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NHS Fife Antibiotic Guidance for the Treatment of Community Managed Infections

The aim of this guidance is to: • promote appropriate antibiotic prescribing • adequately treat the infection that has been diagnosed • minimise the risk of patients developing Clostridium difficile infection • reduce the development of multi-drug resistant bacteria. C. difficile infection is associated with the use of all antibiotics but most strongly with cephalosporins, co-amoxiclav, clindamycin and quinolones. It is therefore particularly important to avoid these agents if at all possible.

Doses are for adults with normal renal function unless otherwise stated.

Antibiotics should be: • used only when there are clear signs of a bacterial infection • targeted at the likely or known pathogens i.e. use as narrow a spectrum agent as possible • used for the shortest duration required to treat the infection • stopped immediately if started inappropriately – don’t ‘complete the course’ just because it has been started.

UPPER INFECTIONS LOWER RESPIRATORY TRACT INFECTIONS URINARY TRACT INFECTIONS The majority of URTI are viral. Consider a “no prescribing” or Acute / Amoxicillin 500mg TDS Do not treat asymptomatic bacteriuria in >65 yrs or those with catheter in situ “delayed prescribing” strategy for those at low risk of complications Antibiotics have little benefit if no co-morbidity. Symptom If true penicillin allergy or resolution can take 3 weeks. Lower Urinary Tract Infection Trimethoprim 200mg BD

Pharyngitis / / Phenoxymethylpenicillin 500mg QDS no response to amoxicillin: Consider immediate antibiotics for those > 65yrs with 2 Non-pregnant women: or or 1G BD Doxycycline 200mg stat then 100mg OD or more of the following or > 80yrs and 1 or more of the Nitrofurantoin 50mg QDS (1G QDS if severe) Do not send pre-treatment MSU on 1st presentation. Avoid antibiotics as 90% resolve in 7 days following: • Hospitalisation in the previous year • Type (or nitrofurantoin MR 100mg BD) Duration: 5 days Send MSU for all treatment failures. without and pain is only reduced by 16 hours Duration: 10 days 1 or 2 diabetes • history of congestive heart failure •

current use of oral glucocorticoids Severe or ≥ 3 symptoms: treat (Avoid nitrofurantoin if Patients with 3 or 4 centor criteria (, If true penicillin allergy: Mild /or ≤ 2 symptoms: use dipstick to guide eGFR <60 ml/min) tonsillar exudate, lymphadenopathy, absence of Clarithromycin 500mg BD Doxycycline 200mg stat then 100mg OD Acute exacerbation of COPD treatment. Nitrite and blood or leucocytes has 92% cough) may benefit more from antibiotics or a Duration: 3 days for females prescription delayed by 2-3 days Duration: 5 days or positive predictive value; negative nitrite, leucocytes Antibiotics usually only of benefit if the patient has Clarithromycin 500mg BD 7 days for males and blood has a 76% negative predictive value. purulent sputum and either increased shortness of Acute Amoxicillin A Cochrane review found no breath or increased sputum volume If clinical failure to above: Men: difference in outcome between 3, 5 or 10 day Avoid antibiotics as 60% better in 24 hours If true penicillin allergy: Co-amoxiclav 625mg TDS Send pre-treatment MSU. If symptoms mild or without; they only reduce pain at 2 days and do Erythromycin suspension non-specific use negative nitrite and leucocytes to course of treatment for uncomplicated LUTI in not prevent deafness. Duration: 5 days exclude UTI. women

Children with otorrhoea or < 2yrs with bilateral Erythromycin suspension is preferable to acute otitis media may benefit more from clarithromycin suspension as it is half the cost Mild Community Acquired If CRB-65 score = 0: Upper Urinary Tract Pyelonephritis Amoxicillin 500mg TDS antibiotics or a prescription delayed by 2-3 days Ciprofloxacin 500mg BD for 7 days See BNF for children for dosages CRB-65 score can be used to help assess severity. Infection (Pyelonephritis) or Acute

