11.1 Administration of drugs to the eyeDrugs are most commonly administered to the eye by topical application as eye drops or eye ointments. When a higher drug concentration is required within the eye, a local injection may be necessary.Eye-drop dispenser devices are available to aid the instillation of eye drops from plastic bottles; they are particularly useful for the elderly, visually impaired, arthritic, or otherwise physically limited patients.Eye drops and eye ointments Eye drops are generally instilled into the pocket formed by gently pulling down the lower eyelid and keeping the eye closed for as long as possible after application; one drop is all that is needed. Instillation of more than one drop should be discouraged because it may increase systemic side-effects. A small amount of eye ointment is applied similarly; the ointment melts rapidly and blinking helps to spread it.When two different eye-drop preparations are used at the same time of day, dilution and overflow may occur when one immediately follows the other. The patient should therefore leave an interval of at least 5 minutes between the two. Systemic effects may arise from absorption of drugs into the general circulation from conjunctival vessels or from the nasal mucosa after the excess preparation has drained down through the tear ducts. The extent of systemic absorption following ocular administration is highly variable; nasal drainage of drugs is associated with eye drops much more often than with eye ointments. Pressure on the lacrimal punctum for at least a minute after applying eye drops reduces nasolacrimal drainage and therefore decreases systemic absorption from the nasal mucosa.For warnings relating to eye drops and contact lenses, see section 11.9.Eye lotions These are solutions for the irrigation of the conjunctival sac. They act mechanically to flush out irritants or foreign bodies as a first-aid treatment. Sterile sodium chloride 0.9% solution (section 11.8.1) is usually used. Clean water will suffice in an emergency.Other preparations Subconjunctival injection may be used to administer anti-infective drugs, mydriatics, or corticosteroids for conditions not responding to topical therapy. The drug diffuses through the cornea and sclera to the anterior and posterior chambers and vitreous humour. However, because the dose-volume is limited (usually not more than 1mL), this route is suitable only for drugs which are readily soluble.Drugs such as antimicrobials and corticosteroids may be administered systemically to treat susceptible eye conditions.Preservatives and sensitisers Information on preservatives and on substances identified as skin sensitisers (see section 13.1.3) is provided under preparation entries.11.2 Control of microbial contaminationPreparations for the eye should be sterile when issued. Eye drops in multiple-application containers include a preservative but care should nevertheless be taken to avoid contamination of the contents during use.Eye drops in multiple-application containers for domiciliary use should not be used for more than 4 weeks after first opening (unless otherwise stated).Eye drops for use in hospital wards are normally discarded 1 week after first opening. Individual containers should be provided for each patient. A separate bottle should be supplied for each eye only if there are special concerns about contamination. Containers used before an eye operation should be discarded at the time of the operation and fresh containers supplied. A fresh supply should also be provided upon discharge from hospital; in specialist ophthalmology units, it may be acceptable to issue eye-drop bottles that have been dispensed to the patient on the day of discharge.In out-patient departments single-application packs should preferably be used; if multiple-application packs are used, they should be discarded at the end of each day. In clinics for eye diseases and in accident and emergency departments, where the dangers of infection are high, single-application packs should be used; if a multiple-application pack is used, it should be discarded after single use.Diagnostic dyes (e.g. fluorescein) should be used only from single-application packs.In eye surgery single-application containers should be used if possible; if a multiple-application pack is used, it should be discarded after single use. Preparations used during intra-ocular procedures and others that may penetrate into the anterior chamber must be isotonic and without preservatives and buffered if necessary to a neutral pH. Specially formulated fluids should be used for intra-ocular surgery; intravenous infusion preparations are not suitable for this purpose. For all surgical procedures, a previously unopened container is used for each patient.11.3 Anti-infective eye preparationsEye infections Most acute superficial eye infections can be treated topically. Blepharitis and conjunctivitis are often caused by staphylococci; keratitis and endophthalmitis may be bacterial, viral, or fungal.Bacterial blepharitis is treated by application of an antibacterial eye ointment to the conjunctival sac or to the lid margins. Systemic treatment may occasionally be required and is usually undertaken after culturing organisms from the lid margin and determining their antimicrobial sensitivity; antibiotics such as the tetracyclines given for 3 months or longer may be appropriate.Most cases of acute bacterial conjunctivitis are self-limiting; where treatment is appropriate, antibacterial eye drops or an eye ointment are used. A poor response might indicate viral or allergic conjunctivitis. Gonococcal conjunctivitis is treated with systemic and topical antibacterials.Corneal ulcer and keratitis require specialist treatment and may call for hospital admission for intensive therapy.Endophthalmitis is a medical emergency which also calls for specialist management and often requires parenteral, subconjunctival, or intra-ocular administration of antimicrobials.Purulent conjunctivitis can be managed by Chloramphenicol eye-drops

