Antimicrobial Prescribing Guidelines

Bedfordshire and Luton Community ANTIMICROBIAL PRESCRIBING GUIDELINES

Important COVID-19 update NICE have issued a RAPID guidance relating to the management of suspected or confirmed pneumonia in adults in the community NICE guideline [NG165] .

Please note the choice of antibiotics differs from the typical choices which are listed within these local guidelines.

Clinicians should refer to the COVID-19 guidelines during this time. Click here to access the NICE Rapid guideline

https://www.nice.org.uk/guidance/ng165/chapter/4-Managing-suspected-or-confirmed- pneumonia

Virus? “Addressing known local sensitivities” Before you open this book…Do you need to prescribe an antibiotic or is it a virus?

Symbol means that a virus is commonly involved.

These guidelines are correct at time of issue (July 2021)

Contents Acknowledgements ...... 5 Introduction ...... 7 Aims...... 8 Principles of treatment ...... 8 Specific prescribing issues ...... 9 Penicillin allergy ...... 9 Macrolides ...... 9 Trimethoprim and Co-trimoxazole interaction with Methotrexate ...... 10 Warfarin Interactions ...... 10 Swallowing Difficulties ...... 10 Prescribing in the frail elderly ...... 10 Antibiotic interactions with hormonal contraception ...... 11 Culture sensitivity reporting ...... 11 IV antibiotics in the community ...... 11 Why should we be worried about Antimicrobial Resistance (AMR)? ...... 11 How can we improve antimicrobial prescribing in primary care? ...... 11 Respiratory tract infections ...... 13 Acute Sore Throat ...... 13 Scarlet Fever ...... 15 Acute Otitis Media (AOM) ...... 15 Otitis Externa ...... 16 Acute Bacterial Sinusitis...... 16 Acute Cough ...... 17 Chronic Obstructive Pulmonary Disease (COPD) Exacerbation ...... 19 Community acquired pneumonia (CAP) ...... 20 Bronchiectasis (non- cystic fibrosis) Exacerbation ...... 22 Prevention of acute exacerbations of non-cystic fibrosis bronchiectasis ...... 25 Treatment and prevention of pertussis in adults ...... 25 Dental infections ...... 25 Mucosal Ulceration and Inflammation (simple gingivitis) ...... 26 Dental Abscess ...... 26 Urinary Tract Infections...... 27 Collecting MSU Samples...... 27 Urinary Tract Infection in Adults (No fever or flank pain) ...... 27 Urinary Tract Infection in Pregnancy ...... 28 Urinary Tract Infection in Men ...... 30 Urinary Tract Infection in Children ...... 30 2

Acute Pyelonephritis ...... 33 Prophylaxis of uncomplicated Urinary Tract Infections in adults ...... 35 Recurrent UTIs (2 in 6 months or > 3 infections/year) ...... 35 Risks of long term prophylactic antibiotics ...... 38 Risks outweigh benefits in the elderly ...... 38 Catheter associated Urinary Tract Infection ...... 39 Genital Infections ...... 43 Prostatitis ...... 43 Epididymo-orchitis ...... 44 Vaginal Discharge in an Adult ...... 45 Trichomonas vaginalis ...... 45 Candidiasis ...... 46 Bacterial Vaginosis ...... 46 Pelvic Inflammatory Disease (PID) ...... 46 Chlamydia trachomatis (CT) ...... 48 Acute Herpes Simplex (Genital Infection) ...... 50 Recurrent Herpes Simplex (Genital Infection) ...... 50 Skin/Soft Tissue Infections ...... 52 Impetigo ...... 52 Secondary bacterial infection of Eczema and other common skin conditions...... 53 Acne Vulgaris ...... 53 Rosacea – acne ...... 53 Cellulitis and Erysipelas ...... 54 Leg Ulcers ...... 56 Mastitis ...... 56 Wound Infections ...... 56 Insect bites and Stings...... 57 Human and animal bites ...... 57 MRSA Infection ...... 58 MRSA Decolonisation ...... 58 Scabies ...... 59 Head lice ...... 59 • Dimeticone 4%: ...... 59 • Insecticides: ...... 59 • Wet combing: ...... 59 Dermatophyte Infections ...... 59 Fungal infection of the Body/Groin/Feet (Tinea Corporis (ringworm) /Tinea Cruris / Tinea Pedis) ...... 59 Fungal infection of the nail (Tinea Unguium / Onchomycosis) ...... 60 Fungal infection of the Scalp (Tinea Capitis)...... 61

Herpes zoster / Chicken Pox and Varicella zoster / Shingles ...... 61 Meningococcal Disease ...... 62 Prophylaxis in Meningococcal Disease ...... 62 Gastro-intestinal Infection ...... 63 Viral ...... 63 Parasitic ...... 63 Giardiasis ...... 63 Travellers’ Diarrhoea ...... 63 Diverticulitis ...... 65 Infestations ...... 65 Threadworms ...... 65 Eye Infections ...... 66 Conjunctivitis ...... 66 Blepharitis ...... 66 Supporting Materials ...... 67 Glossary ...... 69 Reference Sources ...... 70

Acknowledgements Alison Franklin Infection Prevention and Control Nurse, BCCG and LCCG Dr Cliodna McNulty Head of Primary Care Unit and Honorary visiting Professor, Public Health England and Cardiff University Dr Helen Smith GP Dr John Fsadni Chair, Bedfordshire and Luton CCGs Joint Prescribing Committee Dr Jenny Wilson GP Locality Prescribing Lead, Bedford Locality

Dr Nick Brown Consultant Medical Microbiologist, Interim Lead Public Health Microbiologist, East of England. Dr Rohinton Mulla Consultant Microbiologist , L&D University Hospital NHS Foundation Trust Dr Sarah Griffith GP Locality Prescribing Lead, Ivel Valley Locality Dr Simantee Guha Consultant Microbiologist, Bedford Hospital NHS Trust Dr Vinod Varghese GP Luton CCG Elizabeth Beech National Project Lead - Healthcare Acquired Infection and Antimicrobial Resistance Iain Roddick, Wendy Rice, Daniel Eastern Field Epidemiology Unit, National Infection Service, Public Health West England Nisha Patel Antimicrobial Lead Pharmacist, L&D University Hospital NHS Foundation Trust Medicines Management Teams Bedfordshire CCG and Luton CCG Sue Phillips / Jodie Deards Community Matrons, SEPT Dr Dayo Kuku BCCG Respiratory Lead GP Rachel Leff Interim Antimicrobial Lead Pharmacist, L&D University Hospital NHS Foundation Trust Dr Sarah Reynolds Consultant Obstetrician and Gynaecologist, Bedford Hospital NHS Trust Gemma McGuigan Principal Pharmacist, Governance, Formulary, Homecare, Bedford Hospital NHS Trust Dr Enson Thomas Respiratory Consultant, Bedford Hospital NHS Trust Dr Mohammed Azher Respiratory Consultant, Bedford Hospital NHS Trust

Sue Burridge Senior Officer for Public Health – Sexual Health, Bedford Borough, Central Bedfordshire and Milton Keynes Dr Joelle Turner Clinical Director and Consultant in Sexual Health and HIV, Luton Sexual Health, L&D University Hospital NHS Foundation Trust Many thanks to all the many more people who made comments during the guideline update. In addition many thanks to everyone who supported the updating process to try to ensure all interested parties were consulted. The guidelines were ratified by the Bedfordshire and Luton Joint Prescribing Committee (JPC) in September 2016. Minor amendments were ratified by the Bedfordshire and Luton Joint Prescribing Committee (JPC) in December 2017. They will be reviewed in September 2019 or earlier if required. The guidelines were edited by Naomi Currie, Pharmaceutical Advisor, Bedfordshire Clinical Commissioning Group in December 2017 and updated by Dona Wingfield, Assistant Head, Medicines Optimisation, Bedfordshire Clinical

Commissioning Group in November 2018, February 2019 and April 2019. The team welcome any comments on the guidelines. E-mail: [email protected] Contact address: Suite 2, Capability House, Wrest Park, Silsoe, Bedfordshire MK45 4HR Bedfordshire Clinical Commissioning Group 01525 624390 Luton Clinical Commissioning Group 01582 532071 These guidelines are based on the best available evidence but their application can always be modified by professional judgement.

Introduction These Guidelines are intended to provide guidance to primary care prescribers, including GPs, nurses, and pharmacists on when it is appropriate to use an antimicrobial agent and, when the decision has been taken to prescribe, the choice of appropriate antimicrobial agents for commonly encountered community acquired infections. Where a virus is commonly implicated the virus symbol is shown. For these cases, patient education on Self-Care is encouraged using patient leaflets or other tools where needed. The NICE antimicrobial prescribing guidelines and Public Health England guidance on managing common infections and local sensitivity patterns of common pathogens have been taken into account in producing these local antimicrobial prescribing guidelines. Whilst these guidelines have been prepared using current national and local information, it should be recognised that treatment of infections is a constantly changing environment. Practitioners should use these guidelines in conjunction with national recommendations from Public Health England and NICE to assist in making informed decisions. Antimicrobial Resistance (AMR) is linked to inappropriate prescribing and taking. The UK 5 Year action plan “Tackling Antimicrobial Resistance 2019-2024” supports the UK 20 year vision for AMR by focussing on three areas: 1. Reduce the need and unintentional exposure to antibiotics 2. Optimise the use of antimicrobials 3. Invest in innovation, supply and access. In 2017 the World Health Organisation (WHO) published the 21st international report on the selection and use of essential medicines. Click here for the 2017 executive summary As part of the review of antimicrobials, a new categorisation of antibacterial use into three groups was proposed: • ACCESS – first and second choice antibiotics for the empiric treatment of most common infectious syndromes; • WATCH – antibiotics with higher resistance potential whose use as first and second choice treatment should be limited to a small number of syndromes or patient groups; and • RESERVE – antibiotics to be used mainly as ‘last resort’ treatment options. The WHO report provides guidance on empirical antimicrobial treatment choices and encourages use of narrow spectrum antibiotics where clinically appropriate.

If the patient has taken an antibiotic course recently, or is taking a prophylactic antibiotic, resistant organisms may have been selected out requiring a change of therapy if further treatment is indicated. When specimens are sent for culture, it is essential that the request forms have sufficient relevant clinical details including antibiotics used. Preliminary results are usually available the following working day if specimens are received in the laboratory by 15.30. Treatment may need to be altered once culture and sensitivity results are available. More detailed advice on treatment options may be obtained from the Consultant Microbiologists at the respective hospitals. • Luton and Dunstable Hospital: (01582) 497318 / 497319 • Bedford Hospital: (01234) 795913 A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal and hepatic function. This is specified in British National Formulary (BNF) or Summary of Product Characteristics (SPC) for the individual antibiotic. Please refer to either for further dosing, contra- indications and interaction information. Children’s doses are provided when appropriate but refer to the children’s BNF for full information. Always check for hypersensitivity and if patient is genuinely allergic to penicillin use the recommended alternative(s) listed. Notification of Infectious Disease and Reporting of Health Protection

Emergencies should be made to:- Consultant in Communicable Disease Control (CCDC) Public Health England East of England Health Protection Team 2nd Floor, Goodman House, Station Approach, Harlow CM20 2ET Tel: 0300 303 8537; Fax: 01223 724499; ICC Fax: 01223 724498 (Office Hours, Monday – Friday, 9am – 5pm) Medicom: 01603 481272 (Outside office hours) Ask for Public Health 1st on-call Primary Email: [email protected] NHS Email: [email protected]

Aims • To minimise the emergence of bacterial resistance in the community. • To aim to minimise the incidence of antibiotic associated Clostridium difficile and MRSA infections. • To assist primary care prescribers in choosing empirical antimicrobial agents for common community infections. • To encourage rational and cost-effective use of antibiotics. • To aim to minimise the incidence of toxicity and other adverse effects associated with antibiotic prescribing. • To aim to promote the safe and appropriate use of antibiotics encouraging patient education and Self- Care where appropriate. Principles of treatment These guidelines are based on the best current available evidence but their application can always be modified by professional judgement. 1. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. Antibiotic prescribing in primary care influences resistance. Evidence clearly links increased risk of opportunist infections such as Clostridium difficile with high volume prescribing of antibiotics and long term use of proton pump inhibitors. 2. It is important to initiate antibiotics as soon as possible in severe infections. Check ability of patient to be able to get their prescription dispensed to avoid delay in commencing treatment. Use an immediate release preparation in such circumstances as delayed absorption may occur with modified release or enteric coated preparations. 3. When antibiotics are necessary and appropriate, use simple generic ones. Avoid broad spectrum antibiotics, especially co-amoxiclav, quinolones and cephalosporins (mainly 3rd and 4th generation) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs. 4. Do not prescribe an antibiotic for suspected viral infections- educate patient. Use a patient information leaflet to share during the consultation. Refer to “Support Materials” section. 5. Samples should be sent for culture if infections are persistent or recurrent. 6. Topical antibiotics have limited indications and should be used sparingly when appropriate. 7. Avoid prescribing antibiotics over the telephone. Limit prescribing over the telephone to really exceptional cases and immunosuppressed patients. 8. Raised temperature is a good indication of infection but may be absent in the elderly or immunocompromised. 9. Prescribing of an antibacterial for infection where the cause is obscure, such as unexplained pyrexia, can lead to difficulty in establishing diagnosis. Consider taking samples for microbiological analysis. 10. Reduce patient expectation and demand by using strategies such as delayed prescriptions where there is no clinical risk to patient. A prescription may be left at reception or given with advice only to use if symptoms worsen.

11. Consider the use of patient decision aids to explain risk/benefit and emphasise the self- limiting nature of minor ailments. The figures below is taken from resources available from TARGET: Total duration Beneficial effect NNT for one NNT for one untreated from antibiotics additional patient additional adverse to benefit effect Otitis media 4-12 days 8-12 hours 18 9 Sore throat 8 days 12-18 hours 6-20 15 Sinusitis 12-15 days 24 hours 18 8 Bronchitis 20-22 days 11-24 hours 10-22 24

12. Consider patient compliance issues which may influence drug choice, dose frequency and length of treatment. Check ability to swallow tablets or capsules and prescribe acceptable dose form. Although cost is a consideration, the main factors to maximise the effectiveness of an antibiotic are appropriateness and patient concordance. Explain to the patient the reasons why completing the prescribed course is important. 13. In pregnancy avoid tetracyclines, aminoglycosides, quinolones, azithromycin (except in chlamydial infection), clarithromcyin and high dose metronidazole. Nitrofurantoin should be avoided after 36 weeks pregnancy until after delivery. Although trimethoprim can be used in the second and third trimesters (and first trimester if folic acid 5mg daily is given until 12 weeks of pregnancy), the patient information leaflet warns patients not to take it when pregnant and this may cause them concern. 14. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from the Consultant Microbiologists at the Luton and Dunstable Hospital, Bedford Hospital or other provider hospital. 15. Duration and dose depends on the nature of the infection and the response to treatment. Please refer to the current BNF if unsure. In addition, the principle of treatment duration should aim to be minimal length to achieve effect. In uncomplicated infections evidence would indicate 5 days to be adequate, (3 days for uncomplicated UTIs). Bacterial resistance is more likely with inadequate doses or inappropriately short courses. 16. Walk-in centres and out of hours services should be vigilant in supporting appropriate antibiotic use. Where patients have been refused antibiotics by their GP, there must be documented evidence of deterioration in symptoms so that the GP’s original decision is supported wherever possible. The opportunity to reduce patient expectation for antibiotics should be maximised at these services. When an antimicrobial is issued from walk-in centres or by the out of hours services, the antimicrobial choice should be in line with these Antimicrobial Prescribing Guidelines. 17. Immuno-compromised individuals, e.g. those taking corticosteroids or immunosuppressant medication or having a pre-existing immunological condition including HIV/AIDS, are more at risk of overwhelming infection. They in particular need early diagnosis, confirmed by culture whenever possible, and appropriate treatment. Specific prescribing issues Penicillin allergy Check history, which is often inaccurate. Patients commonly report minor skin reactions and stomach upsets as allergy. There is however, no ‘low dose’ test for allergy as the allergic reaction is not dose related. The BNF quotes between 0.5 and 6.5% of penicillin-sensitive patients to be also allergic to cephalosporins. Patients with an immediate hypersensitivity to penicillin should not be given a cephalosporin (Type 1 reaction e.g. anaphylaxis, urticaria or angioedema). See individual treatment tables in this guideline for other alternatives. Macrolides Clarithromycin has better tolerability than erythromycin and patients are more likely to be compliant with its dose regimen of twice a day. The generic standard formulation should be prescribed as the more expensive modified release formulations offer no benefit. 9

