Suspected acute pharyngiti e.g. sore throat I Strep score ‘Symptoms or signs __ Points Temperature >38°c +1 ‘Absence of cough +1 Tender anterior cervical adenopathy +1 Tonsillar exudates or swelling 41 Patient’s age <15 #1 15 to 45 0 >45 a f | Total score <3 Total score = 3 I y © Symptomatic treatment: e.g. anti-pyretic, analgesic, Symptomatic treatment Anti-microbial therapy hydration ¥v Recommended dosage Antibiotics Dosing Duration ‘Remarks Penicillin V 500mg QID/1gBD__| 5-10 days Preferred ‘Amoxicillin 500mg TDS. 5-10 days Alternative EES 800mg BD 5 days Alternative 4. Sore Throat (Acute): Antimicrobial Prescribing, NICE Guideline 2018. 2. Consensus Guideline on Upper Respiratory Tract Infections, Malaysian Society of Otorhinolaryngologists Head & Neck Surgeons (MSO-HNS) 2009.Presence of 22 symptoms one of which should be nasal obstruction or purulent / greenish nasal discharge +#facial pain, headache tsmell disturbance Examination: anterior rhinoscopy yv v Symptoms increasing after 5 Symptons sa.ceys oh days or persistent after 10 improving thereafter days f 1 I ‘ ee Mild Moderate Severe VAS = 0 to 3* VAS 4 to 7* VAS 8 to 10* =. 1 v = ety Symptomatic relief Symptomatic relief Treat accordingly Symp biom ste retel medication** medication** medication F ‘ + Topical steroid + Topical steroid + Consider ¥ antibiotic*** worsening after 5 days No improvement after 10 days or ¥ Topical steroid e.g. Budesonide nasal spray Improvement within 3 days Na Yes I f I No improvement after 14 days Continue treatment }+-—p Refer to specialist ane 7-14 * Severity of disease can be based on Visual ‘Analogue Score (VAS). The patient is asked: “How troublesome are your symptoms” Not troublesome (0) to Worst thinkable troublesome (10) ** May include analgesics, nasal saline Irrigation & decongestants *** atleast 3 of: = purulent/greenish nasal discharge severe local pain fever elevated ESR/CRP double sickening (becoming worse again after initial recovery) Recommended dosage Antibiotics _| Dosing _ Duration | Remarks = ‘Amoxicillin | 500mg TDS 5-10 days _| Preferred Augmentin | 500/125mg TDS | 5-7days _| Preferred Azithromycin | 500mg od B3days _| Alternative Cefuroxime | 250-500mg BD _| 5-10 days _| Alternative 2 Clinical Practice Guidelines, Management of Rhinosinusitis in Adolescents and Adults 2016, MOH/P/PAK/318.16(GU).Suspected acute otitis media: Otalgia / fever / crying / irritable / URTI symptoms / poor appetite / vorniting / diarrhea (not all symptoms may be present) y Otoscopy signs of: middle ear effusion (reduced TM mobility, bulging TM, otorrhea) and middle ear inflammation (erythematous TM, otalgia) No Yes y | Not AOM Assess severity / perforation y y TM intact AND non-severe illness Perforated TM OR severe illness (mild otalgia, T <39 °C) (moderate to severe otalgia, T 239°C) ¥ v Observe for 48-72 hours Pel Amoxycillin / clavulanate 625mg tds Give paracetamol for pain relief for 5 days } 1 { 1 Resolution Not resolving Resolution Not resolving or red flag: 1. Recurrent acute otitis ¥ media Start antibiotics: 2. Persistent otorrhea Amoxicillin 80-90mg/ke/day 3.Concerns about divided qh8h: mastoiditis or other complications of AOM 4. Perceived need for tympanocyntesis and/or myringotomy 5. Abnormal audiological + 10 days if <6 years +5 days if 26 years In penicillin allergy: Azithromycin 500mg PO on day 1, ‘i followed by 250mg PO OD for on Refer ENT [e—| valuation day 2 through day 5 ¥. Review in 48-72 hours 1, Effects of clinical pathways for common outpatient infections on antibiotic prescribing, The American Journal of Medicine (2013) 126, 327-335. 2. Consensus Guidelines on URTI, Malaysian Society of — Otorhinolaryngologists Head & Neck Surgeons (MSO-HNS) q 2009. 5 E +3. Management of infection guidance for primary care for Resolution Not resolving consultation and local adaptation. Public Health England 2014.Suspected pneumo: acute bronc! acute cough + sputum < 3 weeks Consider differential diagnosis: e.g. URTI, asthma, COPD, CCF, post nasal drip, y ACE:| induced cough Vital Sign Abnormalities — if any of the following: Tachycardia (HR > 100 beats/min) Tachypnoea (RR > 24 breaths/min) Fever (Temperature > 38°C) Hypoxemia (SPO2 <95%) Yes [ No ¥ Physical Examination: Abnormalities suggestive of consolidation or pleural effusion? Physical Examination: Abnormalities suggestive of consolidation or pleural effusion? Yes Yes No No { 1 { 1 Treat as Pneumonia Do CXR, does it Uncomplicated Acute Bronchitis likely: Do CXR as baseline suggest pneumonia? No | ~S¥mptoms suggestive of acute bronchitis: low grade fever, wheezing, chest