Antibiotic Guidelines - Indications for use of Cephalosporins, Quinolones and Co-Amoxiclav Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs. Illness Choice of drug Adult Dose Duration Comments 1st choice: Nitrofurantoin 100mg MR BD or 50mg qds if All for 7 Pregnant women, men, children or young people: immediate Lower urinary tract (avoid at term) - if eGFR ≥45 ml/minute MR unavailable days antibiotic. infection in pregnancy 2nd choice : Amoxicillin (only if culture When considering antibiotics, take account of severity of results available and susceptible) OR 500mg TDS symptoms, risk of complications, previous urine culture and NICE Visual Summary cefalexin 500mg BD susceptibility results, previous antibiotic use which may have led Children and young people (3 months and over) first choice: All for 3 to resistant bacteria and local antimicrobial resistance data. Lower urinary tract trimethoprim (if low risk of resistance) OR days Treatment of asymptomatic bacteriuria in pregnant women: infection in children nitrofurantoin (if eGFR ≥45 ml/minute) choose from nitrofurantoin (avoid at term), amoxicillin or Children and young people (3 months and over) second choice: cefalexin based on recent culture and susceptibility results NICE Visual Summary nitrofurantoin (if eGFR ≥45 ml/minute and not used as first choice) OR For dosing in children and young people under 16 years please amoxicillin (only if culture results available and susceptible) OR cefalexin see visual summary Non-pregnant women and men first 500mg BD or TDS (up to 1g to 1.5g 7–10 days Advise paracetamol (+/- low-dose weak opioid) for pain for Acute pyelonephritis choice: TDS or QDS for severe infections) people over 12. (upper urinary tract) cefalexin OR Offer an antibiotic. co-amoxiclav (only if culture results 625mg TDS 7–10 days When prescribing antibiotics, take account of severity of NICE Visual Summary available and susceptible) OR symptoms, risk of complications, previous urine culture and trimethoprim (only if culture results 200mg BD 14 days susceptibility results, previous antibiotic use which may have led available and susceptible) OR to resistant bacteria and local antimicrobial resistance data. Avoid antibiotics that don’t achieve adequate levels in renal ciprofloxacin (consider safety issues) 500mg BD 7 days tissue, such as nitrofurantoin. For pregnant women and second choice antibiotics for all see Pregnant women first choice: cefalexin 500mg BD or TDS (up to 1g to 1.5g 7–10 days Visual Summary. TDS or QDS for severe infections) Children and young people (3 months and over) first choice: cefalexin OR co-amoxiclav (only if culture results available and susceptible) For dosing in children and young people under 16 years please see visual summary First choice antibiotic prophylaxis: 200mg single dose when exposed to a trigger First advise about behavioural and personal hygiene measures, Recurrent urinary tract trimethoprim (avoid in pregnancy) OR or 100mg at night and self-care (with D-mannose or cranberry products) to reduce infection the risk of UTI. nitrofurantoin (avoid at term) - if eGFR ≥45 100mg single dose when exposed to a trigger For postmenopausal women, if no improvement, consider ml/minute or 50 to 100mg at night NICE Visual Summary vaginal oestrogen (review within 12 months). Second choice antibiotic prophylaxis: 500mg single dose when exposed to a trigger For non-pregnant women, if no improvement, consider single- amoxicillin OR or 250mg at night dose antibiotic prophylaxis for exposure to a trigger (review cefalexin 500mg single dose when exposed to a trigger within 6 months). or 125mg at night For non-pregnant women (if no improvement or no identifiable trigger) or with specialist advice for pregnant women, men, children or young people, consider a trial of daily antibiotic prophylaxis (review within 6 months). Non-pregnant women and men first choice 500mg BD or TDS (up to 1g Antibiotic treatment is not routinely needed for asymptomatic Catheter-associated if upper UTI symptoms are present: to 1.5g TDS or QDS for severe bacteriuria in people with a urinary catheter. UTI cefalexin OR infections) Consider removing or, if not possible, changing the catheter if it 7 -10 days has been in place for more than 7 days. But do not delay NICE Visual Summary co-amoxiclav (only if culture results antibiotic treatment. 625mg TDS available and susceptible) OR Advise paracetamol for pain. Advise drinking enough fluids to avoid dehydration. trimethoprim (only if culture results Offer an antibiotic for a symptomatic infection. 200mg BD available and susceptible) OR 14 days When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and ciprofloxacin (consider safety issues) 500mg BD 7 days susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data. 500mg BD or TDS (up to 1g 7–10 days Do not routinely offer antibiotic prophylaxis to people with a Pregnant women first choice: cefalexin to 1.5g TDS or QDS for severe short-term or long-term catheter. infections) Cephalosporins Children and young people (3 months and over) first choice: trimethoprim (if low risk of resistance) OR amoxicillin (only if culture results available and susceptible) OR cefalexin OR co-amoxiclav (only if culture results available and susceptible) For dosing in children and young people under 16 years see visual summary Diverticulitis First-choice (uncomplicated acute Acute diverticulitis and systemically well: Consider diverticulitis): no antibiotics, offer simple analgesia (for example NICE Visual Summary co-amoxiclav 625mg TDS All 5 days * paracetamol), advise to re-present if symptoms persist or Penicillin allergy or co-amoxiclav worsen. Acute diverticulitis and systemically unwell, 500mg BD or TDS (up to unsuitable: immunosuppressed or significant comorbidity: offer 1g to 1.5g TDS or QDS if severe)) cefalexin (caution in penicillin allergy) an antibiotic. AND metronidazole 400mg TDS Give oral antibiotics if person not referred to hospital for OR suspected complicated acute diverticulitis. trimethoprim 200mg BD If CT-confirmed uncomplicated acute diverticulitis, review AND metronidazole 400mg TDS the need for antibiotics. OR * A longer course may be needed based on clinical ciprofloxacin (only if switching from IV 500mg BD assessment. ciprofloxacin with specialist advice; consider safety issues) AND metronidazole 400mg TDS Gonorrhoea Ceftriaxone 1000mg IM Stat Antibiotic resistance is now very high. OR Use IM ceftriaxone if susceptibility not known prior to treatment. ciprofloxacin 500mg Stat Use Ciprofloxacin only If susceptibility is known prior to (only if known to be sensitive) treatment and the isolate is sensitive to ciprofloxacin at all sites of infection. Refer to GUM. Test of cure is essential. Pelvic Inflammatory First line therapy: Refer women and sexual contacts to GUM. Disease ceftriaxone PLUS 1000mg IM STAT Raised CRP supports diagnosis, absent pus cells in HVS smear metronidazole PLUS 400mg BD 14 days good negative predictive value. doxycycline 100mg BD 14 days Exclude: ectopic, appendicitis, endometriosis, UTI, irritable Second line therapy: bowel, complicated ovarian cyst, functional pain. Metronidazole PLUS 400mg BD 14 days ofloxacin . 400mg BD 14 days Moxifloxacin has greater activity against likely pathogens, but OR moxifloxacin alone 400mg OD 14 days always test for gonorrhoea, chlamydia, and M. genitalium . (first line for M. genitalium associated PID) If M. genitalium tests positive use moxifloxacin. Hospital-acquired See guidance in Quinolones section on hospital acquired pneumonia ( below community acquired pneumonia entry ) pneumonia