11.3.1 AntibacterialsBacterial infections are generally treated topically with eye drops and eye ointments. Systemic administration is sometimes appropriate in blepharitis.Chloramphenicol has a broad spectrum of activity and is the drug of choice for superficial eye infections. Chloramphenicol eye drops are well tolerated and the recommendation that chloramphenicol eye drops should be avoided because of an increased risk of aplastic anaemia is not well founded.Other antibacterials with a broad spectrum of activity include the quinolones, ciprofloxacin, levofloxacin, and ofloxacin; the aminoglycosides, gentamicin and neomycin [unlicensed] are also active against a wide variety of bacteria. Gentamicin, quinolones, and polymyxin B are effective for infections caused by Pseudomonas aeruginosa.Ciprofloxacin eye drops are licensed for corneal ulcers; intensive application (especially in the first 2 days) is required throughout the day and night.Trachoma which results from chronic infection with Chlamydia trachomatis can be treated with azithromycin by mouth [unlicensed indication].Fusidic acid is useful for staphylococcal infections. Propamidine isetionate is of little value in bacterial infections but is specific for the rare but potentially devastating condition of acanthamoeba keratitis [unlicensed indication] (see also section 11.9).With corticosteroids Many antibacterial preparations also incorporate a corticosteroid but such mixtures should not be used unless a patient is under close specialist supervision. In particular they should not be prescribed for undiagnosed red eye which is sometimes caused by the herpes simplex virus and may be difficult to diagnose (section 11.4).Administration Frequency of application depends on the severity of the infection and the potential for irreversible ocular damage; antibacterial eye preparations are usually administered as follows:Eye drops Apply 1 drop at least every 2 hours then reduce frequency as infection is controlled and continue for 48 hours after healing.Eye ointment Apply either at night (if eye drops used during the day) or 34 times daily (if eye ointment used alone).Sub-sections Chloramphenicol (Non-proprietary) Eye drops, chloramphenicol 0.5%. Net price 10mL = 2.15 Eye ointment, chloramphenicol 1%. Net price 4g = 2.14 Note Chloramphenicol 0.5% eye drops (in max. pack size 10mL) and 1% eye ointment (in max. pack size 4g) can be sold to the public for treatment of acute bacterial conjunctivitis in adults and children over 2 years; max. duration of treatment 5 daysCIPROFLOXACINIndications superficial bacterial infections, see notes above; corneal ulcersCautions not recommended for children under 1 yearPregnancy manufacturer advises use only if potential benefit outweighs riskBreast-feeding manufacturer advises cautionSide-effects local burning and itching; lid margin crusting; hyperaemia; taste disturbances; corneal staining, keratitis, lid oedema, lacrimation, photophobia, corneal infiltrates; nausea and visual disturbances reportedDose Superficial bacterial infection, see Administration in notes aboveCorneal ulcer, apply eye drops throughout day and night, day 1 apply every 15 minutes for 6 hours then every 30 minutes, day 2 apply every hour, days 314 apply every 4 hours (max. duration of treatment 21 days)Apply eye ointment throughout day and night; apply 1.25cm ointment every 12 hours for 2 days then every 4 hours for next 12 days Ciloxan (Alcon) Ophthalmic solution (= eye drops), ciprofloxacin (as hydrochloride) 0.3%. Net price 5mL = 4.70 Excipients include benzalkonium chlorideEye ointment, ciprofloxacin (as hydrochloride) 0.3%. Net price 3.5g = 5.22FUSIDIC ACIDIndications see notes aboveDose See under preparation belowSub-sections Fucithalmic (LEO) Eye drops, m/r, fusidic acid 1% in gel basis (liquifies on contact with eye). Net price 5g = 1.96 Excipients include benzalkonium chloride, disodium edetateDose apply twice dailyGENTAMICINIndications see notes aboveDose See Administration in notes aboveSub-sections Genticin (Roche) Drops (for ear or eye), gentamicin 0.3% (as sulphate). Net price 10mL = 2.13 Excipients include benzalkonium chlorideLEVOFLOXACINIndications see notes aboveCautions not recommended for children under 1 yearPregnancy manufacturer advises avoidsystemic quinolones have caused arthropathy in animal studiesBreast-feeding manufacturer advises avoidSide-effects transient ocular irritation, visual disturbances, lid margin crusting, lid or conjunctival oedema, hyperaemia, conjunctival follicles, photophobia, headache, rhinitisDose See Administration in notes aboveSub-sections Oftaquix (Kestrel Ophthalmics) Eye drops, levofloxacin 0.5%, net price 5mL = 6.95 Excipients include benzalkonium chlorideEye drops, levofloxacin 0.5%, net price 30 0.5-mL single use units = 17.95 