Antimicrobial Prescribing Quick Reference Guide for Primary Care in Nottinghamshire

For further information and management of other infections not listed here please refer to the full guideline on the Area Prescribing Committee website: http://www.nottsapc.nhs.uk Where empirical therapy has failed or special circumstances (e.g. previous C.difficile infection) exist, clinical advice should be sought from Microbiology Department at either Nottingham University Hospitals 01159249924 ext 61163 or Sherwood Forest Hospitals 01623622515 ext 3616

Infection Notes Recommended Agent(s) Doses are for adults unless otherwise stated Upper Respiratory Tract Infections  Consider a delayed prescription (3-5 days) / as the majority are viral 1g BD for 10 days (or 500mg - 1g QDS if severe)  90% resolve in 7 days without

NICE CG69  Consider immediate or a 3 day delayed : prescription if Centor score of 3 or 4: Clarithromycin 250-500mg BD for 5 days CKS Lymphadenopathy, No cough, , (consider Erythromycin syrup in children) Tonsillar Exudate for 5 days  Consider no or delayed prescribing if not Neonate 7-28 days: 30mg/kg TDS, acutely unwell; illness resolves over 4 days 1month-1 yr: 125mg TDS, 1-5yrs: 250mg TDS, >5yrs and adults: 500mg TDS Acute in 80% without antibiotics.

 If acutely unwell (, fever, pain for Penicillin allergy: CKS >48h and otorrhoea) prescribe immediate Clarithromycin 250-500mg BD for 5 days antibiotics. Consider Erythromycin syrup in children: 1month-2yrs: 125mg QDS; 2-8yrs: 250mg QDS; >8yrs: 500mg QDS for 5 days First line:  Organisms usually present as secondary Acetic acid 2% TDS (EarCalm Spray) for 7 days colonisers Otitis Externa  Cure rates similar at 7 days for acetic acid Second line options:

or +/- steroid Gentisone HC, Locorten-Vioform, Sofradex CKS  Oral antibiotics only indicated if spreading If spreading cellulitis: 500mg QDS for 5 days  Majority are viral and resolve in 7-10 days Treat for 7 days: without antibiotics Acute Sinusitis Phenoxymethylpenicillin 500mg QDS  Reserve antibiotics for severe or or

symptoms >10 days Amoxicillin 500mg TDS (1g TDS if severe) CKS  In persistent infection despite first line or therapy, use co-amoxiclav. Doxycycline 200mg stat then 100mg OD

Lower Respiratory Tract Infections  Numerous RCTs have shown little or no Doxycycline 200mg stat then 100mg OD for benefit of antibiotics in otherwise healthy Acute Cough, 5 days adults Bronchitis  Consider antibiotics if >80yrs and one of or the following: hospitalisation in past year, CKS oral steroids, diabetic, heart failure. Or if Amoxicillin 500mg TDS for 5 days >65yrs and two of the above. Doxycycline 200mg stat then 100mg OD Acute  Antibiotics are helpful when purulent or Exacerbation of sputum and increased shortness of breath Amoxicillin 500mg TDS COPD and/or increased sputum volume. or

 Consider risk factors for resistant Clarithromycin 500mg BD for 5 days CKS organisms: frequent exacerbations, severe

COPD, comorbid disease, antibiotics in If resistance likely: NICE CG12 last 3 months. Co-amoxiclav 625mg TDS for 5 days Use CRB65 score to guide management: CRB65 = 0: Amoxicillin 500mg TDS or Confusion (new AMT <8) Doxycycline 200mg stat / 100mg OD or Community Respiratory rate >30 breaths/minute Clarithromycin 500mg BD for 5 days Acquired BP systolic <90 or diastolic <60 Pneumonia Age >65 years CRB65 = 1 and at home:

Doxycycline 200mg stat / 100mg OD for 7-10 BTS 2009 0= suitable for home treatment days or 1-2 = hospital assessment or admission Amoxicillin 500mg-1g TDS plus 3-4 = urgent hospital admission Clarithromycin 500mg BD for 7-10 days

Authors: Dr Amelia Joseph, Specialty Registrar and Dr Fiona Donald, Consultant in Microbiology, Nottingham University Hospitals NHS Trust; James Sutton, Formulary Pharmacist, Mansfield and Ashfield CCG. Updated May 2015. Review date: May 2018.