Erythromycin and clarithromycin have a number of important interactions because they inhibit the hepatic enzymes. It is advisable to check the significance of a macrolide interaction with new drugs. Drugs in common use that are affected include direct oral anticoagulants (DOACs), statins and amlodipine. The interaction is due to the inhibitor effect of these macrolides on the hepatic enzymes CYP3A4 which break down these drugs. If a macrolide is the only option, azithromycin can be used. A statin should be temporarily stopped until the course of antibiotic is completed or patients should be warned to be alert for any signs of myopathy (i.e. unexplained muscle pain, tenderness or weakness or dark coloured urine). If myopathy does occur, the statin should be stopped immediately. Trimethoprim and Co-trimoxazole interaction with Methotrexate The use of methotrexate for a number of medical conditions has increased. A patient should not take trimethoprim or co-trimoxazole whilst taking methotrexate because of increased risk of haematological toxicity. Warfarin Interactions Patients on warfarin who are prescribed antibiotics are at risk of over or under coagulation. How much the change of INR control is due to the antibiotic itself or due to the infection and inflammation is difficult to say. Antibiotics are not usually given to ‘healthy’ people. Infections and inflammations have been shown to affect the cytochrome p450 enzyme system, which plays an important part in metabolising drugs. Fever associated with infection, use of Over the Counter (OTC) medication during the illness, antibiotic-induced diarrhoea, and poor oral intake of vitamin K all affect INR control. It is important to take all these factors into account when deciding how often patients should be tested after starting antibiotics. Some antibiotics are more likely than others to cause severe over anticoagulation, but even these antibiotics might not affect other patients at all. Patients who have reacted in a certain way to a specific antibiotic are likely to react in a similar way if given the antibiotic again. Antibiotics likely to increase the effect of warfarin and therefore cause raised INRs are clarithromycin, erythromycin, ciprofloxacin, sulfamethoxazole / trimethoprim, and metronidazole. Penicillins such as amoxicillin rarely affect INR control. Rifampicin can reduce anticoagulation such that 5-7 days later warfarin doses up to 20mg per day are needed to maintain a therapeutic INR. As rifampicin has such a marked effect on INR status it is important to refer back to anticoagulation services when it is stopped for INR to be rechecked and warfarin doses to be reduced. If patients on Warfarin are started on an antibiotic, use one that is less likely to affect the anticoagulation when possible (e.g. a penicillin instead of clarithromycin / erythromycin), and inform the Anticoagulation Service or GP Practice monitoring the INR as soon as possible. For clarithromycin INR checks are normally carried out on days 3 or 4 and for other antibiotics day 7 dependent on the overall health of the patient. Swallowing Difficulties This can be a very common cause of antibiotic failure due to poor concordance and it is essential to establish the ability of the patient to swallow a solid formulation particularly if the infection is severe. Whilst in some cases liquids may be considerably more expensive, where alternatives may compromise sensitivities, cost should not be the prime consideration and the liquid should be prescribed. However, some liquid antibiotics are particularly unpleasant and this can compromise efficacy and result in waste. Use an alternative antibiotic liquid which is more palatable. Where an alternative is not available, for a minority of patients where risk of poor compliance due to palatability of liquid is high, capsules may be emptied and sprinkled visibly onto yogurt or other palatable food. (Off label use). Such instructions should be written on the prescription for the pharmacy to include on the label. Prescribing in the frail elderly The most important effect of age is reduced renal clearance. For many antibiotics, consideration of renal function may be specified in the SPC for each antibiotic. Fever and infection can lead to dehydration and

10 that increases the risk of renal failure. The prescriber should take into account the patient’s age, weight, co-morbidities presence or lack of renal/hepatic problems, other interactive medication etc. before choosing the most appropriate antibiotic or deciding the appropriate dose. (This is also important for paracetamol, because paracetamol dosing is also dependent on muscle mass or weight). In the elderly, it is crucial to ensure that the antibiotic dose is adequate because infection poses a greater risk in this age group than that from commonly used antibiotics. Antibiotic interactions with hormonal contraception According to current guidance from the Faculty of Sexual and Reproductive Healthcare (January 2012) on drug interactions with hormonal contraceptives, additional contraceptive precautions are only required with enzyme-inducing antibiotics, rifabutin and rifampicin, and when antibiotics or concurrent illness cause diarrhoea or vomiting. Health professionals are advised to remind women about the importance of correct contraceptive practice during periods of illness. Culture sensitivity reporting Samples sent to the laboratory for sensitivity testing carry out specific culture tests in the context of the suspected disease. The sensitivity report names a specific antibiotic within a class as it is not possible to test the whole range of antibiotics within each class. So where sensitivity to phenoxymethylpenicillin (penicillin V) is reported, the alternative of amoxicillin could be considered in the context of the suitable choices for the infection. This is also applicable to reporting sensitivity to erythromycin, as clarithromycin is the choice within the guidelines. IV antibiotics in the community The use of IV antibiotics in the community is becoming more common to prevent delayed discharge from hospital, e.g. treatment of cellulitis. Planning for the use of antibiotics in the community is currently managed on an individual patient basis and the initial choice and prescribing of the antibiotic would normally involve liaison between the microbiologist and the GP. Future arrangements for this to be managed in primary care need to be fully supported through clear patient pathways. At the time of printing there are locality differences between community services in Bedfordshire and Luton in the provision of this service. Why should we be worried about Antimicrobial Resistance (AMR)? The growing threat of AMR to human and animal health has been well publicised since the publication of the Chief Medical Officer’s (CMO) annual report on infections and the rise of antimicrobial resistance. The report highlights antibiotic resistance as a global risk requiring action at all levels and makes many recommendations including the need for better hygiene measures, the prescribing of fewer antibiotics and better surveillance across the NHS and worldwide. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/1 38331/CMO_Annual_Report_Volume_2_2011.pdf

How can we improve antimicrobial prescribing in primary care? There are numerous ways healthcare professionals can get involved in improving antimicrobial prescribing. Patient focused strategies may involve: • Antibiotic leaflets. • Decision aids. • Delayed prescriptions. • ‘No prescription’ patient leaflet. These strategies are aimed at educating the public in reducing expectation for antibiotic treatment. Clinician focused strategies may involve: • Clinical audit within practice. • Case study discussion. • Availability of infection control nurse. 11

• Antibiotic stewardship leader in the practice and locality. • Availability of local guidelines to all clinical staff. These strategies provide peer review and shared practice to drive local implementation of guidelines. The following programmes and tools are excellent resources to support putting these strategies into practice: • The Antibiotic Stewardship programme. This is seen as a means of improving the quality of prescribing. Primary care prescribers are encouraged to adopt antimicrobial stewardship initiatives by following the Bedfordshire and Luton Antimicrobial Prescribing Guidelines and reducing their use of broad spectrum antibiotics co-amoxiclav, cephalosporins and quinolones. • The RCGP TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) toolkit provides numerous tools to support the whole primary care team within the GP practice or out of hours setting in their consultations with patients. Available at: http://www.rcgp.org.uk/TARGETantibiotics . These include: o TARGET Self-Assessment Tool where you can compare your practice with your peers in an anonymised format. o Training resources such as an eLearning module on Antibiotic Resistance in Primary Care o Leaflets to share with patients available in multiple languages o Audit toolkits on a variety of symptoms o Posters and videos for clinical and waiting areas • English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) is a national programme which brings together data on antimicrobial utilisation and resistance surveillance from both primary and secondary care. Recent reports are available at www.gov.uk • Become an Antibiotic Guardian. Take the pledge to become an antibiotic guardian and encourage other members of staff and patients to take the pledge also, see www.antibioticguardian.com .

Respiratory tract infections Antibiotics are rarely indicated for upper respiratory tract infections and an NNT value of 4000 to prevent one serious complication has been calculated. (Peterson et al BMJ 2007 335:982). Patient education is particularly important in this area in line with National programmes to reduce prescribing. In both upper and lower respiratory tract infections, excluding Pharyngitis, Streptococcus pneumoniae is the commonest pathogen, and if antibiotics are indicated, this organism must be covered. The only quinolone with sufficient activity against S. pneumonia is levofloxacin which would not normally be indicated in primary care, clinicians should take into account the MHRA CHM Advice March 2019

Acute Sore Throat Virus?

Antibiotics should not be used to secure symptomatic relief in sore throats most cases resolve in 7 days. Antibiotics on average shorten duration of symptoms by about 16 hours. (NICE NG84). Antibiotics can prevent non-suppurative complications of beta-haemolytic streptococcal pharyngitis but, in developed societies, such complications are rare. Antibiotics to prevent Quinsy NNT>4000, antibiotics to prevent otitis media NNT 200. When considering no antibiotic prescription, clinicians should consider the unlikely event of complications if antibiotics are withheld and possible adverse effects particularly diarrhoea and nausea. NICE NG84 recommends to offer an immediate antibiotic prescription with advice or further appropriate investigation and management for patients who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or at high-risk of complications. Otherwise, a no prescribing or delayed prescribing strategy should be agreed with the patient or carer after addressing their concerns and expectations. Always share self-care advice and safety net. Patient information leaflets can be accessed via this link: https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/target-antibiotic- toolkit.aspx. Self-care advice for people with acute sore throat includes:

• Considering paracetamol for pain or fever, or if preferred and suitable, ibuprofen. • Advising patients about the adequate intake of fluids. • Explaining that some adults may wish to try medicated lozenges containing either a local anaesthetic, a non-steroidal anti-inflammatory drug (NSAID) or an antiseptic (they may only help to reduce pain by a small amount) • Patients should be made aware that NICE NG84 states no evidence was found on non-medicated lozenges, mouthwashes, or local anaesthetic mouth spray used on its own

Results of a bacterial throat swab can be available within 2 working days but a Group A streptococcal infection will be notified in 24 hours. Use FeverPAIN Score (1 point for each):

Sign (Score 1 point for each) Score Fever in last 24 hours Purulence (pus on tonsils) Attend rapidly (within 3 days after onset of symptoms) Severely Inflamed tonsils No cough or coryza (inflammation of mucus membranes in the nose) Total FeverPAIN Score:

Score 0-1: 13-18% streptococci, consider no antibiotic prescription with advice; Score 2-3: 34-40% streptococci, consider no antibiotic prescription or a backup antibiotic prescription with advice (not needed immediately, 3 to 5 day delay, seek medical help if symptoms worsen rapidly); Score 4-5: 62-65% streptococci, consider an immediate antibiotic prescription or a backup antibiotic prescription with advice (not needed immediately, 3 to 5 delay, seek medical help if symptoms worsen rapidly).

Acute Sore Throat Virus?

Table 1: Antibiotics for adults aged 18 years and over

Drug Name Dose Frequency Duration Comments

First choice Self-limiting and often triggered by viral infection. Provide self-care advice and None safety net. If symptoms persist i.e. they do not improve after a week, or rapid worsening, assess FeverPAIN Score and manage appropriately. Second choice 5-10 days If a liquid preparation is needed Phenoxymethylpenicillin 500mg Four times (consider longer choice could be amoxicillin (at the (Penicillin V) daily course lengths clinician’s discretion) due to for FeverPAIN 4- unpalatable nature of 5 or recurrent phenoxymethylpenicillin (penicillin V) infection) liquid Or 1gm Twice daily 5 – 10 days If a liquid preparation is needed (consider longer choice could be amoxicillin (at the course lengths clinician’s discretion) due to for FeverPAIN 4- unpalatable nature of 5 or recurrent phenoxymethylpenicillin (penicillin V) infection) liquid If penicillin allergic 250- Twice daily 5 days If a liquid preparation is needed and Clarithromycin 500mg the patient finds clarithromycin liquid unpalatable, erythromycin liquid is an alternative, but this is given four times a day and may not be as well tolerated. If penicillin allergic AND 250- Four times 5 days pregnant 500mg a day Erythromycin * Clinical judgement important as it is sometimes difficult to differentiate a streptococcal sore throat from glandular fever and morbilliform rashes have been associated with glandular fever in patients receiving amoxicillin. Table 2: Antibiotics for children and young people under 18 years

Drug Name Dose Frequency Duration Comments

First choice Assess and manage children under 5 who present with fever as outlined in the None NICE guideline on fever in under 5s. https://www.nice.org.uk/Guidance/CG160 Self- limiting and often triggered by viral infection. Provide self-care advice and safety net. If symptoms persist, i.e. they do not improve after a week, or rapid worsening, assess FeverPAIN Score and manage appropriately Second choice Refer to BNF for 5-10 days If a liquid preparation is needed choice Phenoxymethylpenicillin (consider could be amoxicillin (at the clinician’s (Penicillin V) children longer course discretion) due to unpalatable nature of lengths for phenoxymethylpenicillin (penicillin V)

FeverPAIN 4-5 liquid (especially for children)* BD or recurrent dosage may support medicines infection) adherence if this is an issue e.g. children at school

If penicillin allergic Refer to BNF for 5 days Tablets are recommended for children Clarithromycin over 12 years. Children under 12 years children who are able to swallow tablets should be offered them.

If a liquid preparation is needed and the patient finds clarithromycin liquid unpalatable, erythromycin liquid is an alternative, but this is given four times a day and may not be as well tolerated. If penicillin allergic AND Refer to BNF for 5 days pregnant Erythromycin children * Clinical judgement important as it is sometimes difficult to differentiate a streptococcal sore throat from glandular fever and morbilliform rashes have been associated with glandular fever in patients receiving amoxicillin. Refer people to hospital if they have acute sore throat associated with any of the following: • A severe systemic infection (see the NICE guideline on sepsis https://www.nice.org.uk/guidance/ng51) • Severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal abscess or retropharyngeal abscess or Lemierre syndrome)

Scarlet Fever Scarlet fever is caused by Streptococcus pyogenes, or group A streptococcus (GAS). Prompt treatment with antibiotics significantly reduces the risk of complications. Observe immunocompromised individuals as they are at increased risk of developing invasive infection.

Drug Name Dose Frequency Duration Comments

First choice 500mg Four times 10 days If a liquid preparation is needed choice could Phenoxymethylpenicillin a day be amoxicillin due to the unpalatable nature (Penicillin V) of phenoxymethylpenicillin (penicillin V) liquid (especially for children). If penicillin allergic 250- Twice a 5 days Clarithromycin 500mg day

Acute Otitis Media (AOM) Available evidence suggests that antibiotic treatment should NOT be routinely prescribed, as 60% of cases resolve within 24 hours without antibiotics. Use NSAID or paracetamol. A study of predictors of poor outcome found that in children with AOM but without fever and vomiting, antibiotic treatment had little benefit. (Sanders et al 2004). The lack of antibiotic did not lead to a poor outcome. Children at highest risk of poor outcome are those with systemic features (high temperature or vomiting) and these are the most likely to be targeted for antibiotic treatment. Poor outcome is also more likely if recurrent. Immediate antibiotic prescribing strategy may be needed for children under 2 years with bilateral acute otitis media or children with acute otitis media and otorrhoea depending on severity. Where antibiotic treatment is deemed appropriate it should be remembered that penetration of amoxicillin into the middle ear is limited, especially if there is a purulent exudate contained within. The main concern with lower dose is that concentrations of the antibiotic below that required to kill streptococci will generate resistance. This would not only lead to treatment failure but difficulty treating the infection thereafter. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness, and their use is associated with increased adverse effects, such as nausea and diarrhoea. Viruses are a common cause.

Acute Otitis Media (AOM) Virus?

Drug Name Dose Frequency Duration Comments 15

First choice Ensure that regular analgesia is given for at least 4 None days. Second choice Child doses Amoxicillin 500mg Three 5 days Neonate 7-28 days 30mg/kg three times a day. times daily 1 month-1 year: 125mg three times a day. 1-5 years: 250mg three times a day. >5 years: 500mg three times a day. If penicillin 500mg Twice daily 5 days Tablets are recommended for children over 12 allergic years and children under 12 years who are able to Clarithromycin swallow tablets should be offered them. If a liquid preparation is needed and the patient finds clarithromycin liquid unpalatable, erythromycin liquid is an alternative. However, this is given four times a day and may not be as well tolerated.

Otitis Externa • Antibiotics are often not appropriate and good local hygiene may solve the problem. • Culture of any discharge is valuable at first presentation to guide rational prescribing. Non- resolving problems may be fungal. • Acetic acid can be tried for one week and can be purchased as EarCalm®. • Repeated use of topical antibiotics can result in the selection of antibiotic resistant organisms including fungi. Where topical antibiotic is appropriate, use neomycin with a corticosteroid ear preparation 3 drops three times a day for no less than 7 days and no more than 14 days. (Contraindicated in perforated ear drum). Discontinue if no clinical improvement in 7 days. Sensitivity to neomycin is possible. • Recurrent problems especially in the elderly may be worsened by baths or showers. Using a wick of olive oil in ear during personal care may help. • If cellulitis or disease extending outside ear canal, or systemic signs of infection start oral flucloxacillin (250-500mg QDS for 7 days) and refer to ENT to exclude malignant otitis externa.

Acute Bacterial Sinusitis Virus? Usually self-limiting, watch and wait. Reserve treatment for severe or persistent cases of at least 7-10 days duration in adults and 10-14 days duration in children. There is very little evidence that antimicrobials are effective in children and many infections are viral, resolving in 7 days.

Drug Name Dose Frequency Duration Comments

First choice Give Self-Care advice including steam inhalation. None Consider a high dose nasal corticosteroid for 14 days for adults and children aged over 12 years who have had symptoms for more than10 days with no improvement. Second choice Phenoxymethylpenicillin 500mg Four times a day 5 days Penicillin allergy: 200mg stat Daily 5 days Doxycycline then 100mg Clarithromycin 500mg Twice a day 5 days Use erythromycin in pregnant women with penicillin allergy Third choice (if worsening symptoms on the above antibiotics for at least 2-3 days) Co-amoxiclav 500/125 Three times a day 5 days Consult microbiology for advice in penicillin allergic patients who require

alternative treatment

Acute Cough Acute cough is commonly defined as a cough that lasts less than 21 days (3 weeks). The average duration is 18 days, although it can sometimes last for up to 29 days (over 4 weeks). It is most commonly caused by an upper respiratory tract infection, such as a cold or flu, which are viral infections. It can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial. Acute cough is usually self-limiting and gets better within 3 to 4 weeks without antibiotics. Acute bronchitis is a lower respiratory tract infection with temporary inflammation of the airways (the trachea and major bronchi) that causes cough and mucus production lasting for up to 3 weeks. It is usually caused by a viral infection, but may be caused by a bacterial infection.