NEOMYCIN SULPHATEIndications see notes aboveDose See Administration in notes aboveSub-sections Neomycin (Non-proprietary) Eye drops, neomycin sulphate 0.5% (3500units/mL). Net price 10mL = 3.11 Available from special-order manufacturers or specialist importing companiesEye ointment, neomycin sulphate 0.5% (3500units/g). Net price 3g = 2.44 Available from special-order manufacturers or specialist importing companies With other antibacterials Neosporin (TEVA UK) Eye drops, gramicidin 25units, neomycin sulphate 1700units, polymyxin B sulphate 5000units/mL. Net price 5mL = 4.86 Excipients include benzalkonium chlorideDose apply 24 times daily or more frequently if requiredOFLOXACINIndications see notes abovePregnancy manufacturer advises use only if benefit outweighs risk; systemic quinolones have caused arthropathy in animal studiesBreast-feeding manufacturer advises avoidSide-effects local irritation including photophobia; dizziness, numbness, nausea and headache reportedDose Apply every 24 hours for the first 2 days then reduce frequency to 4 times daily (max. 10 days treatment)Sub-sections Exocin (Allergan) Ophthalmic solution (= eye drops), ofloxacin 0.3%. Net price 5mL = 2.17 Excipients include benzalkonium chloridePOLYMYXIN B SULPHATEIndications see notes aboveSide-effects local irritation and dermatitisDose See Administration in notes aboveSub-sections With other antibacterials Polyfax (TEVA UK) Eye ointment, polymyxin B sulphate 10000units, bacitracin zinc 500units/g. Net price 4g = 3.26PROPAMIDINE ISETIONATEIndications local treatment of infections (but see notes above)Dose See preparationsSub-sections Brolene (Sanofi-Aventis)Eye drops, propamidine isetionate 0.1%. Net price 10mL = 2.80 Excipients include benzalkonium chlorideDose apply 4 times dailyNote Eye drops containing propamidine isetionate 0.1% also available from Typharm (Golden Eye Drops)Eye ointment, dibrompropamidine isetionate 0.15%. Net price 5g = 2.92 Dose apply 12 times dailyNote Eye ointment containing dibrompropamidine isetionate 0.15% also available from Typharm (Golden Eye Ointment)11.3.2 AntifungalsFungal infections of the cornea are rare but can occur after agricultural injuries, especially in hot and humid climates. Orbital mycosis is rarer, and when it occurs it is usually because of direct spread of infection from the paranasal sinuses. Increasing age, debility, or immunosuppression can encourage fungal proliferation. The spread of infection through blood occasionally produces metastatic endophthalmitis.Many different fungi are capable of producing ocular infection; they can be identified by appropriate laboratory procedures. Antifungal preparations for the eye are not generally available. Treatment will normally be carried out at specialist centres, but requests for information about supplies of preparations not available commercially should be addressed to the Strategic Health Authority (or equivalent), or to the nearest hospital ophthalmology unit, or to Moorfields Eye Hospital, 162 City Road, London EC1V 2PD (tel. (020) 7253 3411) or www.moorfields.nhs.uk11.3.3 AntiviralsHerpes simplex infections producing, for example, dendritic corneal ulcers can be treated with aciclovir or ganciclovir. Aciclovir eye ointment is used in combination with systemic treatment for ophthalmic zoster (section 5.3.2).Slow-release ocular implants containing ganciclovir (available on a named-patient basis from specialist importing companies) may be inserted surgically to treat immediate sight-threatening CMV retinitis. Local treatments do not protect against systemic infection or infection in the other eye. For systemic treatment of CMV retinitis, see section 5.3.2.2.ACICLOVIR(Acyclovir)Indications local treatment of herpes simplex infectionsSide-effects local irritation and inflammation, superficial punctate keratopathy; rarely blepharitis; very rarely hypersensitivity reactions including angioedemaDose Apply 5 times daily (continue for at least 3 days after complete healing)Sub-sections Zovirax (GSK) Eye ointment, aciclovir 3%. Net price 4.5g = 9.34 GANCICLOVIRIndications local treatment of herpes simplex infectionsSide-effects burning sensation, tingling, superficial punctate keratitisDose Apply 5 times daily until healing complete, then apply 3 times daily for a further 7 daysSub-sections Virgan (Spectrum) Ophthalmic gel, ganciclovir 0.15%, net price 5g = 19.99

12 Ear, nose, and oropharynx12.1 Drugs acting on the ear12.1.1 Otitis externaOtitis externa is an inflammatory reaction of the meatal skin. It is important to exclude an underlying chronic otitis media before treatment is commenced. Many cases recover after thorough cleansing of the external ear canal by suction or dry mopping. A frequent problem in resistant cases is the difficulty in applying lotions and ointments satisfactorily to the relatively inaccessible affected skin. The most effective method is to introduce a ribbon gauze dressing or sponge wick soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution. When this is not practical, the ear should be gently cleansed with a probe covered in cotton wool and the patient encouraged to lie with the affected ear uppermost for ten minutes after the canal has been filled with a liberal quantity of the appropriate solution.If infection is present, a topical anti-infective which is not used systemically (such as neomycin or clioquinol) may be used, but for only about a week as