Optimise NSAID and Paracetamol If true penicillin allergy: Prostatitis or Duration: 5 days CRB-65 score: 1 point for each of: Clarithromycin 500mg BD Co-amoxiclav TDS for 14 days ● Confusion (new onset) (AMT <8) Send MSU for culture & sensitivity and start Acute Otitis Externa First use aural toilet and optimise analgesia ● Resp Rate >30/min If clinical failure to above: anitibiotics Prostatitis If treatment required: ● BP diastolic ≤60mmHg or systolic <90mmHg If cellulitis or disease extends outside the ear Acetic acid 2% , 1 spray TDS for 7 days Doxycycline 200mg stat then 100mg OD If no response within 24 hours, admit 1st line: Ciprofloxacin 500mg BD canal start oral antibiotics and refer ● Age >65years If CRB-65 score = 1 and treating at home: 2nd Line: Trimethoprim 200mg BD CRB65 = 0: suitable for home treatment unless co- Acute Rhinosinusitis Amoxicillin 500mg - 1G TDS Amoxicillin 500mg TDS Quinolones achieve higher prostate levels both for 28 days morbidity/social concern. Avoid antibiotics as 80% resolve in 14 days or CRB65 = 1 or 2: hospital referral and assessment plus Clarithromycin 500mg BD Catheter-Related Urinary Tract Infection without treatment Doxycycline 200mg stat then 100mg OD required. If true penicillin allergy or clinical failure to above: Dipstick tests are not recommended for diagnosing catheter related UTI. Catheterised patients with Use adequate analgesia CRB65 score = ≥3: urgent hospital referral 2nd line for persistent symptoms: Doxycycline 200mg stat then 100mg OD asymptomatic bacteriuria should not receive antibiotics (SIGN 88). Antibiotics only required if patient has Consider 7 day delayed or immediate Co-amoxiclav 625mg TDS Hypoxia is also an admission indicator (aim for O2 sats signs/symptoms of UTI e.g. fever, flank/suprapubic discomfort, change in voiding pattern, nausea, antibiotics if purulent pharyngeal discharge of 94-98% or if at risk of hypercapnic If patient presents with/post : vomiting, , confusion. If treatment is required, where possible the catheter should be removed in the Duration: 7 days 88-92%). Doxycycline 200mg stat then 100mg OD first 24 hours of treatment and replaced only if necessary. or For adults, if delayed admission or life threatening and Treatment as for lower or upper UTI dependent on clinical signs/symptoms no known penicillin allergy give immediate: Co-amoxiclav 625mg TDS GASTRO-INTESTINAL TRACT INFECTIONS benzylpenicillin 1200mg IV or amoxicillin 1g oral Urinary Tract Infection in pregnancy Trimethoprim 200mg BD Duration: 7 days Eradication of st Send MSU for culture & sensitivity and start (avoid in 1 trimester) See Fife Formulary for eradication regimes empirical antibiotics or Do not use clarithromycin or metronidazole if used in past year for any infection Clostridium difficile Infection (CDI) Nitrofurantoin 50 mg QDS Short term use of nitrofurantoin in pregnancy is IN ALL CASES (or nitrofurantoin MR 100mg BD) Infectious Diarrhoea - Patients should be fully assessed by a doctor when they are identified as being C. difficile positive. unlikely to cause problems to foetus (avoid close to term or eGFR < 60ml/min) Antibiotics not indicated unless patient systemically unwell. If systemically unwell and - Appropriate infection control measures should be taken until patient has been asymptomatic for 48 hours. Avoid trimethoprim if low folate status or on folate campylobacter suspected consider Clarithromycin 250-500mg BD for 5 days if treated early. - The need for any currently prescribed antibiotics should be reviewed and if possible stopped. If they do need to be continued antagonist (e.g. antiepileptic ) Duration: 7 days Antibiotics should not be prescribed if E.coli 0157 is suspected. the narrowest spectrum agent suitable for the indication should be used. - Antimotility agents and gastric acid suppressive therapy should be stopped if possible. - Fluid, electrolyte and nutritional status should be assessed and replaced/supplemented if indicated. Urinary Tract Lower UTI:

Traveller’s Diarrhoea Infection in children Trimethoprim or Nitrofurantoin Only consider stand-by antibiotics for patients travelling to remote areas or those people at SEVERE DISEASE: Duration: 3 days - All patients with symptoms/signs of severe CDI should be admitted to hospital. < 3 months with suspected UTI: admit high risk of severe illness: Private prescription for Ciprofloxacin 500mg BD for 3 days. ° In areas of high ciprofloxacin resistance (e.g. South Asia) consider Pepto-Bismol 2 tabs QDS for 2 days - Symptoms/signs that indicate severe disease include a temperature >38.5 C, blood or mucous in the stool, abdominal Upper UTI: distension (suggestive of colonic dilatation), acute abdomen, clinical signs of dehydration, and if blood results known If ≥3 months use positive nitrite to start antibiotics.

