Antimicrobial Guide and Management of Common Infections in Primary Care Settings

2015

Antimicrobial Guidelines and Management of Common Infections in Primary Care

Strategies to Optimise Prescribing of Antimicrobials in Primary Care

Adapted from the Pan-Mersey Antimicrobial guidelines 2014 Produced by joint initiative between Aintree University Hospitals NHS Trust, Alder Hey Children’s NHS Foundation Trust, Liverpool Heart and Chest Foundation Trust, Liverpool Women’s Hospital NHS Foundation Trust, The Royal Liverpool & Broadgreen University Hospitals NHS Trust, Southport & Ormskirk NHS Trust, St Helens & Knowsley Teaching Hospitals NHS Trust, Warrington & Halton Hospitals NHS Foundation Trust, Merseycare NHS Trust, 5 Boroughs Partnership, Liverpool Community Health , Liverpool CCG, Knowsley CCG, Sefton CCG, South Sefton CCG, Southport & Formby CCG, St Helens CCG, Halton CCG , Warrington CCG, West Lancashire CCG

This edition issued April 2015 Review April 2016

Contents

INTRODUCTION ...... 2 LABORATORY SENSITIVITY REPORTS ...... 4 PENICILLIN ALLERGY ...... 4 CLOSTRIDIUM DIFFICILE INFECTION ...... 5 MRSA BACTERAEMIA ...... 6 TREATMENT OF SPLENECTOMY PATIENTS ...... 8 EYE EAR NOSE AND THROAT ...... 11 RESPIRATORY TRACT INFECTIONS ...... 14 GASTROINTESTINAL INFECTIONS ...... 19 URINARY TRACT INFECTIONS ...... 22 GENITO-URINARY INFECTIONS ...... 29 SKIN INFECTIONS ...... 31 CHILDREN’S DOSES ...... 36 MISCELLANEOUS ...... 40 ENDOCARDITIS ...... 41 MALARIA ...... 42 CURRENT STATUTORILY NOTIFIABLE DISEASES AND FOOD POISONING...... 42 LIST OF CONTRIBUTORS ...... 43 USEFUL CONTACT NUMBERS ...... 44 INDEX OF INFECTIONS ...... 45

Antimicrobial Guide and Management of Common Infections in Primary Care settings

Introduction

This edition of the ‘Antimicrobial Guidelines and Management of Common Infections in Primary Care’ has been designed with three aims in mind:  To encourage the rational and evidence-based use of antibiotics  To minimise the emergence of bacterial resistance  To provide a simple, pragmatic approach to the management of common infections in primary care

Antimicrobials should only be prescribed when there is proven or strongly suspected bacterial infection and in all cases the benefit of administering the medicine should be considered in relation to the risk involved. This is particularly important during pregnancy, when breastfeeding, using drugs in children and the elderly, and considering documented allergies to antimicrobials previously prescribed. These guidelines are not based on costs. Some of the recommendations in this guideline are unsuitable for pregnant women (unless otherwise stated). Please refer to BNF for alternative antimicrobials in pregnancy.

Management of an infection will not always mean prescribing an antimicrobial drug. Prescribers using this guide will have the best chance of using the most effective strategy first.

Things you can do to make a difference:

 Don’t prescribe antibiotics for viral sore throats, simple coughs and colds  Use this guideline to reduce the risk of antimicrobial resistance by avoiding unnecessary use of broad spectrum antimicrobials such as cephalosporins, quinolones, clindamycin and co-amoxiclav.  Limit prescribing for uncomplicated cystitis to three days in non-pregnant, otherwise fit women of child-bearing age.  Avoid widespread use of topical antibiotics, especially when available systemically.  Don’t prescribe antibiotics over the telephone, other than in exceptional cases.  Don’t list antibiotics on your repeat prescribing system, other than in exceptional cases.  Use this guide, and consider using a ‘delayed’ prescription where this has been shown to be effective.  Using patient information leaflets can reduce antibiotic use. See useful references p3.  Always check previous positive microbiology results prior to starting antibiotics. The empirical regimes in this guideline cover most organisms, however, if the patient has a history of multi-resistant organisms not covered by this guideline, please contact the microbiology department:

1) MicroPath automated switchboard 01244 362500 option 3 (WUTH microbiology) during normal working hours Or 2) Arrowe Park Switchboard 0151 678 5111 if out-of-hours 2

This Antimicrobial Guide aims to produce rational prescribing by the individual practitioner for their patients. The British National Formulary (BNF) and Summary of product Characteristics provide additional information on the side effects and contraindications of all the drugs listed. Doses in this guideline are for adults unless otherwise stated.

Useful References

Public Health England. Management of Infection Guidance for Primary Care. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377509/ PHE_Primary_Care_guidance_14_11_14.pdf

RCGP TARGET Antibiotics Toolkit The toolkit has been developed by the RCGP, PHE and The Antimicrobial Stewardship in Primary Care (ASPIC) in collaboration with professional societies including GPs, pharmacists, microbiologists, clinicians, guidance developers and other stakeholders.

The aim of the toolkit is to provide a central resource for clinicians and commissioners about safe, effective, appropriate and responsible antibiotic prescribing, http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx

European Antibiotics Awareness Day

A collection of campaign materials used for this awareness day on November 18th. http://ecdc.europa.eu/en/EAAD/Pages/Home.aspx

Laboratory sensitivity reports

Please note that sensitivities for antimicrobials other than those recommended in these Guidelines may be reported, but should only be prescribed where the guideline choices are inappropriate. Empirical treatment should always be used according to these guidelines unless sensitivities indicate otherwise.

“Help your Microbiology Department to help you”. Including as much clinical information as possible on the sample request form will allow the most appropriate sensitivities to be reported e.g. type of urine sample, antimicrobials already tried, pregnancy, significant co- morbidities such as chronic kidney disease, allergies.

Penicillin allergy

All medical and non-medical prescribers are reminded of the advice contained in the BNF www.bnf.org/

“Individuals with a history of anaphylaxis, urticaria or rash immediately after penicillin administration are at risk of immediate hypersensitivity to a penicillin; these individuals 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. As patients with a history of immediate hypersensitivity to penicillins may also react to cephalosporins and other beta-lactam antimicrobials, they should not receive these antimicrobials.

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.”

Clostridium difficile infection – risk assessment and reduction strategies

Clostridium difficile can be present in the gut without causing illness. It is estimated that 66% of infants and 3% of healthy adults carry Clostridium difficile. In some circumstances, Clostridium difficile can produce toxins that cause Clostridium difficile infection [CDI]. The spectrum of CDI ranges from mild diarrhoea to severe colitis/ toxic megacolon and can be life threatening.

Risk factors for CDI include:

 Recent treatment with broad-spectrum antibiotics  Serious underlying disease +/- immunosuppression  Age > 65 years  Recent treatment with acid suppressants, particularly PPIs

Environmental contamination with C. diff spores has been documented in healthcare establishments, including care homes, and can persist for many months, with carpets and soft furnishings acting as potential reservoirs for infection of a susceptible patient. Alcohol gels are ineffective against C. difficile spores. Recent experience in the care home sector has highlighted the continuing need for ALL PRESCRIBERS to be cautious when prescribing broad spectrum antibiotics or PPIs, particularly for the elderly.

Every opportunity should be taken to review patients on long-term PPIs and to step down and stop treatment if appropriate.

Care homes have residents registered with various GP practices & so individual prescribers may be unaware that there have been cases of C. difficile in a specific home. Even when the staff of the home rigorously apply infection control procedures, it is still vital that ALL PRESCRIBERS continue to follow the advice in the current Primary Care Antimicrobial Guideline.

Advice on infection prevention and control of C. difficile can be obtained from the community Infection prevention and control team.

References Department of Health (2007) A Simple Guide to Clostridium difficile. 16/07/07 www.dh.gov.uk

Department of Health and Health Protection Agency (2009) Clostridium difficile infection: How to deal with the problem. Department of Health, Jan 2009. www.dh.gov.uk/publications Public Health England Topics A-Z Clostridium difficile https://www.gov.uk/health- protection/infectious-diseases

Public Health England (2013) Updated guidance on the management and treatment of Clostridium difficile infection. June 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/321891/Clostri dium_difficile_management_and_treatment.pdf 5

MRSA bacteraemia – risk assessment and reduction strategies

Known risk factors for MRSA bacteraemia:

 Invasive indwelling devices – such as indwelling urinary

catheter

 Chronic illness – especially diabetes, renal dysfunction,

impaired immunity

 Chronic skin conditions  Wounds / non intact skin rd  Antimicrobial therapy especially 3 generation cephalosporins and fluoroquinolones  Advanced age  Previous hospitalisation  Male gender

Screening for MRSA

Early identification of patients at risk of MRSA bacteraemia may prevent the patient from becoming septic & requiring hospital admission.