Genital Tract Infections Vaginal All topical and oral azoles give 75% cure. Clotrimazole 500mg pessary or Candidiasis 10% vaginal cream 5g single application CKS In avoid oral azoles and use or BASHH intravaginal treatment for 7 days. Fluconazole 150mg orally single dose  Opportunistically screen 16-25yr olds. Azithromycin 1g single dose or  Refer to GUM for contact tracing and full Chlamydia Doxycycline 100mg BD 7 days sexual health screen. trachomatis  Pregnancy or : Azithromycin Pregnancy or breastfeeding: BASHH is the most effective option (unlicensed). Azithromycin (off-label) 1g single dose Lower cure rate in pregnancy, test for cure or Erythromycin 500mg QDS for 7 days at 6 weeks. or Amoxicillin 500mg TDS for 7 days  Refer to GUM for management, contact tracing and full sexual health screen. If Neisseria patient unwilling or cannot access within a 500mg IM injection gonorrhoeae reasonable time, then treatment for plus uncomplicated gonorrhoea can be initiated Azithromycin 1g PO single dose BASHH on basis of a positive Microbiology result.  is no longer recommended.  Test of cure at 2-4 weeks recommended. Send pre-treatment MSU and review with Acute Prostatitis Treat for 28 days: results. First line: Ciprofloxacin 500mg BD Quinolones more effective but risk of CKS Second line: Trimethoprim 200mg BD adverse events e.g. C.difficile. Send cervical swab for MC&S for Pelvic Ceftriaxone 500mg IM stat N.gonorrhoeae, and cervical swab for Inflammatory plus NAATs for C.trachomatis +/- N.gonorrhoeae Disease 400mg BD for 14 days Consider referral to GUM plus Suspected PID in pregnancy requires urgent BASHH Doxycycline 100mg BD for 14 days hospital assessment

Gastrointestinal Infections  Treat positives in known DU, GU or low- First line: grade MALToma. Lansoprazole 30mg BD plus  Do not offer eradication in GORD. Amoxicillin 1g BD plus Eradication of  Treatment duration is 7 days for DU / GU Either Clarithromycin 500mg BD or H.pylori and 14 days for MALToma. Metronidazole 400mg BD

 Do not use clarithromycin or metronidazole NICE CG184 if used in the past year for another Penicillin allergy:

indication. Lansoprazole 30mg BD plus Clarithromycin 500mg BD plus See full guideline for second line therapy and Metronidazole 400mg BD treatment failures.  Stop unnecessary antibiotics and PPIs. Mild disease: Clostridium  Avoid anti-motility drugs in Metronidazole 400mg TDS for 10-14 days difficile diarrhoea suspected/confirmed disease.

For severe or recurrent disease see full PHE C.difficile  Assess severity (see full guideline) and consider admission if severe. guideline.  Treat household contacts concurrently. Mebendazole in >6 months: Threadworms  Hygiene advice: morning baths/showers, 100mg single dose (not in pregnancy) hand-washing, nail cutting, wash bed linen. Piperazine/senna sachet 3-6 months: CKS Mebendazole contraindicated in pregnancy  2.5ml stirred into water, repeat after 2 wks and in <6 months of age.  Routine use of antibiotics in uncomplicated Co-amoxiclav 625mg TDS for 7 days Acute diverticulitis is to be avoided. Diverticulitis Penicillin allergy:  Restrict prescribing to patients with signs of systemic infection and review within 48 Ciprofloxacin 500 mg BD plus CKS hours to assess clinical response. Metronidazole 400mg TDS for 7 days

Skin and Soft Tissue Infections  Topical therapy should be reserved for First line: only very minor infections to minimise Flucloxacillin resistance. 1mnth-2yrs: 125mg QDS  The topical agent of choice is: 2-10yrs: 250mg QDS Polyfax Ointment applied BD for 5 days. >10yrs and adult: 500mg QDS  Topical fusidic acid should be avoided due to resistance rates, which may lead to Clarithromycin for 7 days: treatment failures. >12yrs and adults: 250-500mg BD In children consider Erythromycin syrup: 1mnth-2yrs: 125mg QDS Oral therapy is advised in all but very minor 2-8yrs: 250mg QDS infections. Child >8yrs: 500mg QDS  If there is evidence of systemic infection, rapidly spreading cellulitis or severe pain Treat for 7-14 days until clinical response. urgent hospital referral is required. First line:  In facial cellulitis, use Co-amoxiclav 625mg Cellulitis Flucloxacillin 500mg QDS TDS instead to extend cover to respiratory

pathogens. CKS Penicillin allergy:  In South Nottinghamshire there is a Clarithromycin 500mg BD community based IV antibiotics service for In children consider Erythromycin syrup. uncomplicated cellulitis as an alternative to hospital admission, contact 0115 846 2376 Leg ulcers In the absence of cellulitis, treatment not indicated. Send swabs only if clinical evidence of PHE infection. Consider referral to Tissue Viability if difficult cases.  Antibiotics should only be used when First line: Diabetic foot surrounding cellulitis present. Co-amoxiclav 625mg TDS for 7-14 days infections  Refer to hospital if ulcer rapidly Penicillin allergy: deteriorating or systemically unwell. Clindamycin 300mg QDS for 7-14 days Refer to full guideline for information on Human or Animal prophylaxis and treatment on bite wounds. First line: Bites When Co-amoxiclav is unsuitable and in Co-amoxiclav 625mg TDS for 7 days CKS penicillin allergy, refer to the full guideline.  Most are self-limiting, 64% self-resolve. If severe: Chloramphenicol 0.5% drops Bacterial  Consider delayed prescribing strategy 4-5 2 hourly for 48 hours, then 4 hourly. Conjunctivitis days for mild cases. Treat if severe or Chloramphenicol 1% eye ointment TDS infection.