Acute prostatitis First choice (guided by susceptibilities Advise paracetamol (+/- low-dose weak opioid) for pain, or when available): ciprofloxacin OR 500mg BD ibuprofen if preferred and suitable. NICE Visual Summary ofloxacin OR 200mg BD Offer antibiotic. trimethoprim (if unable to take quinolone, 200mg BD Review antibiotic treatment after 14 days and either stop seek specialist advice ) 14 days then antibiotics or continue for a further 14 days if needed (based on Second choice (after discussion with review assessment of history, symptoms, clinical examination, urine and specialist): levofloxacin OR 500mg OD blood tests).Consider safety issues of quinolones co-trimoxazole 960mg BD Acute pyelonephritis As above: see previous entry regarding Acute pyelonephritis Catheter-associated As above: see previous entry regarding Catheter-associated UTI UTI Diverticulitis As above: see previous entry regarding diverticulitis Helicobacter pylori For first choice, Penicillin allergy, previous Clarithromycin, and Third line Always test for H.pylori before giving antibiotics. choice please refer to full guidelines for antibiotic choice. Treat all positives in known DU, GU or low grade MALToma. NNT in non-ulcer dyspepsia: 14. For relapse and previous metronidazole Do not offer eradication for GORD. Do not use clarithromycin, and clarithromycin: metronidazole or quinolone if used in the past year for any infection Penicillin allergy: use PPI PLUS Clarithromycin and Metronidazole. If PPI PLUS previous clarithromycin use PPI PLUS bismuthate salt PLUS metronidazole PLUS tetracycline. Amoxicillin PLUS 1000mg BD 7 days For relapse and penicillin allergy (no exposure to quinolone): use PPI tetracycline hydrochloride OR 500mg QDS PLUS metronidazole PLUS levofloxacin. levofloxacin ( if tetracycline cannot be 250mg BD MALToma Retest for H.pylori: post DU/GU, or relapse after second line therapy, used 14 days using urea breath test or stool antigen test; consider referral for endoscopy and culture. Pelvic Inflammatory As above: see previous entry regarding Pelvic Inflammatory Epididymitis Doxycycline OR 100mg BD 10 - 14 days Usually due to Gram-negative enteric bacteria in men over 35 years ofloxacin OR 200mg BD 14 days with low risk of STI. ciprofloxacin 500mg BD 10 days If under 35 years or STI risk, refer to GUM Acute exacerbation of First choice: Many exacerbations are not caused by bacterial infections so will not COPD amoxicillin OR 500mg TDS respond to antibiotics. Consider an antibiotic, but only after taking into doxycycline OR 200mg stat then 100mg OD All for 5 account severity of symptoms (particularly sputum colour changes and NICE Visual Summary clarithromycin 500mg BD days increases in volume or thickness), need for hospitalisation, previous Second choice: use alternative first choice exacerbations, hospitalisations and risk of complications, previous Alternative choice (if person at higher sputum culture and susceptibility results, and risk of resistance with risk of treatment failure): repeated courses. co-amoxiclav OR 625mg TDS Some people at risk of exacerbations may have antibiotics to keep at co-trimoxazole OR 960mg BD home as part of their exacerbation action plan. levofloxacin (with specialist advice if 500mg OD co-amoxiclav or co-trimoxazole cannot (see BNF for doses in severe infection) be used consider safety issues) Acute exacerbation of First choice empirical treatment: Send a sputum sample for culture and susceptibility testing. bronchiectasis (non- amoxicillin (preferred if pregnant) OR 500mg TDS Offer an antibiotic. cystic fibrosis) doxycycline (not in under 12s) OR 200mg stat then 100mg OD 7-14 days When choosing an antibiotic, take account of severity of symptoms Clarithromycin 500mg BD Alternative choice (if person at and risk of treatment failure. People who may be at higher risk of NICE Visual Summary higher risk of treatment failure) treatment failure include people who’ve had repeated courses of empirical treatment: antibiotics, a previous sputum culture with resistant or atypical co-amoxiclav OR 625mg TDS 7-14 days bacteria, or a higher risk of developing complications. levofloxacin (adults only: with 500mg OD or BD Course length is based on severity of broncheictasis, exacerbation specialist advice if co amoxiclav cannot history, severity of exacerbation symptoms, previous culture and