Follow your local Infection Prevention and Control procedures for screening patients.

Suppression therapy (also known as decolonisation)

For patients known to have MRSA, suppression may be indicated. The purpose of suppression is to lower the burden of MRSA in the nose and on the skin in order to reduce the risk of bacteraemia / other severe infections and to reduce transmission.

MRSA can develop resistance to the products used for suppression. Therefore suppression therapy should only be used when there is a clear indication.

Always follow local Infection Prevention and Control procedures for suppression therapy.

PVL producing Staphylococcus aureus

Panton – Valentin Leukocidin (PVL) is a toxin produced by some strains of Staphylococcus aureus (both MRSA and MSSA). They can occasionally cause severe infections such as bacteremia or necrotizing pneumonia. Young healthy people can be affected especially those living in communal settings or partaking in contact sports.

A history of recurrent boils / pus producing skin infection is an indication of PVL. If you suspect PVL please take samples and specifically request PVL testing as not all laboratories routinely test for PVL. For further advice contact the Infection Prevention and Control Team / Microbiologist.

FOR ADVICE ON MRSA SUPPRESSION, PLEASE REFER TO LOCAL POLICIES OR CONTACT THE LOCAL INFECTION PREVENTION & CONTROL

TEAM: 0151 604 7750

References

Department of Health (2006) Saving Lives: a delivery programme to reduce Healthcare Associated Infection, inc MRSA. Screening for Meticillin Resistant Staphylococcus aureus (MRSA) colonization. A strategy for NHS Trusts: a summary of best practice. November 2006.

Fraise A.P & Bradley C (2009) Ayliffe’s Control of Healthcare-Associated Infection. A Practical Handbook, 5th edition. Hodder Arnold Publishing

Public Health England (2009) Frequently Asked Questions on MRSA. http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/StaphylococcusAureus/Gener alInformation/staphFrequentlyAskedQuestions/

Public Health England (2008) Guidance on the diagnosis and management of PVL- associated Staphylococcus aureus infections (PVL-SA) in England. https://www.gov.uk/government/publications/pvl-staphylococcus-aureus-infections- diagnosis-and-management

Treatment of Splenectomy Patients

Patients who suffer with asplenia or hyposplenia are at increased risk of overwhelming bacterial infection. Infection is most commonly pneumococcal but other organisms such as Haemophilus influenzae type b and meningococci may be involved.

This risk is greatest in the first two years following splenectomy and is greater amongst children but persists into adult life.

Vaccination schedule Schedule for immunising individuals with asplenia, splenic dysfunction or complement disorders (including those receiving complement inhibitor therapy*) depending on the age at which their at-risk condition is diagnosed. Individuals with asplenia or splenic dysfunction aged six months or older should also be offered influenza vaccine.

First diagnosed under six months ●● Give the MenB vaccine at 2, 3 and 4 months along with the routine infant immunisations (if the routine schedule has already been initiated, then give 3 doses of MenB with an interval at least one month apart) ●● If MenC has not yet been given as part of routine schedule, give one dose of MenACWY conjugate vaccine followed by a second dose at least one month apart. If MenC has already been given as part of routine schedule, then give one additional dose of MenACWY at least one month later ●● Give the routine 12-month boosters: Hib/MenC, PCV13 and MMR ●● Give a MenB booster, an extra dose of PCV13 and one dose of MenACWY conjugate vaccine two months after the 12-month boosters ●● After the second birthday, an additional dose of Hib/MenC should be given, along with the pneumococcal polysaccharide vaccine (PPV23).

First diagnosed at 6-11 months ●● Give 2 doses of MenB vaccine at least two months apart (the second dose may be given with the routine 12-month boosters) ●● If MenC has not yet been given as part of routine schedule, give one dose of MenACWY conjugate vaccine followed by a second dose at least one month apart. If MenC has already been given as part of routine schedule, then give one additional dose of MenACWY at least one month after any MenC dose. ●● Give the routine 12-month boosters: Hib/MenC, PCV13 and MMR ●● Give a dose of MenACWY conjugate vaccine and an extra dose of PCV13 two months after the Hib/MenC booster ●● After the second birthday, an additional dose of Hib/MenC and the MenB booster should be given, along with the pneumococcal polysaccharide vaccine (PPV23).

First diagnosed at 12-23 months ●● If not yet administered, give the routine 12-month boosters: Hib/MenC, PCV13 and MMR ●● Give a dose of MenACWY conjugate vaccine and an extra dose of PCV13 two months after the Hib/MenC and PCV13 boosters ●● Give 2 doses of MenB vaccine at least two months apart (either of these doses can be given at the same time as the other vaccine visits) ●● After the second birthday, an additional dose of Hib/MenC should be given, along with the pneumococcal polysaccharide vaccine (PPV23) ●● This age group should also receive an additional dose of MenB vaccine with an interval of 12 to 23 months after the primary course.

First diagnosed from two years onwards ●● Ensure that the child has been immunised according to national schedule, including the 12-month boosters ●● Give an additional dose of Hib/MenC and the first dose of MenB vaccine, along with the pneumococcal polysaccharide vaccine (PPV23)** ●● Give a dose of MenACWY conjugate vaccine and the second dose of MenB two months after the Hib/MenC booster***.

* Soliris acts by down regulating the terminal complement components so those on Soliris therapy are not at increased risk of pneumococcal disease and do not require PPV23. ** Severely immunocompromised individuals aged five years or over should receive one dose of PCV13 followed by PPV at least two months later, as well as annual influenza vaccinations, but do not require meningococcal conjugate vaccination. *** In adolescents (from 11 years of age) and adults, this interval can be reduced to one month.

Please check online for most up to date information https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/309218/Green _Book_Chapter_7_v1_3.pdf

Prophylactic antibiotics should be offered to all patients.

Lifelong antibiotic prophylaxis is appropriate for high-risk groups including those individuals:  aged less than 16 years or greater than 50 years  with inadequate serological response to pneumococcal vaccination,  a history of previous invasive pneumococcal disease,  splenectomy for underlying haematological malignancy, particularly in the context of on-going immunosuppression.

Low-risk patients should be counselled as to the risks and benefits of prophylaxis, particularly where adherence is an issue.

Lifelong compliance with prophylactic antibiotics is problematic. If the patient does not continue to be at high risk as per the criteria above, the patient must have antibiotic prophylaxis until at least 2 years after splenectomy.

If compliance is a problem, patient must be advised to have an emergency supply of amoxicillin or erythromycin to take in the event of fever as well plus be advised to seek medical attention urgently.

Phenoxymethylpenicillin is preferred unless cover is also needed against Haemophilus influenza for a child (in which case, give amoxicillin) or if the patient is allergic to penicillin, give erythromycin).

Phenoxymethylpenicillin Children < 1 year 62.5mg bd Children 1-5 years 125mg bd Children 5 years - Adult 250mg bd

Amoxicillin Child 1 month – 5 years 125mg bd Child 5 -12 years 250mg bd Child 12 – 18 years 500mg bd

Erythromycin Child under 2 years 125mg bd Child 2-8 years 250mg bd > 8 years and adults 500mg bd

Adapted from BNF for children January 2015

Other measures to reduce risk include:

 Patients should be asked to consult if they have a febrile illness and may be given a stock of antibiotics to start treatment by themselves. They should carry a card and/or Medic-Alert bracelet or necklace.  When travelling abroad patients should obtain advice from a reputable travel advice centre (e.g. Liverpool School of Tropical Medicine) to ensure precautions are adequate and up to date.  Patients should avoid malaria (which is more severe in asplenic patients) by avoiding malaria areas or, if going to such areas, adhere scrupulously to antimalarial prophylaxis and anti-mosquito precautions.  Avoid tick bites as there is a risk of Babesiosis and Lyme disease.

References Davies JM, Lewis MP, Wimperis J et al. (2011) Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato- Oncology task force. Br J Haematol 155(3):308-17

Eye, Ear Nose and Throat

Management of acute sore throat Clinicians should consider the potential for bacterium Group A β-haemolytic streptococcus (GABHS) infection.

