Antimicrobial Guide and Management of Infections in Primary Care

Gastrointestinal Infections Clinical diagnosis Treatment advice Comments and guidelines for lab testing Campylobacter treatment not usually indicated unless the symptoms are systemic and prolonged. Note Notifiable to Consultant in Health Protection Initiate treatment on the advice of microbiologist if the patient is systemically unwell. , acute Provide symptomatic relief prior to admission. Urgently admit to hospital anyone with suspected acute cholecystitis. Clostridium difficile Stop unnecessary , PPIs, and antimotility agents. May occur up to eight weeks after antibiotic treatment (confirmed) Mild and moderate CDI: Metronidazole 400 mg TDS for 10–14 days. Consider hospital referral if severe symptoms and to rule out toxic  PHE Clostridium difficile Review after four days. .  BNFC Metronidazole Severe symptoms, or recurrent disease, or both: Oral Refer to the Public Health England guidance on management of 125 mg QDS for 10–14 days. C. difficile which defines mild, moderate and severe criteria.  BNFC Vancomycin Definition of severe: Temperature > 38.5 °C, or WCC > 15, or rising Pan Mersey APC recommends that Fidaxomicin should only be

creatinine or signs or symptoms of severe colitis. prescribed on the advice of a consultant microbiologist or consultant in infectious diseases. Fidaxomicin may be prescribed only if recommended by a microbiologist, see comment opposite. Testing for clearance of toxin is not required. Antimotility agents e.g. should NOT be prescribed. Metronidazole liquid: contains the prodrug metronidazole benzoate which requires enzyme activation that may be reduced in patients with diarrhoea. For those with swallowing difficulties consider the off-label use of tablets, crushed.

Ref: AG08 - Version 15 - Issued Feb 2018 - Review Feb 2019 1 Pan Mersey Area Prescribing Committee Gastrointestinal infections Antimicrobial Guide and Management of Infections in Primary Care

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Diarrhoea and , acute Oral rehydration is the mainstay of treatment. Children Usually viral and self-limiting. aged less than six months may be prescribed rehydration sachets, Note Food poisoning is Antibiotics only tend to prolong the carrier state, do not shorten in older age groups clear fluids are adequate. notifiable to Consultant in the duration of illness and may be contraindicated. Antibiotics Health Protection Antimotility agents e.g. loperamide should only be prescribed for should only be commenced on the advice of microbiologist or the short-term management of symptoms (1-2 days) in the absence Consultant in Health Protection or Infection Prevention and See also  Clostridium difficile of fever or bloody diarrhoea and only for adults and children over Control. 12 years. Check travel, food, hospitalisation and antibiotic history Review and stop any prokinetic treatment. (Clostridium difficile is increasing in incidence). Standby treatment for traveller’s diarrhoea must not be prescribed Suggest stool specimen in: at NHS expense. 1. Patients with inflammatory bowel disease. 2. Immunosuppressed patients. 3. Persistent diarrhoea (more than one week) if no obvious cause 4. Bloody diarrhoea. Sample essential. Antibiotics may be contraindicated e.g. E coli 0157 5. Recent foreign travel 6. Suspected food poisoning. , acute Co-amoxiclav 500/125 mg TDS for 7 days Consider admission for severe cases. exacerbation In non-severe penicillin allergy: Metronidazole 400 TDS AND Review within 48 hours or sooner if symptoms deteriorate. Arrange  BNFC Co-amoxiclav Cefalexin 500 mg BD OR Ciprofloxacin (in severe penicillin allergy) admission if symptoms persist or deteriorate. 500 mg BD for 7 days  BNFC Metronidazole  BNFC Cefalexin Giardia lamblia Metronidazole 2 g single dose* daily for 3 days Consider ‘blind’ treatment of family contacts only if they are symptomatic.  BNFC Metronidazole

* Caution in pregnancy

Pan Mersey Area Prescribing Committee | Issued Feb 2018 | Review Feb 2019 2 Gastrointestinal infections Antimicrobial Guide and Management of Infections in Primary Care

Clinical diagnosis Treatment advice Comments and guidelines for lab testing Helicobacter pylori, First line Choose either Clarithromycin* or Metronidazole depending upon eradication previous exposure to these antimicrobials in the last 12 months. PPI BD AND  NICE CG184 Amoxicillin 1 g BD AND Second line treatment involves the use of whichever antimicrobial Clarithromycin* 500 mg BD OR Metronidazole 400 mg BD (Clarithromycin* or Metronidazole) was not used first-line.  PHE Summary guidance All for 7 days Diabact UBT test kit available on FP10  BNFC Peptic ulceration In penicillin allergy Refer to NICE guidance on Dyspepsia or local Dyspepsia pathway for  BNFC Amoxicillin First line: PPI BD AND information on testing.  BNFC Clarithromycin Clarithromycin* 500 mg BD AND Metronidazole 400 mg BD In paediatrics, a test and treat strategy is not recommended, nor is  BNFC Metronidazole the faecal antigen test recommended for diagnosis. If previous clarithromycin: PPI BD AND Bismuth subsalicylate 525 mg BD AND Bismuth subsalicylate availability is subject to local variation. Metornidazole 400 mg BD AND Tetracyline 500 mg QDS All for 7 days For children, refer to a specialist for advice.

* Caution in pregnancy Antibiotic treatment not usually indicated. Note Notifiable to Consultant Initiate treatment on the advice of microbiologist if the patient is in Health Protection systemically unwell.

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Clinical diagnosis Treatment advice Comments and guidelines for lab testing Threadworm or pinworm Mebendazole 100 mg STAT For adults and children > 6 months All members of the family require treatment at the same time. (Enterobius vermicularis) A second dose may be given after 2 weeks for adults and Hygiene measures are needed to avoid re-infection for two weeks.  BNFC Mebendazole children > 6 months as re-infection is very common. Wash sleepwear, linen, dust and vacuum on day one. Note this is an unlicensed use for children under 2 years Washing hands and scrubbing nails before eating and after visiting the toilet are essential. A bath in the morning removes ova laid overnight. For children under 6 months of age, seek paediatric specialist advice.

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