Quinolones Quinolones be used; consider safety issues) OR susceptibility results, and response to treatment. ciprofloxacin (children only: with For childrens doses please Do not routinely offer antibiotic prophylaxis to prevent exacerbations. specialist advice if co-amoxiclav use visual summary cannot be used; consider safety issues) Seek specialist advice for preventing exacerbations in people with repeated acute exacerbations. This may include a trial of antibiotic prophylaxis after a discussion of the possible benefits and harms, and the need for regular review. For detailed information click on the visual summary. For IV antibiotics click on visual summary. When current susceptibility data available choose antibiotic accordingly Community-acquired First choice (low severity in adults or Assess severity in adults based on clinical judgement guided by pneumonia non-severe in children):a mortality risk score (CRB65 or CURB65). See the NICE guideline on amoxicillin 500mg TDS (higher doses pneumonia for full details: can be used, see BNF) All 5 days low severity – CRB65 0 or CURB65 0 or 1 NICE Visual Summary Alternative first choice (low severity * Stop in adults or non-severe in children): antibiotics moderate severity – CRB65 1 or 2 or CURB65 2 doxycycline (not in under 12s) OR 200mg stat then 100mg OD after 5 high severity – CRB65 3 or 4 or CURB65 3 to 5. clarithromycin OR 500mg BD days 1 point for each parameter: confusion, (urea >7 mmol/l), respiratory erythromycin ( in pregnancy ) 500mg QDS unless rate ≥30/min, low systolic (<90 mm Hg) or diastolic (≤60 mm Hg) microbiolog blood pressure, age ≥65. First choice (moderate severity in ical results adults): suggest a Assess severity in children based on clinical judgement. amoxicillin 500mg TDS (higher doses longer Offer an antibiotic. Start treatment as soon as possible after diagnosis, WITH (if atypical pathogens can be used, see BNF) course is within 4 hours (within 1 hour if sepsis suspected and person meets suspected) needed or any high risk criteria clarithromycin OR 500mg BD the person erythromycin (in pregnancy) 500mg QDS When choosing an antibiotic, take account of severity, risk of is not complications, local antimicrobial resistance and surveillance data, Alternative first choice (moderate clinically recent antibiotic use and microbiological results. severity in adults): stable doxycycline OR 200mg stat then 100mg OD clarithromycin 500mg BD For detailed information click on the visual summary. See also the First choice (high severity in adults NICE guideline on pneumonia. or severe in children): For IV antibiotics click on visual summary .For childrens doses click on co-amoxiclav 625mg TDS visual summary WITH (if atypical pathogens suspected) clarithromycin OR 500mg BD erythromycin ( in pregnancy ) 500mg QDS Alternative first choice (high severity in adults): levofloxacin (consider safety issues) 500mg bd Hospital-acquired First choice (non-severe and not If symptoms or signs of pneumonia start within 48 hours of hospital pneumonia higher risk of resistance): admission, see community acquired pneumonia. co-amoxiclav 625mg TDS Offer an antibiotic. Start treatment as soon as possible after diagnosis, NICE Visual Summary within 4 hours (within 1 hour if sepsis suspected and person meets Adults alternative first choice (non- any high risk criteria – see the NICE guideline on sepsis). severe and not higher risk of resistance) 5 days When choosing an antibiotic, take account of severity of symptoms or Choice based on specialist then signs, number of days in hospital before onset of symptoms, risk of microbiological advice and local review developing complications, local hospital and ward-based antimicrobial resistance data resistance data, recent antibiotic use and microbiological results, Options include: recent contact with a health or social care setting before current doxycycline 200mg stat then 100mg OD admission, and risk of adverse effects with broad spectrum antibiotics. cefalexin (caution in penicillin allergy) 500mg BD or TDS (can No validated severity assessment tools are available. Assess severity increase to 1 to 1.5g TDS or QDS ) of symptoms or signs based on clinical judgement. 960mg BD co-trimoxazole Higher risk of resistance includes relevant comorbidity (such as 500mg OD or BD levofloxacin (only if switching from IV severe lung disease or immunosuppression), recent use of broad levofloxacin with specialist advice; spectrum antibiotics, colonisation with multi-drug resistant bacteria, consider safety issues) and recent contact with health and social care settings before current Children alternative first choice (non- admission. severe and not higher risk of If symptoms or signs of pneumonia start within days 3 to 5 of hospital resistance): clarithromycin See visual summary admission in people not at higher risk of resistance, consider following Other options may be suitable based on community acquired pneumonia for choice of antibiotic. specialist microbiological advice and For detailed information click on the visual summary. See also the local resistance data NICE guideline on pneumonia. For first choice IV antibiotics (severe or higher risk of resistance) and antibiotics to be added if suspected or confirmed MRSA infection see visual summary