Clinical prediction for the presence or absence of Group A β-haemolytic streptococcus in acute sore throat in adults (GABHS)

The Centor Criteria  The presence of 3 out of 4 of the Centor criteria have a positive  Tonsillar exudate predictive value of 40-60% for  Tender anterior cervical GABHS lymphadenopathy  Absence of cough  The absence of 3 out of 4 of the  Current pyrexia > 38º C Centor criteria has a negative predictive value of 80%. Recommendations  If the patient has three or four of the Centor criteria present treat with antibiotics  If the patient has only one or two of the Centor criteria present do not treat with antibiotics  Risk of GABHS is higher in age group 3 – 14 years  Provide analgesics and antipyretics if necessary regardless of the presence of these criteria  If in doubt or the patient is insistent on an antibiotic consider using a deferred prescription.

The use of delayed prescriptions

 Giving out antibiotics automatically for sore throat increases the number of future consultations for the same symptoms  For every 9 patients not automatically given antibiotics one future consultation is avoided.  See NICE Clinical Guideline 69 for information on the average total length of common respiratory tract infections http://www.nice.org.uk/nicemedia/pdf/cg69fullguideline.pdf

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Acute viral sore throat No antibiotic indicated Use CENTOR to guide diagnosis

Issue Patient Information If 3 or 4 present treat as for Leaflet (PIL) on viral sore bacterial sore throat (see below) throats (see useful references p3) N.B. If symptoms persist refer to ENT If in doubt, use of deferred prescription is an option

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Acute laryngitis No antibiotic indicated

Issue Patient Information Leaflet (PIL) on viral sore throats see useful references p3

Acute bacterial sore Phenoxymethylpenicillin Take a throat swab if Centor throat 500mg qds for 10 days criteria apply, and in persistent or infections lasting 3-4 weeks Clarithromycin 500mg bd for 5 (CKS) or family or institutional days if allergic to penicillin outbreaks Treatment advice also applies to Scarlet Fever. In penicillin allergy, prescribe clarithromycin for 10 days.

Acute sinusitis Use symptomatic Avoid antibiotics as 80% resolve relief (analgesia) before in 14 days without, and they only prescribing antibiotics offer marginal benefit after 7 days. Amoxicillin 500 mg tds for 7 days or Doxycycline 200mg stat. then 100mg od for 7 days (penicillin allergic children under 12 use clarithromycin instead of doxycycline) For persistent symptoms Co-amoxiclav 625mg tds for 7 days Chronic sinusitis Refer to ENT and treat according to advice

Conjunctivitis Chloramphenicol 0.5% eye Treat if severe, as most viral or drops 2 hourly for 2 days then self-limiting. 65% of cases 4 hourly (whilst awake) and resolve on placebo by day 5. Chloramphenicol 1% ointment at night For neonatal infections, take a swab for Chlamydia prior to Fusidic acid 1% gel two times initiation of therapy. If no a day response after 3 days refer. Treat for 48 hours after resolution.

Management of acute otitis media (AOM)

 Consider whether admission or referral is necessary. For children younger than 3 months of age with acute otitis media (AOM), maintain a low threshold for admission.  Treat pain and fever with paracetamol or ibuprofen if there are no contraindications.  Consider whether antibiotics are required. For most people with suspected acute AOM, advise a no antibiotic prescribing strategy or a delayed antibiotic prescribing strategy.  For children younger than 3 months of age with AOM, maintain a low threshold for prescribing antibiotics.

Offer an immediate antibiotic prescription to:  People who are systemically very unwell (but who do not require admission)  People at high risk of serious complications because of significant heart, lung, renal, liver, or neuromuscular disease, immunosuppression, or cystic fibrosis, and young children who were born prematurely  People whose symptoms of AOM have already lasted for 4 days or more and are not improving.

Depending on severity, consider offering an immediate antibiotic prescription to:

 Children younger than 2 years of age with bilateral AOM  Children with perforation and/or discharge in the ear canal (otorrhoea) associated with AOM.

Children under the age of 2 years are more at risk than older children. If antibiotics are withheld, careful surveillance is recommended. See NICE Clinical Guideline 160 for information on managing fever in children under 5 years http://guidance.nice.org.uk/CG160

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Acute otitis media First line treatment is paracetamol 80% of cases will resolve in or ibuprofen and observe 72 hours. If no vomiting and If no improvement after 72 hours; temp <38.5 use Paracetamol Amoxicillin 500mg tds: or ibuprofen. or if allergic to penicillin Clarithromycin bd for 5 days. If in doubt, use of a See pages 37-38 for paediatric DELAYED PRESCRIPTION is doses. an option

Chronic otitis media Refer to ENT Otitis externa First use aural toilet (if available) and analgesia. If cellulitis or disease extending First line: acetic acid 2% outside ear canal, start oral (EarCalm®) antibiotics and refer. 1 spray tds for 7 days.

Second line: neomycin sulphate with corticosteroid 3 drops tds, 7 days minimum to 14 days maximum

Respiratory Tract Infections

Management of acute bronchitis in otherwise healthy adults

Recommendations  Exclude pneumonia as a likely diagnosis using patient history and physical examination. The NICE clinical guideline on feverish illness in children (CG160) may be used to aid the diagnosis in children: http://publications.nice.org.uk/feverish-illness-in-children-cg160  Do NOT use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity.  Provide a patient information leaflet explaining the limitations of antibiotics for this indication. More than 90% of cases of acute bronchitis do not have a bacterial cause  Purulent sputum can arise from either viral or bacterial infection. The presence of purulent sputum is not a predictor of bacterial infection  Consider using a delayed prescription for antibiotics  Annual immunisation against influenza & immunisation against pneumococcal infection should be offered to all at-risk patients including patients over 65 years.

See NICE Clinical Guideline 69 Respiratory Tract Infections: http://www.nice.org.uk/nicemedia/pdf/cg69fullguideline.pdf

NICE Clinical Guideline CG191 Pneumonia: http://www.nice.org.uk/guidance/CG191

The CRB-65 score may be used as a tool to predict the severity of community acquired pneumonia in adults:

Use CRB-65 score to help guide and review: Each scores 1:

Confusion (recent); Respiratory rate >30/min; BP systolic <90 or diastolic ≤ 60; Age ≥65;

Score 0: suitable for home treatment; Score 1-2: hospital assessment or admission Score 3-4: urgent hospital admission

Confusion = abbreviated Mental Test score 8 or less, or new disorientation in person, place or time

Mortality relating to CRB65 score: 0: low risk (less than 1% mortality risk) 1 or 2: intermediate risk (1-10% mortality risk) 3 or 4: high risk (more than 10% mortality risk).

Explain to patients with low-severity community-acquired pneumonia treated in the community, and when appropriate their families or carers, that they should seek further medical advice if their symptoms do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening. 14

Explain to patients with community-acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by: 1 week: fever should have resolved 4 weeks: chest pain and sputum production should have substantially reduced 6 weeks: cough and breathlessness should have substantially reduced 3 months: most symptoms should have resolved but fatigue may still be present 6 months: most people will feel back to normal.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Community acquired If CRB-65 = 0, amoxicillin Only a small range of pathogens Pneumonia in adults 500 mg tds for 7 days or causes CAP, with Streptococcus Clarithromycin 500 mg bd pneumoniae being the most frequent. for 7 days or The frequency of pathogens can vary Doxycycline 200 mg stat in specific patient groups. then 100 mg od - 7 days in Mycoplasma infections are less total frequent in the elderly. For those patients referred to hospital If CRB-65 = 1 & AT HOME, with suspected CAP, general Amoxicillin 500 mg tds for practitioners may consider 7- days AND administering antibiotics Clarithromycin 500 mg bd immediately where the illness is for 7 days or considered to be life threatening or if Doxycycline alone 200 mg there are likely to be delays (>2 hours) stat then 100 mg od for 7 in admission (BTS guidelines 2009). days Community acquired pneumonia in children http://www.brit- Refer to paediatric thoracic.org.uk/Guidelines/Pneumonia 0-3 months specialist -Guidelines.aspx Consider using traffic light ˃ 3 months assessment tool in the http://publications.nice.org.uk/feverish- NICE guideline on Feverish illness-in-children-cg160 Illness in Children to assess the need for admission to hospital

Seek specialist advice on treatment or referral

Clinical diagnosis Treatment advice Comments and guidelines for lab testing

Acute cough, Likely to be viral and not Symptom resolution can take 3 bronchitis in require antibiotics. weeks. Consider use of otherwise healthy delayed antibiotic prescription adults If antibiotics are indicated: and advice leaflet Amoxicillin 500mg tds for 5 http://www.rcgp.org.uk/clinical- days or and-research/target-antibiotics- Doxycycline 200mg stat then toolkit/patient-information- 100 mg daily - 5 days in total leaflets.aspx

Acute cough, Consider immediate Refer to NICE CKS guidance bronchitis with antibiotics if > 80yr and ONE http://cks.nice.org.uk/chest- existing co- of: infections-adult morbidities and adults hospitalisation in past year, over 65. oral steroids, diabetic, congestive heart failure

OR> 65yrs with 2 of above

If antibiotics are indicated: Amoxicillin 500mg tds for 5 days or Doxycycline 200mg stat then 100 mg daily - 5 days in total

Acute infective Amoxicillin 500mg tds for 5 Treat exacerbations promptly with exacerbations of days or antibiotics if purulent sputum and chronic obstructive Doxycycline 200mg stat then increased shortness of breath pulmonary disease 100mg od - 5 days in total or and/or increased sputum volume. Clarithromycin 500 mg bd for 5 days Antibiotics are less effective if only one symptom present.