excessive use may result in fungal infections; these may be difficult to treat and require expert advice. Sensitivity to the anti-infective or solvent may occur and resistance to antibacterials is a possibility with prolonged use. Aluminium acetate ear drops are also effective against bacterial infection and inflammation of the ear. Chloramphenicol may be used but the ear drops contain propylene glycol and cause hypersensitivity reactions in about 10% of patients. Solutions containing an anti-infective and a corticosteroid (such as Locorten-Vioform) are used for treating cases where infection is present with inflammation and eczema. In view of reports of ototoxicity in patients with a perforated tympanic membrane (eardrum), the CSM has stated that treatment with a topical aminoglycoside antibiotic is contra-indicated in those with a tympanic perforation. However, many specialists do use these drops cautiously in the presence of a perforation in patients with otitis media (section 12.1.2) and when other measures have failed for otitis externa.A solution of acetic acid 2% acts as an antifungal and antibacterial in the external ear canal. It may be used to treat mild otitis externa but in severe cases an anti-inflammatory preparation with or without an anti-infective drug is required. A proprietary preparation containing acetic acid 2% (EarCalm spray) is on sale to the public.For severe pain associated with otitis externa, a simple analgesic, such as paracetamol (section 4.7.1) or ibuprofen (section 10.1.1), can be used. A systemic antibacterial (Table 1, section 5.1) can be used if there is spreading cellulitis or if the patient is systemically unwell. When a resistant staphylococcal infection (a boil) is present in the external auditory meatus, flucloxacillin is the drug of choice; ciprofloxacin (or an aminoglycoside) may be needed in pseudomonal infections which may occur if the patient has diabetes or is immunocompromised.The skin of the pinna adjacent to the ear canal is often affected by eczema. Topical corticosteroid creams and ointments (section 13.4) are then required, but prolonged use should be avoided.ALUMINIUM ACETATEIndications inflammation in otitis externa (see notes above)Dose Insert into meatus or apply on a ribbon gauze dressing or sponge wick which should be kept saturated with the ear dropsSub-sections Aluminium Acetate (Non-proprietary)Ear drops 13%, aluminium sulphate 2.25g, calcium carbonate 1g, tartaric acid 450mg, acetic acid (33%) 2.5mL, purified water 7.5mL Available from manufacturers of special order productsEar drops 8%, dilute 8 parts aluminium acetate ear drops (13%) with 5 parts purified water. Must be freshly prepared Anti-infective preparationsCHLORAMPHENICOL Indications bacterial infection in otitis externa (but see notes above)Cautions avoid prolonged use (see notes above)Side-effects high incidence of sensitivity reactions to vehicleSub-sections Chloramphenicol (Non-proprietary) Ear drops, chloramphenicol in propylene glycol, net price 5%, 10mL = 5.09; 10%, 10mL = 5.62 Dose ear, apply 23 drops 23 times dailyCLIOQUINOLIndications mild bacterial or fungal infections in otitis externa (see notes above)Cautions avoid prolonged use (see notes above); manufacturer advises avoid in perforated tympanic membrane (but used by specialists for short periods)Side-effects local sensitivity; stains skin and clothingSub-sections With corticosteroid Locorten-VioformCLOTRIMAZOLEIndications fungal infection in otitis externa (see notes above)Side-effects occasional local irritation or sensitivitySub-sections Canesten (Bayer Consumer Care)Solution, clotrimazole 1% in polyethylene glycol 400 (macrogol 400). Net price 20mL = 2.43 Dose ear, apply 23 times daily continuing for at least 14 days after disappearance of infectionFRAMYCETIN SULPHATEIndications bacterial infection in otitis externa (see notes above)Cautions avoid prolonged use (see notes above)Contra-indications perforated tympanic membrane (see notes above)Side-effects local sensitivitySub-sections With corticosteroid Sofradexsee DexamethasoneGENTAMICINIndications bacterial infection in otitis externa (see notes above)Cautions avoid prolonged use (see notes above)Contra-indications perforated tympanic membrane (but see also notes above and section 12.1.2)Side-effects local sensitivitySub-sections Genticin (Amdipharm) Drops (for ear or eye), gentamicin 0.3% (as sulphate). Net price 10mL = 2.13 Excipients include benzalkonium chlorideDose ear, apply 23 drops 34 times daily and at night; eye, section 11.3.1 With corticosteroidNEOMYCIN SULPHATEIndications bacterial infection in otitis externa (see notes above)Cautions avoid prolonged use (see notes above)Contra-indications perforated tympanic membrane (see notes above)Side-effects local sensitivitySub-sections With corticosteroid12.1.2 Otitis mediaAcute otitis media Acute otitis media is the commonest cause of severe aural pain in small children. Many infections, especially those accompanying coryza, are caused by viruses. Most uncomplicated cases resolve without antibacterial treatment and a simple analgesic, such as paracetamol, may be sufficient. In children without systemic features, a systemic antibacterial (Table 1, section 5.1) may be started after 72 hours if there is no improvement, or earlier if there is deterioration, if the patient is systemically unwell, if the patient is at high risk of serious complications (e.g. in