There may be other infective causes of acute cough, e.g. pneumonia, chronic obstructive pulmonary disease or bronchiectasis. It is important to consider differential diagnosis and treat the suspected underlying cause of acute cough. Please refer to the relevant sections of the guideline to treat underlying infective cause. Consider the treatment options below if the infective cause of cough is not related to the conditions covered in this guideline.

For children under 5 with an acute cough and fever follow the NICE guideline on fever in under 5s. https://www.nice.org.uk/Guidance/CG160. For adults with an acute cough and suspected pneumonia refer to the community acquired pneumonia section of this guideline and NICE guideline https://www.nice.org.uk/guidance/CG191

In relation to self-care options (not to be prescribed), it should be noted that some people may wish to try or have tried the following interventions which have limited evidence of some benefit for the symptomatic relief of cough symptoms: honey (for people over 1 year), pelargonium (herbal medicine in people aged 12 and over), over the counter cough medicines containing the expectorant guaifenesin (in people aged 12 years and over) and over the counter cough medicines containing cough suppressants, except codeine (in people aged 12 years and over who do not have a persistent cough, such as in asthma or excessive secretions). Limited evidence suggests that antihistamines, decongestants and codeine-containing cough medicines do not help cough symptoms. Patient information leaflets can be accessed here https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/target-antibiotic-toolkit.aspx

For people with an acute cough who are identified at a face-to-face clinical examination as systemically very unwell, offer an immediate antibiotic prescription.

For people with an acute cough who are identified at a face-to-face clinical examination as at higher risk of complications, consider an immediate antibiotic prescription or a back-up antibiotic prescription.

People with an acute cough who may be at higher risk of complications include: • a pre-existing comorbidity, such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression or cystic fibrosis • young children who were born prematurely • •older than 65 years with 2 or more of the following criteria, or older than 80 years with 1 or more of the following criteria: • hospitalisation in previous year • type 1 or type 2 diabetes • history of congestive heart failure • current use of oral corticosteroids.

For people with an acute cough associated with an upper respiratory tract infection: • Do not offer an antibiotic to treat people who are not systemically very unwell or at higher risk of complications 17

• Do not offer an oral or inhaled bronchodilator (e.g. salbutamol) or an oral or inhaled corticosteroid unless the person has an underlying airways disease e.g. asthma • Do not offer a mucolytic

For people with an acute cough associated with acute bronchitis: • Do not offer a mucolytic • Do not routinely offer an antibiotic to treat who are not systemically very unwell or at higher risk of complications

Table 1 Antibiotics for adults aged 18 years and over

Antibiotic 1 Dosage and course length 2

First choice

Doxycycline3 200 mg on first day, then 100 mg once a day for 4 – 6 days (5- 7 day course in total)

Alternative first choices 4

Amoxicillin 500 mg three times a day for 5 - 7 days

Clarithromycin 250 mg to 500 mg twice a day for 5- 7days

Erythromycin 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5- 7 days

1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breast-feeding. 2 Doses given are by mouth using immediate-release medicines, unless otherwise stated. 3 Doxycycline should not be given to pregnant women, and the possibility of pregnancy should be considered in women of childbearing age (BNF, December 2018). 4 Amoxicillin or erythromycin are preferred in women who are pregnant.

Table 2 Antibiotics for children and young people under 18 years

Antibiotic 1 Dosage and course length

First choice

Refer to BNF for children Amoxicillin2 Duration 5 - 7days

Alternative first choices3

Clarithromycin Refer to BNF for children Duration 5 - 7 days

Erythromycin2 Refer to BNF for children Duration 5 - 7 days

Refer to BNF for children Doxycycline3(for children aged 12 to 17 years) Duration 5 - 7 days

1 See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment. 2 Amoxicillin or erythromycin are preferred in young women who are pregnant. 3 Doxycycline should not be given to young women who are pregnant, and the possibility of pregnancy should be considered in young women of childbearing age (BNF for children, December 2018).

Refer people with an acute cough to hospital, or seek specialist advice on further investigation and management, if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis, a pulmonary embolism or lung cancer).

Chronic Obstructive Pulmonary Disease (COPD) Exacerbation An exacerbation is a sustained worsening of the person's symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. Treat infective exacerbations promptly with: • Increase frequency of short acting bronchodilator • Oral antibiotics • Prednisolone 30mg daily for 7 to 14 days – for all patients with significant increase in breathlessness, unless contraindicated, especially if affecting their daily activities of living. Patients suffering frequent exacerbations should be provided with rescue medication (prednisolone and oral antibiotics as above) supported by a clear written self-management plan. Further information is detailed in the Bedfordshire COPD/ ACO guidelines 2019 available on GP Ref www.gpref.bedfordshire.nhs.uk and in the NICE guideline NG 114 ‘Chronic Obstructive Pulmonary Disease (acute exacerbation): Antimicrobial Prescribing’. A separate patient advice leaflet on medication to treat an exacerbation is also available on this site and within the local Primary Care guideline which can be printed off for patients. NB: Culture of the sputum is advised where multiple exacerbations are occurring and first line treatments are not effective. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD (MRC 3 and above), frequent exacerbations or antibiotics in last 3 months.

Drug Name Dose Frequency Duration Comments

First choice (empirical treatment or guided by most recent sputum culture and susceptibilities)

Amoxicillin 500mg Three times daily 5 to 7 Give patient advice leaflet on COPD days exacerbations. Second choice (no improvements in symptoms on first choice after 2-3 days or if penicillin allergic) Doxycycline 200mg stat Daily 5 to 7 Give patient advice leaflet on COPD then 100mg days exacerbations. Clarithromycin 500mg Twice daily 5 to 7 Give patient advice leaflet on COPD days exacerbations.

Third choice (no improvements in symptoms on first choice after 2-3 days or if penicillin allergic) Use alternate As above second choice Fourth choice (guided by susceptibility when available, at higher risk of treatment failure*) Co-amoxiclav 625mg Three times daily 5 to 7 Give patient advice leaflet on COPD days exacerbations. *People who may be at higher risk of treatment failure include people who have repeated courses on antibiotics, a previous sputum culture with resistant or atypical bacteria or a higher risk of developing complications. Community acquired pneumonia (CAP) Pneumonia is an infection of the lung tissue and diagnosis is made based on symptoms and signs of an acute lower respiratory tract infection e.g. the presence of focal chest signs, illness severity or other features. Community acquired pneumonia is used to describe a pneumonia that develops outside of hospital. Pneumonia that develops in a nursing home resident would be classed as community acquired. For full details on the diagnosis and management of pneumonia please refer to the NICE guidelines Pneumonia in adults: diagnosis and management (CG191) and Pneumonia (community-acquired): antimicrobial prescribing (NG138)

When a clinical diagnosis of CAP is made in primary care in adults over 18 a severity assessment using the CRB65 score described below should be completed to determine whether the patient is at low, intermediate or high risk of mortality. Assessment of severity in children and young people under 18 is based on clinical judgement.

CRB65 score for mortality risk assessment in primary care CRB65 score is calculated by giving 1 point for each of the following prognostic features Confusion (abbreviated mental test score of 8 or less, or new disorientation in person, place or time) Raised respiratory rate (30 breaths per minute or more) Low Blood pressure (diastolic less than 60mmHg or systolic less than 90mmHg) Age > 65 years

CRB65 score Mortality risk 0 Low (less than 1%) Consider home based care 1 or 2 Intermediate (1-10%) Consider hospital assessment 3 or 4 High (more than 10%) Require hospital assessment

All patients diagnosed with CAP should be offered antibiotics and treatment should be started as soon as possible (preferably within 4 hours of diagnosis). Treatment options are detailed below in separate tables for adults and children.

Antibiotics for adults aged 18 years and over

Antibiotic Dose Frequency Duration 1 Comments First choice for LOW SEVERITY (CRB65 score = 0) Amoxicillin 500mg Three times a day 5 -7 days Alternative for LOW SEVERITY in Penicillin allergy or if amoxicillin unsuitable (e.g. atypical pathogen suspected) Doxycycline 200mg stat then 100mg once a day 5 -7 days total for 4 days Clarithromycin 500mg Twice a day 5 -7 days Erythromycin 500mg Four times a day 5 7 days In pregnancy First choice for MODERATE SEVERITY (CRB65 = 1 or 2) Amoxicllin 500mg Three times a day 5 -7 days Use erythromycin in PLUS (if atypical place of pathogens suspected) clarithromycin in 20

Clarithromycin 500mg Twice a day 5 -7 days pregnancy Alternative for MODERATE SEVERITY in Penicillin allergy Doxycycline 200mg stat then 100mg once a day 5 – 7 days total for 4 days Clarithromycin 500mg Twice a day 5 – 7 days 1 Stop antibiotic treatment after 5 – 7 days unless microbiological results suggest a longer course is needed or the person is not clinically stable. 2 In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019

Antibiotics for children and young people aged 1 month to 18 years – Refer children under 1 month to a paediatric specialist

Antibiotic 1 Dosage and course length

First choice if non-severe symptoms or signs (based on clinical judgement)

Refer to BNF for children Amoxicillin2 Duration 5 – 7 days

Alternative if non-severe symptoms or signs for penicillin allergy or if amoxicillin unsuitable (e.g. atypical pathogens suspected)

Clarithromycin2 Refer to BNF for children Duration 5 – 7 days

Refer to BNF for children Doxycycline3 (for children aged 12 to 17 years) Duration 5 -7 days

First choice if severe symptoms or signs

Co-amoxiclav

Refer to BNF for children PLUS (if atypical pathogens suspected) Duration 5 -7 days Clarithromycin2

Consult local microbiologist for advice in patients with severe symptoms and penicillin allergy

1 See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment. 2 Use erythromycin in place of clarithromycin in young women who are pregnant. 3 Doxycycline should not be given to young women who are pregnant, and the possibility of pregnancy should be considered in young women of childbearing age (BNF for children, December 2018). 21

Bronchiectasis (non- cystic fibrosis) Exacerbation Bronchiectasis is defined as persistent or recurrent bronchial sepsis related to irreversibly damaged and dilated bronchi. An acute exacerbation of bronchiectasis is characterised by an acute deterioration of normal symptoms and signs usually over several days. It presents with worsening local symptoms (such as cough, increased sputum volume, change of sputum viscosity, or increased sputum purulence) with or without increased wheeze, breathlessness or haemoptysis. Fever or pleurisy may also be present. (British Thoracic Society's 2010 guideline on non-cystic fibrosis bronchiectasis). Referral and seeking specialist advice (See NICE NG 117 https://www.nice.org.uk/guidance/ng117 and NICE CKS Bronchiectasis https://cks.nice.org.uk/bronchiectasis for further information)

Refer people with an acute exacerbation of bronchiectasis to hospital if they have any symptoms or signs suggesting a more serious illness or condition (such as cardiorespiratory failure or sepsis) these signs include:

• Cyanosis. • Confusion. • A respiratory rate of more than 25 breaths per minute. • Marked breathlessness, rapid respiration, or laboured breathing. • Peripheral oedema. • Have a temperature of 38°C or more.

Refer children and young people with an acute exacerbation of bronchiectasis to hospital if they:

• Are cyanosed. • Have increased respiratory rate and work of breathing. • Have signs of cardiorespiratory failure (such as marked breathlessness, rapid respiration, laboured breathing, cyanosis, or worsening peripheral oedema). • Have a temperature of 38°C or more. • Are unable to take oral therapy. • Have failed to respond adequately to oral therapy.

Seek specialist advice for people with an acute exacerbation of bronchiectasis if they:

• have symptoms that are not improving with repeated courses of antibiotic treatment or • have bacteria that are resistant to oral antibiotics or • cannot take oral medicines (to explore locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where this is appropriate) • unable to cope at home

For people not requiring hospital admission:

• Send sputum for culture and sensitivity testing before starting antibiotics. If the person is taking long-term antibiotics, advise them to stop.

• Prescribe an antibiotic for 7–14 days. Do not await the results of culture.

Table 1 Antibiotics for adults aged 18 years and over

Drug Name Dose Frequency Duration

First choice1,2 (empirical treatment in the absence of current susceptibility data(guided by most recent sputum culture and susceptibilities where possible) Check allergy status Amoxicillin3 500mg Three times daily 7 to 14 days4 Clarithromycin 500mg Twice daily 7 to 14 days4 Second choice1,2 Doxycycline 200mg stat then 100mg Daily 7 to 14 days4 Alternative choice (if person at higher risk of treatment failure5) for empirical treatment in the absence of oral antibiotics current susceptibility data (guided by most recent sputum culture and susceptibilities (third line) where possible) Co-amoxiclav 625mg Three times daily 7 to 14 days4 Levofloxacin6 500mg Once or twice a day1 7 to 14 days4 (consider safety issues) 1 See the British national formulary (BNF) and product license www.medicines.org.uk for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding. 2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class. 3 Amoxicillin is the preferred choice for women who are pregnant.

4 Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment. 5 People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications. 6In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019 Avoid use of a corticosteroid with a fluroquinolone since co- administration could exacerbate fluoroquinolone induced tendinitis and tendon rupture.

Table 2 Antibiotics for children and young people under 18 years

Antibiotic1,2 Dosage and course length 23

First choice oral antibiotics (empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible) Check allergy status

Amoxicillin3 Refer to BNF for children Duration 7-14 days4 Clarithromycin Refer to BNF for children Duration 7-14 days4 Second choice oral antibiotic

Doxycycline7 (for children aged 12 years and Refer to BNF for children over) Duration 7-14 days4

Alternative choice oral antibiotics/ third line (if person at higher risk of treatment failure5) for empirical treatment in the absence of current susceptibility data (guided by most recent sputum culture and susceptibilities where possible)

Co-amoxiclav Refer to BNF for children Duration 7-14 days4

Ciprofloxacin (on specialist advice, consider Refer to BNF for children safety issues)6 Duration 7-14 days4

1 See the BNF/BNFC for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment. 2 When a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class. 3 Amoxicillin is the preferred choice in young women who are pregnant.

4 Course length based on an assessment of the severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment. 5 People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications. 6In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019 Avoid use of a corticosteroid with a fluroquinolone since co-administration could exacerbate fluoroquinolone induced tendinitis and tendon rupture.

7Tetracyclines are contraindicated in children under 12 years (deposition in growing bones and teeth, by binding to calcium, causes staining and occasionally dental hypoplasia) (BNFC, September 2018-2019)

Prevention of acute exacerbations of non-cystic fibrosis bronchiectasis Do not routinely offer antibiotic prophylaxis to prevent acute exacerbations of bronchiectasis. Give advice about seeking medical help if symptoms of an acute exacerbation develop. Seek specialist advice about options for preventing exacerbations in people with repeated acute exacerbations, which may include a trial of antibiotic prophylaxis. Only start a trial of antibiotic prophylaxis (with oral or inhaled antibiotics) in people with repeated acute exacerbations on the advice of a specialist.

Treatment and prevention of pertussis in adults

For full information on the Public Health management of Pertussis including the current recommendations for antibiotic treatment and prophylaxis please refer to Guidelines for the Public Health Management of Pertussis in England (updated May 2018) accessed at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/762766/ Guidelines_for_the_Public_Health_management_of_Pertussis_in_England.pdf

Outbreaks of pertussis can occur in households, schools, healthcare settings and in the community. If outbreaks are detected at an early stage, prompt action including chemoprophylaxis and vaccination can limit the spread. Chemoprophylaxis and vaccination of close contacts may also be of benefit in reducing transmission to those who are most at risk of severe or complicated infection and is therefore recommended in settings where there is a vulnerable person or an individual who may facilitate on-going transmission to vulnerable groups.

For suspected, epidemiologically linked or confirmed cases, antibiotics should be administered as soon as possible after onset of illness in order to eradicate the organism and limit on-going transmission. The effect of treatment on reducing symptoms however, is limited or lacking especially when given late during the disease and therefore antibiotic treatment for the case is recommended within three weeks of onset of illness.

Dental infections Some general guidance is provided below as it is recognised that patients present themselves to GPs in some cases attempting to avoid dental care or through genuine fear of dental procedures. The GMC’s ‘Good Medical Practice’ is very clear about working within the limits of one’s knowledge and training – most GPs have very little or no training in dentistry. Therefore, GPs should not be treating dental problems. Patients requiring dental access urgently should contact their regular dentist for advice or if they do not have a regular dentist, telephone 111 (NHS 111).

Good mouth hygiene is paramount to preventing mouth infections and GPs should not prescribe antiseptic mouthwashes or toothpastes (such as chlorhexidine) long-term on repeat prescription. Chlorhexidine has been associated with idiosyncratic allergic reactions and it stains the teeth and leads to development of resistance. These products may be requested in cases of dementia or learning disabilities where it is common to refuse mouth cleaning. Staff need to explore simple methods of encouragement such as trying different flavoured toothpastes. Encourage carers to contact a dentist to give advice Pericoronitis (partly erupted wisdom tooth) Refer to dentist for irrigation and debridement. For persistent swelling or systemic symptoms e.g. lymph node involvement Drug Name Dose Frequency Duration Comments 25

Amoxicillin 500mg Three times 3 days daily Metronidazole 400mg Three times 3 days daily

Use antiseptic mouthwash in combination with antibiotics if pain and trismus limit oral hygiene. See Mouth Ulceration and Inflammation section for antiseptic mouthwash choices.