Co-amoxiclav should be Obtain sputum sample reserved for patients with risk wherever possible (before factors for antimicrobial second line antibiotic used) resistance e.g. co-morbid For further information refer to disease, severe COPD, frequent exacerbations, http://www.nice.org.uk/CG12 antibiotics in last 3 months Co-amoxiclav 625 tds for 5 http://www.goldcopd.org/Guideline days s/guidelines-resources.html

Clinical diagnosis Treatment advice Comments and guidelines for lab testing

Acute viral Antibiotics not indicated. exacerbations in Symptomatic treatment only asthma

Viral coughs and cold Antibiotics not indicated. Symptomatic treatment only. Cough may persist for several weeks

Whooping cough Treatment should be given to Treatment of children does not  Any person in whom the affect duration of illness, but may clinician suspects control the spread of infection as pertussis infection OR untreated children shed organism  Any person with an acute for many weeks. Non-infectious cough lasting for ≥ 14 coughing may continue for days without an apparent several weeks. cause plus one or more NB. Cases of pertussis should be of the following: notified to Public Health England o paroxysms of but treatment should be coughing commenced as soon as possible o post-tussive and not withheld until advice is vomiting sought. o inspiratory whoop Clarithromycin 500mg bd for https://www.gov.uk/government/c 7 days ollections/pertussis-guidance- If allergic to macrolides: data-and-analysis co-trimoxazole 960mg bd for 7 days (not in pregnancy) Bronchiolitis / croup Antibiotics NOT indicated. in children Symptomatic treatment only.

Infective exacerbation Discuss with appropriate Always send a sputum sample of Bronchiectasis Specialist

Gastrointestinal Infections

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Acute diarrhoea & Oral rehydration therapy is Usually viral and self-limiting. vomiting the mainstay of treatment. Antibiotics only tend to prolong Children aged less than six the carrier state, do not shorten months may be prescribed the duration of illness and may (NB. Food poisoning is rehydration sachets, in older be contraindicated. Antibiotics notifiable to Consultant in age groups clear fluids are should only be commenced on Health Protection) adequate. advice of microbiologist or Consultant in Health Protection. (see also Clostridium Antimotility agents e.g. difficile section) loperamide should only be Check travel, food, prescribed for short-term hospitalisation and antibiotic management of symptoms history (Clostridium difficile is (1-2 days) in the absence of associated with disruption in fever or bloody diarrhoea normal bowel flora) and only for adults and children over 12 years Suggest stool specimen if: 1. Patients with inflammatory bowel disease. 2. Immunosuppressed patients. 3. Patients with hypochlorhydria. 4. Severe symptoms or diarrhoea longer than three days 5. Bloody diarrhoea - sample essential. Antibiotics may be contraindicated (e.g. E coli 0157). 6. Recent foreign travel 7. Post antibiotic therapy and hospitalisation 8. Suspected food poisoning 9. Food handlers

Campylobacter enteritis Antibiotic treatment not usually indicated. N.B. Notifiable to Consultant in Health Initiate on the advice of Protection microbiologist if the patient is systemically unwell.

Salmonellosis Antibiotic treatment not usually indicated. N.B. Notifiable to Consultant in Health Initiate on the advice of Protection microbiologist if the patient is systemically unwell.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Clostridium difficile Stop unnecessary May occur up to eight weeks (confirmed) antimicrobials +/or PPIs after antibiotic treatment. Consider hospital referral if Mild disease: severe symptoms and to rule Patients with mild disease out toxic colitis. may not require specific C. difficile antibiotic treatment. PHE Guidance on management If treatment is required, oral May 2013 metronidazole 400mg- https://www.gov.uk/government/ 500mg tds for 10-14 days publications/clostridium-difficile- infection-guidance-on- Moderate disease: management-and-treatment Metronidazole 400mg- 500mg tds for 10-14 days Testing for clearance of toxin is not required Severe infection: Severe symptoms or signs: Antimotility agents e.g. treat with oral vancomycin loperamide should NOT be 125mg QDS, review prescribed progress closely and/or consider hospital referral.

Admit if: T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis

Recurrent disease: fidaxomicin 200mg bd 10 days, or oral vancomycin 125mg QDS 10-14 days (consider taper) Giardia lamblia Metronidazole: Consider ‘blind’ treatment of Adults: 400mg tds for 5 days family contacts only if they are or 2g single symptomatic dose daily for 3 days

Children: 1-3 years 500mg daily for 3 days 3-7 years 600-800mg daily for 3 days 7-10 years 1g daily for 3 days Threadworms, pinworms Mebendazole 100mg stat. All members of the family (Enterobius vermicularis) For adults and children > 6 require treatment. months; as re-infection is very common, a second Good hygiene is needed to dose may be given after 2 avoid re-infection.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing weeks. NB this is an unlicensed use Washing hands and scrubbing for children under 2 years nails before eating and after visiting the toilet are essential.

A bath in the morning removes ova laid overnight.

Acute cholecystitis Provide symptomatic relief Urgently admit to hospital prior to admission. anyone with suspected acute cholecystitis

Acute exacerbation of Co-amoxiclav 625 tds Consider admission for severe diverticulitis cases. If penicillin allergic: Review within 48 hours or Ciprofloxacin 250-500mg bd sooner if symptoms deteriorate. PLUS metronidazole 400 mg Arrange admission if symptoms tds, both for 7 days persist or deteriorate

Urinary Tract Infections

Management of uncomplicated cystitis Consider whether urine culture is needed Do not send urine if asymptomatic unless antenatal

THE ELDERLY: Asymptomatic bacteriuria in the over 65s is very common and is not related to increased morbidity or mortality. Investigation and treatment will increase side-effects and medicalise the condition. Only sample if: two signs of infection, especially dysuria, pyrexia >38o C or new incontinence. Treat the patient NOT the urine

ACUTE UNCOMPLICATED UTI IN ADULT WOMEN: Affects up to 15% of women each year Routine urine culture is unnecessary. Use symptoms, urine appearance and dipstick urine tests to diagnose UTI and reduce antibiotic use and unnecessary laboratory investigations. 50% of women with symptoms of UTI have negative culture and symptoms are due to inflammation of the urethra – the ‘so called’ urethral syndrome.

ASSESS SYMPTOMS ≥ 3 typical symptoms of UTI dysuria; urgency; frequency, No vaginal 90% polyuria; suprapubic tenderness; AND discharge culture Give empirical haematuria or irritation positive antibiotic treatment

Obtain Mild or ≤ 2 symptoms of Urine NOT cloudy urine Examine UTI (as above) 97% negative specimen predictive value DO NOT TREAT Perform dipstick test with nitrite*

positive nitrite nitrite, leucocytes negative nitrite negative nitrite & leucocyte +/- leucocyte protein, blood positive leucocyte positive blood or protein +/- protein all negative 95% NPV

Probable UTI UTI very unlikely Review time of specimen* Consider other diagnosis Consider other diagnosis UTI or other diagnosis Reassure and give advice Probably urethral syndrome equally likely on management of symptoms

Treat with Reassure and give advice Treat if severe symptoms and first line agents on management symptoms send urine for culture

*Nitrite is produced by the action of bacterial nitrate reductase in urine. As contact time between bacteria and urine is needed, morning specimens are most reliable. Leucocyte esterase detects intact and lysed leucocytes produced in inflammation. Haematuria and proteinuria occur in UTI but are also present in other conditions. When reading test WAIT for the time recommended by manufacturer.