immunosuppression, cystic fibrosis), if mastoiditis is present, or in children under 2 years of age with bilateral otitis media. Perforation of the tympanic membrane in patients with acute otitis media usually heals spontaneously without treatment; if there is no improvement, e.g. pain or discharge persists, a systemic antibacterial (Table 1, section 5.1) can be given. Topical treatment of acute otitis media is ineffective and there is no place for drops containing a local anaesthetic.Otitis media with effusion Otitis media with effusion (glue ear) occurs in about 10% of children and in 90% of children with cleft palates. Systemic antibacterials are not usually required. If glue ear persists for more than a month or two, the child should be referred for assessment and follow up because of the risk of long-term hearing impairment which can delay language development. Untreated or resistant glue ear may be responsible for some types of chronic otitis media.Chronic otitis media Opportunistic organisms are often present in the debris, keratin, and necrotic bone of the middle ear and mastoid in patients with chronic otitis media. The mainstay of treatment is thorough cleansing with aural microsuction which may completely resolve long-standing infection. Local cleansing of the meatal and middle ear may be followed by treatment with a sponge wick or ribbon gauze dressing soaked with corticosteroid ear drops or with an astringent such as aluminium acetate solution; this is particularly beneficial for discharging ears or infections of the mastoid cavity. An antibacterial ear ointment may also be used. Acute exacerbations of chronic infection may also require systemic treatment with amoxicillin (or erythromycin if penicillin-allergic); treatment is adjusted according to the results of sensitivity testing. Parenteral antibacterials are required if Pseudomonas aeruginosa and Proteus spp. are present.The CSM has stated that topical treatment with ototoxic antibacterials is contra-indicated in the presence of a perforation (section 12.1.1). However, many specialists use ear drops containing aminoglycosides (e.g. neomycin) or polymyxins if the otitis media has failed to settle with systemic antibacterials; it is considered that the pus in the middle ear associated with otitis media carries a higher risk of ototoxicity than the drops themselves. Ciprofloxacin or ofloxacin ear drops [both unlicensed; available on named-patient basis from a specialist importing company] or eye drops used in the ear [unlicensed indication] are an effective alternative to aminoglycoside ear drops for chronic otitis media in patients with perforation of the tympanic membrane.12.2 Drugs acting on the noseRhinitis is often self-limiting but bacterial sinusitis may require treatment with antibacterials (Table 1, section 5.1). There are few indications for nasal sprays and drops except in allergic rhinitis and perennial rhinitis (section 12.2.1). Many nasal preparations contain sympathomimetic drugs which may damage the nasal cilia (section 12.2.2). Sodium chloride 0.9% solution may be used as a douche or sniff following endonasal surgery.

Ear, nose, and oropharynxPericoronitisMetronidazole or amoxicillinAntibacterial required only in presence of systemic features of infection or of trismus or persistent swelling despite local treatment; treat for 3 days or until symptoms resolveAcute necrotising ulcerative gingivitisMetronidazole or amoxicillinAntibacterial required only if systemic features of infection; treat for 3 days or until symptoms resolvePeriapical or periodontal abscessAmoxicillin or metronidazoleAntibacterial required only in severe disease with cellulitis or if systemic features of infection; treat for 5 daysPeriodontitisMetronidazole or doxycyclineAntibacterial used as an adjunct to debridement in severe disease or disease unresponsive to local treatment aloneThroat infectionsPhenoxymethylpenicillin (or clarithromycin(1) if penicillin-allergic)Most throat infections are caused by viruses and many do not require antibacterial therapy. Consider antibacterial, if history of valvular heart disease, if marked systemic upset, if peritonsillar cellulitis or abscess, or if at increased risk from acute infection (e.g. in immunosuppression, cystic fibrosis); prescribe antibacterial for beta-haemolytic streptococcal pharyngitis; treat for 10 days. Avoid amoxicillin if possibility of glandular fever, see section 5.1.1.3. Initial parenteral therapy (in severe infection) with benzylpenicillin, then oral therapy with phenoxymethylpenicillin or amoxicillin(2)SinusitisAmoxicillin(2) or doxycycline or clarithromycin(1)Antibacterial should usually be used only for persistent symptoms and purulent discharge lasting at least 7 days or if severe symptoms. Also, consider antibacterial for those at high risk of serious complications (e.g. in immunosuppression, cystic fibrosis). Treat for 7 days. Consider oral co-amoxiclav if no improvement after 48 hours. Initial parenteral therapy with co-amoxiclav or cefuroxime may be required in severe infectionsOtitis externaFlucloxacillin (or clarithromycin(1) if penicillin-allergic)Consider systemic antibacterial if spreading cellulitis or patient systemically unwell. Use ciprofloxacin (or an aminoglycoside) if pseudomonas suspected. For topical preparations see section 12.1.1Otitis mediaAmoxicillin(2) (or clarithromycin(1) if penicillin-allergic)Many