Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 1 of 12

1

BNSSG Antimicrobial Prescribing Guideline – Summary

These summary guidelines are to be used alongside the full BNSSG antimicrobial prescribing guidelines and do not

cover every infection in the full guidelines. The links take you to the appropriate section of the full guideline

Infection Comment Antibiotic Penicillin Allergy Course Length Meningitis – see full guideline

Upper respiratory tract infections

Sore throat/ Pharyngitis/ Tonsillitis

Avoid antibiotics Delayed antibiotics

Penicillin V

Clarithromycin

10 days Pen V 5 days Clarith

Acute otitis media Target antibiotics Amoxicillin Clarithromycin 5 days Acute rhinosinusitis Avoid antibiotics

Delayed antibiotics Amoxicillin

Doxycyline

7 days

Lower respiratory tract infections

Acute cough, Bronchitis

Avoid antibiotics Delayed antibiotics

Amoxicillin

Doxycycline

5 days

Acute exacerbation COPD

Amoxicillin

Doxycycline

5-7 days

Acute exacerbation of bronchiectasis

Amoxicillin

Doxycycline

7-14 days

Community acquired pneumonia

CRB-65 score= 0 Amoxicillin

Doxycycline or Clarithromycin

5-7 days

CRB-65 score = 1 Amoxicillin Plus Clarithromycin

Doxycycline 7 days

Urinary tract infections UTI adults First line Nitrofurantoin or Trimethoprim Women 3-7 days

3 days for uncomplicated Men 7 days

Increased risk of resistance eGFR>30ml/min

Nitrofurantoin

Increased risk of resistance eGFR<30ml/min

Pivmecillinam (a penicillin)

Not type 1 – Cefalexin Type 1 - Trimethoprim

Piv – 3 days M&W Cef & Trim – Women 3-7 days 3 days for uncomplicated Men 7 days

Acute Prostatitis Ciprofloxacin or Ofloxacin (if STD) 28 days

Acute Pyelonephritis (not pregnant)

Co-amoxiclav Ciprofloxacin 14 days co-amox 7 days cipro

UTI in pregnancy First line Nitrofurantoin (avoid at term)

7 days

UTI in children Lower UTI – first line

Trimethoprim 3 days

Upper UTI Co-amoxiclav Cefalexin 10-14 days

Gastro-intestinal Tract Infections – see full guideline

Genital Tract Infections – see full guideline Skin Infections

Impetigo Flucloxacillin Clarithromycin 5 days Cellulitis Flucloxacillin Clarithromycin

Or Clindamycin 5 days

Facial cellulitis Co-amoxiclav 5 days

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 2 of 12

2

Aims-

To provide a simple, effective, economical and empirical approach to the treatment of common infections . To target the use of antibiotics and antifungals in primary care To minimise the emergence of bacterial resistance in the community.

Principles of Treatment 1. This guidance is based on the best available evidence but professional judgement should be used and patients should be

involved in the decision. 2. It is important to initiate antibiotics as soon as possible in severe infection.

3. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. Children’s doses are provided when appropriate and BNF for children can be accessed through the symbol. Refer to BNF for further dosing and interaction information (e.g. interaction between macrolides and statins) and check for known

hypersensitivity in patient records and with patients or carers. 4. Type 1 penicil l in allergy is an obvious allergic reaction with swelling of the lips and tongue, itchy, lumpy rash , difficulty breathing.

If there is a type 1 anaphylactic reaction to penicil l ins do not give penicil lins or cephalosporins or beta-lactams of any kind. 5. Lower threshold for antibiotic use in immunocompromised or those with multiple morbidities; consider culture and seek advice.

6. Prescribe an antibiotic only when there is l ikely to be a clear clinical benefit. 7. Consider a ‘no antibiotic’ strategy or delayed antibiotic strategy for acute self-l imiting URTI and mild UTI symptoms.

8. Limit prescribing over the telephone to exceptional cases. 9. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins)

when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs. 10. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g. fusidic acid). 11. In pregnancy take specimens to inform treatment; where possible avoid tetracyclines, aminoglycosides, quinolones, high dose

metronidazole (2 g) unless benefit out ways risks . UK Teratology Information Centre 0844 892 0909 12. Microbiological advice can be obtained from secondary care trusts Southmead Hospital 0117 3232656

UHB 0117 3422514 Weston Hospital 01934 647053 For specialist virology advice contact UHB 0117 342 5033

We would like to thank the following for their contribution; Dr Martin Williams - Consultant Microbiologist UHBristol, Dr Alisdair Mcgowan - Consultant Microbiologist NBT, Dr Isabel Baker - Consultant Microbiologist WGH, Dr Paddy Horner- Consultant Bristol Sexual Health Clinic and PHE for providing the guidance template.

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Upper Respiratory Tract Infections

Influenza treatment

PHE Influenza

For prophylaxis see: NICE

Influenza

Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not recommended.