LABORATORY TESTING FOR CULTURE AND SENSITIVITY SHOULD BE PERFORMED IN;  Pregnancy - in all at first antenatal visit  Recurrent UTI, as resistance more to screen for asymptomatic bacteriuria, common as associated with pyelonephritis and  Catheterised patients: Avoid premature delivery. (Dipstick testing unnecessary samples as bacteriuria is should not be used to screen for UTI in usual. Send sample if features of pregnancy) systemic infection  Pregnancy – if symptomatic, for  Failed antibiotic treatment or persistent investigation of possible UTI symptoms  Suspected UTI in children, any sick  Abnormalities of genitourinary tract e.g. child and every young child with calculus, neurogenic bladder, unexplained fever vesicoureteric reflux  Suspected pyelonephritis (temp ≥ 39.4  Renal impairment. °C rigors; nausea; vomiting; diarrhoea;  Suspected UTI in men loin pain or tenderness)  Impaired host defences e.g. poorly controlled diabetes, immunosuppression

In sexually active young men and women with urinary symptoms, consider Chlamydia trachomatis

Infants and Children NICE CG 54: Urinary Tract Infection in Children. Available at: www.nice.org.uk/guidance/CG54

Refer urgently to a paediatric specialist a child of any age where there is a high risk of serious illness.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Uncomplicated cystitis in Fluids and Nitrofurantoin women. capsules 100mg MR bd for 3 days if GFR over 45ml/min. GFR 30-45: only use if resistance & no alternative or Trimethoprim 200 mg bd for 3 days

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Complicated UTI in Fluids and Trimethoprim Submit MSU whenever possible women 200mg bd for 10 days or and prescribe when nitrofurantoin 100mg MR sensitivities are known. When one or more factors bd for 10 days are present predisposing Choice of antimicrobial agent person to persistent or Renal impairment should be based on sensitivities recurrent infection or CKD stages 1,2 or 3: of the urine isolate and clinical treatment failure e.g. UTI Trimethoprim 200mg bd for assessment. with: 10 days in patients with urinary tract abnormalities eGFR >30 If patient suffers a repeat including calculi; impaired infection but had responded to a host defences, impaired Nitrofurantoin capsules first line agent on a previous renal function 100mg MR bd for 10 days occasion, that same agent (see NICE Clinical is 2nd line alternative if should be restarted rather than Knowledge Summaries eGFR >45 (CKD stage 1) assuming that an alternative (CKS) definitions at: agent will be necessary. http://cks.nice.org.uk/urinar Patients with CKD 4 or 5 ie y-tract-infection-lower- eGFR<30: Cefalexin If trimethoprim is unavoidable in women#!backgroundsub) 500mg bd for 10 days patients at risk of hyperkalaemia i.e. CKD 4&5, then U&E monitoring is advised. Review and consider temporary withdrawal of ACE-I, ARB or spironolactone depending on clinical assessment and indication for these drugs.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing UTI in Men Fluids and Nitrofurantoin Submit MSU wherever possible. capsules 100mg MR bd for 7 days if GFR over Consider referral. 45ml/min. Or GFR 30-45: only use if Consider Chlamydia in sexually resistance & no alternative active age group. or Trimethoprim 200mg bd for Avoid PSA testing – levels will 7 days be raised

Renal impairment CKD stages 1,2 or 3: Nitrofurantoin capsules 100mg MR bd for 7 days is 1st line alternative only if eGFR >45 or Trimethoprim 200mg bd for 7 days in patients with eGFR >30

Patients with CKD 4 or 5 ie eGFR<30: Cefalexin 500mg bd for 7 days

UTI in Pregnant women Fluids and Nitrofurantoin Submit MSU for culture and 100mg MR bd for 7 days repeat MSU after treatment except at term completed.

Or Cefalexin 500mg bd for Asymptomatic bacteriuria in 7 days pregnancy should usually be treated. Or trimethoprim 200mg bd for 7 days (off-label) unless Amoxicillin may be folate deficient (see recommended where resistance adjacent comment) patterns are low.

Trimethoprim should be supplemented with folate in 1st trimester. Avoid if taking other folate antagonists e.g. antiepileptic or proguanil)

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Recurrent UTI in non- To reduce recurrence, first Treat on basis of culture and pregnant women > 3 advise simple measures sensitivity. Consider referral as UTIs/year due to relapse or including hydration or may be underlying cause. reinfection. cranberry juice. Relapse is likely caused by Often multi-resistant. same strain of organism if Treat for 7 days infection recurs within a short period e.g. within 2 weeks after treatment. Reinfection is recurrent UTI with a different strain or species of organism and is the likely cause if UTI recurs more than 2 weeks after treatment.

Prophylaxis for recurrent Post-coital or stand by Refer to urology. Patients UTI in adults antibiotics may reduce should be reviewed at regular occurrence intervals to assess the risk: Nitrofurantoin 50-100mg benefits in relation to C difficile post-coital stat or infection. Prophylactic trimethoprim 100mg antibiotics should be reviewed prophylaxis nocte (off – after 6 months and stopping label) should be considered. Acute pyelonephritis in Ciprofloxacin 500mg bd for Submit MSU and consider blood adults 7 days culture and admission. Or co-amoxiclav 500/125 Prescribe analgesia for 14 days (paracetamol or ibuprofen) for pain and fever. If lab report shows sensitive: trimethoprim 200mg bd for 14 days

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Bladder catheter in situ Treat only if associated 1. Ensure high fluid intake. with systemic symptoms 2. Where adequate fluid intake e.g. pyrexia, rigors. cannot be assured and bladder washout indicated, use saline. 3. There is a high incidence of bacteriuria with long-term catheters. Antibiotics do not eliminate these, but lead to the growth of resistant organisms. 4. Dipstick testing should not be performed on catheter specimen of urine (SIGN guidelines) 5. Culture of urine is not normally advised 6. Antibiotics will not eradicate asymptomatic bacteruria: only treat if the patient is systemically unwell or if pyelonephritis is likely. 7. Do not use prophylactic antibiotics for catheter changes unless history of catheter-change associated UTI or trauma. Epididymo-orchitis Ceftriaxone 500 mg IM stat, Sexual history is imperative. If if available, or oral cefixime sexually active (especially < 35 400 mg stat as an years) C trachomatis and / or Refer to GUM/Sexual alternative to IM N gonorrhoea most likely – refer Health Service if sexually ceftriaxone. to GUM/Sexual Health service. active plus Submit MSU. If infection follows Doxycycline 100mg bd for recent hospitalisation with 14 days in sexually active bladder catheterisation or in the men elderly, use ciprofloxacin. For further guidance in Ciprofloxacin 500mg bd for assessing the patient see the 10 days if NICE CKS for scrotal swellings Enterobacteriaceae

Prostatitis Ciprofloxacin 500mg bd for Prolonged treatment required. 4 weeks Consider Chlamydia infection. 2nd line trimethoprim 200mg bd 28 days

Urethritis Refer to GUM/Sexual Health Service and submit MSU.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Sterile pyuria If sexually active consider Chlamydia and refer to GUM/Sexual Health service. Tuberculosis, fastidious organisms and tumours or stones are associated with sterile pyuria (as is concurrent antimicrobial treatment). Refer to urology.

UTI in infants < 3 months Refer immediately to Paediatrician. Cystitis / Lower UTI – Treat if positive nitrite on Always submit a pre-treatment Infants & children > 3 dipstick urine sample, clean catch if months Trimethoprim for 3 days possible. Or Consider prophylaxis after Nitrofurantoin for 3 days treatment if recurrent infection or systemically Treatment failures: Guided unwell and refer to by microbiology results Paediatrician. Acute pyelonephritis / Co-amoxiclav tds for 7 days Always submit urine sample, Upper UTI - Infants & clean catch if possible. children > 3 months Consider referral to Paediatrician, depending on severity or in penicillin allergy.