infections caused by viruses. Most uncomplicated cases resolve without antibacterial treatment. In children without systemic features, antibacterial treatment may be started after 72 hours if no improvement. Consider earlier treatment if deterioration, if systemically unwell, if at high risk of serious complications (e.g. in immunosuppression, cystic fibrosis), if mastoiditis present, or in children under 2 years of age with bilateral otitis media. Treat for 5 days (longer if severely ill); consider co-amoxiclav if no improvement after 48 hours; initial parenteral therapy in severe infection with co-amoxiclav or cefuroxime Previous: Eye | Top | Next: Skin (1) Where clarithromycin is suggested azithromycin or erythromycin may be used. (2) Where amoxicillin is suggested ampicillin may be used. 12.2.3 Nasal preparations for infectionThere is no evidence that topical anti-infective nasal preparations have any therapeutic value in rhinitis or sinusitis; for elimination of nasal staphylococci, see below.Systemic treatment of sinusitissee Table 1 section 5.1Sub-sections Betnesol-N Nasal staphylococciNasal staphylococciElimination of organisms such as staphylococci from the nasal vestibule can be achieved by the use of a cream containing chlorhexidine and neomycin (Naseptin), but re-colonisation frequently occurs. Coagulase-positive staphylococci are present in the noses of 40% of the population.A nasal ointment containing mupirocin is also available; it should probably be held in reserve for resistant cases. In hospital or in care establishments, mupirocin nasal ointment should be reserved for the eradication (in both patients and staff) of nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA). The ointment should be applied 3 times daily for 5 days and a sample taken 2 days after treatment to confirm eradication. The course may be repeated if the sample is positive (and the throat is not colonised). To avoid the development of resistance, the treatment course should not exceed 7 days and the course should not be repeated on more than one occasion. If the MRSA strain is mupirocin-resistant or does not respond after 2 courses, consider alternative products such as chlorhexidine and neomycin cream.Sub-sections Bactroban Nasal Naseptin12.3.2 Oropharyngeal anti-infective drugsThe most common cause of a sore throat is a viral infection which does not benefit from anti-infective treatment. Streptococcal sore throats require systemic penicillin therapy (Table 1, section 5.1). Acute ulcerative gingivitis (Vincents infection) responds to systemic metronidazole (section 5.1.11).Preparations administered in the dental surgery for the local treatment of periodontal disease include gels of metronidazole (Elyzol, Colgate-Palmolive) and of minocycline (Dentomycin, Blackwell).Oropharyngeal fungal infectionsAdditional information interactions (Miconazole).Fungal infections of the mouth are usually caused by Candida spp. (candidiasis or candidosis). Different types of oropharyngeal candidiasis are managed as follows:Thrush Acute pseudomembranous candidiasis (thrush), is usually an acute infection but it may persist for months in patients receiving inhaled corticosteroids, cytotoxics or broad-spectrum antibacterials. Thrush also occurs in patients with serious systemic disease associated with reduced immunity such as leukaemia, other malignancies, and HIV infection. Any predisposing condition should be managed appropriately. When thrush is associated with corticosteroid inhalers, rinsing the mouth with water (or cleaning a childs teeth) immediately after using the inhaler may avoid the problem. Treatment with nystatin or miconazole may be needed. Fluconazole (section 5.2.1) is effective for unresponsive infections or if a topical antifungal drug cannot be used or if the patient has dry mouth. Topical therapy may not be adequate in immunocompromised patients and an oral triazole antifungal is preferred (section 5.2.1).Acute erythematous candidiasis Acute erythematous (atrophic) candidiasis is a relatively uncommon condition associated with corticosteroid and broad-spectrum antibacterial use and with HIV disease. It is usually treated with fluconazole (section 5.2.1).Denture stomatitis Patients with denture stomatitis (chronic atrophic candidiasis), should cleanse their dentures thoroughly and leave them out as often as possible during the treatment period. To prevent recurrence of the problem, dentures should not normally be worn at night. New dentures may be required if these measures fail despite good compliance.Miconazole oral gel can be applied to the fitting surface of the denture before insertion (for short periods only). Denture stomatitis is not always associated with candidiasis and other factors such as mechanical or chemical irritation, bacterial infection, or rarely allergy to the dental base material, may be the cause.Chronic hyperplastic candidiasis Chronic hyperplastic candidiasis (candidal leucoplakia) carries an increased risk of malignancy; biopsy is essentialthis type of candidiasis may be associated with varying degrees of dysplasia, with oral cancer present in a high proportion of cases. Chronic hyperplastic candidiasis is treated with a systemic antifungal such as fluconazole (section 5.2.1) to eliminate candidal overlay. Patients should avoid the use of tobacco.Angular cheilitis Angular cheilitis (angular stomatitis) is characterised by soreness, erythema