Mucosal Ulceration and Inflammation (simple gingivitis) The primary cause for mucosal ulceration or inflammation needs to be evaluated and treated.

As a temporary solution, the treatment should be used until lesions resolve or less pain allows oral hygiene measures. These are suitable for Self-Care. Drug Name Dose Frequency Duration Comments

Simple saline ½ teaspoon salt Twice daily Until lesions resolve Always spit out after use. mouthwash dissolved in glass of or less pain allows warm water. oral hygiene. Chlorhexidine 5ml diluted with 5-10ml Twice daily Until lesions resolve Rinse mouth for 1 minute. 0.12-0.2% of water. or less pain allows Always spit out after use. oral hygiene. Do not use within 30 minutes of toothpaste. Hydrogen 15ml diluted in ½ glass Three times Until lesions resolve Rinse for 2 minutes. peroxide 6% warm water. daily or less pain allows Always spit out after use. (20 volume) oral hygiene.

Dental Abscess GP’s should not routinely be involved in treatment as the abscess requires drainage by dentist. Patients may present to a GP in order to avoid dental care. Advise urgent dental consultation as repeated courses of antibiotics for abscess are not appropriate. Antibiotics are only recommended if there are signs of severe infection, systemic symptoms e.g. diffuse swelling, pyrexia or high risk of complications e.g. co-morbidities such as diabetes, cardio-vascular disease or compromised immunity and should be prescribed by a dentist if needed. Otherwise, self-care with regular analgesia should be advised until a dentist can be seen such as ibuprofen 400mg four times a day, paracetamol 1g four times a day or both (if not contraindicated). Codeine is not recommended for dental pain. Patients with infection causing air restriction and systemic symptoms should be referred to Hospital / A & E.

Urinary Tract Infections A Quick Reference Guide for primary care on the diagnosis of UTIs is available at: https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis. The Royal College of General Practitioners (RCGP) has a free training module on managing UTIs available at www.rcgp.or.uk

It is important that clinicians are aware that local sensitivities have determined first and second line choices as supplied by microbiology. These should be followed to minimise the risks of resistance developing. The use of co-amoxiclav, a quinolone or a 3rd or 4th generation cephalosporins can favour Clostridium difficile colitis and should ONLY be used where there is no other option. There is also evidence of increasing numbers of patients with Extended Spectrum Beta Lactamase positive organisms (ESBL) where IV antibiotics may be necessary. ESBL producing E.coli are able to resist penicillins and cephalosporins. Consultant Microbiologists can advise on treatment options. Patients may choose to purchase cranberry products to minimise occurrence of UTIs. It is not an appropriate treatment during an acute attack of cystitis as it contains hippuric acid and will worsen symptoms and reduce the effectiveness of antibiotics. It also interacts with medication, in particular warfarin.

MSU sensitivities locally are reviewed by the microbiology team and where clinically appropriate, the antimicrobial treatment recommendation will be based on the formulary choices endorsed in this local guideline.

Self-care The NICE guideline NG109 recommend the following interventions in relation to self-care: • Advise people with lower UTI about using paracetamol for pain, or if preferred and suitable ibuprofen. • Advise people with lower UTI about drinking enough fluids to avoid dehydration. • Be aware that no evidence was found on cranberry products or urine alkalinising agents to treat lower UTI

Collecting MSU Samples Many samples sent into microbiology are inappropriately contaminated and results are meaningless. This can delay appropriate treatment. Advice sheets have been produced for patients and carers to instruct on collecting samples. These are available on clinical systems and should be printed off for patients. http://www.patient.co.uk/health/midstream-specimen-of-urine-msu. It is also essential that sample bottles are provided to prevent inappropriately contaminated containers being used by patients.

Urinary Tract Infection in Adults (No fever or flank pain) Treat women with severe/or ≥ 3 symptoms. Women with mild/or ≤ 2 symptoms and urine not cloudy- 97% negative predictive value, so do not treat unless other risk factors for infection. If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% positive predictive value; nitrite, leucocytes, blood all negative 76% negative predictive value. NICE suggests as part of the management for non- pregnant women over 16 years of age to consider a back-up antibiotic prescription (to use if symptoms do not start to improve within 48 hours or worsen at any time). Nitrofurantoin is first line choice if GFR 45ml/min and over. GFR 30-44 ml/min: suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk. In treatment failure, always perform culture.

In the case of mixed growth cultures, repeat the sample and delay treatment until the repeat results are available. If clinically necessary e.g. the patient is septic or the patient is symptomatic and pregnant, give empirical treatment with first line therapy.

Urinary tract infection (lower): antimicrobial prescribing, NICE guideline [NG109] Published date: October 2018, https://www.nice.org.uk/guidance/ng109 includes the following information with respect to antibiotic choices:-

When prescribing antibiotic treatment for lower UTI, take account of local antimicrobial resistance data and follow: • table 1 for non-pregnant women aged 16 years and over • table 2 for pregnant women aged 12 years and over • table 3 for men aged 16 years and over

Table 1 Antibiotics for non-pregnant women aged 16 years and over Antibiotic 1 Dosage and course length 2 First choice 3 Nitrofurantoin – if eGFR ≥45 ml/minute4 100 mg modified-release twice a day for 3 days Pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg three times a day for a total of 3 days Second-choice (no improvement in lower UTI symptoms on first-choice taken for at least 48 hours, or when first-choice not suitable) 3,6 Nitrofurantoin – if eGFR ≥45 ml/minute4 and not used as 100 mg modified-release twice a day for first-choice 3 days Pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg three times a day for a total of 3 days Third choice Trimethoprim – if low risk of resistance5 200 mg twice a day for 3 days Fosfomycin7 3g single dose sachet 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breastfeeding. 2 Doses given are by mouth using immediate-release medicines, unless otherwise stated. 3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly. 4 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018). 5 A lower risk of resistance may be more likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of resistance may be more likely with recent use and in older people in residential facilities. 6 If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), see the recommendations on choice of antibiotic in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing. 7 Fosfomycin should be commenced upon microbiology advice Abbreviations: eGFR, estimated glomerular filtration rate.

Urinary Tract Infection in Pregnancy Where possible, antibiotic choice should be informed by culture and sensitivity tests. The decision on which drug to use should be based on the clinical condition of the pregnant woman, weighing any risks to the foetus against the potential adverse effects for the mother and foetus from an untreated infection. Send MSU for culture, start antibiotics in all with significant positive culture even if asymptomatic.

Nitrofurantoin MR is the first line choice where clinically appropriate, and its short-term use in pregnancy is unlikely to cause problems to the foetus. However, there is a theoretical risk of haemolytic anaemia in the foetus or neonate, and BNF recommends “avoid at term” as appropriate (after 36 weeks of pregnancy until after delivery, unless otherwise clinically stated). Furthermore, an increased incidence of neonatal jaundice has been reported with use of nitrofurantoin in the last 30 days of pregnancy. The recommendation is to avoid nitrofurantoin at term, defined as after 36 weeks of pregnancy until after delivery, unless otherwise clinically stated as appropriate. Also, the eGFR should be 45ml/min or over; eGFR 30-44: only use suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk. Avoid in G6PD deficiency upper UTI/pyelonephritis.

Table 2 Antibiotics for pregnant women aged 12 years and over Antibiotic 1 Dosage and course length 2 Treatment of lower UTI First choice 3 Cefalexin 500 mg twice a day for 7 days Nitrofurantoin (avoid at term) – if eGFR 100 mg modified-release twice a day for 7 days ≥45 ml/minute4,5 Second-choice: If sensitivities available – prescribe in accordance with MSU results If sensitivities unavailable and no improvement in lower UTI symptoms on first-choice taken for at least 48 hours or when first-choice not suitable - consider choices below 3,6 Cefalexin 500 mg twice a day for 7 days Nitrofurantoin (avoid at term) – if eGFR 100 mg modified-release twice a day for 7 days ≥45 ml/minute4,5 Third-choice3,6 Alternative third-line choices Consult local microbiologist, choose antibiotics based on culture and susceptibility results

Treatment of asymptomatic bacteriuria Choose from nitrofurantoin4,5, amoxicillin or cefalexin based on recent culture and susceptibility results 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment. 2 Doses given are by mouth using immediate-release medicines, unless otherwise stated. 3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly. 4 Avoid at term in pregnancy (after 36 weeks of pregnancy until after delivery, unless otherwise clinically stated as appropriate); may produce neonatal haemolysis (BNF, August 2018). 5 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018). 6 If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment failure), see the recommendations on choice of antibiotic in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing. Abbreviations: eGFR, estimated glomerular filtration rate.

Urinary Tract Infection in Men Consider prostatitis or pyelonephritis as differential diagnosis and send pre-treatment MSU or if symptoms mild/non-specific, use negative dipstick to exclude UTI. Always adopt safety net approach. Patients over 65 may be regarded as complicated in many cases due to their co-morbidities and commonly poor fluid intake. Patients >65 years: treat if fever ≥38oC or 1.5oC above base twice in 12 hours AND dysuria OR ≥2 other symptoms. Do not treat asymptomatic bacteriuria as it is common but not associated with increased morbidity. Adequate fluid intake is often difficult but encouragement should be for frequent small volumes or jellies and frozen lollies as options.

Table 3 Antibiotics for men aged 16 years and over Antibiotic 1 Dosage and course length 2 First choice 3 Nitrofurantoin – if eGFR ≥45 ml/minute4,5 100 mg modified-release twice a day for 7 days Second choice Pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg three times a day for a total of 7 days Third-choice (no improvement in UTI symptoms on first-choice taken for at least 48 hours or when first-choice not suitable) 3 Trimethoprim 200 mg twice a day for 7 days Consider alternative diagnoses and follow recommendations in the NICE guidelines on pyelonephritis (acute): antimicrobial prescribing or prostatitis (acute): antimicrobial prescribing, basing antibiotic choice on recent culture and susceptibility results. 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment. 2 Doses given are by mouth using immediate-release medicines, unless otherwise stated. 3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly. 4 Nitrofurantoin is not recommended for men with suspected prostate involvement because it is unlikely to reach therapeutic levels in the prostate. 5 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018). Abbreviations: eGFR, estimated glomerular filtration rate.

Urinary Tract Infection in Children The NICE Clinical Guideline on Urinary Tract Infection in children: Diagnosis, treatment and long-term management CG54 advises that infants and children who have bacteriuria and fever of 38°C or higher should be considered to have acute pyelonephritis/upper urinary tract infection. Infants and children presenting with fever lower than 38°C with loin pain/tenderness and bacteriuria should also be considered to have acute pyelonephritis/upper urinary tract infection. All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have cystitis/lower urinary tract infection. Only refer for imaging if child < 6 months or recurrent or atypical UTI.

Children under 3 months with suspected UTI should be referred urgently for assessment. Children 3 months or older with positive nitrite should commence antibiotics and a pre-treatment MSU taken. 30

Check current Children’s BNF for dosages and frequency. Liquids may be suitable for children unable to take capsules or tablets. Please refer to Scriptswitch/Optimise for cost-effective preparations. Trimethoprim suspension, if suitable, should be used in preference to nitrofurantoin suspension which is very costly.

The NICE Clinical Guideline on Urinary Tract Infection in children: Diagnosis, treatment and long-term management CG54 2018 update includes the following recommendations:

1) Refer all infants under 3 months with a suspected UTI to paediatric specialist care, and • send a urine sample for urgent microscopy and culture • manage in line with the NICE guideline on fever in under 5s.

2) Urine samples should be sent for culture: • in infants and children who are suspected to have acute pyelonephritis/upper urinary tract infection • in infants and children with a high to intermediate risk of serious illness • in infants under 3 months • in infants and children with a positive result for leukocyte esterase or nitrite • in infants and children with recurrent UTI • in infants and children with an infection that does not respond to treatment within 24–48 hours, if no sample has already been sent • when clinical symptoms and dipstick tests do not correlate.

3) Use dipstick testing for infants and children 3 months or older but younger than 3 years with suspected UTI. • If both leukocyte esterase and nitrite are negative: do not start antibiotic treatment; do not send a urine sample for microscopy and culture unless at least 1 of the criteria in the recommendation above apply. • If leukocyte esterase or nitrite, or both are positive: start antibiotic treatment; send a urine sample for culture

Antibiotics for children and young people under 16 years

Antibiotic 1 Dosage and course length 2

Children under 3 months

Refer to paediatric specialist and treat with intravenous antibiotics (in secondary care) in line with the NICE guideline on fever in under 5s.

Children aged 3 months and over

First choice 3,4,8,9

Trimethoprim – if low risk of resistance5 Refer to BNF for children

Duration 3 days

Nitrofurantoin2 – if eGFR ≥45 ml/minute6 Use tablets or capsules where possible as nitrofurantoin suspension is a current cost pressure.

Refer to BNF for children

Duration 3 days

Second-choice (no improvement in lower UTI symptoms on first-choice taken for at least 48 hours or when first-choice not suitable) 3,4,7,8,9

Nitrofurantoin2 – if eGFR ≥45 ml/minute6 and not Use tablets or capsules where possible as nitrofurantoin used as first-choice suspension is a current cost pressure.

Refer to BNF for children

Duration 3 days

Amoxicillin (only if culture results available and Refer to BNF for children susceptible) Duration 3 days

Cefalexin Refer to BNF for children

Duration 3 days

1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic and renal impairment. See ‘Table 2: Antibiotics for pregnant women aged 12 years and over’ if a young woman is pregnant.

2 Nitrofurantoin suspension is significantly more expensive than nitrofurantoin capsules or nitrofurantoin tablet, NHS list price for Nitrofurantoin 25mg/5ml Oral Suspension, December 2018: £446.95

3 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly. Where a child or young person is receiving prophylactic antibiotics, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.

4 If 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost. Some children may also be able to take a tablet or part-tablet, rather than a liquid formulation, if the dose is appropriate.

5 A lower risk of resistance may be more likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of resistance may be more likely with recent use and in older people in residential facilities.

6 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNFC, August 2018).

7 If there are symptoms of pyelonephritis or the person has a complicated UTI (associated with a structural or functional abnormality, or underlying disease, which increases the risk of a more serious outcome or treatment

failure), see the recommendations on choice of antibiotic in the NICE guideline on pyelonephritis (acute): antimicrobial prescribing.

8 In reference to combination therapy (most commonly used in secondary care) if 2 or more antibiotics are appropriate, choose the antibiotic with the lowest acquisition cost

9many children may also be able to take a tablet or part-tablet, rather than a liquid formulation, if the dose is appropriate.

Abbreviations: eGFR, estimated glomerular filtration rate.

Acute Pyelonephritis If admission is not needed, send an MSU for culture and susceptibility and start antibiotics. Acute pyelonephritis requires appropriate choice of antibiotic which reaches sufficient blood levels. (See treatment table). If no response within 24 hours, admit to hospital. If ESBL risk, consult microbiologist for advice.

NICE guideline [NG111] Pyelonephritis (acute): antimicrobial prescribing, Published: October 2018, https://www.nice.org.uk/guidance/ng111, includes the following information with respect to oral antibiotic choice:-

When prescribing an antibiotic for acute pyelonephritis, take account of local antimicrobial resistance data and follow: • table 1 for non-pregnant women and men aged 16 years and over • table 2 for pregnant women aged 12 years and over • table 3 for children and young people under 16 years.

The committee agreed, based on experience, that several oral and intravenous antibiotics should be available for people with acute pyelonephritis. This enables antibiotics to be selected based on the severity of illness, antibiotic susceptibilities from culture results when available, local resistance patterns, risk of resistant bacteria, the setting, and known patient factors (such as whether the person has a higher risk of developing complications). In line with antimicrobial stewardship, narrower-spectrum antibiotics should be used wherever possible. • Nationally for England, resistance of E. coli (the main causative organism of acute pyelonephritis) in laboratory-processed urine specimens to the following antibiotics is: o cefalexin: 9.9% (varies by area from 8.1 to 11.4%) o ciprofloxacin: 10.6% (varies by area from 7.8 to 13.7%) o co-amoxiclav: 19.8% (varies by area from 10.8 to 30.7%) o trimethoprim: 30.3% (varies by area from 27.1 to 33.4%).

(Public Health England. Antimicrobial resistance quarterly surveillance: March 2018) • The committee also discussed that prescribers should be aware of their local antimicrobial prescribing data, because resistance rates do vary by area.

Table 1 Antibiotics for non-pregnant women and men aged 16 years and over Antibiotic Dosage and course length First-choice oral antibiotic

Cefalexin 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days Co-amoxiclav (only if culture results 500/125 mg three times a day for 7 to 10 days available and susceptible) Trimethoprim (only if culture results 200 mg twice a day for 14 days available and susceptible) Second choice oral antibiotic Ciprofloxacin1 (consider safety issues) 500 mg twice a day for 7 days

1 In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019

Table 2 Antibiotics for pregnant women aged 12 years and over Antibiotic Dosage and course length First-choice oral antibiotic Cefalexin 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days Second-choice alternatives (if first line unsuitable e.g. penicillin allergic) Check sensitivities and consultant local microbiologist for advice.