Genito-urinary Infections

Clinical diagnosis Treatment advice/ Comments and guidelines for adult dosages lab testing Vaginal Discharge Clotrimazole pessary Investigate recurrent cases a) Candidiasis 500mg stat or (4 or more episodes annually) vaginal cream 10% stat at and refer if appropriate night or Fluconazole 150mg stat orally In pregnancy avoid oral azoles and use intravaginal treatment for 7 days clotrimazole 100mg pessary nocte for 6 nights or miconazole 2 % cream 5g intravaginally bd for 7 days b) Trichomonas vaginalis Metronidazole 400mg bd MUST be referred to for 7 days GUM/Sexual Health Services for contact tracing & follow-up. In pregnancy or Sexual partners should be breastfeeding avoid 2g treated simultaneously. single dose metronidazole. c) Bacterial vaginosis Metronidazole 400mg bd Refer to GUM/Sexual Health for 7 days Services if diagnosis is If pregnant, Clindamycin uncertain 2% cream 5g pv at night for 7 nights Or metronidazole 0.75% vaginal gel 5g applicatorful at night for 5 nights d) Children Be guided by swab and Consider all possible causes culture sensitivity as often including foreign bodies and unexpected pathogens abuse. If abuse suspected refer such as H influenzae, urgently to paediatricians and pneumococci or group A consider safeguarding issues streptococci are present

Candida balanitis Clotrimazole cream 2% bd Check for underlying problems until symptoms settle

Clinical diagnosis Treatment advice/ Comments and guidelines for adult dosages lab testing Pelvic sepsis / pelvic Ofloxacin 400mg bd for 14 Consider Chlamydia infection. inflammatory disease days plus MUST be referred to Metronidazole 400mg bd GUM/Sexual Health Services for for 14 days contact tracing and follow-up It may be preferable to initiate treatment in primary care if there would be a delay of >24h until the patient was assessed by GUM/Sexual Health Service. If gonorrhoea likely, refer to GUM/Sexual Health Service Chlamydia infection Azithromycin 1g stat Treat partners & refer to local or Sexual Health / GU service Doxycycline 100mg bd for 7 days Look for signs of PID or epididymitis and refer to If at risk of pregnancy: appropriate guidance. Azithromycin 1g stat (most effective but off-label use) Exclude other STI. If or gonorrhoea is not reasonably Erythromycin 500mg qds excluded, use of azithromycin for 7 days alone may contribute to Or development of resistance. Amoxicillin 500mg tds for 7 days Patients should be advised that they should refrain from any Pregnant patients should sexual activity until they and be given a test of cure 5 their partner(s) have completed weeks after completing treatment. therapy (6 weeks after N.B. May be asymptomatic or azithromycin). mild symptoms of infection

For suspected epididymitis in men over 35 years with low risk of STI ofloxacin 400mg bd 14 day Doxycycline 100mg bd 14 days Genital herpes Aciclovir 400mg tds for 5 It may be preferable to initiate Refer all patients to days treatment in primary care if GUM/Sexual Health there would be a delay of >24h Service for virological until the patient was assessed in confirmation. GUM/Sexual Health Service Phone local department same day.

Skin Infections

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Impetigo As resistance is increasing, Advise on importance of personal topical treatment should only hygiene e.g. not to share towels, be used when a few flannels etc. Avoid topical localised lesions are present: steroids or long term topical antibiotic use. Further advice may Fusidic Acid ointment tds for be obtained from the community 5 days, infection control nurse. Or for MRSA only, topical mupirocin tds for 5 days.

For more extensive infection:

Flucloxacillin 500mg qds for 7 days or Clarithromycin 500mg bd for 7 days (if allergic to penicillin)

Or for MRSA only: Doxycyline 200mg od on day 1 followed by 100mg od for another 6 days (i.e. 7 days in total)

Cellulitis / Erysipelas Flucloxacillin 500mg qds for If febrile and ill or river or sea 7 days or water exposure discuss with Medical Microbiologist. Clarithromycin 500mg bd for 7 days if allergic to penicillin

Review response to treatment after 7 days. If slow response, continue for further 7 days.

Facial Cellulitis Co-amoxiclav 500/125 tds If febrile and ill, or river or sea for 7 days water exposure, discuss with Medical Microbiologist If penicillin allergic: Clarithromycin 500mg bd for 7 days

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Post-operative wound Flucloxacillin 500mg qds for Swab wound for culture & infections 7 days. sensitivity

Clarithromycin 500mg bd for Consider nature of operation and 7 days if allergic to penicillin likely pathogens including MRSA status

Consider hospital admission and discuss with Medical Microbiologist. Boils If cellulitis has been (Also see recurrent boils) excluded antibiotics not indicated. Drainage is advised.

Recurrent boils Topical antiseptic for one Swabs to confirm nasal carriage associated with carriage week – see page 6. of Staphylococcus aureus. Ask of Staph. aureus for PVL testing to be carried out. Mupirocin 2% nasal ointment tds for 5 days

Leg ulcers Flucloxacillin 500mg qds for Ulcers always colonized. 7 days or Clarithromycin 500mg bd for Check MRSA status. 7 days Antibiotics do not improve healing unless active infection. If active infection, send pre-treatment swab. Review antibiotics after culture results.

Active infection if cellulitis/increased pain/pyrexia/ purulent exudate/odour

Refer to wound care formulary or tissue viability nurse.

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Infected animal bites Co-amoxiclav 500/125 tds Adequate wound toilet is (from non-rabies for 7 days essential & the mainstay of endemic areas), Or if allergic to penicillin: treatment. Consider surgical prophylaxis for cat bite, Doxycycline 100 mg bd for 7 debridement if required severe cat scratches days plus Metronidazole and complicated dog 400mg tds for 7 days Assess rabies risk for animal bite bites occurring abroad. Advise patient to re-consult if Assess tetanus immunisation Refer serious bites failing to improve as status (especially in children) prophylaxis is sub-optimal. to AED N.B. Consider risk of blood borne Children under 12 years with virus transmission. Further confirmed penicillin allergy: guidance from Public Health Seek microbiology advice England

Prophylaxis for human Co-amoxiclav 500/125 tds Adequate wound toilet is bite for 7 days essential & the mainstay of or if allergic to penicillin: treatment. Consider surgical Doxycycline 100 mg bd for 7 debridement if required days plus Metronidazole 400mg tds for 7 days Assess HIV/Hepatitis B risk for or human bites. Clarithromycin 500mg bd for 7 days plus metronidazole N.B. Consider risk of blood borne 400mg tds for 7 days virus transmission. Further guidance from Public Health Advise patient to re-consult if England failing to improve as prophylaxis is sub-optimal.

In growing toe nail Flucloxacillin 500mg qds for Wound debridement. infection 7 days Lateral nail ablation OR if allergic to penicillin: recommended when infection Clarithromycin 500mg bd for settled if problem is recurrent. 7 days

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Superficial skin and soft Flucloxacillin 500mg qds for Wound debridement if suspected tissue infections 7 days or foreign body and swab. Clarithromycin 500mg bd for Empirical antibiotic treatment Paronychia 7 days if allergic to penicillin

If infection due to MRSA, use doxycycline 100mg bd for 7 days Use sensitivity results to guide therapy.

Diabetic Foot Ulcer Flucloxacillin 1g qds (Grade 0 or 1) OR Clarithromycin 500mg bd Refer to foot ulcer clinic for 7 days if allergic to penicillin Herpetic lesions: Children: antiviral treatment Virus is highly communicable. a) Chicken pox / not recommended < 14 Admit patient urgently if Varicella zoster years immunocompromised Adults: If onset of rash <24h Seek advice from obstetrician for or severe pain or dense/oral pregnant patients with chicken rash or secondary household pox. case or steroids or smoker Contacts: For babies less than consider: one month old contact Medical Aciclovir 800mg five times a Microbiologist for advice. day for 7 days if within 24 Non-immune pregnant contacts hours of onset of rash may be offered specific immunoglobulin1. Contact microbiologist for advice. http://www.hpa.org.uk/Topics/Infe ctiousDiseases/InfectionsAZ/Chic kenpoxVaricellaZoster/GeneralInf ormation/ b) Shingles / Varicella Aciclovir 800mg five times a Treatment not normally zoster day for 7 days if within 72 recommended unless over 50 hours of onset of rash years. Refer urgently if ocular Or involvement Valaciclovir 1g tds for 7days Or Third line if compliance a problem, as ten times cost: Famciclovir 500mg tds or 750mg bd for 7 days c) Oral Herpes Aciclovir 5% cream five Cold sores do not normally times a day for 5 days at first require antiviral treatment. sign of attack. Mainstay for primary acute oral herpes stomatitis is oral fluids. d) Genital Herpes See page 29

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Mastitis Flucloxacillin 500mg The most common cause of qds for 14 days if clinical mastitis is ineffective attachment evidence of infection. at the breast. It is essential that this is corrected otherwise the If penicillin allergic: problem will persist & secondary Erythromycin 250-500mg problems may result despite qds for 14 days antibiotic treatment