Treat ‘at risk’ patients, when influenza is circulating in the community and ideally within 48 hours of onset (do not wait for lab report) or in a care home where influenza is likely. At risk: pregnant (including up to two weeks post partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic

neurological, renal or liver disease, morbid obesity (BMI>=40). Use 5 days treatment with oseltamivir 75mg bd. If resistance to oseltamivir or severe immunosuppression, use zanamivir 10mg BD (2 inhalations by diskhaler for up to 10 days) and seek advice. See PHE Influenza guidance for treatment of patients under 13 years or in severe immunosuppression (and seek advice).

Acute sore throat/

Pharyngitis/

Tonsillitis (Purulent tonsils,

fever, tender lymph nodes, no cough.) CKS

Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours

If Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate) consider 2- or 3-day delayed or immediate antibiotics.

Antibiotics to prevent Quinsy NNT >4000

Antibiotics to prevent Otitis media NNT 200

10 d penicillin lower relapse vs 7d in RCT in <18yrs

Phenoxymethylpenicillin

Penicillin allergy:

Clarithromycin

500 mg QDS

1g QDS when severe

250-500mg BD

10 days

5 days

Acute

Rhinosinusitis

(Purulent nasal discharge, facial pain, unwell)

CKS

Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days, NNT 15.

Use adequate analgesia

Consider 7-day delayed or immediate antibiotic

when purulent nasal discharge NNT 8

In persistent infection use an agent with anti-anaerobic activity e.g. Co-amoxiclav

Amoxicillin

or

Doxycyline

For persistent symptoms:

Co-amoxiclav

Penicillin allergy:

Clarithromycin

500mg TDS

Or 1gram TDS if severe

200 mg stat then 100 mg OD

625mg TDS

500mg BD

7 days

7 days

7 days

7 days

Acute Otitis Externa

CKS

First use aural toilet (if available) & optimise patient analgesia

Cure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid

If cellulitis or disease extending outside ear canal, start oral antibiotics and refer

Topical antibiotic therapy to be used only if tympanic membrane intact.

First-line topical therapies:

Acetic acid 2% spray

Gentisone HC®

Sofradex®

Alternative topical therapy:

Locorten-Vioform®

One spray TDS

Three drops QDS

Three drops QDS

Three drops BD

7 days

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 3 of 12

3

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Acute Otitis

Media (AOM)- Child

(Ear pain,

bulging red ear

drum, unwell)

CKS

NICE feverish child

Optimise analgesia and target antibiotics

AOM resolves in 60% in 24 h without antibiotics, which only reduce pain at 2 days (NNT 15) and does not prevent deafness

Consider 2 or 3-day delayed or immediate antibiotics for pain relief if:

<2 years AND bilateral AOM (NNT 4) or bulging membrane & ≥ 4 marked symptoms

All ages with otorrhoea NNT 3

Antibiotics to prevent Mastoiditis =NNT >4000

Amoxicillin

Penicillin allergy:

Clarithromycin

Child doses

Neonate 7-28 days

30mg/kg TDS

1 month-1 yr: 125mg TDS

1-5 years: 250mg TDS

5-18 years: 500mg TDS

Child 1 month–12 years

Body-weight under 8 kg: 7.5 mg/kg BD

Body-weight 8-11 kg:

62.5 mg BD

Body-weight 12–19 kg:

125 mg BD

Body-weight 20–29 kg:

187.5 mg BD

Body-weight 30–40 kg:

250 mg BD

Child 12–18 years

250 mg BD

5 days

5 days

Lower Respiratory Tract Infections

Note: Low doses of penicillins are more likely to select out resistance. Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal

activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms.

Acute Cough,

Bronchitis (Cough with

purulent sputum)

CKS NICE CG69

Antibiotic offer little benefit if no co-morbidity

Consider 7 day delayed antibiotic with advice

Symptom resolution can take 3 weeks.

Consider immediate antibiotics if >80 years and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure OR >65 years with 2 of above

Consider using CRP if pneumonia suspected. If CRP <20mg/L no antibiotics, 20-100mg/L delayed, >100mg/L immediate antibiotics

Only if needed:

Amoxicillin

or

Doxycycline

500 mg TDS

200 mg stat then 100 mg OD

5 days

5 days

Acute Exacerbation

of COPD (Purulent

sputum, cough

worse, chest

signs and

worsening

dyspnoea) Gold

NICE CG101

BNSSG

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume.

Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months

If recurrent exacerbations send sputum sample

First-line:

Amoxicillin

or Doxycycline

Alternative if resistance:

Co-amoxiclav

500 mg TDS

200 mg stat then 100 mg OD

625 mg TDS

5-7 days

5-7 days

5-7 days

Acute Exacerbation of

Bronchiectasis

CKS

BNSSG

Send sputum sample for culture and sensitivity and start empirical antibiotics while awaiting results. Previous culture results can guide treatment choice. Specify bronchiectasis patient on sputum form. If new growth of P.aeruginosa discuss eradication therapy with specialists.