soreness, Yes mild SOB - Symptomatic relief - Bronchodilator to shorten duration of Recommended dosage (mild CAP only) cough No comorbidit “Antibiotics —_ | Dosing Duration | Remarks Amoxycillin [500mg TDS _| 5-7 days _| Preferred Doxycycline_[ 100mg BD | 7days __| Alternative Consider Influenza during outbreak: Comorbidity or recent antibiotic therapy (3 months) Antibiotics Dosing Duration ‘Augmentin 625mg TDS | 7 days plus Erythromycin 800mg BD | 7 days ethylsuccinate - acute fever and myalgia Oral Tamiflu 75mg BD for 5 days indicated for: ~ high risk patients* - when taken within 48 hours of onset of symptoms (for non-high risk patients) Patients at higher risk for influenza: Consider hospitalization if outbreal either: - cough 2 2weeks - Confusion = paroxysms of cough = RR > 30 breaths/min - post-tussive vomiting - BP < 90/60mmHg - inspiratory whoop ~ Age 2 65 years old days Consider Pertussis during Oral EES 800mg BD for 14 = Age < 2 years or2 65 years old - Pregnant women or immunosuppressed viduals ~ Patients with chronic medical conditions e.g. CCF, IHD, chronic lung disease, asthma, CKD, DM, ‘malignancy, chronic liver disease, etc. ~ Morbid obesity (BMI2 40 kg/m?)Symptoms suggestive of urinary tract infection: Frequency, dysuria, hematuria, suprapubic pain, urgency, polyuria ~———— pounce Risk factors for uncomplicated UTI: immunocompetent No co-morbidities Non pregnant Premenopausal No urological abnormalities Risk factors for complicated UTI: Immunosuppressed Diabetes mellitus Pregnancy Pre-adolescent / post-menopausal Urological abnormalities (e.g. stones, stents, polycystic kidneys) y 1 Perform urinalysis Perform urinalysis and urine culture 1 q v y Assess for presence of pyelonephritis: : Nit-ve Nit-ve High grade fever, nausea / vomiting, flank pain, Nit +ve uees teueve: leukocytosis, costovertebrae tenderness I + Yes No Probable UTI Unlikely UTI Zz. Treat with Consider other dx antibiotics e.g. vaginitis Refer hospital Treat with antibiotics = UTI or other dx equally likel ¥ Review technique and time of specimen (morning most reliable) T. Amoxycillin / Clavulanate 625mg tds 1/52 or T. Cefuroxime 250mg bd 1/52 T. Nitrofurantoin 50-100mg qid 5/7* or T. Cephalexin 250-500mg gid 3/7 or T. Amoxicillin / Clavulanate 625mg tds 3/7 y y v Severe sx Non-severe sx (patient has > (patient has < TCA to review symptoms and 3.x suggestive | | 3 sx suggestive culture of UT) of UTI) = = 5 Send urine culture and Treat with es Be consider delayed antibiotics acta And antibiotic prescription ‘ * Nitrofurantain contraindicated in patients with eGFR< 30 mi/mi |, Management of infection guidance for primary care for consultation and local adaptation. Public Health England 2014.Signs and symptoms of pos: le skin and soft tissue infection (SSTI Erythema, swelling, increased temperature, pain, tender on palpation, fever J Consistent with SSTI No_,! consider alternative cause Te ee Yes _| Severe infection or systemic illness +_No Fluctuancy Abscess Not abscess v Incision & Drainage Impetigo celluli Antibiotic therapy indicated? df H ~ extensive surrounding Localised: Generalised: cellulitis ; vias : reat Ae Topical 2% fusidic acid Cephalexin 500mg PO - Inadequate drainage q8-12h for 7 days gid 5-7 days - diabetes mellitus valvular heart disease Yes No. Antibiotic therapy not indicated * penicillin allergy EES 800mg PO BD for 7 days Before starting antibiotics, take pus for C&S and grams stain Cloxacillin 500mg PO g6h for 5- 7 days* Cephalexin 500mg PO QID x 5-7 days or Amoxycillin 500mg PO q8H x 5- 7 days* 1. Effects of clinical pathways for common outpatient infections on antibiotic prescribing, The American Journal of Medicine (2013) 126, 327-335. 2. Practice guidelines for the diagnosis and management of skin and soft tissue Infections: 2014, Update by the Infectious Diseases Society of America, 3, Management of infection guidance for primary care for consultation and local adaptation. Public Health England 2014Symptoms of acute gastroenter Vomiting, diarrhea, colicky abdominal pain Consider other causes of non-infective diarrhea y Presence of: Severe illness - Age <6 months old or > 70 years old - Gross blood in stool ~ High grade fever >38°c with chills - Worsening or relapse / persistent of symptoms > 1 week - Immunocompromised host - Excessive bowel movement >8 times per day *in the absence of these features, the aetiology is usually viral in origin and anti needed No. Yes Initiate symptomatic treatment Refer hospital for fluid repletion, further e.g. encourage clear fluid intake, ORS investigations and empirical antibiotics