Table 3 Antibiotics for children and young people under 16 years Antibiotic Dosage and course length Children under 3 months Refer to paediatric specialist and treat with intravenous antibiotics (in secondary care) in line with the NICE guideline on fever in under 5s. Children aged 3 months and over First-choice oral antibiotic 3 Cefalexin Refer to BNF for children Duration 7-10 days Co-amoxiclav (only if culture results available Refer to BNF for children and susceptible) Duration 7-10 days

Prophylaxis of uncomplicated Urinary Tract Infections in adults Prophylactic antibiotics are actively discouraged in primary care. Assuming any need for referral has been eliminated, particularly following the referral guidelines for suspected cancer (NICE 2015 NG12), the use of prophylactic treatments is not supported in most cases by the consultant microbiologist. Recommendations for prophylaxis may come from urologists and paediatricians. Increasing resistance to trimethoprim and nitrofurantoin is encouraged by overuse of prophylactic antibiotics.

Recurrent UTIs (2 in 6 months or > 3 infections/year) Relapse is defined as a recurrent UTI with the same strain of bacteria, usually two or less weeks after treatment which suggests the possibility of a reservoir of infection. Re-infection is more likely in recurrences over two weeks after a previous infection and involves infection with a different strain or species of bacteria. This is the commonest occurrence. Management of recurrent infections involves assessing and eliminating risk factors. In the older person, risk factors such as oestrogen deficiency, incontinence, incomplete voiding and sometimes quite violent objection to personal hygiene attempts particularly in dementia can be linked to recurring infections. Review all medication in the elderly in particular reviewing the need for drugs which cause urine retention such as anticholinergics, anti-depressants etc. and re-evaluate clinical need.

GPs should not initiate prophylactic treatment before undertaking the following steps: • Frail elderly do not consume enough fluid and should be encouraged in ways of increasing fluid intake with ice lollies, jellies etc. • Advice on good personal hygiene and referral to social work teams in cases of dementia. • Check bowel management to ensure that frequent constipation is not a problem leading to residual urines and faecal incontinence thereby increasing risk of UTI. • Use the MSU sensitivity for each episode to determine treatment. This is especially important for repeated infections. Management of complex patients with multiple resistance patterns can be supported by advice from an urologist and/or microbiologist. • In all cases check concordance with treatment. Is the patient taking the whole course prescribed as instructed? • Risk factors for increased antimicrobial resistance include: care home resident, recurrent UTI, hospitalisation >7days in the last 6 months, unresolving urinary symptoms, recent travel to a country with increased antimicrobial resistance (outside Northern Europe and Australasia) especially health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones. • If increased resistance risk, send culture for susceptibility testing and give safety net advice. If GFR<45 ml/min or elderly consider pivmecillinam or fosfomycin (3g stat in women plus 2nd 3g dose in men 3 days later). Fosfomycin has been approved for use by the JPC for the treatment of uncomplicated lower urinary tract infections caused by identified multi-resistant organisms to avoid admission to hospital for the administration of intravenous antibiotics.

NICE guideline [NG112] Urinary tract infection (recurrent): antimicrobial prescribing, Published date: October 2018, https://www.nice.org.uk/guidance/ng112, includes the following treatment strategy with respect to preventing recurrent urinary tract infections:-

• Manage an acute UTI as outlined in the NICE guidelines on urinary tract infection (lower): antimicrobial prescribing or pyelonephritis (acute): antimicrobial prescribing. • Be aware that recurrent UTI: • includes lower UTI and upper UTI (acute pyelonephritis) • may be due to relapse (with the same strain of organism) or reinfection (with a different strain or species of organism) • is particularly common in women. 35

Give advice to people with recurrent UTI about behavioural and personal hygiene measures and self-care treatments that may help to reduce the risk of UTI.

Referral and seeking specialist advice Refer or seek specialist advice on further investigation and management for: • men aged 16 years and over • people with recurrent upper UTI • people with recurrent lower UTI when the underlying cause is unknown • pregnant women • children and young people under 16 years in line with the NICE guideline on urinary tract infection in under 16s • people with suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral.

Self-Care Options:- • Some women with recurrent UTI may wish to try cranberry products if they are not pregnant (evidence of benefit is uncertain and there is no evidence of benefit for older women) • Some children and young people under 16 years with recurrent UTI may wish to try cranberry products with the advice of a paediatric specialist (evidence of benefit is uncertain).

Advise people taking cranberry products about the sugar content of these products, which should be considered as part of the person's daily sugar intake. Be aware that evidence is inconclusive about whether probiotics (lactobacillus) reduce the risk of UTI in people with recurrent UTI. Provide Urinary Tract Infection Information Leaflet.

Treatment for women with recurrent UTI who are not pregnant:- Consider vaginal oestrogen (if clinically appropriate and consider alternate diagnoses) in women using British menopausal society guidance with postmenopausal recurrent UTI if behavioural and personal hygiene measures alone are not effective or are not appropriate. Discuss the risks and benefits of this treatment with the woman to ensure shared decision-making.

Antibiotic Prophylaxis For women with recurrent UTI who are not pregnant, consider a trial of antibiotic prophylaxis only if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or not appropriate. Robust evidence for benefits of long term prophylactic use of antibiotics in older women in particular is not available and is generally not supported by the local consultant microbiologist.

For women with recurrent UTI who are not pregnant, ensure that any current UTI has been adequately treated then consider single-dose antibiotic prophylaxis for use when exposed to an identifiable trigger. Some people (mainly women) may be able to identify 1 or more triggers that often brings on a UTI (for example, dehydration or sexual intercourse - see table 2: post-coital antibiotic choices).These triggers may vary for different people.

Take account of: • the severity and frequency of previous symptoms • the risk of developing complications • previous urine culture and susceptibility results • previous antibiotic use, which may have led to resistant bacteria • the woman's preferences for antibiotic use

Table 1: Antibiotic prophylaxis for people aged 16 years and over

Refer or seek specialist advice on further investigation and management for: • men aged 16 years and over • pregnant women • children and young people under 16 years in line with the NICE guideline on urinary tract infection in under 16s

Antibiotic prophylaxis 1,2 Dosage 3

First choice: Self-Care

Void bladder, local washing and on-going adequate fluid intake, vaginal oestrogen (if clinically appropriate) see ‘self-care options’ section above. Provide Urinary Tract Infection Information Leaflet.

Second choice

Trimethoprim4 200 mg single dose when exposed to a trigger or 100 mg at night

Nitrofurantoin – if eGFR ≥45 ml/minute5 100 mg single dose when exposed to a trigger or 50 to 100 mg at night

Third choice

Amoxicillin6 500 mg single dose when exposed to a trigger or 250 mg at night

Cefalexin 500 mg single dose when exposed to a trigger or 125 mg at night

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

2 Choose antibiotics according to recent culture and susceptibility results where possible, with rotational use based on local policies. Select a different antibiotic for prophylaxis if treating an acute UTI.

3 Doses given are by mouth using immediate release medicines, unless otherwise stated.

4 Teratogenic risk in first trimester of pregnancy (folate antagonist; BNF, August 2018). Manufacturers advise contraindicated in pregnancy (trimethoprim summary of product characteristics). If clinically indicated (in second or third trimester) prescribe adjuvant folate supplementation.

5 Avoid at term in pregnancy (after 36 weeks of pregnancy until after delivery, unless otherwise clinically stated as appropriate); may produce neonatal haemolysis (BNF, August 2018).

6 Amoxicillin is not licensed for preventing UTIs, so use for this indication would be off-label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

Abbreviations: BNF, British natural formulary; eGFR, estimated glomerular filtration rate.

A common trigger for urinary tract infection is post sexual intercourse. Post-coital antibiotics are sometimes initiated in primary care but a current literature search reveals that evidence to support this practice is based on small studies insufficient to present as a recommendation of good practice. The risk of increasing antimicrobial resistance is now of prime concern and before offering prophylactic drug treatment, consider the frequency, severity, and impact of recurrent cystitis, and whether referral for urological investigation would be appropriate to exclude an underlying cause. If a continuous course is deemed appropriate, nitrofurantoin 50-100mg would be the local recommendation but its effectiveness should be frequently reviewed and no longer than 6 month’s duration without appropriate monitoring.

Following treatment failure in both sexually active and non-sexually active women: • In cases where symptoms fail to resolve despite therapy, the possibility of an alternative diagnosis should be considered and patients referred to urology for further investigation. • Advice to initiate prophylactic antibiotics should come from secondary care in the majority of cases and should be time defined • Prophylactic courses need to be reviewed every six months and appropriate monitoring carried out.

Risks of long term prophylactic antibiotics Minimising antibiotic exposure is essential if we are to maintain the effectiveness of the currently available antibiotic classes in an era of increasing resistance while still providing effective treatment. Prophylaxis does not stop UTI infections and increases the risks to the patient of acquiring Clostridium difficile.

Risks outweigh benefits in the elderly • Do not treat asymptomatic bacteriuria; it is common but is not associated with increased mortality. • The manufacturer of trimethoprim recommends regular blood counts on long term therapy, checking for hyperkalaemia and depression of haematopoiesis. Reference to the BNF highlights symptoms of blood disorders and such risks are increased in long term treatment. • Long-term treatment with nitrofurantoin requires monitoring of liver function and the development of any respiratory or peripheral neuropathic symptoms. Nitrofurantoin is now contraindicated in most patients if eGFR is less than 45ml/minute/1.73m2. A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 ml/min/1.72m2.

Catheter associated Urinary Tract Infection Catheter-associated UTI is defined as the presence of symptoms or signs compatible with a UTI in people with a catheter with no other identified source of infection plus significant levels of bacteria in a catheter or a midstream urine specimen when the catheter has been removed within the previous 48 hours (adapted from Infectious Diseases Society of America's guideline on catheter- associated UTI [2009]). Catheter-associated UTI is a symptomatic infection of the bladder or kidneys in a person with a urinary catheter; the longer a catheter is in place, the more likely bacteria will be found in the urine. After 1 month nearly all people have bacteriuria and antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter. Asymptomatic bacteriuria is defined as the presence of significant levels of bacteria in the urine with no symptoms of urinary tract infection (UTI). (NICE NG 113). There is NO VALUE in sending urine from asymptomatic patients with longstanding catheters. Cloudiness and smell in the urine are not reasons for culturing urine. Antimicrobial therapy should be commenced in patients who are symptomatic. Do not commence antimicrobial therapy on urine sample results alone. Give advice about managing symptoms with self-care (use paracetamol for pain and drink enough fluids to avoid dehydration) to all people with catheter associated UTI. Consider removing or, if this cannot be done, changing the catheter as soon as possible in people with a catheter-associated UTI if it has been in place for more than 7 days. Do not allow catheter removal or change to delay antibiotic treatment. Obtain a urine sample before antibiotics are taken for culture and susceptibility testing, noting a suspected catheter-associated infection (ensure urine specimen is labelled CSU) and any antibiotic prescribed. Take the sample from the catheter, via a sampling port if provided, and use an aseptic technique (in line with NICE CG139 Infection control guidance) If the catheter has been changed, obtain the sample from the new catheter. If the catheter has been removed, obtain a midstream specimen of urine. Offer an antibiotic to people with catheter associated UTI taking into account symptom severity (upper UTI symptoms), risk of complications, previous urine culture, susceptibility results and previous antibiotic use. Reassess if symptoms worsen at any time or do not start to improve within 48 hours of taking the antibiotic. Antibiotic and antiseptic bladder washouts are not recommended. Occasionally calcium and ammonium phosphate salts encrust the catheters. Advice should be obtained from continence team where there is a persistent problem. Community nurses utilise the catheterisation procedures and catheter care within the Royal Marsden Clinical Nursing Guidelines. http://www.rmmonline.co.uk/ The HOUDINI method and the Royal Marsden guidance on catheter insertion are references used to assist staff on making the decision on whether a catheter is required. There is also a Public Health England 2018 UTI quick reference tool for primary care which can be accessed via https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis Table 1 Antibiotics for non-pregnant women and men aged 16 years and over to treat catheter related UTI

Antibiotic1 Dosage and course length

First-choice oral antibiotic if no upper UTI symptoms2

Nitrofurantoin – if eGFR≥45 ml/minute3,4 100 mg modified-release twice a day for 7 days

Trimethoprim – if low risk of resistance5 200 mg twice a day for 7 days

Amoxicillin (only if culture results 500 mg three times a day for 7 days available and susceptible)

Second-choice oral antibiotic if no upper UTI symptoms (when first-choice not suitable)2

Pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg three times a day for a total of 7 days

First-choice oral antibiotic if upper UTI symptoms2

Cefalexin 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days

Co-amoxiclav (only if culture results 500/125 mg three times a day for 7 to 10 days available and susceptible)

Trimethoprim (only if culture results 200 mg twice a day for 14 days available and susceptible) Second-choice oral antibiotic if upper UTI symptoms2 (If choices listed above are inappropriate/ have been tried)

Ciprofloxacin (consider safety issues)6 500 mg twice a day for 7 days

1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment and breastfeeding, and administering intravenous antibiotics. 2 Check any previous urine culture and susceptibility results and antibiotic prescribing, and choose antibiotics accordingly. 3 May be used with caution if eGFR 30–44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug-resistant bacteria and only if potential benefit outweighs risk (BNF,August 2018). 4 Nitrofurantoin and pivmecillinam are only licensed for uncomplicated lower UTIs, and are not suitable for people with upper UTI symptoms or a blocked catheter. 5 A lower risk of resistance is likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of resistance is likely with recent use and in older people in care homes. 6In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019 Abbreviations: BNF, British natural formulary; eGFR, estimated glomerular filtration rate.

Table 2 Antibiotics for pregnant women aged 12 years and over to treat catheter related UTI

1 Antibiotic Dose and course length

2 First-choice oral antibiotic

Cefalexin 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days

1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics. 2 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly.

Table 3 Antibiotics for children and young people under 16 years to treat catheter related UTI

Antibiotic1 Dosage and course length

Children under 3 months

Refer to paediatric specialist and treat with intravenous antibiotics in line with the NICE guideline on fever in under 5s.

Children aged 3 months and over

First-choice oral antibiotics2

Trimethoprim – if low risk of resistance3 Refer to BNF for children Duration 7-10 days

Amoxicillin (only if culture results available Refer to BNF for children and susceptible) Duration 7-10 days

Cefalexin Refer to BNF for children Duration 7-10 days

Second-choice oral antibiotics2

Co-amoxiclav (only if culture results available Refer to BNF for children and susceptible) Duration 7-10 days

1 See BNF for children (BNFC) for appropriate use and dosing in specific populations, for example, hepatic impairment and renal impairment, and administering intravenous antibiotics. See table 2 if a young woman is pregnant. 2 Check any previous urine culture and susceptibility results and antibiotic prescribing and choose antibiotics accordingly. If a child or young person is receiving prophylactic antibiotics, treatment should be with a different antibiotic, not a higher dose of the same antibiotic. 3 A lower risk of resistance is likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where local epidemiology data suggest resistance is low. A higher risk of resistance is likely with recent use.

Do not routinely offer antibiotic prophylaxis to prevent catheter-associated UTIs in people with a short- term or a long-term (indwelling or intermittent) catheter.

Referral and seeking specialist advice Refer people with catheter-associated UTI to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, sepsis). Consider referring or seeking specialist advice for people with catheter- associated UTI if they: • are significantly dehydrated or unable to take oral fluids and medicines or are pregnant or • have a higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract, or underlying disease [such as diabetes or immunosuppression]) or • have recurrent catheter-associated UTIs or • have bacteria that are resistant to oral antibiotics

Genital Infections

UK national guidelines on the management of Sexually Transmitted Infections (STIs) and related conditions in General Practice was published by BASHH in conjunction with Royal College of General Practitioners and outlines how primary care practitioners can provide high quality service to patients with STIs. Lazaro N. Sexually Transmitted Infections in Primary Care 2013 (RCGP/BASHH) available at http://www.rcgp.org.uk/ and www.bashh.org/guidelines

In relation to specific STIs • All sexually transmitted infections are becoming more common. Syphilis Serology is advisable. • Patients with sexually transmitted diseases and their partners require full microbiological investigation and referral to the Sexual Health clinic. Self-referral is also possible. • For further information on the national screening programme, including self-referral pathways and patient information leaflets, please refer to iCaSH Bedfordshire - www.icash.nhs.uk/where- to-go/icash-bedfordshire or Luton Sexual Health - www.lutonsexualhealth.org.uk • People with risk factors should be screened for chlamydia, HIV, gonorrhoea and syphilis. Risk factors include younger than 25, no condom use, recent (less than 12 months) or frequent change in partners, symptomatic partner.

Prostatitis An MSU should be sent for culture and start antibiotics. Antimicrobial choice should be reassessed when urine culture results are available and referral made to Sexual Health clinic if a sexually transmitted infection is identified. A 14 day course, then review and if required a further 14 day course (4 week course in total) may prevent chronic prostatitis. Quinolones achieve higher prostate levels.

NICE guideline [NG110] Prostatitis (acute): antimicrobial prescribing, Published: October 2018, https://www.nice.org.uk/guidance/ng110, includes the following information with respect to oral antibiotic choice:-

*Take account of local antimicrobial resistance data and follow table 1 for adults aged 18 years and over.

Table 1 Antibiotics for adults aged 18 years and over Antibiotic Dosage and course length

First-choice oral antibiotic (guided by susceptibilities when available)

Ciprofloxacin1 500 mg twice a day for 14 days then review - either stop the antibiotic (consider safety or continue for a further 14 days if needed, based on an assessment of issues) the person's history, symptoms, clinical examination, urine and blood tests.

Ofloxacin1 200 mg twice a day for 14 days then review- either stop the antibiotic or (consider safety continue for a further 14 days if needed, based on an assessment of the issues) person's history, symptoms, clinical examination, urine and blood tests.