First-line:

Amoxicillin

Penicillin allergy or on regular macrolide:

Doxycycline

1 g TDS

100 mg BD

7-14 days

If no resolution seek specialist advice

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 4 of 12

4

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Community

Acquired Pneumonia-

treatment

in the

community

BTS 2009 Guideline

NICE 191

Use CRB65 score to help guide and review. Each scores 1:

Confusion (AMT<8)

Respiratory rate >30/min

BP systolic <90 or diastolic ≤ 60

Age >65

Score 0: suitable for home treatment;

Score 1-2: consider hospital assessment or admission particularly those with a score of 2

Score 3-4: urgent hospital admission

Mycoplasma infection is rare in over 65s

IF CRB65=0:

Amoxicillin

or Doxycycline

or Clarithromycin

500 mg TDS

200 mg stat then 100 mg OD

500 mg BD

5-7 days

5-7 days

5-7 days

If CRB65=1 & AT HOME

Amoxicillin

AND Clarithromycin

or Doxycycline alone

500 mg TDS

500 mg BD

200 mg stat then 100 mg OD

7 days

7 days

Meningitis

Prevention of secondary case of meningitis: Only prescribe following advice from the Health Protection Unit (Rivergate) 03003038162 (option 2)

Suspected meningococcal disease

PHE Meningo

Transfer all patients to hospital immediately.

IF time before admission, and non-blanching rash, give IV or IM benzylpenicillin or ceftriaxone, unless definite history of Type-1 hypersensitivity

IV administration preferred over IM

IM ceftriaxone should be divided between two injection sites

Benzylpenicillin

or

Ceftriaxone

Age 10+ years: 1200 mg IV/IM

Children 1 - 9 yr: 600 mg IV/IM

Children <1 yr: 300 mg IV/IM

Age 12 and over:

2 gram IV infusion over at least 30 minutes but if vein cannot be found give IM.

Child 1 month-11 years & 50kg or more:

2 gram IV infusion over at least 30 minutes but if vein cannot be found give IM.

Child 1 month -11 years & less than 50kg: 80mg/kg IV infusion over at least 30 minutes

STAT dose

Urinary tract Infections – refer to PPHHEE UUTTII gguuiiddaannccee ffoorr ddiiaaggnnoossiiss iinnffoorrmmaattiioonn

As E. coli bacteraemia in the community is increasing ALWAYS safety net and consider risks for resistance

Do not treat asymptomatic bacteriuria (except in pregnancy) there no evidence of benefit.

Trimethoprim: May cause rise in serum creatinine due to inhibition of tubular secretion and may cause hyperkalaemia.

UTI in adults

(no fever or flank pain)

Symptoms: Dysuria, Frequency, Suprapubic tenderness, urgency, polyuria, haematuria

PHE URINE

SIGN

CKS women, CKS men

RCGP UTI clinical module

SAPG UTI

Treat women with severe/or ≥ 3 symptoms

Women mild/or ≤ 2 symptoms AND

a) Urine NOT cloudy 97% negative predictive value, do not treat unless other risk factors for infection.

b)If cloudy urine use dipstick to guide treatment. Nitrite plus blood or leucocytes has 92% positive predictive value (treat); nitrite, leucocytes, blood all negative - 76% negative predictive value

c) Consider a back-up / delayed antibiotic option if treatment not defined in (a) and (b)

Men: Consider prostatitis and send pre-treatment MSU OR if symptoms mild/non-specific, use negative dipstick to exclude UTI.

Always safety net.

In treatment failure: always perform culture, second-line treatment choice depends on sensitivity of organism isolated. When sending samples state antibiotics started empirically, so sensitivity of isolated organisms to agent prescribed can be checked.

Nitrofurantoin

Trimethoprim

Risk of increased resistance (see below) GRF>30ml/min:

Nitrofurantoin

Risk of increased resistance (see below) GFR <30ml/min:

Pivmecillinam (do not use if history of penicillin allergy)

Penicillin allergy (not type 1)

Cefalexin

Penicillin allergy (type 1)

Give Trimethoprim and review with sensitivities

100mg MR BD

200mg BD

100mg MR BD

400mg TDS

500mg BD

200mg BD

Women all ages 3 - 7 days with 3 days for uncomplicated

Men 7 days

Women all ages 3 – 7 days with 3 days for uncomplicated

Men 7 days

3 days (Men and Women)

Women all ages 3 -7 days with 3 days for uncomplicated

Men 7 days

Risk factors for increased resistance include: care home resident, recurrent UTI, hospitalisation >7d 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 & give safety net advice. Previous cultures should also guide empirical treatment.

Nitrofurantoin – avoid if eGFR <30ml/min. If eGFR 30-45ml/min can be used as a short course to treat resistant pathogens when the benefits outweigh the risks.

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 5 of 12

5

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Acute Prostatitis

BASHH, CKS

Send MSU and start antibiotics. 4-wk course may prevent chronic prostatitis Quinolones achieve higher prostate levels.

Consider STI screen (gonorrhoea / Chlamydia) and consider referral to GUM.

Ciprofloxacin or

Ofloxacin

(Ofloxacin if STI suspected)

Second-line:

Trimethoprim

500 mg BD

200 mg BD

200 mg BD

28 days

28 days

28 days

UTI in

Pregnancy

HPA

CKS

UKTIS

Send MSU for culture and start antibiotics, so sensitivity of isolated organisms to agent prescribed can be checked.

Short-term use of nitrofurantoin in pregnancy unlikely to cause problems to the foetus but avoid at term due to risk of neonatal haemolysis.