and fissuring at the angles of the mouth. It is commonly associated with denture stomatitis but may represent a nutritional deficiency or it may be related to orofacial granulomatosis or HIV infection. Both yeasts (Candida spp.) and bacteria (Staphylococcus aureus and beta-haemolytic streptococci) are commonly involved as interacting, infective factors. A reduction in facial height related to ageing and tooth loss with maceration in the deep occlusive folds that may subsequently arise, predisposes to such infection. While the underlying cause is being identified and treated, it is often helpful to apply miconazole cream or sodium fusidate ointment ; if the angular cheilitis is unresponsive to treatment, miconazole and hydrocortisone cream or ointment can be used.Immunocompromised patients For advice on prevention of fungal infections in immunocompromised patients see Immunocompromised Patients.Drugs used in oropharyngeal candidiasis Nystatin is not absorbed from the gastro-intestinal tract and is applied locally (as a suspension) to the mouth for treating local fungal infections. Miconazole is applied locally (as an oral gel) in the mouth but it is absorbed to the extent that potential interactions need to be considered. Miconazole also has some activity against Gram-positive bacteria including streptococci and staphylococci. Fluconazole (section 5.2.1) is given by mouth for infections that do not respond to topical therapy or when topical therapy cannot be used. It is reliably absorbed and effective. Itraconazole (section 5.2.1) can be used for fluconazole-resistant infections.If candidal infection fails to respond to 1 to 2 weeks of treatment with antifungal drugs the patient should be sent for investigation to eliminate the possibility of underlying disease. Persistent infection may also be caused by reinfection from the genito-urinary or gastro-intestinal tract. Infection can be eliminated from these sources by appropriate anticandidal therapy; the patients partner may also require treatment to prevent reinfection.For the role of antiseptic mouthwashes in the prevention of oral candidiasis in immunocompromised patients and treatment of denture stomatitis, see section 12.3.4.MICONAZOLEAdditional information interactions (Miconazole).Indications see preparationsCautions avoid in acute porphyria (section 9.8.2); interactions: Appendix 1 (antifungals, imidazole)Contra-indications with oral gel, impaired swallowing reflex in infants, first 56 months of life of an infant born pretermHepatic impairment avoidPregnancy manufacturer advises avoid if possibletoxicity at high doses in animal studiesBreast-feeding manufacturer advises cautionno information availableSide-effects nausea, vomiting; rash; with buccal tablets, abdominal pain, taste disturbance, burning sensation at application site, pruritus, and oedema; with oral gel, very rarely diarrhoea (usually on long-term treatment), hepatitis, toxic epidermal necrolysis, and Stevens-Johnson syndromeDose see preparationsSub-sections (1)Daktarin (Janssen-Cilag) Oral gel, sugar-free, orange-flavoured, miconazole 24mg/mL (20mg/g). Net price 15-g tube = 2.85, 80-g tube = 4.38. Label: 9, counselling, hold in mouth, after food Dose prevention and treatment of oral and intestinal fungal infections, 510mL in the mouth after food 4 times daily, retained near oral lesions before swallowing; child 4 months2 years 2.5mL twice daily, smeared around the mouth; 26 years 5mL twice daily, retained near lesions before swallowing; over 6 years 5mL 4 times daily, retained near lesions before swallowingNote Treatment should be continued for 48 hours after lesions have healedLocalised lesions, adult and child over 2 years, smear small amount on affected area with clean finger 4 times daily for 57 days (dental prostheses should be removed at night and brushed with gel); treatment continued for 48 hours after lesions have healedDental prescribing on NHS May be prescribed as Miconazole Oromucosal Gel Buccal preparation Loramyc (SpePharm) Mucoadhesive buccal tablets, white-yellow, miconazole 50mg, net price 14-tab pack = 45.61. Label: 10, counselling, administration Dose oropharyngeal candidiasis in immunocompromised adult, 50mg daily preferably taken in the morning for 7 days; if no improvement, continue treatment for a further 7 daysCounselling Place rounded side of tablet on upper gum above an incisor tooth and hold upper lip firmly over the gum for 30 seconds using a finger. If tablet detaches within 6 hours, replace with a new tablet. With each dose, use alternate sides of the gumNote The Scottish Medicines Consortium has advised (November 2008) that miconazole mucoadhesive buccal tablets (Loramyc) are not recommended for use within NHS Scotland.NYSTATINIndications oral and perioral fungal infectionsSide-effects oral irritation and sensitisation, nausea reported; see also section 5.2Dose Treatment, adult and child, 100000units 4 times daily after food, usually for 7 days (continued for 48 hours after lesions have resolved)Note Unlicensed for treating candidiasis in neonateSub-sections Nystan (Squibb) Oral suspension, yellow, nystatin 100000units/mL. Net price 30mL with pipette = 1.91. Label: 9, counselling, use of pipette, hold in mouth, after food Dental prescribing on NHS Nystatin Oral Suspension may be prescribedOropharyngeal viral infectionsThe management of primary herpetic gingivostomatitis is a soft diet, adequate