WCC >15 X10 9/L, acutely rising serum creatinine or creatinine >1.5 times baseline. Co-amoxiclav > 6mths: Mebendazole 100mg stat Imaging: Only refer children < 6 months or those Thread worms Immunocompromised patients should also be managed as severe cases. (Off label if < 2 yrs) Duration: 7-10 days with atypical UTI Treat all household contacts at same time plus or NON-SEVERE DISEASE:: Send pre-treatment MSU for all See BNF for children for dosages hygiene measures for 2 weeks Piperazine/senna sachet: - Non-severe cases (i.e. patient symptomatic but does not meet any of the criteria for severe CDI) may be managed at home (hand hygiene, pants at night, morning shower) Adults & 1-6yrs: 1 sachet stat depending on co-morbidity and social circumstances. 3-12 mths: One level 2.5ml spoonful stat - Treat with oral metronidazole 400mg 8 hourly for 10 days . If no improvement after 5 days of metronidazole, change to oral vancomycin 125mg 6 hourly for 10 days. Relapses can occur and these cases should be discussed with the microbiologist. Issued by: NHS Fife Antimicrobial Management Team Also, wash sleepwear, bed linen, dust & repeat after 2 weeks Authorised by: NHS Fife Area Drug and Therapeutics Committee vacuum on day one < 3 months: 6 weeks hygiene ASYMPTOMATIC: Asymptomatic C. difficile toxin positive patients do not require treatment Issued: Sept 2010 Review date: Sept 2011 Page 1 of 2 SKIN / SOFT TISSUE INFECTIONS MENINGITIS Cellulitis Flucloxacillin 500mg QDS Scabies Permethrin 5% cream Suspected IV or IM Benzylpenicillin: (Also: other skin and soft tissue Treat whole body from ear/chin downwards & 2 applications one week apart If true penicillin allergy: Adults and child >10yrs: 1200mg under nails. <2yrs & elderly also face and Transfer all patients to hospital immediately infections) Clarithromycin 500mg BD If allergy: 1-9 yrs: 600mg scalp If possible administer benzylpenicillin or cefotaxime < 1 yr: 300mg If patient is afebrile and otherwise If mild facial cellulitis: Malathion 0.5% aqueous liquid Treat all household and sexual contacts prior to admission, unless hypersensitive i.e. healthy, flucloxacillin should be used Co-amoxiclav 625mg TDS 2 applications one week apart within 24 hours history of difficulty breathing, collapse, loss of IV or IM Cefotaxime: as a single agent. If MRSA known/suspected: consciousness or rash Adult and child >12 yrs: 1G

If river or sea water exposure, consult Doxycycline 200mg OD Varicella Zoster / Chicken pox If antivirals are indicated: < 12 yrs: 50mg/kg Microbiologist Ideally IV but IM if a vein cannot be found (check sensitivities once available) If pregnant or immunocompromised or First Line treatment for both If febrile and ill, or severe facial neonate: seek urgent advice chicken pox and shingles: Duration: 7 days cellulitis admit for IV treatment GENITAL TRACT INFECTIONS If slow response continue for further 7 days Consider aciclovir if treatment can be started Aciclovir 800mg 5 times / day within 24 hrs of onset of rash and patient is Diabetic Foot Infection Depending on history and severity: >14 yrs, or has severe pain, or is on steroids, Vaginal candidiasis Clotrimazole 500mg pessary - stat 2nd line for shingles only if compliance Flucloxacillin 500mg QDS or is a smoker or is a secondary household or Specialist podiatry referral advised. issue as 10 times the cost: All topical and oral azoles give 75% cure rate. or case. Clotrimazole 10% vaginal cream, 5g - stat Ulcers will always be colonised by Co-amoxiclav 625mg TDS Valaciclovir 1G TDS Avoid oral azole in pregnancy. Use intravaginal or bacteria and antibiotics do not improve healing. Only send culture swabs and Herpes Zoster / Shingles or clotrimazole 100mg pessary nocte for 6 nights Fluconazole 150mg orally, stat dose If true penicillin allergy: treat with antibiotics if clinical signs/ If pregnant or immunocompromised or Famciclovir 250mg TDS Discuss with Microbiologist. Candidal vulvitis can be treated locally with symptoms of infection e.g. cellulitis, neonate: seek urgent advice increased pain, enlarging ulcer, pyrexia, If MRSA known/suspected: Clotrimazole 1% cream applied bd - tds Always treat if active ophthalmic or Ramsey Duration: 7 days purulent or odour Doxycycline 200mg OD or 100mg BD Withhold antibiotics pending podiatry Hunt or eczema. Bacterial vaginosis Metronidazole 400mg BD for 7 days (check sensitivities once available) Also treat > 50yrs if < 72 hrs of onset of rash. review and/or culture results when or Oral metronidazole is as effective as topical treatment but feasible. Review at 7 days or sooner if deterioration Metronidazole 0.75% vaginal gel 5g is cheaper (may require prolonged therapy) Fungal infections of the skin Terbinafine 1% topically BD applicatorful nocte for 5 nights Always review antibiotic therapy A 2 gram stat dose of metronidazole may be prescribed if Terbinafine is fungicidal so treatment time is once culture results are available. Duration: 7-14 days concerns about compliance but there is less relapse at 4 or If osteomyelitis contact Microbiologist for advice shorter than for imidazoles. or weeks with 7 days treatment than with 2 gram stat dose. Clindamycin 2% cream 5g applicatorful nocte Candidal skin infections should be treated Chronic Leg Ulcers Flucloxacillin 500mg QDS Clotrimazole 1% or Miconazole 2% Avoid 2g stat dose in pregnancy & breast feeding for 7 nights with imidazoles initially. topically BD Ulcers will always be colonised by If true penicillin allergy: If intractable send skin scrapings. If infection bacteria and antibiotics do not improve continue for 1-2 weeks after healing Azithromycin 1 gram stat dose Clarithromycin 500mg BD is confirmed, use oral itraconazole or oral Chlamydia trachomatis healing. Only send culture swabs and or Duration: 7 days terbinafine Opportunistically screen all aged 15-25yrs treat with antibiotics if clinical signs/ Doxycycline 100mg BD for 7 days symptoms of infection e.g. cellulitis, Discuss scalp infections with specialist Treat partners and refer to GUM clinic. Review antibiotics once culture results available increased pain, enlarging ulcer, pyrexia, (avoid in pregnancy) If slow response continue for further 7 days In pregnancy & breast feeding azithromycin is the m ost purulent exudate or odour Fungal infections of the Amorolfine 5% nail lacquer effective option but is ‘off label’ (see SIGN 109 for other proximal fingernail or toenail Apply 1-2 times per week options). Due to lower cure rate in pregnancy, test for Impetigo Crystacide® or Fusidic acid topically TDS