Acute Otitis First choice: Amoxicillin For dosing in children and 5 - 7 days Regular paracetamol or ibuprofen for pain (right dose for age or Media young people under 18 years weight at the right time and maximum doses for severe pain). Penicillin Allergy: please see visual summary 5 - 7 days Otorrhoea or under 2 years with infection in both ears: no, back-up or NICE Visual Summary Clarithromycin OR immediate antibiotic. Erythromycin (preferred if 5 - 7 days Otherwise: no or back-up antibiotic. pregnant) Systemically very unwell or high risk of complications: immediate Second choice: Co-amoxiclav 5 - 7 days antibiotic Sinusitis First choice: Advise paracetamol or ibuprofen for pain. Little evidence that nasal Phenoxymethylpenicillin 500mg QDS saline or nasal decongestants help, but people may want to try them. Penicillin Allergy: Symptoms for 10 days or less: no antibiotic. NICE visual summary Doxycycline (not in under 12s) OR 200mg stat then 100mg OD Symptoms with no improvement for more than 10 days: no antibiotic Clarithromycin 500mg BD All 5 days or back-up antibiotic depending on likelihood of bacterial cause. OR Erythromycin (preferred if pregnant) 250 to 500mg QDS or Consider high-dose nasal corticosteroid (if over 12 years). Second choice or first choice if 500 to 1000mg BD Systemically very unwell or high risk of complications: immediate systemically very unwell or high risk of antibiotic. complications: Co-amoxiclav 625mg TDS Acute exacerbation of As above: see previous entry regarding Acute exacerbation of COPD COPD Acute exacerbation of As above: see previous entry regarding Acute exacerbation of bronchiectasis (non-cystic fibrosis) bronchiectasis (non-