Trimethoprim: AVOID if low folate status or folate antagonist prescribed (eg antiepileptic or proguanil) & ensure folate supplement used for 1st trimester plus consider increase to 5mg daily dose.

First-line

Nitrofurantoin

Amoxicillin (if susceptible)

Second-line:

Trimethoprim

Third-line:

Cefalexin

100mg MR BD

500 mg TDS

200 mg BD (off-label)

500 mg BD

Follow up at 48hrs

to assess response to treatment.

All for 7 days

UTI in

Children

HPA

CKS-Children

NICE

Child <3 months: refer urgently for assessment

Child ≥ 3 months: use positive nitrite to start antibiotics. Send pre-treatment MSU for all.

Imaging: only refer if child <6 months, recurrent or atypical UTI

Lower UTI:

Trimethoprim or Nitrofurantoin (liquid is v. expensive)

if susceptible Amoxicillin

Second- line: Cefalexin

Upper UTI:

First line: Co-amoxiclav

Second line: Cefalexin

Lower UTI:

3 days

Upper UTI :

10 - 14 days

Acute

pyelonephritis (systemically

unwell, loin pain)

CKS

If admission not needed, send MSU for culture & sensitivities and start antibiotics.

If no response within 24 hours, admit

If ESBL risk d/w microbiology

Do not prescribe Nitrofurantoin, Pivmecillinam or Fosfomycin if clinical evidence of pyelonephritis

Ciprofloxacin

or

Co-amoxiclav

If lab results sensitive

Trimethorpim

500 mg BD

625 mg TDS

200mg BD

7 days

14 days

14 days

Acute

pyelonephritis in pregnancy

CKS

UKTIS

For pregnant women who do not require admission. If admission not needed, send MSU for culture & sensitivities and start antibiotics

If no response within 24 hours, admit.

Cefalexin

Second-line:

Ciprofloxacin (for use when alternatives unsuitable - see BNF and UKTIS for risks)

500 mg BD

500 mg BD

14 days

7 days

Recurrent UTI

non-pregnant women ≥ 3 UTIs/year

CKS

To reduce recurrence first advise simple

measures including hydration and cranberry

products. Then standby or post-coital antibiotics.

Nightly prophylaxis is not generally

recommended as adverse effects are possible

including development of resistance.

Nitrofurantoin

or

Trimethoprim

50–100 mg

100 mg

Post-coital: Stat

(off-label)

Prophylaxis:

Every night

UTI in Catheterised

patients

CKS women

CKS men

Do NOT treat or send routine catheter specimens

unless systemically unwell or evidence of

pyelonephritis. State symptoms on sample

request e.g. fever, loin pain, new confusion. Consider referral to secondary care if symptoms

are severe eg nausea, vomiting, reduced urine

output.

If clinical evidence of

pyelonephritis treat as

acute pyelonephritis above

Lower UTI First-line – if cannot wait for sensitivity:

Nitrofurantoin

Or

Trimethoprim

Or

Pivmecilliam (is a penicillin)

100mg MR BD

200mg BD

400mg TDS

5 days

5 days

3 days

Catheter changes

Do not use prophylactic antibiotics for catheter

changes unless history of catheter-change-

associated UTI

Gentamicin or based on

previous sensitivities

80mg IM Single dose

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 6 of 12

6

Gastro-Intestinal Tract Infections

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF TREATMENT

Oral

Candidiasis

CKS

For localized or mild oral candidal infection:

After 7 days if some response to initial treatment

agent offer further 7 days. After 7 days if initial

treatment has had little or no effect, despite

adequate adherence, offer Miconazole oral gel

for 7 days. Avoid Miconazole if patient on warfarin.

Oral candidiasis is rare in immunocompetent

adults, consider undiagnosed risk factors

including HIV

Nystatin suspension

(100, 000 units/mL)

Second line

Miconazole oral gel

(24 mg/mL)

1ml QDS after food, retain

near oral lesion before

swallowing.

5–10 mL QDS after food,

retain near oral lesion before swallowing.

7 days (continue

treatment for

2 days after symptoms resolve)

For extensive or severe candidiasis or if the

patient is immunosupressed: If infection not

resolved after 7 days, offer further 7 days

Fluconazole 50 mg OD 7 days

Eradication of Helicobacter pylori

NICE

PHE

CKS

Eradication is beneficial in known DU, GU or low grade MALToma

For NUD, the NNT is 14 for symptom relief

Consider test and treat in persistent uninvestigated dyspepsia.

Do not offer eradication for GORD.

DU/GU relapse: retest for H. pylori using breath or stool test OR consider endoscopy for culture & susceptibility. NUD: Do not retest, offer PPI or H2RA

Do not use clarithromycin or metronidazole if used in the past year for any infection see BNF for treatment options

Omeprazole 20 mg BD or Lansoprazole 30 mg BD

PLUS

Clarithromycin 250 mg BD with Metronidazole 400mg BD

OR

Clarithromycin 500mg BD with Amoxicillin 1gram BD

7 days

Infectious

diarrhoea

CKS

Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection. Antibiotic therapy not indicated unless systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider Clarithromycin 250-500mg BD for 5-7 days if treated early (within 3 days) and send sample. Notify suspected cases of food poisoning to Health Protection Unit (Rivergate) 03003038162 (option 2)

Clostridium difficile

PHE

BNSSG Guidance

Stop unnecessary antibiotics and/or PPIs 70% respond to metronidazole in 5 days; 92% in 14 days If severe symptoms or signs (see below) should discuss treatment with microbiology, review progress closely and/or consider hospital referral.