Alternative first-choice oral antibiotic for adults unable to take a fluoroquinolone (guided by susceptibilities when available)

Trimethoprim 200 mg twice a day for 14 days then review- either stop the antibiotic or continue for a further 14 days if needed, based on an assessment of the person's history, symptoms, clinical examination, urine and blood tests.

Second-choice oral antibiotic (after discussion with specialist)

Levofloxacin1 500 mg once a day for 14 days then review- either stop the antibiotic or (consider safety continue for a further 14 days if needed, based on an assessment of the issues) person's history, symptoms, clinical examination, urine and blood tests.

Co-trimoxazole 960 mg twice day for 14 days then review- either stop the antibiotic or continue for a further 14 days if needed, based on an assessment of the person's history, symptoms, clinical examination, urine and blood tests.

1In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019

Nationally for England, resistance of E. coli (the main causative organism of acute prostatitis) in laboratory processed urine specimens to the following antibiotics is: o ciprofloxacin: 10.6% (varies by area from 7.8% to 13.7%) o trimethoprim: 30.3% (varies by area from 27.1% to 33.4%) (Public Health England. Antimicrobial resistance quarterly surveillance: March 2018). NICE recommend that prescribers should be aware of their local antimicrobial prescribing data, because resistance rates do vary by area. The committee agreed that a minimum of a 14-day course of all the recommended antibiotics was required for acute prostatitis. At 14 days, treatment should be reviewed, and either stopped or continued for a further 14 days as needed based on clinical assessment.

Epididymo-orchitis For epididymo-orchitis most probably due to any sexually transmitted pathogen: Drug Name Dose Frequency Duration Comments

Ceftriaxone 1g Single dose If ceftriaxone is contraindicated e.g. intramuscularly patient has a “serious penicillin allergy PLUS (immediate hypersensitivity”, patient is under 12 years of age (doxycycline Doxycycline 100mg orally Twice daily 10-14 days contraindication), contact sexual health / local microbiology for advice.

Ceftriaxone injection is available as 1g vials. When reconstituted, the resultant solution is given. Ceftriaxone is supplied as a powder which is reconstituted with 1% lidocaine injection, consult current SPC for full details. If most probably due to chlamydia or other non-gonococcal organisms (i.e. where gonorrhoea considered unlikely as microscopy is negative for Gram negative intracellular diplococci and no risk factors for gonorrhoea identified) could consider: 44

Drug Name Dose Frequency Duration Comments

Doxycycline 100mg Twice daily 10-14 days Not suitable for children under 12 years of OR orally age.

1 Ofloxacin 200mg Twice daily 14 days See footnote1 (consider safety orally issues) 1 In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019

Common risk factors for gonorrhoea are: previous N. gonorrhoea infection; known contact of gonorrhoea; presence of purulent urethral discharge, men who have sex with men and black ethnicity.

For epididymo-orchitis most probably due to enteric organisms in non-sexually active men: Drug Name Dose Frequency Duration Comments

1 Ciprofloxacin 500mg by Twice daily 10 days See footnote1 (consider mouth safety issues) 1 In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019

Vaginal Discharge in an Adult Common causes are chlamydia, trichomonas, candidiasis and bacterial vaginosis. Culture samples required as listed under Pelvic Inflammatory Disease.

Trichomonas vaginalis Treatment of the sexual partner may be indicated, especially if there is recurrence of the infection.

Drug Name Dose Frequency Duration Comments

Metronidazole 400mg Twice daily 7 days

Metronidazole 2g One dose only Not in breast feeding or pregnancy. Clotrimazole pessary 100mg At night 6 nights For symptom relief (not cure) if metronidazole is declined. Candidiasis For vulval symptoms only use topical clotrimazole 1% cream. With recurrent infections (> 4 infections in 12 months), consider treating the sexual partner and check predisposing factors such as pregnancy, contraceptive pills, antibiotics, diabetes and reservoir infections. BASHH guideline does not suggest the use of any other diagnostic tests and makes no reference to the use of high vaginal swabs. If there is uncertainty regarding the diagnosis following history and examination, a referral to sexual health services should be made for microscopy and consideration of candida resistance. Women should be advised to: • Avoid local irritants (e.g. soaps, bath salts and shower gels containing perfumes) • Use vulval moisturisers as a soap substitute • Avoid tight fitting synthetic clothing Drug Name Dose Frequency Duration Comments

Clotrimazole pessary 500mg Once at night One night only Available OTC. Clotrimazole pessary 100mg Once at night 6 nights For use in pregnancy. Available OTC. Fluconazole capsules 150mg Once daily One day only. Available OTC. Not in pregnancy. For recurrent infection (>4 One dose every 72 6 months episodes / year) hours for 3 doses Fluconazole capsules 150mg then one dose once a week for 6 months

Bacterial Vaginosis Patients may be asymptomatic. Oral metronidazole is as effective as topical treatment and is less expensive. Treating partners does not reduce relapse.

Drug Name Dose Frequency Duration Comments

Metronidazole 400mg Twice daily 7 days Preferred regimen in pregnancy. Less relapse with 7 days than 2g stat at 4 weeks. Metronidazole 2g One dose only Not in breast feeding or pregnancy.

Metronidazole 0.75% 5g Once at night 5 nights Vaginal Gel Clindamycin 2% cream 5g Once at night 7 nights

Pelvic Inflammatory Disease (PID) • Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens in PID. The UK National Guidelines (BASHH) have been revised; as quinolones (ofloxacin, levofloxacin and moxifloxacin) can cause disabling and potentially permanent side-effects involving tendons, muscles, joints and the nervous system, they are now recommended as second line therapy except for the treatment of M

46 genitalium associated PID where no alternative therapy is available. In this case, Ofloxacin and Metronidazole as dual therapy is recommended. If the patient has suspected M genitalium associated PID, please refer to sexual health team for management. Please refer to the 2019 interim guidelines for more information https://www.bashhguidelines.org/media/1217/pid-update-2019.pdf • Vulvovaginal NAAT testing for chlamydia and gonorrhoea (+ M. genitalium if available) are important to identify a sexually transmitted cause of PID. • Occasionally organisms forming part of the normal vaginal flora may be implicated. Treatment, until the identity of the pathogen is known, is broad spectrum: Drug Name Dose Frequency Duration Comments

First line Ceftriaxone 1g by Single dose This is an unlicensed use of ceftriaxone. If ceftriaxone is deep IM intramuscularly contraindicated e.g. patient has a serious penicillin injection allergy, contact Sexual Health / Local microbiology for advice. Pregnancy / breastfeeding – refer to Sexual PLUS Health / Local microbiology. Doxycycline 100mg Twice daily 14 days orally

PLUS 400mg Twice daily 14 days Metronidazole orally Second line Ofloxacin1 400mg Twice daily 14 days Not suitable for patients who are at high risk of (consider orally gonococcal PID because of increasing quinolone safety issues) resistance in the UK – 28% of Neisseria gonorrhoea 400mg Twice daily 14 days isolates now resistant to quinolones.. Pregnancy / PLUS orally breastfeeding – refer to Sexual Health / Local Metronidazole microbiology. 1 In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019

For patients at high risk of gonococcal PID, treat as per first line choice as listed in the table above or refer to Sexual Health. Gonococcal PID is likely if partner has gonorrhoea, patient has severe symptoms, or patient has had sexual contact abroad. Ceftriaxone injection is available as 1g vials. When reconstituted, the resultant solution is given. Ceftriaxone is supplied as a powder which is reconstituted with 1% lidocaine injection, consult current SPC for full details. Metronidazole is included to improve coverage for anaerobes which are of greater importance in severe PID.

Chlamydia trachomatis (CT) The BASHH chlamydia guidelines can be accessed via this link: https://www.bashhguidelines.org/current-guidelines/urethritis-and-cervicitis/chlamydia-2019/ As a consequence of its potential to select for macrolide resistance in MGen and its inadequacy as a treatment for rectal CT, BASHH no longer recommends single dose azithromycin for treatment of uncomplicated chlamydia infection at any site, regardless of the gender of the infected individual. Vulvo vaginal swabs are the specimens of choice for women. First catch urine is the sample of choice to identify urethral chlamydia in men. Chlamydia testing for genital and extra-genital chlamydia should be performed using dual nucleic acid amplification tests (NAATs), if locally commissioned. As there is a lower cure rate in pregnancy, “test for cure” (TOC) at least 3 weeks after end of treatment. The BASHH guideline states that TOC is not routinely recommended for uncomplicated genital chlamydia infection. The National Chlamydia Screening Programme and 2015 UK National Guideline for management of infection with Chlamydia Trachomatis recommends that patients aged 24 years and under are rescreened 12 weeks following treatment. The iCaSH Bedfordshire service offer an STI screening postal kit called ‘Express Test,’ that screens for chlamydia, gonorrhoea, syphilis and HIV as well as, where indicated, Hepatitis B and Hepatitis C which can be accessed via their website. Luton Sexual Health also offer a postal kit called ‘Freetest.me 4-in-1 Kit’ that screens for chlamydia, gonorrhoea, syphilis and HIV. For further information on how to access these kits online, the national screening programme, including self-referral pathways and patient information leaflets, please refer to iCaSH Bedfordshire - www.icash.nhs.uk/where-to-go/icash- bedfordshire or Luton Sexual Health - www.lutonsexualhealth.org.uk Partner notification and contact details are essential for reducing the risk of re-infection and onward transmission of infection. If the patient declines to give details please refer to the sexual health team who can perform provider referral (anonymous partner notification).

Drug Name Dose Frequency Duration Comments

First line choice for uncomplicated, urogenital, pharyngeal and rectal chlamydia infections (with test of cure as per BASHH 2015 guidelines) : Doxycycline 100mg Twice daily 7 days Contraindicated in pregnancy. Children above 12 orally years only tetracycline bone side effects First line choice for pregnant women or for individuals who are allergic to, or intolerant of tetracyclines: Azithromycin 1 gram As a single dose followed “Off label” use. In pregnancy or breastfeeding: orally by 500mg daily for 2 days azithromycin is the most effective option.

Alternative treatment choices •Erythromycin 500mg four times 7 days Suitable for use in pregnancy orally daily

or 500mg twice daily 14 days orally Amoxicillin 500mg three times 7 days Suitable for use in pregnancy orally a day

Neisseria gonorrhoea, uncomplicated All patients should be offered a referral to the sexual health team, however it is acknowledged that some patients may prefer to be treated at practice level, and for uncomplicated neisseria gonorrhoea the antimicrobial treatment options are listed below. Patients with complicated neisseria gonorrhoea (e.g. non responsive to treatment, associated PID) should be referred directly to the sexual health team/ microbiology team for advice and management. Partner notification and contact details is essential to

48 reducing the risk of re-infection and onward transmission of infection, if the patient declines to give details please refer to the sexual health team who could will use provider referral (anonymous partner notification). In 2019, BASHH reviewed the treatment recommendations; and now support the use of ceftriaxone monotherapy as first line empirical treatment (previously dual therapy with azithromycin was recommended). This recommendation is based on the lack of high quality evidence regarding the best strategy to delay the emergence of resistance. Since 2011, the prevalence of azithromycin resistance in the UK and globally has increased (9.2% in Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) 2017). When treating Gonorrhoea, BASHH recommends that treatment for Chlamydia is included in the regimen if co-infection present. Ceftriaxone injection is available as 1g vials. When reconstituted, the resultant solution is given. Ceftriaxone is supplied as a powder which is reconstituted with 1% lidocaine injection, consult current SPC for full details.

Drug Name Dose Frequency Duration Comments

Ceftriaxone 1g by deep IM Single This is an unlicensed use of ceftriaxone. If injection injection dose ceftriaxone is contraindicated e.g. patient has a serious penicillin allergy, contact Sexual Health / Local microbiology for advice. Pregnancy / breastfeeding – refer to Sexual Health / Local microbiology. If the antimicrobial susceptibility is known prior to treatment prescribe: 1 Ciprofloxacin 500mg orally Single See foot note1 (consider safety dose issues) 1If this regimen is unsuitable or unavailable, contact the local microbiology or sexual health team for advice. In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019 If chlamydia co-infection present: ADD 100mg Twice daily 7 days Contraindicated in pregnancy. Children above 12 Doxycycline orally years only tetracycline bone side effects OR: For pregnant women or for individuals who are allergic to, or intolerant of tetracyclines: ADD 1 gram As a single dose followed “Off label” use. In pregnancy or breastfeeding: Azithromycin orally by 500mg daily for 2 days azithromycin is the most effective option.

Alternative Regimen is an option ONLY if IM ceftriaxone is contraindicated or refused by patient. Clinicians should consult with microbiology/Sexual Health before prescribing this regimen due to resistance issues.

Drug Name Dose Frequency Duration Comments

Cefixime tablets 400mg orally Single dose If cefixime is contraindicated e.g. patient has a serious penicillin allergy, contact Sexual Health PLUS / Local microbiology for advice. Pregnancy / breastfeeding – refer to Sexual Health / Local Azithromycin 2g orally Single dose microbiology.

If chlamydia co-infection present: If an individual has already received azithromycin 2g for the treatment of gonorrhoea then this should be sufficient to treat chlamydia and no further doses of azithromycin are required.

Follow-up and test of cure (TOC)

For information of the detection on gonorrhoea please refer to the Public Health England guidance https://www.gov.uk/government/publications/guidance-for-the-detection-of-gonorrhoea-in-england

All patients diagnosed with gonorrhoea should be advised to return for TOC, with extra emphasis given to patients:

1. With persistent symptoms or signs 2. With pharyngeal infection 3. Treated with anything other than first line recommended regimen when antimicrobial susceptibility unknown 4. Who acquired infection in the Asia-Pacific region when antimicrobial susceptibility unknown

A positive TOC could be due to treatment failure, reinfection or residual non-viable organism and should be discussed with the Sexual Health Team for advice.

Cases of possible ceftriaxone treatment failure in England should be reported to Public Health England using the on-line form: https://hivstiwebportal.phe.org.uk/login.aspx

Acute Herpes Simplex (Genital Infection) The diagnosis of genital herpes should be carried out by specialist in Sexual Health as follow up is necessary. Drug Name Dose Frequency Duration Comments

Aciclovir 400mg orally Three times a day 5 days “Off label” use. May improve compliance versus 5 times a day dosing.

Recurrent Herpes Simplex (Genital Infection) (From NICE Clinical Knowledge Summaries: Herpes Simplex Genital Scenario recurrent episodes age 13 onwards, April 2017 available at https://cks.nice.org.uk/herpes-simplex-genital ) Self-care measures may be helpful for some people. If not already tried, advise the person to: • Clean the affected area with plain or salt water to help prevent secondary infection and promote healing of lesions. • Apply vaseline or a topical anaesthetic (e.g. lidocaine 5%) to lesions to help with painful micturition, if required. • Increase fluid intake to produce dilute urine (which is less painful to void). Urinate in a bath or with water flowing over the area to reduce stinging. • Avoid wearing tight clothing (which may irritate lesions) and use adequate pain relief (e.g. oral paracetamol).

• Avoid sharing towels and flannels with household members (although it is very unlikely that the virus would survive on an object long enough to be passed on, it is sensible to take steps to prevent this). • Try to avoid identified trigger factors (e.g. ultraviolet light, excess alcohol). If self-care measures are not controlling symptoms, prescribe oral aciclovir 800 mg three times a day for 2 days. For future attacks use either: • Episodic antiviral treatment if attacks are infrequent (e.g. less than six attacks per year). Consider self- initiated treatment, so antiviral medication can be started early in the next attack. • Suppressive antiviral treatment (e.g. oral aciclovir 400 mg twice daily for 6–12 months) if attacks are frequent (e.g. six or more attacks per year), causing psychological distress, or affecting the person's social life: - After 1 year, stop treatment for a minimum period of two recurrences. - If attacks are still considered problematic, restart suppressive treatment. If attacks are not considered problematic (off treatment), future attacks can be controlled with episodic antiviral treatment (if needed). - If the person has breakthrough attacks on suppressive treatment, seek specialist advice.

Skin/Soft Tissue Infections Impetigo

Advise people with impetigo and their parents or carers, if appropriate, about good hygiene measures to reduce the spread of impetigo to other areas of the body and other people.

For localised non-bullous impetigo consider hydrogen peroxide, if this is unsuitable (e.g. if impetigo is around the eyes) then a topical antibiotic should be considered.

For widespread non-bullous impetigo offer a short course of topical or oral antibiotics. Do not give combination treatment with topical and oral antibiotics.

For bullous impetigo or in an individual who is showing systemic signs of infection or at high risk of complications offer an oral antibiotic.

Topical treatment options (NB – Repeated use of topical antibacterials may lead to the development of resistance)

Drug Name Dose Frequency Duration Comments

Hydrogen Peroxide Apply two or three times 5 days Topical antiseptic 1% a day If hydrogen peroxide is unsuitable (e.g. if impetigo is around the eyes) or ineffective Fusidic acid 2% Apply three times a day 5 days If fusidic acid resistance is suspected or confirmed Mupirocin 2% Apply three times a day 5 days

Oral treatment options:

Drug Name Dose Frequency Duration Comments

Flucloxacillin 500mg four times a day 5 days In penicillin allergy Clarithromycin 250mg twice a day 5 days Erythromycin 250 - 500mg four times a 5 days In pregnant women with penicillin allergy day

Microbiological samples (skin swabs) should be considered where patients have not responded or the condition has worsened following empirical treatment (either topical or oral antibiotics).

In cases of recurrent impetigo, send skin swabs and also consider a nasal swab and commencing decolonisation treatment.