Children’s Doses for antimicrobials recommended in this guideline See Children’s BNF http://www.bnf.org/bnf/index.htm Amoxicillin 1 month – 1 year 125mg tds increased if necessary up to 30 mg/kg 3 times daily 1 – 5 years 250mg tds increased if necessary up to 30 mg/kg 3 times daily 5 - 12 years 500mg tds increased if necessary up to 30 mg/kg 3 times daily (max 1g) 12–18 years 500mg tds increased to 1g tds in severe infection Benzylpenicillin by Under 1 year 300mg IV or IM injection for 1 – 9 years 600mg suspected meningitis 10 years and over 1.2gram Cefalexin 1 month - 1 year 125mg bd 1 - 5 years 125mg tds 5 - 12 years 250mg tds 12 – 18 years 500mg bd or tds, increased to 1–1.5g tds or qds for severe infections Clarithromycin 1 month – 12 years: Body-weight under 8kg 7.5mg/kg bd Body-weight 8–11kg (1 – 2 yrs) 62.5mg bd Body-weight 12–19kg (3 – 6 yrs) 125mg bd Body-weight 20-29kg (7-9 yrs) 187.5mg bd Body-weight 30-40kg (10-12 yrs) 250mg bd 12 – 18 years 250mg – 500mg bd Co-amoxiclav 1 month – 1 year 0.25ml/kg of 125/31 suspension tds 1 – 6years 5ml of 125/31 suspension tds 6 – 12years 5ml of 250/62 suspension tds 12 -18 years One 250/125 tablet tds Use double dose in severe infection Co-amoxiclav dose for 2 months – 2 years twice daily (400/57) 2 - 6 years (13 – 21kg) 0.15ml/kg of 400/57 suspension bd suspension 7 – 12years (22 – 40kg) 2.5ml of 400/57 suspension bd 5ml of 400/57 suspension bd Flucloxacillin 1 month - 2 years 62.5 - 125mg qds 2 – 10 years 125 - 250mg qds 10 - 18 years 250 - 500mg qds Consider using cefalexin liquid as an alternative to flucloxacillin liquid due to very poor palatability

Metronidazole Anaerobic infections 1 month – 2 months 7.5mg/kg bd 2 months – 12 years 7.5mg/kg (max 400mg) tds 12 – 18 years 400mg tds Pelvic inflammatory disease 12 – 18 years 400mg bd Dental infections 1 – 3 years 50mg tds 3 – 7 years 100mg bd 7 – 10 years 100mg tds 10 – 18 years 200mg – 250mg tds Nitrofurantoin Child 3 months–12 years 750micrograms/kg 4 times daily for 3–7 days Child 12–18 years 50mg 4 times daily for 3–7 days; increased to 100 mg 4 times daily in severe chronic recurrent infections

Phenoxymethylpenicill 1 month - 1 year 62.5mg qds in (Penicillin V) 1 - 6 years 125mg qds 6 - 12 years 250mg qds 12 – 18 years 500mg qds (max 1gram qds) Dose can be increased to ensure at least 12.5mg/kg in severe infection Trimethoprim treatment 1 month – 12 years 4mg/kg (max 200mg) bd 12 – 18 years 200mg bd prophylaxis 1month – 12 years 2mg/kg (max 100mg) on 12 – 18 years 100mg on

Referral to Out-patient Parenteral Antimicrobial Therapy (OPAT) Service

Wirral University Teaching Hospital (WUTH) are hosting a specialist team to support the delivery of IV antibiotic therapy in the community by the Community Nursing Service.

Key Messages for GPs

The referrer will retain responsibly for any monitoring and/or review of the patient.

Patient Selection:

Inclusion criteria (All must apply)  Medically stable and fit for discharge (as assessed by medical team, registrar or above) or medically stable and fit to remain within the community setting (as assessed by GP)  Able to understand and consent to OPAT  Safe and appropriate IV access  Registered with a GP on the Wirral  Age > 18  Definitive diagnosis known

Exclusion criteria (Any one will exclude the patient)  History of allergy to agent being administered or related agent  Known risk of sudden death  Immunocompromised / neutropenic  Septic (ie 2 or more of the following: heart rate > 90bpm, temp > 38.3ºC, respiratory rate > 20 breaths per minute, WCC > 12x109 /L or <4x109 /L or new altered mental state  Unable to communicate / confusion  Intravenous drug misuser

*Note – if WCC are not available at time of assessment, and any one of the other SIRS criteria are met, OPAT can only be met if arrangements are made for same day FBC. If this is not possible, or the result is outside the recommended range, OPAT is not appropriate.

Caution: Patients with a history of anaphylactic reaction from causes other than the agent being administered should be risk assessed prior to referral.

 The referring GP must have given confirmation to the community nursing team that they will remain responsible for any re-assessment of the patient’s condition  There is no treatment available via any other route (for example oral) which could be prescribed as an alternative  The referring GP has discussed treatment with a consultant microbiologist and there are no contraindications to the proposed treatment  The patient has been prescribed an antibiotic that is on the agreed list of medicines listed below  The patient’s home situation must be suitable. There must be running water, access to a telephone, adequate lighting and sufficient space to maintain a sterile field

Prescribing:  It is the responsibility of the patient’s own GP to prescribe intravenous antibiotics, diluents and flushes on a FP10 prescription  The referrer must contact the Microbiologist for advice on the correct antibiotic and route of administration. The Patient Medicines Administration Chart (PMAC) must be endorsed with “Discussed with the Microbiologist”  The GP must complete and sign a PMAC  The prescriber must provide clear, precise written instructions regarding the medicine, dose, frequency of administration and duration of treatment as well as allergy status. Volumes of any prescribed diluents must be stated on the PMAC together with duration of infusion  Verbal orders for commencement of or changes to intravenous medications will NOT be taken

Supplies of Intravenous Antibiotics  The antibiotics plus diluents and flushes must be prescribed on an FP10 prescription. The FP10 prescription must be filled by a community pharmacy. Ringing the community pharmacy in advance is good practice in order to allow them to order in stock where necessary and reduce any delays in initiating treatment  Wirral Community Nursing Service do not stock IV antibiotics  Lloyds Pharmacy Arrowe Park Hospital keep a selected list of IV antibiotics (plus diluents and flushes) in stock for the Wirral Community Nursing Service Team

List of Intravenous Antibiotics which have been locally agreed for IV administration

 Amoxicillin (not if allergic to any penicillins or other beta-lactam antibiotics)  Ceftazidime (not if allergic to any penicillins or other beta-lactam antibiotics)  Ceftriaxone (not if allergic to any penicillins or other beta-lactam antibiotics)  Co-amoxiclav (not if allergic to any penicillins or other beta-lactam antibiotics)  Ertapenem (not if allergic to any penicillins or other beta-lactam antibiotics)  Flucloxacillin (not if allergic to any penicillins or other beta-lactam antibiotics)  Meropenem (not if allergic to any penicillins or other beta-lactam antibiotics)  Piperacillin with tazobactam [Tazocin] (not if allergic to any penicillins or other beta-lactam antibiotics)  Temocillin (not if allergic to any penicillins or other beta-lactam antibiotics)  Teicoplanin

Referral Process:

First contact for recruitment into the service is via a Consultant Microbiologist (Contact number 01244 362500). The referring clinician should then:  Complete a referral proforma and fax to 01244 366777, or email to Wih- [email protected]  Complete PMAC  Contact the relevant Community Nursing team - Contact details are available at http://www.wirralct.nhs.uk/services/nursing/community-nursing-service?showall=&start=2

Further information on the Outpatient Parenteral Antimicrobial Therapy (OPAT) service is available at http://www.wuth.nhs.uk/patients-and-visitors/services/t/tests,-scans-and- investigations/microbiology/ 39

Miscellaneous

Clinical diagnosis Treatment advice/ Comments and guidelines for adult dosages lab testing Bacterial meningitis / If not allergic to penicillin Give IM only if venous access Meningococcal administer Benzylpenicillin cannot be found. septicaemia IV/IM prior to admission: In this instance allergy means a < 1 year 300mg stat clear history of anaphylaxis. A 1-9 years 600mg stat history of rash following > 10 years 1.2g stat penicillin is not a Notifiable immediately to OR contraindication. Close contacts Consultant in Health Cefotaxime IV/IM prior to of meningococcal infection will Protection admission: be offered chemoprophylaxis by <12 years 50mg/kg stat Consultant in Health Protection >12 years 1 gram stat

Admit urgently

Antimicrobial Prophylaxis

Endocarditis Refer to the NICE Clinical Guideline Number 64 issued in March 2008 – Prophylaxis against infective endocarditis. http://publications.nice.org.uk/prophylaxis-against-infective-endocarditis-cg64

Regard people with the following cardiac conditions as being at risk of developing infective endocarditis:  acquired valvular heart disease with stenosis or regurgitation  valve replacement  structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised.  hypertrophic cardiomyopathy  previous infective endocarditis.

Offer people at risk of infective endocarditis clear and consistent information about prevention, including:  the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended the importance of maintaining good oral health.  symptoms that may indicate infective endocarditis and when to seek expert advice.  the risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

Do not offer antibiotic prophylaxis against infective endocarditis:  to people undergoing dental procedures  to people undergoing non-dental procedures at the following sites: o upper and lower gastrointestinal tract o genitourinary tract; this includes urological, gynaecological and obstetric procedures, and childbirth o upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy

Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people at risk undergoing dental procedures.