Admit if severe: T >38.5oC, WCC >15x109/L, acutely rising creatinine or signs/symptoms of severe colitis

Antimotility agents should not be prescribed

1st episode non-severe:

Metronidazole

If failure to improve, 1st relapse or previous Metronidazole

Vancomycin

If recurrent or severe infection contact local microbiologist for advice

400 mg TDS

125mg qds

10-14 days

contact microbiology if no improvement in symptoms after 5 days treatment

Traveller’s diarrhoea

-standby

treatment

CKS NaTHNaC

Only consider standby antibiotics for remote areas or people at high-risk of severe illness if they contract travellers’ diarrhoea

If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private Rx). If quinolone resistance high (e.g. South Asia): consider antimotility agent bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment (Bismuth subsalicylate is not available on the NHS). Further information - The National Travel Health Network and Centre (NaTHNaC) http://www.nathnac.org/

Threadworm

CKS

Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower) PLUS wash sleepwear, bed linen, dust, and vacuum on day one

6 months or older:

Mebendazole (off label if <2yrs)

<6 months: 6 weeks of hygiene measures, including perianal wet wiping or

washes 3 hourly during the day

100 mg

Stat dose. If reinfection occurs second dose may be needed after two weeks

Diverticulitis

CKS

People with mild, uncomplicated diverticulitis can be managed at home with paracetamol, clear fluids, and oral antibiotics

See BNF for Co-trimoxazole dosing advice, avoid in blood disorders and discontinue immediately if blood disorders or rash develop

Co-amoxiclav

Penicillin allergic:

Co-trimoxazole

PLUS

Metronidazole

625mg TDS

960mg BD

400mg TDS

7 days

Ensure review at 48 hours

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 7 of 12

7

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Genital Tract Infections Contact UK Teratology Information Service www.uktis.org/ for information on foetal risks if patient is pregnant.

STI screening People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individuals and partners to GUM service.

Risk factors: < 25y, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner, areas of high HIV

Chlamydia trachomatis

SIGN, BASHH

PHE

CKS

Opportunistically screen all aged 15-25yrs

Treat partners &/or refer to GUM service if required.

Risk of testing positive 10-15% in next 3-6 months. Repeat Chlamydia test advised at 3 months.

Pregnancy or breastfeeding: azithromycin is the most effective option

Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment

Doxycyline

or Azithromycin

Pregnant or breastfeeding:

Azithromycin

or Erythromycin

100mg BD

1g

1g (off-label use)

500 mg QDS

7 days

stat

stat

7 days

Epididymo-orchitis

BASHH

STIs infection probable*

(purulent discharge, man who has sex with men, black ethnicity, contact gonorrhoea) add Ceftriaxone 500mg IM and refer to GUM

*remember to assess and treat partner(s) epidemiologically

Enteric organism suspected

Aetiology unclear

Traditional risk linked to age, with >35yrs indicating enteric micro-organism more likely. But >10-13% men aged 35-65 have at least on new sexual partner in the last year (NATSAL 2013)

Doxycyline

Ciprofloxacin

Ofloxacin

100mg BD

500mg BD

200mg BD

14 days

10 days

14 days

Vaginal candidiasis

BASHH

PHE, CKS

All topical and oral azoles give 75% cure

Pregnancy: avoid oral azoles, use intravaginal treatment for 7 days

Clotrimazole

or oral Fluconazole

Pregnant:

Clotrimazole

or Miconazole

500 mg PV pessary

150 mg orally

100 mg PV pessary at night

5g intravaginal 2% cream BD

Stat (nocte)

Stat (nocte)

6 nights

7 days

Bacterial

Vaginosis

BASHH

PHE, CKS

Oral metronidazole is as effective as topical

treatment but is cheaper.

Less relapse with 7 days than 2g stat at 4 wks

Pregnant/breastfeeding: avoid 2g stat

Metronidazole treatment of BV in pregnancy does not reduce premature delivery rates if BV+ past history of premature delivery use

Treating partners does not reduce relapse

oral Metronidazole

or oral Metronidazole

or Metronidazole 0.75% intravaginal gel

or Clindamycin 2% intravaginal cream

or Clindamycin

400 mg BD

2 g

5 g applicatorful at night

5 g applicatorful at night

300mg BD

7 days

stat

5 nights

7 nights

7 days

TrichomoniasisBASHH

PHE, CKS

Treat partners refer to GUM service.

In pregnancy or breastfeeding: avoid 2g single dose metronidazole.

Oral Metronidazole

or oral Metronidazole

400 mg BD

2 g

5-7 days

Stat

Pelvic

Inflammatory

Disease

BASHH, CKS

Refer woman and contacts to GUM service Always test for chlamydia and gonorrhoea using a NAAT AND culture for gonorrhoea. 36% of gonorrhoea isolates now resistant to quinolones. If gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM.