Secondary bacterial infection of Eczema and other common skin conditions

Do not routinely offer antibiotics (topical or oral) to those with secondary infections who are systemically well due to the risk of development of resistance. For patients who require antimicrobial treatment, due to systemic signs of infection associated with bacterial infection of the skin, treat as per the table below:

Treatment Antibiotic, dosage and course length For secondary bacterial infection of eczema in Do not routinely offer either a topical or oral people who are not systemically unwell antibiotic First choice topical Fusidic acid 2% - apply three times a day for 5 – 7 days For localised infections only. Extended or recurrent use may increase the risk of developing antimicrobial resistance First choice oral option Flucloxacillin – 500mg QDS for 5 -7 days Alternative oral option in penicillin allergy Clarithromycin – 250mg BD for 5 -7 days (can be increased to 500mg BD in severe infection) Alternative oral option in pregnant women with Erythromycin – 250-500mg QDS for 5-7 days penicillin allergy If methicillin-resistant Staphylococcus aureus is Consult a microbiologist suspected on confirmed

Acne Vulgaris Please refer to the Bedfordshire Acne summary pathway on GP ref for further management advice. Oral antibiotics may be indicated in patients with moderate acne which is not responding to topical treatments alone. Oral antibiotics should be combined with an appropriate topical agent to reduce the risk of bacterial resistance. Topical and oral antibiotics should not be combined. Patients should be changed to an alternative oral antibiotic if there is no improvement (or acne has worsened) within 3 months. Evidence suggests there is little additional benefit in using oral antibiotics for more than 3 months and that the risk of P.acnes resistance increases, therefore oral antibiotics should be stopped after 3 months and patients continued on topical treatment only. Antibiotics courses could be repeated if needed.

Drug Name Dose Frequency Duration Comments

Lymecycline 408mg Daily 6 -12 Then review – if no response switch to doxycycline. weeks Avoid in children under 12 years. Doxycycline 100mg Daily 6 -12 Then review – if no response to 2 antibiotics then weeks consider referral to dermatology. Avoid in children under 12 years. Erythromycin 500mg Twice daily 6 – 12 Then review – if responded continue for maximum weeks of 3 months. Only use when a tetracycline is poorly tolerated or contraindicated (e.g. pregnancy or breast feeding) due to the high risk of P. acnes resistance. Rosacea – acne For mild or moderate papulopustular acne rosacea (limited number of papules and pustules, with no plaques) prescribe topical metronidazole or azelaic acid.

o Metronidazole 0.75% gel or cream applied twice daily for 6-9 weeks (the cream may be more suitable for sensitive skin), or o Azelaic acid 15% applied twice daily may be more effective however it may cause adverse effects especially in people who have sensitive skin. For moderate to severe papulopustular acne rosacea (extensive papules, pustules, or plaques), consider oral antibiotics for 3 months. For patients with infrequent recurrences a course of treatment can be repeated. If symptoms recur frequently, once symptoms have settled on a standard dose of treatment the patient can then be kept on a lower dose of the antibiotic to reduce flare-ups.

Drug Name Dose Frequency Comments

Oxytetracycline 500mg Twice daily For 6-12 weeks then review Doxycycline 100mg Daily For 6-12 weeks then review Lymecycline 408mg Daily For 6-12 weeks then review Erythromycin 500mg Twice daily For 6-12 weeks then review. Only use when tetracycline is poorly tolerated or contraindicated (e.g. pregnancy or breast feeding)

Cellulitis and Erysipelas Offer an antibiotics for people with cellulitis or erysipelas. When choosing an antibiotic take account of: • The severity of symptoms • The site of infection • The risk of uncommon pathogens e.g. penetrating injury or exposure to water-borne pathogen • Previous microbiological results • The person’s MRSA status (if known) Patients should be reminded that the skin can take some time to return to normal after the course of antibiotics have finished, a full resolution of symptoms at 5 to 7 days is not expected.

Table 1: First line antibiotics for adults over 18 years: Drug Name Dose Frequency Duration* Comments

Flucloxacillin 500mg -1g Four times a day 5-7 days

In penicillin allergy: Clarithromycin 500mg Twice a day 5-7 days Give erythromycin 500mg QDS if pregnant and penicillin allergic. Doxycycline 200mg stat then Daily 5-7 days 100mg (total) * A longer course (up to 14 days) may be needed based on clinical assessment

Table 2: Antibiotic choices if infection near the eyes or nose (ADULT) (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes including periorbital cellulitis): Drug Name Dose Frequency Duration* Comments

Co-amoxiclav 625mg Three times a day 7 days

In penicillin allergy: Clarithromycin 500mg Twice a day 7 days PLUS Metronidazole 400mg Three times a day 7 days * A longer course (up to 14 days) may be needed based on clinical assessment

Table 3: Antibiotic choice for SEVERE infection (ADULT)

Drug Name Dose Frequency Duration* Comments

Co-amoxiclav 625mg Three times a day 7 days

In penicillin allergy: Clindamycin 150-300mg Four times a day 7 days (maximum 450mg) *A longer course (up to 14 days) may be needed based on clinical assessment

Table 4: First line antibiotics for children and young people under 18 years

Drug Name Dose Frequency Duration* Comments

Flucloxacillin Refer to BNF for children 5-7 days

Co-amoxiclav Refer to BNF for children 5-7 days If flucloxacillin unsuitable

In penicillin allergy: Clarithromycin Refer to BNF for children 5-7 days Give erythromycin if pregnant and penicillin allergic

*A longer course (up to 14 days) may be needed based on clinical assessment

Table 5: Antibiotic choices if infection near the eyes or nose (under 18 years) (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes including periorbital cellulitis)

Drug Name Dose Frequency Duration* Comments

Co-amoxiclav Refer to BNF for children 7 days

In penicillin allergy: Clarithromycin Refer to BNF for children 7 days PLUS (if anaerobes suspected) Metronidazole *A longer course (up to 14 days) may be needed based on clinical assessment

Table 6: Antibiotic choice for SEVERE infection (under 18 years)

Drug Name Dose Frequency Duration* Comments

Co-amoxiclav Refer to BNF for children 7 days

In penicillin allergy: Clindamycin Refer to BNF for children 7 days 55

*A longer course (up to 14 days) may be needed based on clinical assessment

Antibiotic prophylaxis for cellulitis and erysipelas should only be started by a specialist.

Leg Ulcers

Most leg ulcers are colonised by bacteria but few leg ulcers are clinically infected. There are many causes of leg ulcers including venous insufficiency and oedema and these should be managed to promote healing. Antibiotics do not promote healing when a leg ulcer is not clinically infected. Only offer an antibiotic where there are signs or symptoms of infection, recommended empirical choice of oral antibiotic is listed below. Severely unwell patients should be referred for intravenous antibiotic treatment. Symptoms and signs of an infected leg ulcer include: • Redness or swelling spreading beyond the ulcer • Localised warmth • Increased pain • Fever Do not take a sample for microbiological testing at initial presentation even if it might be infected. A sample from the leg ulcer may be sent if on re-assessment (after 2 – 3 days of antibiotic treatment) the signs and symptoms of infections are worsening or have not improved as expected. Be aware that it will take time for a leg ulcer to resolve, full resolution would not be expected until after the antibiotic course is completed.

Drug Name Dose Frequency Duration Comments

Flucloxacillin 500mg -1g Four times a day 7 days Note 1g QDS is an unlicensed dose of flucloxacillin and is not always well tolerated. In penicillin allergy or flucloxacillin unsuitable : Clarithromycin 500mg Twice a day 7 days Give erythromycin 500mg QDS if pregnant and penicillin allergic. Doxycycline 200mg stat then Daily 7 days 100mg (total)

Mastitis S. aureus is the most common infecting pathogen. In breastfeeding the oral antibiotics recommended are appropriate. Women should continue feeding, including from the affected breast.

Drug Name Dose Frequency Duration Comments

Flucloxacillin 500mg Four times daily 10-14 days

Clarithromycin 500mg Twice daily 10-14 days If penicillin allergic.

Wound Infections It is often useful to send a swab, with the site and nature of the wound specified, especially from a post- operative wound. Infection is commonly due to Staphylococcus aureus.

If wounds become infected and were originally contaminated with soil, manure or faeces; puncture wounds or lacerations that have a significant degree of devitalized tissue – then treat as for bites.

Drug Name Dose Frequency Duration Comments

Flucloxacillin 500mg Four times daily 5 days

Clarithromycin 500mg Twice daily 5 days If penicillin allergic.

Insect bites and Stings Insect bites and stings should not be treated with an antibiotic if there are no symptoms or signs of infection. Refer to community pharmacist for advice about self-care treatments. If there are symptoms or signs of infection manage insect bites and stings as per cellulitis and erysipelas (above).

Human and animal bites

Assess the type and severity of the bite to include the risk of tetanus, rabies or a blood borne infection.

Manage the wound with irrigation and debridement as necessary.

Infected bites should be treated with antibiotics for 5 days as per table 2 (adult) and 3 (children and young people).

Antibiotic prophylaxis for 3 days should be prescribed based on the type and severity of bite as per the table 1, antibiotic choice, where indicated, is given in tables 2 and 3:

Table 1: Antibiotic prophylaxis decision aid for an uninfected bite

Type of bite Bite has not broken the skin Bite has broken the skin but Bite has broken the skin and not drawn blood drawn blood Human bite No antibiotic Consider antibiotic if it is in a Offer antibiotic high risk area1 or person at high risk2 Cat bite No antibiotic Consider antibiotic if the Offer antibiotic wound could be deep Dog or other traditional pet No antibiotic No antibiotic Offer antibiotic if there is bite deep tissue damage or visible contamination. Consider antibiotic if it is in a high risk area1 or person at high risk2 1. High risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation 2. People at high risk include those at high risk of a serious wound infection because of a co-morbidity e.g. diabetes, immunosuppression, asplenia or decompensated liver disease.

Table 2: Antibiotic choice for prophylaxis and treatment of bites in adults

Drug Name Dose Frequency Duration Comments

Co-amoxiclav 250/125mg or Three times a day 5 days 500/125mg (treatment) 3 days (prophylaxis) Alternative where co-amoxiclav unsuitable (e.g. penicillin allergy) Doxycycline 200mg on first day then 100-200mg daily 5 days For pregnant penicillin allergic PLUS (treatment) patients contact microbiology for Metronidazole 400mg three times a day 3 days advice (prophylaxis) 57

Table 3: Antibiotic choice for prophylaxis and treatment of bites in children (over 1 month) and young people under 18 years

Drug Name Dose Frequency Duration Comments

Co-amoxiclav Refer to BNF for Three times a day 5 days children (treatment) 3 days (prophylaxis) Alternative for young people aged 12-17 years where co-amoxiclav unsuitable (e.g. penicillin allergy) Doxycycline 200mg on the first day then 100-200mg daily 5 days For pregnant penicillin allergic PLUS 400mg three times a day (treatment) patients contact microbiology for Metronidazole 3 days advice (prophylaxis) Alternative for children under 12 years where co-amoxiclav unsuitable (e.g. penicillin allergy) Co-trimoxazole Refer to BNF for Twice a day 5 days children (treatment) 3 days (prophylaxis)

MRSA Infection Seek microbiologists’ advice regarding treatment if infection is suspected as sensitivities must be determined. In the majority of cases the presence of MRSA indicates colonisation – such patients may require decolonisation as detailed below. • Patients who are found to be positive prior to in-patient treatment • Patients who are at high risk of developing invasive infection e.g. those with an intravenous catheter, urinary catheter, PEG or other invasive device. • Patients who are immuno-compromised • Patients with wounds • Some patients who reside in care homes MRSA Decolonisation • Apply mupirocin 2% ointment to the inner surface of the nostrils and any wound areas or device exit sites, 3 times daily for 5 days. • Bathe daily with Octenisan®* wash lotion for 5 days. • Use of disposable wipes is recommended for application. • The solution should be applied directly to the disposable wipe and not be added to the water. • Wet the skin and apply the solution to all areas of the body, paying particular attention to the axilla and groin areas. The solution requires a contact time of 3 minutes so it is best to cover the whole body in solution then rinse. • Wash the hair with Octenisan®* wash solution twice in the 5 days. • Use a freshly laundered towel for each day of the treatment regime. • After bathing put on fresh, clean clothes and change the bedding each day for the 5 day treatment regime. * Octenisan® is available as 150ml or 500ml bottles. There is a 5 day eradication protocol leaflet available from the manufacturer (Schulke) which explains how to use the product. This should be explained and given to the patient with the solution. Mupirocin should not be used for prolonged periods or for more than 2 courses.

Scabies Treat all family members of the household, close contacts and sexual contacts simultaneously. Treat whole body including scalp, face, neck, ears and under nails within 24 hours. If the patient is in a residential/nursing home, inform the CCDC as instructed in introduction. Drug Name Dose Frequency Comments

5% Permethrin dermal cream 2 applications 1 week apart Available OTC from pharmacy. 0.5% Malathion aqueous 2 applications 1 week apart If allergy to permethrin. Available OTC lotion from pharmacy. Head lice Treatment is not necessary unless a live louse is found. All treatments can be purchased from pharmacies. There is currently no local policy for the rotation of pesticides. There are several treatment strategies that can be used:

• Dimeticone 4%: this is not an insecticide and works on the principle that the lice are coated and made immobile so that they starve. It can be used as frequently as necessary as it does not cause resistance and contains no solvents that might be a problem with asthma sufferers. It is suitable from 6 months old to adult. It can be purchased as ‘Hedrin®. ’ • Insecticides: two applications of an insecticide are used 7 days apart (Note: this is different to the packaging information, which states that a single application is sufficient). Success is checked by detection combing 2-3 days after the final application. If treatment fails or re-infestation occurs, a course of a different insecticide is used. • Wet combing: this must be undertaken meticulously to be successful. It must be undertaken every 4 days for at least 2 weeks. If lice are found on the second, third, or fourth session, it should be continued until no lice have been seen for three consecutive sessions. Families using this method must be well motivated because of the time involved.

Dermatophyte Infections Dermatophyte infections are superficial fungal infections with varying presentation depending on the site. Dermatophye infections are typically diagnosed clinically, although fungal culture may help to identify the causative organism to direct treatment. Topical therapy with allylamines (e.g. terbinafine) is sufficient in most tinea infections.

Fungal infection of the Body/Groin/Feet (Tinea Corporis (ringworm) /Tinea Cruris / Tinea Pedis) Diagnostic tests are not usually needed in primary care but arrange for skin sampling for fungal microscopy and culture to confirm diagnosis and identify the cause in severe or extensive disease or where the diagnosis is uncertain. Consider oral treatment with terbinafine in adults if there is severe, extensive disease. Children with extensive, severe disease should be referred to a paediatric dermatologist.

Drug Name Dose Frequency Duration Comments

For mild, non-extensive disease in adults and children – recommend self-care Terbinafine 1% cream One or Twice 1 to 2 weeks For adults and children daily over 12 years Clotrimazole 1% cream Twice daily At least 4 weeks

Consider prescribing a mildly potent topical corticosteroid in addition to topical antifungal if there is associated marked inflammation. Fungal infection of the nail (Tinea Unguium / Onchomycosis) Fungal nail infection is a common condition, usually affecting toenails, and often produces only cosmetic symptoms. Treatment is not necessary in such cases.

In mild to moderate cases of superficial onychomycosis, advice includes self-care strategies and topical treatments such as amorolfine 5% which is available over-the-counter.

Oral, topical, or device treatment for fungal nail infection is not normally funded due to limited evidence of clinical effectiveness.

Treatment may however be necessary if onychomycosis causes significant pain, infection, functional impairment (such as difficulty walking or inability to use footwear), or if the patient is at significant risk of complications due to, for example, diabetes, peripheral vascular disease, or immune suppression. Where treatment with oral antifungals is planned, diagnosis of fungal nail infection must first be confirmed with nail clippings / scrapings for fungal microscopy and culture.

Drug Name Dose Frequency Duration Comments

If dermatophyte nail infection is confirmed Terbinafine 250mg Once daily 6 weeks – 3 months (fingers) or 3-6 tabs months (toes) If non-dermatophyte nail infection is confirmed, or second-line for candida Itraconazole 200mg Twice daily 7 days monthly -2 courses (fingers) -3 courses (toes)

Fungal infection of the Scalp (Tinea Capitis) • If the patient has a suspected kerion arrange for an urgent referral to dermatology • Take skin and hair samples for fungal microscopy and culture. • If oral antifungal treatment is considered appropriate prescribe terbinafine (off label). Griseofulvin should not be initiated in primary care. • Consider co-prescribing a topical antifungal agent during initial oral antifungal treatment to reduce the risk of transmission to others. Options include selenium sulfide or ketoconazole shampoo to be used at least twice weekly for 2–4 weeks, or an imidazole cream (in children less than 5 years of age) to be used daily for one week. Where there is associated marked inflammation consider prescribing a mildly potent topical corticosteroid in addition to the topical antifungal.

Herpes zoster / Chicken Pox and Varicella zoster / Shingles • Oral antivirals are not indicated in healthy adults under 50 years of age, as such individuals are unlikely to have severe symptoms and are at very low risk of developing post-herpetic neuralgia. Oral antiviral treatment should be offered to any age presenting within 72 hours of the shingles rash who are at high risk e.g. have ophthalmic shingles, immunocompromised, rash affecting neck, limbs or perineum or who have moderate or severe pain. • Consider starting antiviral treatment up to one week after rash onset if there is a high risk of severe shingles. • Ophthalmic zoster - treatment is always indicated with urgent referral to the eye clinic. • Further information is contained in Clinical Knowledge Summaries https://cks.nice.org.uk/shingles.