Take nail clippings: start therapy only if Duration: Fingers: 6 months cure 6 weeks after treatment. As resistance is increasing reserve *Mupirocin ointment topically TDS infection confirmed. Toes: 12 months topical antibiotics for very localised Metronidazole 400mg BD for 5 days Duration: 5 days Trichomoniasis lesions. If the infection is mild and superficial or or Terbinafine 250mg OD Treat partners simultaneously and refer to GUM clinic For extensive, severe, or bullous use topical treatment. More severe Metronidazole 2 gram stat dose Flucloxacillin 500mg QDS Avoid metronidazole 2g stat dose in pregnancy & breast impetigo, use oral antibiotics infections will require oral therapy. Duration: Fingers: 6 - 12 weeks or feeding. If true penicillin allergy: Liver reactions are rare with oral antifungals Toes: 3 - 6 months Clotrimazole 100mg pessary nocte for *Reserve Mupirocin for MRSA Consider clotrimazole for symptom relief (not cure ) if Clarithromycin 500mg BD 6 nights Oral terbinafine is more effective than Erythromycin suspension is preferable Itraconazole 200mg BD metronidazole treatment declined. Duration: 7 days to clarithromycin suspension as it is itraconazole in dermatophyte infections Duration: Fingers: 7 days/month half the cost See BNF for children for Child dosages Pelvic Inflammatory Disease (PID) Cefixime 400mg stat If candida or non-dermatophyte infection for 2 courses plus confirmed use Itraconazole Refer women and contacts to GUM clinic

Eczema Toes: 7 days/month Metronidazole 400mg BD for 14 days Always test for N. gonorrhoea and Chlamydia. Using topical antibiotics or adding them to topical steroids in eczema encourages resistance and does Children: seek specialist advice for 3 courses plus not improve healing. If visible signs of infection, treat as for impetigo 28% of gonorrhoea isolates are now resistant to Doxycycline 100mg BD for 14 days Conjunctivitis If severe: quinolones. If gonorrhoea likely (e.g. partner has it, or Cat or Dog Bite: Prophylaxis and treatment of Chloramphenicol 0.5% drops severe symptoms, sex abroad) avoid ofloxacin regimen. Thorough irrigation is important cat, dog and human bite: Most bacterial conjunctivitis is self-limiting. Metronidazole 400mg BD Daytime: instil every 2 hours for 2 days Assess tetanus and rabies risk. 65% resolve on placebo by day 5. plus Antibiotic prophylaxis advised for cat bite/ Co-amoxiclav 625mg TDS then reduce to every 4 hours Ofloxacin 400mg BD puncture wound; bite involving hand, foot, If true penicillin allergy: First line treatment: advise regular Plus face, joint, tendon, ligament; Metronidazole 400mg TDS cleansing and hygiene measures. Chloramphenicol 1% ointment nocte both for 14 days immunocompromised; diabetics, elderly, asplenic, cirrhotic Plus Fusidic acid has less Gram-negative activity 2nd line treatment:: Doxycycline 100mg BD Human Bite: Fusidic acid 1% gel applied BD

Thorough irrigation is important Duration: 7 days Issued by: NHS Fife Antimicrobial Management Team Antibiotic prophylaxis advised Duration: to continue for 48 hours after Authorised by: NHS Fife Area Drug and Therapeutics Committee Assess tetanus, HIV, Hepatitis B & C risk Review at 24 and 48 hrs symptom resolution Issued: Sept 2010 Review date: Sept 2011 Page 2 of 2