Investigate and treat promptly any episodes of infection in people at risk of infective endocarditis to reduce the risk of endocarditis developing.

Offer an antibiotic that covers organisms that cause infective endocarditis if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genito-urinary procedure at a site where there is a suspected infection.

Malaria

Malaria prophylaxis should not be prescribed on an NHS prescription form. Patients should be advised to purchase their medicines from a pharmacy where it often costs less than the prescription charge. Mefloquine, Maloprim®, Malarone® and doxycycline are ‘prescription only medicines’ which should be provided on private prescription. Where doxycycline is prescribed for chemoprophylaxis of malaria it should only be prescribed privately. For further information please see the Malaria Prophylaxis Prescribing Policy at: http://mm.wirral.nhs.uk/document_uploads/policies/PPMalariaProphylaxisv1-1.pdf

Local Community Pharmacists have access to up to date advice about appropriate regimes and can advise travellers accordingly.

The length and timing of commencement of prophylaxis is determined by the regime required. Regular GP literature also provides updated advice on the choice of antimalarials for different regions of the world. Further information is available from Liverpool School of Tropical Medicine - 0151 705 3100. Other resources are: http://www.nathnac.org/travel/ http://www.fitfortravel.nhs.uk/home.aspx

Prophylactic medicines do not provide absolute protection against malaria. Personal protection against being bitten using mosquito nets, insect repellents and appropriate clothing is also important.

Current statutorily notifiable diseases and food poisoning (2010)

These infections must be reported to Public Health England (see useful contact numbers)

Acute encephalitis Malaria Acute meningitis Measles Acute poliomyelitis Meningococcal septicaemia Acute infectious hepatitis Mumps Anthrax Plague Botulism Rabies Brucellosis Rubella Cholera SARS Diphtheria Scarlet fever Enteric fever (typhoid or paratyphoid fever) Smallpox Food poisoning Tetanus Haemolytic uraemia syndrome (HUS) Tuberculosis Infectious bloody diarrhoea Typhus Invasive group A streptococcal disease Viral haemorrhagic fever (VHF) Legionnaires’ disease Whooping cough Leprosy Yellow fever

Members of the Antibiotic Guideline Working Group

The Pan-Mersey Antimicrobial guidelines 2014 (from which this guideline was adapted) guidelines were developed by the Pan Mersey Antimicrobial Steering Group 2013.

Members of the Pan Mersey Antimicrobial Steering Group for 2013: Nicola Baxter, Senior Pharmacist West Lancs CCG Rachel Cameron; Antimicrobial Pharmacist Warrington and Halton Hospital Trust Dr Richard Cooke, Consultant Microbiologist University Hospital Aintree Sandra Craggs, Senior Pharmacist, South Sefton CCG and Southport & Formby CCG Nicola Durnin, Antimicrobial Pharmacist University Hospital Aintree Dr Jonathan Folb, Consultant Microbiologist, Royal Liverpool & Broadgreen Hospitals Trust Dr Steve Fraser, GP South Sefton Andrea Giles, Senior Pharmacist St Helens CCG Dr Rashmi Gupta, Consultant Microbiologist, Southport & Ormskirk Hospital Trust Chris Little, Antimicrobial Pharmacist, Southport & Ormskirk Hospital Trust Andrew Lewis, Antimicrobial Pharmacist, St Helens & Knowsley Hospital Trust Dr Kalani Mortimer, Consultant Microbiologist, St Helens & Knowsley Hospital Trust Clare Moss, Senior Pharmacist, Cheshire & Merseyside CSU Anne Neary, Antimicrobial Pharmacist, Royal Liverpool & Broadgreen Hospitals Trust David Sharpe, Antimicrobial Pharmacist, Alder Hey Children’s Hospital Trust Helen Stubbs, Senior Pharmacist, Cheshire & Merseyside CSU Jackie Szynalski, Senior Pharmacist, Liverpool Community Health Dr Gill Thomas, GP South Sefton Dr Sian Alexander White, GP, Liverpool

Adapted for Wirral by: Nicola Bradley, Practice Pharmacist and Antibiotic Lead, Medicines Management Team, NWCSU Dr John Cunniffe, Medical Microbiologist, Wirral University Teaching Hospital NHS Foundation Trust Helen Dingle, Prescribing Adviser, Medicines Management Team, NWCSU

Approved by: Medicines Clinical Guidance Sub-Committee of Wirral Drug and Therapeutics Committee

Useful Contact Numbers

Medical Microbiologists

Where therapy has failed or special circumstances exist, advice can be obtained from Wirral Medical Microbiology, which operates a 24 hour, 365 day clinical microbiology service. Please feel free to phone the Microbiology Department by either contacting:

1) MicroPath automated switchboard 01244 362500 option 3 (WUTH microbiology) during normal working hours Or 2) Arrowe Park Switchboard 0151 678 5111 if out-of-hours

Public Health England switchboard 0844 225 1295 option 1, option 1, option 1 Out of hours advice for health professionals: To contact a public health professional in an emergency out of hours; in the evenings, at weekends or during bank holidays, please phone: 0151 706 2000 ask for “Public Health on call”

Index of Infections

Ashtma, acute viral exacerbations ...... 18 Bacterial meningitis ...... 40 Bacterial vaginosis ...... 29 Bite, cat, prophylaxis for ...... 33 Bite, dog, complicated ...... 33 Bite, human, prophylaxis for ...... 33 Bites, animal, infected, from non-rabies endemic areas ...... 33 Bladder catheter in situ ...... 27 Boils ...... 32 Boils, recurrent associated with carriage of Staph. aureus ...... 32 Bronchiectasis, infective exacerbation ...... 18 Bronchiolitis in children ...... 18 Bronchitis in otherwise healthy adults ...... 17 Bronchitis with existing co-morbidities in adults over 80 years...... 17 Campylobacter enteritis ...... 19 Candidiasis, vaginal ...... 29 Cellulitis ...... 31 Cellulitis, facial...... 31 Chicken pox ...... 34 Chlamydia ...... 30 Cholecystitis, acute ...... 21 Chronic obstructive pulmonary disease, acute infective exacerbations ...... 17 Clostridium difficile ...... 20 Cough, acute in otherwise healthy adults ...... 17 Cough, acute with co-morbidities in adults over 80 years ...... 17 Coughs and cold, viral ...... 18 Croup in children...... 18 Cystitis in infants and children > 3 months ...... 28 Cystitis, uncomplicated in women ...... 23 Diarrhoea and vomiting, acute...... 19 Diverticulitis, acute exacerbation...... 21 Epididymo-orchitis ...... 27 Erysipelas ...... 31 Foot Ulcer, diabetic grade 0 or 1 ...... 34 Giardia lamblia ...... 20 Herpes, genital ...... 30 Herpes, oral ...... 34 Impetigo ...... 31 In growing toe nail infection ...... 33 Laryngitis, acute ...... 12 Leg ulcers...... 32 Mastitis ...... 35 Meningococcal septicaemia ...... 40 Otitis externa ...... 13 Otitis media, acute ...... 13 Paronychia ...... 34 Pelvic inflammatory disease ...... 30 Pelvic sepsis ...... 30 Pinworms ...... 20 Pneumonia, community acquired in adults ...... 16 Pneumonia, community acquired in children ...... 16 Post-operative wound infections ...... 32 Prostatitis ...... 27 Pyelonephritis, acute in adults ...... 26 Pyelonephritis, acute in infants and children > 3 months ...... 28 Pyuria, sterile ...... 28 Salmonellosis ...... 19 Scratches, cat, severe ...... 33 Shingles ...... 34 45

Sinusitis, acute ...... 12 Sinusitis, chronic ...... 12 Skin and soft tissue infections, superficial ...... 34 Sore throat, acute bacterial ...... 12 Sore throat, acute viral ...... 11 Threadworms ...... 20 Trichomonas vaginalis ...... 29 Urethritis ...... 27 UTI in infants < 3 months ...... 28 UTI in Men ...... 25 UTI in Pregnant women ...... 25 UTI, complicated in women ...... 24 UTI, lower in infants and children > 3 months ...... 28 UTI, recurrent in adults, prophylaxis ...... 26 UTI, recurrent in non-pregnant women ...... 26 UTI, upper in infants and children > 3 months ...... 28 Vaginal discharge in children ...... 29 Varicella zoster ...... 34 Whooping cough ...... 18