Metronidazole is included to improve coverage for anaerobic bacteria. Anaerobes are of relatively greater importance in patients with severe PID and if >25 yrs when chlamycia is detected less often.

Metronidazole PLUS

Ofloxacin

If high risk of gonorrhoea

Ceftriaxone PLUS

Metronidazole PLUS

Doxycycline

At risk of Pregnancy, pregnant or breastfeeding

Azithromycin

PLUS

Metrondiazole

Include ceftriaxone as above if high risk of gonorrhoea

400mg BD

400mg BD

500mg IM

400mg BD

100mg BD

1g then

500mg OD

400mg BD

14 days

14 days

Stat

14 days

14 days

Stat (day 1)

4 days (day2-5)

5 days

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 8 of 12

8

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Gonorrhoea

Neisseria

gonorrhoeae

BASHH

For the treatment of uncomplicated anogenital

infection in adults. Treated cases need a test of

cure at 2 weeks. All treatment failures must be

discussed with GUM and reported to Public

Health England. If unable to treat in primary care refer to GUM service for treatment. Refer to

GUM for contact tracing.

Intra-muscular: Reconstitute 1 g vial of

Ceftriaxone with 3.5 ml of 1% Lidocaine solution,

then half of the resulting solution to be given by

deep intra-muscular injection.

NB Cefixime is often inadequate to treat

pharyngeal gonorrhoea

Ceftriaxone

PLUS

Azithromycin

Only if intramuscular injection is contraindicated

or refused by the patient:

Cefixime

PLUS

Azithromycin

500 mg deep IM injection

1 g orally

400 mg orally

2 g orally

Stat

Stat

Refer to GUM for contact tracing

Stat

Stat

Genital

Herpes

BASHH

First episode: treatment indicated within 5 days

of the start of the episode, or while new lesions

are still forming, or if systemic symptoms persist.

Recurrent: first line – supportive therapy only

(saline bathing, Vaseline, analgesia and/or

lidocaine ointment); give standby prescription for

oral Rx, to be started at prodrome (if

recognisable)

For suppression therapy (>=6 recurrences/year) seek advice from GUM.

Aciclovir oral

or

Aciclovir oral

Aciclovir oral

Or

Aciclovir oral

200 mg five times each day

400 mg TDS

800mg TDS

400mg TDS

5 days

5 days

2 days

5 days

Anogenital

Warts

BASHH

The evidence base to advise on 1st and 2nd line

treatment is not strong.

If warts are fleshy and non-keratinised (apply cream/solution directly to warts. Cream may be

easier to apply and comes with a mirror).

If warts keratinised (advise patients to use Aldara

sparingly especially if sub-preputial warts as a

strong response (it is an immune modulator) may result in significant pain and ulceration. Patients

should read instructions carefully).

All treatments have significant failure and relapse

rates. Refer to GUM service for specialist

treatment if no response after 4 weeks

treatment.

Podophyllotoxin

Aldara

At risk of pregnancy or pregnant

Refer to GUM

Twice a day for 3 days then 4 days off

X3 a week

4 weeks

4 weeks

Skin Infections

Impetigo

CKS

For extensive, severe, or bullous impetigo, use

oral antibiotics. Avoid topical antibiotics or reserve for very localised lesions to reduce the

risk of resistance.

oral Flucloxacillin

If penicillin allergic:

oral Clarithromycin

MRSA only:

Doxycycline

Topical treatment:

Hydrogen peroxide 1% cream (Crystacide)

500 mg QDS

500 mg BD

100 mg BD

Apply 2-3 times a day

5 days

5 days

5 days

Up to 3 weeks

Eczema

CKS

If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing.

In eczema with visible signs of infection, use treatment as in impetigo

Moderate and Severe Acne

CKS

Oral antibiotics not recommended for mild acne. Benzoyl peroxide or a topical retinoid are recommended as adjunctive treatment in most cases. Review after two months antibiotics treatment. Severe acne may need specialist assessment and treatment.

Lymecycline oral

408 mg once daily Continued until no further improvement - usually for at least six months.

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 9 of 12

9

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Cellulitis

CKS

If patient afebrile and healthy other than cellulitis,

use oral flucloxacillin alone. If river or sea water exposure, discuss with microbiologist. If febrile and ill, initiate IV treatment. In uncomplicated cellulitis, 5 days of antibiotic treatment is as effective as a 10-day course (IDSA) but skin may look abnormal for weeks, in uncomplicated cellulitis if slow to resolve screen for MRSA.

Stop clindamycin if diarrhoea occurs.

Flucloxacillin

If penicillin allergic:

Clarithromycin

or Clindamycin

facial:

Co-amoxiclav

500 mg QDS

500 mg BD

300 mg QDS

625 mg TDS

5 days

Discuss with microbiology if considering a repeat course of antibiotics

Cellulitis in a

diabetic foot

CKS

If acute ulcer and no recent antibiotics

Flucloxacillin

Penicillin allergy:

Clarithromycin

If ulcer for more than 2 weeks or recent Flucloxacillin:

Co-amoxiclav

Penicillin allergy:

Clindamycin

500mg QDS

500mg BD

625mg TDS

300mg QDS

Upto 14 days

Leg ulcer

PHE

CKS

Ulcers are always colonised with bacteria. Antibiotics do not improve healing unless active infection . If active infection send pre-treatment swab. Signs of active infection include -Increased pain, enlarging ulcer, cellulitis, pyrexia, purulent exudate

Review antibiotics after culture results reported.

