Antimicrobial Prescribing Quick Reference Guide for Primary Care in Nottinghamshire For further information and management of other infections not listed here please refer to the full guideline on the Area Prescribing Committee website: http://www.nottsapc.nhs.uk Where empirical therapy has failed or special circumstances (e.g. previous C.difficile infection) exist, clinical advice should be sought from Microbiology Department at either Nottingham University Hospitals 01159249924 ext 61163 or Sherwood Forest Hospitals 01623622515 ext 3616 Infection Notes Recommended Agent(s) Doses are for adults unless otherwise stated Upper Respiratory Tract Infections Consider a delayed prescription (3-5 days) Pharyngitis / as the majority are viral Phenoxymethylpenicillin 1g BD for 10 days Tonsillitis (or 500mg - 1g QDS if severe) 90% resolve in 7 days without antibiotics NICE CG69 Consider immediate or a 3 day delayed Penicillin allergy: prescription if Centor score of 3 or 4: Clarithromycin 250-500mg BD for 5 days CKS Lymphadenopathy, No cough, Fever, (consider Erythromycin syrup in children) Tonsillar Exudate Amoxicillin for 5 days Consider no or delayed prescribing if not Neonate 7-28 days: 30mg/kg TDS, acutely unwell; illness resolves over 4 days 1month-1 yr: 125mg TDS, 1-5yrs: 250mg TDS, >5yrs and adults: 500mg TDS Acute Otitis Media in 80% without antibiotics. If acutely unwell (vomiting, fever, pain for Penicillin allergy: CKS >48h and otorrhoea) prescribe immediate Clarithromycin 250-500mg BD for 5 days antibiotics. Consider Erythromycin syrup in children: 1month-2yrs: 125mg QDS; 2-8yrs: 250mg QDS; >8yrs: 500mg QDS for 5 days First line: Organisms usually present as secondary Acetic acid 2% TDS (EarCalm Spray) for 7 days colonisers Otitis Externa Cure rates similar at 7 days for acetic acid Second line options: or antibiotic +/- steroid Gentisone HC, Locorten-Vioform, Sofradex CKS Oral antibiotics only indicated if spreading cellulitis If spreading cellulitis: Flucloxacillin 500mg QDS for 5 days Majority are viral and resolve in 7-10 days Treat for 7 days: without antibiotics Acute Sinusitis Phenoxymethylpenicillin 500mg QDS Reserve antibiotics for severe or or symptoms >10 days Amoxicillin 500mg TDS (1g TDS if severe) CKS In persistent infection despite first line or therapy, use co-amoxiclav. Doxycycline 200mg stat then 100mg OD Lower Respiratory Tract Infections Numerous RCTs have shown little or no Doxycycline 200mg stat then 100mg OD for benefit of antibiotics in otherwise healthy Acute Cough, 5 days adults Bronchitis Consider antibiotics if >80yrs and one of or the following: hospitalisation in past year, CKS oral steroids, diabetic, heart failure. Or if Amoxicillin 500mg TDS for 5 days >65yrs and two of the above. Doxycycline 200mg stat then 100mg OD Acute Antibiotics are helpful when purulent or Exacerbation of sputum and increased shortness of breath Amoxicillin 500mg TDS COPD and/or increased sputum volume. or Consider risk factors for resistant Clarithromycin 500mg BD for 5 days CKS organisms: frequent exacerbations, severe COPD, comorbid disease, antibiotics in If resistance likely: NICE CG12 last 3 months. Co-amoxiclav 625mg TDS for 5 days Use CRB65 score to guide management: CRB65 = 0: Amoxicillin 500mg TDS or Confusion (new AMT <8) Doxycycline 200mg stat / 100mg OD or Community Respiratory rate >30 breaths/minute Clarithromycin 500mg BD for 5 days Acquired BP systolic <90 or diastolic <60 Pneumonia Age >65 years CRB65 = 1 and at home: Doxycycline 200mg stat / 100mg OD for 7-10 BTS 2009 0= suitable for home treatment days or 1-2 = hospital assessment or admission Amoxicillin 500mg-1g TDS plus 3-4 = urgent hospital admission Clarithromycin 500mg BD for 7-10 days Authors: Dr Amelia Joseph, Specialty Registrar and Dr Fiona Donald, Consultant in Microbiology, Nottingham University Hospitals NHS Trust; James Sutton, Formulary Pharmacist, Mansfield and Ashfield CCG. Updated May 2015. Review date: May 2018. Genital Tract Infections Vaginal All topical and oral azoles give 75% cure. Clotrimazole 500mg pessary or Candidiasis 10% vaginal cream 5g single application CKS In pregnancy avoid oral azoles and use or BASHH intravaginal treatment for 7 days. Fluconazole 150mg orally single dose Opportunistically screen 16-25yr olds. Azithromycin 1g single dose or Refer to GUM for contact tracing and full Chlamydia Doxycycline 100mg BD 7 days sexual health screen. trachomatis Pregnancy or breastfeeding: Azithromycin Pregnancy or breastfeeding: BASHH is the most effective option (unlicensed). Azithromycin (off-label) 1g single dose Lower cure rate in pregnancy, test for cure or Erythromycin 500mg QDS for 7 days at 6 weeks. or Amoxicillin 500mg TDS for 7 days Refer to GUM for management, contact tracing