CKS  PHE recommend not normally necessary Continue for 48 hours after resolution. to exclude from school or work. Two applications, one week apart  Treat whole body from ears/chin Scabies (can be used in pregnancy and breastfeeding): downwards and under nails. Permethrin 5% cream or  Treat all household and sexual contacts CKS Malathion 0.5% aqueous liquid within 24hr. Best treated systemically:

 Take nail clippings: start therapy only if Dermatophyte Nail First line: Terbinafine 250mg OD for infection confirmed by laboratory. Infection 3 months (fingers) and 6 months (toes).  Terbinafine is more effective than azole,

and liver reactions are rare. CKS Second line: Itraconazole 200mg BD for  In children seek specialist advice. 1 week per month for 2 months (fingers) and 3 months (toes). Dermatophyte  Take skin scrapings for culture. Topical Terbinafine 1% BD for 1 week or Skin Infections See full guideline for dermatophyte scalp Topical Clotrimazole 1% BD for 4-6 weeks CKS infections or intractable disease. Chickenpox:  In pregnancy, neonates, or immunocompromised: seek urgent specialist advice. If treatment indicated: Varicella Zoster  Consider aciclovir if >14yrs, severe pain, Aciclovir 800mg 5 times a day for 7 days Virus Infections on corticosteroids, or a smoker, and onset

of rash <24hrs Second line if compliance a problem CKS Chickenpox Shingles: (ten times the cost of aciclovir):  Treat if >50 years and within 72 hrs of rash Valaciclovir 1g TDS for 7 days CKS Shingles (post-herpetic neuralgia rare if <50 years)

 Treat with valaciclovir if ophthalmic (and refer to Ophthalmology), Ramsey Hunt, eczema, non-truncal distribution, or severe pain or severe rash.

Suspected meningitis / meningococcal disease Suspected Transfer all patients to hospital immediately. meningitis / Administer benzylpenicillin prior to (ideally IV by slow bolus, but IM if vein meningococcal admission, if no history of or cannot be found) disease angioedema to . <1yr: 300mg; 1-9yr: 600mg; Child 10yrs and over and adults: 1.2g

Urinary Tract Infections – Refer to PHE Diagnosis of UTI Guidance. Community E.coli bacteraemia rate increasing: always consider risks for resistance

Women: treat if severe or ≥3 symptoms. If mild or ≤2 symptoms:  Urine NOT cloudy has 97% negative predictive value First line: Nitrofurantoin 100mg M/R BD  If cloudy, use dipstick: Nitrite plus blood or (Avoid nitrofurantoin if eGFR <45ml/min) leucocytes has 92% positive predictive value  Send MSU in treatment failures and when Second line: previous resistance to first line agents If ≥65 years or risk factor for resistance Men: present: Lower UTI  Consider prostatitis and send 400mg stat then 200mg TDS (Cystitis) pre-treatment MSU (Pivmecillinam is a penicillin antibiotic)  If mild/non-specific symptoms use negative PHE dipstick to exclude UTI If <65 years and no risk factors for resistance: SIGN UTI Before prescribing, consider risk factors Trimethoprim 200mg BD for resistance:  >65 years old  Care home resident Third line (use empirically ONLY if first  Recurrent UTI and second line treatments not suitable  Hospitalisation in the last 6 months and no previous MRSA or C.difficile):  Recent travel to country with increased Ciprofloxacin 500mg BD antimicrobial resistance Treat women for 3 days and  Previous resistant organism in urine men for 7 days  Treatment failures If risk factors for resistance present, send a pre-treatment urine sample.

First line: Ciprofloxacin 500mg BD for 7 days Upper UTI Send pre-treatment MSU. (Pyelonephritis) If no response within 24 hours, admit to Second line: CKS hospital. Trimethoprim 200mg BD for 14 days only if lab report confirms sensitive or 500mg BD for 7 days

Patients with recurrent urinary tract infections, previous urogenital surgery, or functional /

anatomical abnormalities of the urinary tract should have previous urine culture results Complicated UTI reviewed and a pre-treatment urine sample sent for MC&S. For therapy, follow the lower or

upper UTI treatment choices above according to clinical symptoms, and review with urine

culture result. Consider a 7 day course depending on response to therapy.

UTI in Pregnancy and See full guideline. UTI in Children Multi-resistant urinary pathogens including ESBL-producing E.coli are increasing. Risk factors include: care home resident, recurrent UTI, hospitalisation in last 6 months, travel to Multi-resistant UTI country with high resistance rates. Send pre-treatment MSU and review previous results. PHE If first line options not suitable due to multiple resistances, (unlicensed) is available after discussion with Microbiology. See full guideline for details regarding supply. Asymptomatic bacteriuria in Do not treat in the absence of symptoms as not associated with increased morbidity. >65yrs

Urinary catheter in Antibiotics will not eradicate bacteriuria. Dipstick tests are unhelpful in the diagnosis of situ possible catheter-associated UTI. Only treat if systemically unwell or pyelonephritis likely.