If active infection:

Flucloxacillin

or Clarithromycin

500 mg QDS

500 mg BD

5 days

Discuss with microbiology if

considering a repeat course of antibiotics

MRSA Skin

Colonisation

PHE

Due to the potential risk of MRSA transmission &

increased risks for certain patients, three attempts at decolonisation should be made for care home residents, persons with regular hospital admission and prior to elective surgery. If unsuccessful seek microbiology advice if decolonisation essential. Re‐swab 48 hours after each 5-day treatment to check success.

Mupirocin 2% nasal ointment

AND

For Adults:

Chlorhexidine gluconate 4% liquid

For children:

Octenidine 0.3% Lotion (Octenisan®)

Apply to inner surface of

each nostril BD

skin wash daily and scalp wash twice in 5 days

skin wash daily and scalp wash twice in 5 days

Five consecutive days, then wait 48 hours and re-swab

MRSA

Infection -

Metici llin-

res istant Staphylococcus

aureus

Use antibiotic sensitivities to guide treatment.

If severe infection or no response to monotherapy after 24-48 hours, seek advice from microbiologist

regarding combination therapy.

Patients being treated for MRSA infection should also receive topical eradication therapy (see colonisation)

If active infection, MRSA confirmed, infection not severe and admission not required

Confirmed active infection:

Doxycycline

OR according to sensitivities

Children:

Seek microbiology advice

100 mg BD

5 days

Wound

infections following surgery

If a patient is MRSA positive discuss with microbiology

See BNF for Co-trimoxazole dosing advice, avoid in blood disorders and discontinue immediately if blood disorders or rash develop

Following ‘clean surgery’

Flucloxacillin

Penicillin allergic:

Clarithromycin

Following ‘contaminated surgery likely to contain bowel flora’

Co-amoxiclav

Penicillin allergic:

Co-trimoxazole

PLUS

Metronidazole

500mg QDS

500mg BD

625mg TDS

960mg BD

400mg TDS

5 days

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 10 of 12

10

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Bites – Human or Animal CKS nathnac

Thorough irrigation is important. Assess risk of tetanus, HIV, hepatitis B&C. Antibiotic prophylaxis is advised. Assess risk of tetanus and rabies.

Give prophylaxis if cat bite or puncture; animal bites to hand or foot or face; wound involving joints or tendon or ligaments; and in those who are immunocompromised, diabetic, asplenic, cirrhotic, prosthetic valve or joint. Seek microbiology advice for other animals

Prophylaxis or treatment: Co-amoxiclav

Penicillin allergic: Metronidazole PLUS Doxycycline (cat/dog/human)

625 mg TDS 400 mg TDS 100 mg BD (not <12 years)

Prophylaxis 5 days Treatment 7 days review at 24 and 48 hours

Mastitis CKS

Consider antibiotics if symptoms have not improved or are worsening after 12–24 hours despite effective milk removal, or bacterial culture is positive, or woman has infected nipple fissure. Use of antibiotics should not prevent breast feeding if child allergy status does not contraindicate

Flucloxacillin If woman or child is penicillin allergic: Clarithromycin

500 mg QDS 500 mg BD

7 days 7 days

Scabies

CKS

Treat all home & sexual contacts within 24 hour period.

Treat whole body from ear/chin downwards and under nails. If under 2 or elderly also face and scalp.

Advise patients to reapply treatment to hands when/if washed during the treatment period.

Permethrin 5% cream

If allergic:

Malathion 0.5% aqueous liquid

Apply to whole body and wash off after 8–12 hours

Apply to whole body and wash off after 24 hours

Two applications

spaced one week apart

Headlice

CKS

Head lice can be mechanically removed by combing wet hair meticulously with a plastic detection comb (probably for at least 30 minutes) over the whole scalp at 4 day intervals for a minimum of 2 weeks, and continued until no lice are found on consecutive sessions; hair conditioner or vegetable oil can be used to facilitate the process

Dimeticone 4% lotion

(All affected individuals in a household should be treated at the same time)

Rub into dry hair and scalp, allow to dry naturally, shampoo after 8 hours (or overnight)

Two applications

spaced one week apart

Dermatophyte infection – skin

CKS body & groin

CKS foot

CKS scalp

Terbinafine is fungicidal, so treatment time shorter than with fungistatic imidazoles. If candida possible, use imidazole e.g.clotrimazole. If intractable: send skin scrapings. If infection confirmed, consider oral terbinafine or itraconazole see BNF for dosing.

Scalp: discuss with specialist

Terbinafine 1% cream

or Clotrimazole 1% cream

BD

BD

1-2 weeks

For 1-2 weeks

after healing

(i.e. 4-6 weeks)

Scarlet fever

PHE

CKS

Notifiable disease

Prescribe antibiotics without waiting for the culture results if scarlet fever is clinically suspected.