cystic fibrosis) Community-acquired As above: see previous entry regarding Community-acquired Pneumonia pneumonia Hospital-acquired As above: see previous entry regarding Hospital -acquired pneumonia pneumonia Acute pyelonephritis As above: see previous entry regarding Acute pyelonephritis Catheter-associated As above: see previous entry regarding Catheter-associated UTI UTI Diverticulitis As above: see previous entry regarding diverticulitis

Amoxiclav Cellulitis and Flucloxacillin 500mg-1g QDS 5 to 7 Exclude other causes of skin redness (inflammatory reactions or non-

- Erysipelas If penicillin allergic or flucloxacillin not days* infectious causes). suitable Consider marking extent of infection with a single-use surgical marker NICE visual summary Clarithromycin OR 500mg BD pen.

Co erythromycin (in pregnancy) OR 500mg QDS 5 to 7 doxycycline (adults only) OR 200mg on day 1, then 100mg days* Offer an antibiotic. Take account of severity, site of infection, risk of OD uncommon pathogens, any microbiological results and MRSA status. co-amoxiclav (children only: not in Infection around eyes or nose is more concerning because of serious penicillin allergy) intracranial complications. For infections near eye/nose *A longer course (up to 14 days in total) may be needed but skin takes Co-amoxiclav 625mg TDS 7 days* time to return to normal, and full resolution at 5 to 7 days is not If pencillin allergy then expected. clarithromycin AND 500mg BD 7 days* metronidazole (only add in children if 400mg TDS 7 days* Do not routinely offer antibiotics to prevent recurrent cellulitis or anaerobes suspected) erysipelas. For detailed information click on the visual summary. For alternative choice antibiotics for severe infection, suspected or confirmed MRSA infection and IV antibiotics click on the visual summary