and full sexual health screen. If Neisseria patient unwilling or cannot access within a Ceftriaxone 500mg IM injection gonorrhoeae reasonable time, then treatment for plus uncomplicated gonorrhoea can be initiated Azithromycin 1g PO single dose BASHH on basis of a positive Microbiology result. Cefixime is no longer recommended. Test of cure at 2-4 weeks recommended. Send pre-treatment MSU and review with Acute Prostatitis Treat for 28 days: results. First line: Ciprofloxacin 500mg BD Quinolones more effective but risk of CKS Second line: Trimethoprim 200mg BD adverse events e.g. C.difficile. Send cervical swab for MC&S for Pelvic Ceftriaxone 500mg IM stat N.gonorrhoeae, and cervical swab for Inflammatory plus NAATs for C.trachomatis +/- N.gonorrhoeae Disease Metronidazole 400mg BD for 14 days Consider referral to GUM plus Suspected PID in pregnancy requires urgent BASHH Doxycycline 100mg BD for 14 days hospital assessment Gastrointestinal Infections Treat positives in known DU, GU or low- First line: grade MALToma. Lansoprazole 30mg BD plus Do not offer eradication in GORD. Amoxicillin 1g BD plus Eradication of Treatment duration is 7 days for DU / GU Either Clarithromycin 500mg BD or H.pylori and 14 days for MALToma. Metronidazole 400mg BD Do not use clarithromycin or metronidazole NICE CG184 if used in the past year for another Penicillin allergy: indication. Lansoprazole 30mg BD plus Clarithromycin 500mg BD plus See full guideline for second line therapy and Metronidazole 400mg BD treatment failures. Stop unnecessary antibiotics and PPIs. Mild disease: Clostridium Avoid anti-motility drugs in Metronidazole 400mg TDS for 10-14 days difficile diarrhoea suspected/confirmed disease. For severe or recurrent disease see full PHE C.difficile Assess severity (see full guideline) and consider admission if severe. guideline. Treat household contacts concurrently. Mebendazole in >6 months: Threadworms Hygiene advice: morning baths/showers, 100mg single dose (not in pregnancy) hand-washing, nail cutting, wash bed linen. Piperazine/senna sachet 3-6 months: CKS Mebendazole contraindicated in pregnancy 2.5ml stirred into water, repeat after 2 wks and in <6 months of age. Routine use of antibiotics in uncomplicated Co-amoxiclav 625mg TDS for 7 days Acute diverticulitis is to be avoided. Diverticulitis Penicillin allergy: Restrict prescribing to patients with signs of systemic infection and review within 48 Ciprofloxacin 500 mg BD plus CKS hours to assess clinical response. Metronidazole 400mg TDS for 7 days Skin and Soft Tissue Infections Topical therapy should be reserved for First line: only very minor infections to minimise Flucloxacillin resistance. 1mnth-2yrs: 125mg QDS The topical agent of choice is: 2-10yrs: 250mg QDS Impetigo Polyfax Ointment applied BD for 5 days. >10yrs and adult: 500mg QDS Topical fusidic acid should be avoided due to resistance rates, which may lead to Clarithromycin for 7 days: treatment failures. >12yrs and adults: 250-500mg BD In children consider Erythromycin syrup: 1mnth-2yrs: 125mg QDS Oral therapy is advised in all but very minor 2-8yrs: 250mg QDS infections. Child >8yrs: 500mg QDS If there is evidence of systemic infection, rapidly spreading cellulitis or severe pain Treat for 7-14 days until clinical response. urgent hospital referral is required. First line: In facial cellulitis, use Co-amoxiclav 625mg Cellulitis Flucloxacillin 500mg QDS TDS instead to extend cover to respiratory pathogens. CKS Penicillin allergy: In South Nottinghamshire there is a Clarithromycin 500mg BD community based IV antibiotics service for In children consider Erythromycin syrup. uncomplicated cellulitis as an alternative to hospital admission, contact 0115 846 2376 Leg ulcers In the absence of cellulitis, treatment not indicated. Send swabs only if clinical evidence of PHE infection. Consider referral to Tissue Viability if difficult cases. Antibiotics should only be used when First line: Diabetic foot surrounding cellulitis present. Co-amoxiclav 625mg TDS for 7-14 days infections Refer to hospital if ulcer rapidly Penicillin allergy: deteriorating or systemically unwell. Clindamycin 300mg QDS for 7-14 days Refer to full guideline for information on Human or Animal prophylaxis and treatment on bite wounds. First line: Bites When Co-amoxiclav is unsuitable and in Co-amoxiclav 625mg TDS for 7 days CKS penicillin allergy, refer to the full guideline. Most are self-limiting, 64% self-resolve. If severe: Chloramphenicol 0.5% drops Bacterial Consider delayed prescribing strategy 4-5 2 hourly for 48 hours, then 4 hourly. Conjunctivitis days for mild cases. Treat if severe or Chloramphenicol 1% eye ointment TDS infection. CKS PHE recommend not normally necessary Continue for 48 hours after resolution.