Penicillin V

Penicillin allergic:

Azithromycin

<1m: 12.5mg/kg QDS

1m-1yr: 62.5mg QDS

1-<6yrs: 125mg QDS

6-<12yrs: 250mg QDS

12-18yrs: 250-500mg QDS

Adults: 500mg QDS

6m-<12yrs: 12mg/kg (max 500mg) OD

12yrs and over: 500mg OD

10 days

5 days

Dermatophyte infection – nail

CKS

Take nail clippings: start therapy only if infection confirmed by laboratory.

Terbinafine is more effective than azoles.

Liver reactions rare with oral antifungals.

If candida or non-dermatophyte infection confirmed, consider oral itraconazole see BNF for dosing.

For children, seek specialist advice.

Superficial only:

Amorolfine 5% nail lacquer

First-line: Terbinafine

Second-line: Itraconazole pulsed therapy

1-2 times per week - fingers

- toes

250 mg OD - fingers

- toes

200 mg BD as 7 day course

- fingers

- toes

6 months

9-12 months

6 – 12 weeks

3 – 6 months

7 days every month

2 courses

3 courses

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 11 of 12

11

ILLNESS COMMENTS MEDICINE ADULT DOSE

Children BNF link =

DURATION OF

TREATMENT

Varicella zoster /chicken pox

CKS

Herpes zoster/ shingles

CKS

Pregnant/immunocompromised/neonate: seek urgent specialist advice

Chicken pox: Treat adults and adolescents >14 years old if onset of rash <24 hours

Shingles: Offer anti-viral if >50 years & within 72 hours of rash or if active ophthalmic or Ramsey Hunt or eczema.

Ophthalmic zoster: Refer to ophthalmology

for consideration for IV aciclovir therapy.

If indicated:

Aciclovir

800 mg five times a day

7 days

In cases of treatment failure seek Virologist advice to guide further treatment

Cold sores Cold sores resolve after 7–10 days without treatment. Topical antivirals applied in prodromal period reduce duration by 12 -24 hours

Eye Infections

Conjunctivitis

CKS

Only treat if severe, as most viral or self-limiting.

Bacterial conjunctivitis is usually unilateral and self-

limiting; it is characterised by red eye with mucopurulent, not watery, discharge.

65% resolve on placebo by day five.

Fusidic acid has less Gram-negative activity.

First-line if treatment required:

Chloramphenicol 0.5% drops

PLUS

Chloramphenicol 1% ointment

Second-line:

Fusidic acid 1% MR gel

2 hourly for 2 days, then

4 hourly (whilst awake)

Applied at bedtime

Apply BD

All for 48 hours after resolution

Ophthalmic zoster

Ophthalmic zoster: Refer to ophthalmology

for consideration for IV aciclovir therapy.

Antimicrobial Prescribing Guidelines for BNSSG Health Community 2015

Note: Doses are oral and for adults (unless stated). Please refer to BNF or BNF for children (BNFc) for further information Version 3.0

Updated Oct 2015 by Medicines Management, North Somerset CCG, based on PHE Management of Infections Guidance Review due: Oct 2017 Page 12 of 12

12

Changes to the Antimicrobial Prescribing Guideline 2015

Section Guideline Change

Upper respiratory tract infections

Influenza treatment Recommendations updated in line with PHE advise

Acute otitis media Dose of amoxicillin changed

Acute rhinosinusitis Penicillin allergy option changed and penicillin allergy option for persistent symptoms added

Lower respiratory tract infections

Acute cough / bronchitis Advice on using CRP added

Acute exacerbation of COPD Course length changed to 5-7 days Acute exacerbation of bronchiectasis

P. aeruginosa colonisation removed

Meningitis Prevention of secondary cases Health protection unit contact number updated Urinary tract infections

UTI in adults Recommendations changed. Introduction of Pivmecillinam

UTI in children Second line upper UTI changed to Cefalexin

UTI in pregnancy 3rd line Co-amoxiclav removed Acute pyelonephritis Added if lab results sensitive – Trimethoprim

Recurrent UTI Wording changed – nightly prophylaxis not generally recommended

UTI in catheterised patients Split into pyelonephritis and lower UTI

Catheter changes Advice added Gastro-intestinal tract infections

Oral candidiasis Advice if patient immunocompromised added

Traveller’s diarrhoea Rifaxamin removed as per PHE Diverticulitis New guideline added

Clostridium difficile Second line Vancomycin added

Genital Tract Infections

Epididymo-orchitis New guideline added Vaginal candidiasis Clotrimazole cream removed

Bacterial vaginosis Oral clindamycin option added Trichomoniasis Clotrimazole pessary option added

Pelvic inflammatory disease New guideline added Gonorrhoea Dose of Cefixime and Azithromycin changed

Anogenital warts Treatment options added

Skin infections PVL Removed Impetigo Penicillin allergic option changed to

Clarithromycin

Cellulitis in a diabetic foot New guideline added Wound infections following surgery

New guideline added

Bites Guidelines rationalised. Different course lengths for treatment and prophylaxis

Scarlet fever New guideline added

Chicken pox Advice on who to treat simplified