfomycin is licensed in the UK. However no UK- Fosfomycin is currently licensed and can be sourced
packaged product is currently available and thus all from Germany, France, Italy and Spain.
supplies must be obtained from abroad and hence are
unlicensed in the UK.
Fosfomycin Prescribing Information

Mode of action Pregnancy
Fosfomycin is a bactericidal antibacterial. Fosfomycin Animal data show no teratogenic effects. Several
inactivates the enzyme pyruvyl transferase required published reports studied the efficacy and safety of
for the biosynthesis of peptidoglycan in bacterial cell oral fosfomycin in all stages of pregnancy. In these
walls. Fosfomycin is concentrated in the bladder and is studies fosfomycin did not cause harm to a foetus.
active against E. coli, Proteus sp. and Enterococci.
Dosing: Uncomplicated UTI in females Contraindications

Fosfomycin 3 gram sachet as a single oral dose is Hypersensitivity to fosfomycin.
effective in the treatment of uncomplicated lower urinary Suspected bacteraemia.
tract infections in adult females. Single dose therapy Different brands and different forms (capsules vs
(3 gram) was equivalent to 7-day course of norfloxacin in sachets) of Fosfomycin have different requirements
a randomised, blinded study (de Jong Z et al. 1991 Urol in terms of renal function and minimum weight of
Int). The microbiologist would advise on dosage and patient required to take this drug safely. Individual
duration in such cases, follow their advice. hospital pharmacy departments will therefore be
able to advise what form they stock and whether
it can be used safely if the patient has renal
impairment or has a low weight.
page 80
Fosfomycin Prescribing Information
Dosing: Complicated UTI or male patients Interactions
Fosfomycin calcium 500mg capsules are licensed at 500mg-1gram No significant drug-drug interactions.
every 8 hours. Fosfomycin 3g sachets have been administered Food intake can slow down the absorption
once every 48-72 hours. A 7-day course (minimum) is of fosfomycin with, as a result, lower
recommended for male patients and for complicated lower urinary concentrations in the urine. Fosfomycin
tract infections (e.g. catheter-associated UTI) without bacteraemia should, therefore, be administered while
(Moroni M 1987 Eur Urol). The microbiologist would advise on fasting or 2 or 3 hours before meals.
dosage and duration in such cases, follow their advice.
Dosing in renal impairment: Side Effects

The microbiologist will advise on dosage and More common than 1%: Rare Serious Reactions:
duration in such cases, follow their advice
Diarrhoea/Abdominal pain (10%) Serious hypersensitivity reactions
(also see information in contra-indications
Nausea/Indigestion (5%) Impairment of hepatic function
box).
Headache (3-10%) Aplastic anaemia
Skin rashes (1%)
Vaginitis (5%)
Asthenia (1%)
Fosfomycin Supplies
If a prescriber is contacted by a microbiologist to recommend this for their patient, then local arrangements have
been made whereby the hospitals keep this in stock. The GP still needs to write a FP10 prescription for the supply
(and possibly a proforma for some hospitals- see individual guidance below), which is given to the patient/carer
to collect the supply from the local acute trust who are recommending the treatment (this will avoid an admission
for IV antibiotics, so most patients/carers are happy to go and collect the medication). It may be possible for some
hospitals to send supplies via their tilley service to GP practices, but depends on when the next service is running as
may not be convenient. The patient MUST NOT be advised to take the script to a local community pharmacy as the
drug would then be ordered as a special which may incur a large cost and also a delay in obtaining the supply. The
local acute trusts can provide this treatment for approximately £20, for which the CCG is invoiced. The prescriptions
are NOT sent onto the Prescription Pricing Department (PPD) for charging but are merely used in order to provide a
legal prescription for supply.
For further information on the supply arrangements from individual acute trusts see:
RUH: http://nww.banes-pct.nhs.uk/GPsDentistsPharmacists/BCAPPrescribingandTherapeutics/Pages/AntibioticInfectionControl.aspx
GWH: Guidance being agreed and written. Will be added to this section of the formulary pages shortly: http://nww.gwh.nhs.uk/SMNHS/
Departments/Pharmacy/FormularyRelatedGuidelines.aspx
SFT: Guidance being agreed and written. Will be added to ICID formulary webpages shortly. http://www.icid.salisbury.nhs.uk/Pages/home-l.aspx
If you need any further help/advice with getting hold of supplies, please contact the medicines management team on: 01380 733881 or
prescribingwiltshire@nhs.net if you need to send us confidential patient information.
page 81
Appendix 6
Educational resources
Probiotics
This is accredited by the royal pharmaceutical society and the British dietetic society:
http://www.probioticsinpractice-elearning.co.uk/rps-bda/index.php
TARGET toolkit
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx
This antibiotic information leaflet in the Target toolkit is also useful:

http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/~/media/Files/CIRC/TARGET/
Patient-Antibiotic-leaflet.ashx
HPA: http://www.hpa.org.uk/Publications/
page 82
page 83
© Copyright reserved. NHS Wiltshire. March 2013
CS34848 – Produced by NHS Creative

Guia para Prescripcion de Antibioticos

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Guia para Prescripcion de Antibioticos

Uploaded by

Copyright:

Available Formats

NHS Wiltshire CCG,

BaNES CCG & Swindon CCG

All prescribers are advised to follow

In order to be able to distinguish

Additional guidance that is of relevance:

Urine samples should be sent for culture:

Notes on sending appropriate information to microbiology labs with urine samples:

Clostridium difficile infection (CDI) Antimicrobials to avoid where possible

Agree a no antibiotic or delayed antibiotic prescribing However, also consider

Offer all patients:

Prescribers: if you do need to treat a patient with an antibiotic,

If you have any comments please contact the author Rachel.Hobson@wiltshire.nhs.uk

Investigating and Recording Drug Allergies

Type 1 reaction – Immediate anaphylaxis (IgE mediated)

Type 2 reaction – Delayed reaction (non-IgE mediated)

NOTE: T he principal side-effect of the Cephalosporins is hypersensitivity and about 0.5–6.5%

Contra-Indicated Penicillin G (Benzylpenicillin)

Cefaclor Cefradine NOTE: Risk of allergic reaction is

Caution Cefixime Ceftazidime

Amikacin Gentamicin Rifampicin

When is Fosfomycin indicated? What is an ESBL?

What is Fosfomycin’s licensing status in the UK? Where is Fosfomycin licensed?

Fosfomycin Prescribing Information

Dosing: Uncomplicated UTI in females Contraindications

Dosing in renal impairment: Side Effects

This antibiotic information leaflet in the Target toolkit is also useful:

You might also like

NOTE: T he principal side-effect of the Cephalosporins is hypersensitivity and about 0.5–6.5%