Drug Name Dose Frequency Duration Comments

Aciclovir 800mg Five times daily 7 days

Meningococcal Disease If Meningococcal septicaemia or meningitis is suspected give benzylpenicillin as a stat dose immediately whilst admission to hospital is arranged.

Drug Name Dose Comments

Benzylpenicillin Age 10+ years 1.2g IV or IM In children aged 1-9 years 600mg In children <1 year 300mg Cefotaxime >12 years and adults 1g IV/IM For penicillin allergy. If there is a history of <12 years 50mg/kg (maximum 1g) IV / IM penicillin anaphylaxis transfer to hospital immediately. All forms of meningitis particularly meningococcal meningitis or septicaemia should be notified on suspicion to the CCDC at Public Health England East of England. Phone: 0300 303 8537 Fax: 0300 303 8541 (Office Hours, Monday – Friday, 9am – 5pm). Medicom: 01603 481272 (Outside office hours) Ask for Public Health 1st on-call. GPs should report to the CCDC as soon as possible even when the patient is admitted to hospital or the diagnosis is uncertain. GPs should not assume that the hospital will report the case. Prophylaxis in Meningococcal Disease Prophylaxis should only be initiated after discussion with the CCDC or Consultant in Public Health Medicine. Prophylaxis is given to those who had ongoing and continuous contact with the index case, such as household contacts, to eradicate any carriage. Staff who gave mouth-to-mouth resuscitation should be given prophylaxis. Please note that the prophylaxis does not offer complete protection against the disease. CCDC will decide on the wider public health control measures where these are required.

Drug Name Dose Frequency and Duration Comments

Ciprofloxacin1 12 years to adult Single dose orally Not licensed for this (consider safety issues) 500mg indication in children. 5-12 years Single dose orally Children’s doses are as 1st choice for ALL age 250mg specified in the HPA groups and in pregnancy. Children < 5 years Single dose orally document March 2012*. 30mg/kg up to Ciprofloxacin 250mg/5ml is maximum of 125mg available. 1 In patients at risk for aortic aneurysm and dissection, fluoroquinolones should only be used after careful assessment of the benefits and risks and after consideration of other therapeutic options. See MHRA DSU November 2018 In October 2018 EMA’s Pharmacovigilance Risk Assessment Committee (PRAC) recommended restricting the use of fluoroquinolone and quinolone antibiotics (by mouth, injection or inhalation) following a review of disabling and potentially long-lasting side effects reported with these medicines. See EMA guidance. Disabling, long-lasting or potentially irreversible adverse reactions affecting musculoskeletal and nervous systems have been reported very rarely with fluoroquinolone antibiotics. Healthcare professionals are advised to inform patients to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy, and CNS effects, and to contact their doctor immediately, special caution for people older than 60 years, those with renal impairment or solid organ transplants because they are at higher risk of tendon injury MHRA CHM Advice March 2019 Where patients are unsuitable for treatment with ciprofloxacin, the Consultant in Public Health will advise alternative treatment on a case by case basis.

*NB: The children’s doses listed in the HPA document (in table above) differ from those listed in the BNF for children (BNFC). Ref: Guide for Public Health Management of Meningococcal Disease in the UK. Health Protection Agency, Meningococcus and Haemophilus Forum. March 2012.

Gastro-intestinal Infection Virus? Please note food poisoning and infectious bloody diarrhoea is are statutorily notifiable to the CCDC. Stool specimens should be sent for microbiological examination, which helps in the surveillance of the diseases.

Viral Viral infections are self-limiting and common. Norovirus is extremely contagious and people can remain contagious from the time they begin to feel ill up to at least 3 days after recovery (immunocompromised individuals may excrete the virus for 2 weeks or longer). Immunity is short lived (up to 6 months). Testing: stool samples may be required to confirm outbreaks on the advice of the CCDC. There is no treatment. Most people improve in 1-2 days. The very young, frail elderly and immunocompromised may need treatment for dehydration.

Bacterial The commonest bacterial causes are campylobacter, salmonella (non-typhoid) and shigella spp. Most infections are self-limiting and do not require antibacterial therapy. Helicobacter pylori is associated with gastric and duodenal ulcers. Local guidelines should be followed to decide which patients should be appropriately tested for the presence of the bacterium. Eradication treatment should not be initiated until confirmation is received. Post treatment samples should not be sent as test can remain positive for up to 6 weeks. Consult BNF for current price and Bedfordshire Primary Care Formulary for current cost-effective choice of PPI.

Helicobacter pylori eradication For advice on treatment options please refer to PHE / NICE guidance.

Parasitic The commonest parasitic causes are giardia sp and cryptosporidium sp. There is no specific therapy for cryptosporidial diarrhoea.

Giardiasis Drug Name Dose Frequency Duration Comments

Metronidazole 2 grams Once daily 3 days

Travellers’ Diarrhoea Only consider standby antibiotics for remote areas or people at high risk of severe illness or for those visiting high risk areas. If appropriate, use Azithromycin 500mg OD for 1-3 days (private prescription as this is not treatment for a current condition). For prophylaxis or treatment consider bismuth subsalicylate (Pepto-Bismol) tablets, which are available OTC at a pharmacy, 2 tablets four times a day for 2 days. Clostridium difficile Clostridium difficile is a spore forming bacteria commonly found in the normal gut flora of infants and a small proportion (less than 5%) of adults. In the environment Clostridium difficile spores can survive for long periods in harsh conditions and are resistant to heat, drying and many disinfectants. Diarrhoeal illness can occur when the normal flora of the bowel is disrupted. When Clostridium difficile is not held in check, the bacteria flourishes and produces toxins that damage the cells of the intestine, resulting in diarrhoea. Symptoms vary in severity from mild discomfort to severe colitis and death. Since 2008 it has been mandatory to report all cases of Clostridium difficile infection via the Healthcare Associated Infection data capture system.

Foul smelling, profuse diarrhoea (described as a ‘barn-yard smell’) is the most common symptom. Non-specific symptoms include temperature, abdominal pain and tenderness and loss of appetite.

A stool sample of the diarrhoea must be taken as soon as possible.

Only liquid stool samples are tested for Clostridium difficile (Bristol stool chart type 6-7). Please give a detailed description of the symptoms and all recent antibiotic use on the laboratory request form.

Testing for Clostridium difficile is a combination of two tests, the first of which is GDH EIA followed by a sensitive toxin EIA test. Laboratory reporting of the presence of Clostridium difficile glutamine dehydrogenase environmental impact assessment (GDH EIA) and A and B toxins in a patient with diarrhoea confirms a positive case. Patients found to be GDH EIA positive and toxin negative may be carriers. Patients found to be carriers of Clostridium difficile may require treatment if they have symptoms of diarrhoea (Bristol stool chart type 6-7). Please contact the microbiologist for advice in each individual case.

Do not take repeat stool samples following diagnosis or after treatment unless another cause is suspected and please state this on the request form.

Clostridium difficile can remain in the stools for long periods of time and therefore the presence of the bacteria in stools, when the patient has no symptoms, is not significant. • Antibiotic treatments should be stopped whenever possible. • Antimotility agents such as loperamide must not be used. • Proton pump inhibitor drugs should be discontinued if possible when infection is confirmed. • Consider stopping iron treatments temporarily as they may mask or interfere with symptoms. • Continue good hygiene including washing hands well with soap and water, careful handling of any soiled linen and thorough environmental cleaning. • Seek microbiology advice if patient condition deteriorates. • It is important to prescribe at least 10 days of treatment. • More than one course of treatment may be required if symptoms do not improve. • Recurrence of symptoms can occur and the patient may require a second course of treatment. There is no requirement to send a repeat specimen. • Severe cases may require hospitalisation. • Contact the microbiologist if you have any concerns about the patient.

Drug Name Dose Frequency Duration Comments

1st episode positively 70% respond to metronidazole in 5 days; 92% in identified - 14 days. Metronidazole 400mg Three times 10-14 tablets daily days 2nd episode / severe/ Definition of severe: Temp>38.5oC, or WCC>15, type 027- or rising creatinine or signs / symptoms of Oral Vancomycin 125mg Four times daily 10-14 severe colitis. Review progress closely and /or days consider hospital referral.

Recurrent disease - Tapering course: 125mg QDS for one week, Oral Vancomycin 125 - Four times daily 10-14 125mg TDS for one week, 125mg BD for one 250mg consider days week, 125mg daily for one week, 125mg on tapering course alternate days for one week, 125mg every third day for one week. Seek microbiology advice for alternative treatment. 64

Severe disease at 200mg Twice a day 10 days Only on the advice of a Consultant high risk of recurrent Microbiologist disease - Fidaxomicin Diverticulitis

Antibiotics should not be offered to patients with diverticular disease. For advice on the management of diverticular disease please refer to the NICE guidelines Diverticular disease: diagnosis and management (NG 147) accessed at https://www.nice.org.uk/guidance/ng147/resources/diverticular-disease-diagnosis-and- management-pdf-66141784856005. For patients with acute diverticulitis who are systemically well:

• Consider a no antibiotic prescribing strategy • Offer simple analgesia e.g. Paracetamol • Advise the person to re-present if symptoms persist or worsen Offer an antibiotic prescribing strategy if the person with acute diverticultis is systemically unwell, is immunosuppressed, has significant comorbidity or they do not meet the criteria for suspected complicated acute diverticulitis (as per NICE guideline 147) Drug Name Dose Frequency Duration Comments

First choice Co-amoxiclav 625mg Three times a day 5 days

Alternative if penicillin allergy or co-amoxiclav is unsuitable Cefalexin 500mg Two or three times a day Caution with cefalexin in penicillin allergy PLUS 5 days Metronidazole 500mg Three times a day

Trimethoprim 200mg Twice a day PLUS 5 days Metronidazole 500mg Three times a day Infestations Threadworms Diagnosis can be confirmed by a sellotape slide. Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene- keep fingernails short, wash hands and scrub nails before each meal and after each visit to the toilet), pants at night, morning shower (include perianal area) plus wash sleepwear, bed linen and dust, vacuum on day one. For children < 6 months add perianal wet wiping or washes 3 hourly during the day.

Drug Name Dose Frequency and Comments duration Mebendazole 100mg One dose only Offer Self-Care advice as mebendazole is available OTC for > 2year olds. All patients over 6 months: mebendazole 100mg Stat (off-label if used < 2 years). Also, repeat in 2 weeks if infestation persists. Patients < 6 months mebendazole is unlicensed, use hygiene measures alone for 6 weeks. Do not treat during pregnancy.

Eye Infections Most acute superficial infections (conjunctivitis and blepharitis) are often caused by staphylococci and can be treated topically. Most bacterial conjunctivitis is self-limiting and resolves within 1-2 weeks with careful hygiene and bathing with boiled salt water. Encourage self-care as chloramphenicol eye drops and eye ointment can be purchased OTC for > 2 years olds (not pregnant or breast feeding). True conjunctivitis presents as a red eye with mucopurulent (not watery) discharge which starts in one eye but often spreads to both. Severe infections may require treatment and for school children and some childcare, treatment may be needed. Refer if no improvement and particularly if patient wears contact lens. Microbiological investigations are not considered necessary in primary care when a person presents with a short history of infective conjunctivitis because most cases will settle spontaneously. However, management of chronic infections requires microbiological identification of the causative organism. Failure to respond or worsening symptoms require urgent referral to ophthalmologist. Long term use of chloramphenicol can lead to bone marrow suppression and should not be prescribed on repeat. Endophthalmitis and keratitis may be bacterial, viral or fungal and require URGENT referral for specialist management. Fucithalmic® 1% eye drops are expensive and less effective, appropriate alternatives are available. Conjunctivitis Drug Name Dose Frequency Duration Comments

None Advise on Self-Care as above. Chloramphenicol 0.5% One drop 2 hourly for 2 days, Use for 48 Use in severe infections. Avoid in eye drops then 4 hourly hours after pregnancy and breast feeding. AND/OR (whilst awake). resolution. Chloramphenicol 1% Apply small Apply four times Maximum 7 eye ointment amount daily for 2 days days. (1cm) then twice daily or once at night if used with eye drops. Ciprofloxacin eye drops One drop 2 hourly for 2 days, Maximum Use in severe infections. Only 0.3% then 4 times daily duration of use in pregnancy if benefits OR (whilst awake). treatment 21 outweigh risks. Caution in use in days. breast-feeding. Ciprofloxacin eye 1.25 cm Three times daily ointment 3mg/g for 2 days, then Adults and children 1 year and twice daily for 5 above. days.

Blepharitis Good lid hygiene is the mainstay of treatment. The eyelids should be cleaned twice daily initially then reduced to once daily as symptoms improve. Consider prescribing a topical antibiotic (Chloramphenicol 1% ointment twice a day for a 6 week trial) if there are clear signs of staphylococcal infection or if hygiene measures are ineffective after 2 weeks. Oral antibiotics should be considered ONLY if topical antibiotics are ineffective or there are signs of Meibomian gland dysfunction or acne rosacea. See table below for oral antibiotic dose recommendations.

Drug Name Dose Frequency Duration Comments

Oxytetracycline 500mg Twice a day 4 weeks Initial dose Then Twice a day 8 weeks Maintenance dose 250mg Doxycycline 100mg Once a day 4 weeks Initial dose Then 50mg Once a day 8 weeks Maintenance dose 66

Supporting Materials There are a range of support materials available from Public Health England (PHE), Department of Health (DH) and the Royal College of General Practitioners (RCGP) which can be downloaded and used by the whole primary care team within the GP practice or out of hours setting: TARGET (Treat Antibiotics Responsibly, Guidance, Education and Tools): Antibiotic toolkit for primary care. http://www.rcgp.org.uk/TARGETantibiotics The TARGET Antibiotics Toolkit available on the RCGP website aims to help influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers’ and patients’ responsible antibiotic use, helping to fulfil CPD and revalidation requirements. These include:

• Leaflets to share with patients- Many are available in multiple languages. They are designed to be shared with patients during the consultation and aim to improve the patient’s confidence to Self-Care and the prescriber’s communication with the parents.

• Audit toolkits -Templates for accurate and easy auditing, including Read codes, current guidance and action plans. Audits available include sore throat, urinary tract infection, otitis media and acute cough.

• National Antibiotic Management Guidance

• Training resources including an antibiotics group presentation, online training courses on antibiotic resistance in primary care, skin infections, managing acute respiratory tract infections, urinary tract infections and managing infectious diarrhoea.

• Resources for clinical and waiting areas - Posters for clinical and waiting areas

-Videos for clinical and waiting areas

• Self-assessment checklist Antimicrobial Resistance Resource Handbook April 2016 contains a list of current national policy, guidance and supporting materials on antimicrobial resistance, antimicrobial stewardship and infection prevention and control resources which are relevant for primary care (and other healthcare) settings. Available at: https://www.gov.uk/government/publications/antimicrobial-resistance-resource-handbook

Glossary ACO Asthma-COPD Overlap Syndrome AMR Antimicrobial Resistance AOM Acute Otitis Media BASHH British Association for Sexual Health and HIV BNF British National Formulary BNFC British National Formulary for children CAP Community Acquired Pneumonia CCDC Consultant in Communicable Disease Control CDI Clostridium difficile infection CMO Chief Medical Officer COPD Chronic Obstructive Pulmonary Disease CSU Catheter Specimen of Urine DH Department of Health eGFR estimated Glomerular Filtration Rate ESBL Extended Spectrum Beta Lactamase positive organisms ESPAUR English Surveillance Programme for Antimicrobial Utilisation and Resistance GDH EIA Glutamine dehydrogenase environmental impact assessment GFR Glomerular Filtration Rate GP Ref Information Website for Bedfordshire CCG healthcare professionals www.gpref.bedfordshire.nhs.uk GRASP Gonococcal Resistance to Antimicrobials Surveillance Programme SEXUAL Genitourinary Medicine HEALTH HIV/AIDS Human Immunodeficiency virus / Acquired Immune Deficiency Syndrome HPA Health Protection Agency (now part of Public Health England) IM Intramuscular route of administration INR international normalized ratio IV Intravenous route of administration JPC Bedfordshire and Luton Joint Prescribing Committee MALToma Mucosa-associated lymphoid tissue lymphoma-a slow growing type of non-Hodgkin lymphoma. MRSA methicillin-resistant Staphylococcus aureus MSU Midstream specimen of urine

NG Nice Guidance NICE National Institute for Health and Care Excellence NNT Number Needed to Treat NSAID Non-Steroidal Anti-inflammatory Drug OTC Over The Counter PEG Percutaneous endoscopic gastrostomy PHE Public Health England PID Pelvic Inflammatory Disease PPI Proton Pump Inhibitor RCGP Royal College of General Practitioners SPC Summary of Product Characteristics STI Sexually Transmitted Infection TARGET Treat Antibiotics Responsibly, Guidance, Education and Tools UTI Urinary Tract Infection

Reference Sources This guidance does not include an extensive reference list for individual infections. It is adapted from the NICE and Public Health England (PHE) Management of infection guidance for primary care October 2019 which was produced in consultation with GPs and specialists in the field. In addition, the PHE guidance is in agreement with other guidance including CKS, SIGN and NICE and is fully referenced and graded. The PHE guidance, the BNF and relevant Summary of Product Characteristics were used to compile the dosage, frequency and duration tables.