fluid intake, and analgesics as required, including local use of benzydamine (section 12.3.1). The use of chlorhexidine mouthwash (section 12.3.4) will control plaque accumulation if toothbrushing is painful and will also help to control secondary infection in general. In the case of severe herpetic stomatitis, a systemic antiviral such as aciclovir is required (section 5.3.2.1). Valaciclovir and famciclovir are suitable alternatives for oral lesions associated with herpes zoster. Aciclovir and valaciclovir are also used for the prevention of frequently recurring herpes simplex lesions of the mouth, particularly when implicated in the initiation of erythema multiforme. See section 13.10.3 for the treatment of labial herpes simplex infections.Herpes infections of the mouth may also respond to rinsing the mouth with doxycycline(section 12.3.1).12.3.4 Mouthwashes, gargles, and dentifricesSuperficial infections of the mouth are often helped by warm mouthwashes which have a mechanical cleansing effect and cause some local hyperaemia. However, to be effective, they must be used frequently and vigorously. A warm saline mouthwash is ideal and can be prepared either by dissolving half a teaspoonful of salt in a glassful of warm water or by diluting compound sodium chloride mouthwash with an equal volume of warm water. Mouthwash solution-tablets are used to remove unpleasant tastes.Mouthwashes containing an oxidising agent, such as hydrogen peroxide, may be useful in the treatment of acute ulcerative gingivitis (Vincents infection) since the organisms involved are anaerobes. It also has a mechanical cleansing effect arising from frothing when in contact with oral debris.Chlorhexidine is an effective antiseptic which has the advantage of inhibiting plaque formation on the teeth. It does not, however, completely control plaque deposition and is not a substitute for effective toothbrushing. Moreover, chlorhexidine preparations do not penetrate significantly into stagnation areas and are therefore of little value in the control of dental caries or of periodontal disease once pocketing has developed. Chlorhexidine mouthwash is used in the treatment of denture stomatitis. It is also used in the prevention of oral candidiasis in immunocompromised patients. Chlorhexidine mouthwash reduces the incidence of alveolar osteitis following tooth extraction. Chlorhexidine mouthwash should not be used for the prevention of endocarditis in patients undergoing dental procedures.Chlorhexidine can be used as a mouthwash, spray or gel for secondary infection in mucosal ulceration and for controlling gingivitis, as an adjunct to other oral hygiene measures. These preparations may also be used instead of toothbrushing where there is a painful periodontal condition (e.g. primary herpetic stomatitis) or if the patient has a haemorrhagic disorder, or is disabled. Chlorhexidine preparations are of little value in the control of acute necrotising ulcerative gingivitis.There is no convincing evidence that gargles are effective.CHLORHEXIDINE GLUCONATEIndications see under preparations belowSide-effects mucosal irritation (if desquamation occurs, discontinue treatment or dilute mouthwash with an equal volume of water); taste disturbance; reversible brown staining of teeth, and of silicate or composite restorations; tongue discoloration; parotid gland swelling reportedNote Chlorhexidine gluconate may be incompatible with some ingredients in toothpaste; leave an interval of at least 30 minutes between using mouthwash and toothpasteSub-sections Chlorhexidine (Non-proprietary)Mouthwash, chlorhexidine gluconate 0.2%, net price 300mL = 2.21 Dose oral hygiene and plaque inhibition, oral candidiasis, gingivitis, and management of aphthous ulcers, rinse mouth with 10mL for about 1 minute twice dailyDenture stomatitis, cleanse and soak dentures in mouthwash solution for 15 minutes twice daily Dental prescribing on NHS Chlorhexidine Mouthwash may be prescribed HYDROGEN PEROXIDEIndications oral hygiene, see notes aboveSide-effects hypertrophy of papillae of tongue on prolonged usedSub-sections Hydrogen Peroxide Mouthwash, BPMouthwash, consists of Hydrogen Peroxide Solution 6% (=approx. 20 volume) BP Dose rinse the mouth for 23 minutes with 15mL diluted in half a tumblerful of warm water 23 times dailyDental prescribing on NHS Hydrogen Peroxide Mouthwash may be prescribed SODIUM CHLORIDEIndications oral hygiene, see notes aboveSub-sections Sodium Chloride Mouthwash, Compound, BPMouthwash, sodium bicarbonate 1%, sodium chloride 1.5% in a suitable vehicle with a peppermint flavour. Dose extemporaneous preparations should be prepared according to the following formula: sodium chloride 1.5g, sodium bicarbonate 1g, concentrated peppermint emulsion 2.5mL, double-strength chloroform water 50mL, water to 100mLTo be diluted with an equal volume of warm waterDental prescribing on NHS Compound Sodium Chloride Mouthwash may be prescribedTHYMOLIndications oral hygiene, see notes aboveSub-sections Mouthwash Solution-tabletsConsist of tablets which may contain antimicrobial, colouring, and flavouring agents in a suitable soluble effervescent basis to make a mouthwash suitable for dental purposes. Net price 100-tab pack = 15.09 Dose dissolve 1 tablet in a tumblerful of warm waterNote Mouthwash solution tablets may contain ingredients such as thymolDental prescribing on NHS Mouthwash Solution-tablets may be prescribed