Leg Ulcer Infection First choice : Manage any underlying conditions to promote ulcer healing. Flucloxacillin 500mg to 1g QDS All 7 days Only offer an antibiotic when there are symptoms or signs of infection NICE visual summary OR for penicillin allergy or when (such as redness or swelling spreading beyond the ulcer, localised fluxcloxacillin is unsuitable: warmth, increased pain or fever). Few leg ulcers are clinically infected Doxycyline OR 200mg stat , then 100mg OD, but most are colonised by bacteria. can be increased to 200mg OD Clarithromycin OR 500mg BD When prescribing antibiotics, take account of severity, risk of Erythromycin ( in pregnancy) 500mg QDS complications and previous antibiotic use. For detailed information click on the visual summary. Second choice co-amoxiclav OR 625mg TDS For antibiotic choices if severely unwell or MRSA suspected or co-trimoxazole (in penicillin allergy) 960mg BD confirmed, click on the visual summary Human and animal First choice : Offer an antibiotic for a human or animal bite if there are symptoms or Bites co-amoxiclav 375–625mg TDS 3 days for signs of infectionTake a swab for microbiological testing if there is Penicillin allergy or co-amoxiclav prophylaxis discharge (purulent or non-purulent) from the wound. NICE Visual Summary unsuitable : 5 days for treatment ( Do not offer antibiotic prophylaxis if a human or animal bite has metronidazole AND 400mg TDS not broken the skin. doxycyline 200mg day 1, then 100mg or can extend 200mg daily to 7 days Human bite: dependent For MRSA discuss with Offer antibiotic prophylaxis if the human bite has broken the skin and on clinical microbiologist assessment drawn blood. Seek specialist advice in pregnancy and with Consider antibiotic prophylaxis if the human bite has broken the skin review)) but not drawn blood if it is in a high-risk area or person at high risk.

Cat bite: Offer antibiotic prophylaxis if the cat bite has broken the skin and drawn blood. Consider antibiotic prophylaxis if the cat bite has broken the skin but not drawn blood if the wound could be deep. Dog or other traditional pet bite (excluding cat bite): Do not offer antibiotic prophylaxis if the bite has broken the skin but not drawn blood. Offer antibiotic prophylaxis if the bite has broken the skin and drawn blood if it has caused considerable, deep tissue damage or is visibly contaminated (for example, with dirt or a tooth). Consider antibiotic prophylaxis if the bite has broken the skin and drawn blood if it is in a high risk area or person at high risk.

For doses in children please refer to the relevant NICE visual summary or the BNF for Children.

See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.

Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.

Produced by West Essex CCG Medicines Optimisation Team

Approved at MOPB 31st January 2019; NICE Updates agreed MOPB 28th February 2019; Summary Updated March 2019 Latest NICE updates approved by MOPB chairman’s action April 2020.Latest NICE update approved at MOPB April 21 and HMMC May 21

Document Consultation Page Changes / where deviates from NICE history from Process (s) March 2020 NICE updates Approved by 1 Acute diverticulitis added March 2020 MOPB 2 Bronchiectasis added chairman’s 2-3 Community and hospital acquired pneumonia added action April 3 2020 4 Leg ulcer infection (replaces PHE guidance from Feb 2019). Review March Approved by 1 Rationale added. 2020 to align MOPB guidance with chairman’s 1 Pelvic inflammatory disease updated in line with NICE NICE. action April 3 Cellulitis and Erysipelas updated in line with NICE 2020 Feb 2021 Information on COVID -19 rapid guidelines on community acquired pneumonia, link links are added in line with ICS and NICE already approved April 2021 MOPB 2-4 Community acquired pneumonia reverts to NICE sep19. Human and animal bites section detail expanded