RECOMMENDATION FOR THE USE OF ANTIBIOTICS FOR THE TREATMENT OF INFECTION

Aims

to provide a simple, best guess approach to the treatment of common infections, based on known sensitivity and resistance patterns in Cumbria to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance in the community

Principles of Treatment 1. This guidance is based on the best available evidence but its application must be modified by professional judgement in the light of co-existing diseases and other drug therapy. 2. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 3. Limit prescribing over the telephone to exceptional cases. 4. Use simple generic antibiotics first whenever possible. 5. The use of new and more expensive antibiotics (e.g., quinolones and cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective. Antibiotics are listed in order of preference. 6. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations). 7. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole. Short-term use of trimethoprim (theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus. 8. Doses quoted are intended for otherwise fit adults. Doses may need to be changed in children and those with renal impairment. The duration of therapy will vary by individual patient, disease severity and speed of resolution. 9. Where a best guess therapy has failed or special circumstances exist, microbiological advice can be obtained from the Consultant Microbiologists at: West Cumberland Hospital 01946 693181 Cumberland Infirmary 01228 814641 Furness General Hospital 01229 491022 This guidance has been produced in consultation with the consultant microbiologists and the Cumbria Medicines Management team. Published: December 2012, Review date: November 2014 Condition UPPER RESPIRATORY TRACT/ENT Delayed prescriptions are a useful strategy as most upper respiratory tract infections are viral, self-limiting and improve without antibiotics. Regular use of analgesics such as paracetamol and ibuprofen should be encouraged. Influenza Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not recommended. Treat at risk patients, ONLY within 48 hours of onset and when influenza is circulating in the community or in a care home where influenza is likely. At risk: pregnant 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 AVOID ANTIBIOTICS as 90% resolve in 7 days without and pain only reduced by 16 hours. If Centor score 3 to 4: lymphadenopathy history of fever tonsillar exudate no cough consider 2 or 3-day delayed antibiotics or immediate antibiotics. Antibiotics to prevent quinsy, NNT >4000 Antibiotics to prevent otitis media, NNT 200 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 OSELTAMIVIR 75mg BD or, if there is resistance to oseltamivir ZANAMIVIR 10mg BD (2 inhalations by diskhaler) For prophylaxis, see NICE. (NICE Influenza). Patients under 13 years see HPA Influenza link. 5 Comments Drug and dose (listed in order of preference) Duration (days)

Tonsillitis/pharyngitis/sore throat

ANTIBIOTIC TREATMENT NOT ROUTINELY RECOMMENDED If antibiotic is required, PHENOXYMETHYLPENICILLIN 500mg QDS (severe), or CLARITHROMYCIN 250-500mg BD 10 5

Acute rhinosinusitis

ANTIBIOTIC TREATMENT NOT ROUTINELY RECOMMENDED If antibiotic is required, AMOXICILLIN 500mg TDS, or DOXYCYCLINE 200mg stat, then 100mg daily, or CLARITHROMYCIN 250mg BD 2nd line CO-AMOXICLAV 625mg TDS 5 5 5 5

Condition Otitis externa (acute)

Comments First use aural toilet and analgesia. Cure rates similar for topical acetic acid or antibiotic steroid Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness. Use paracetamol or NSAID. Otitis media resolves in 60% of patients in 24 hours without antibiotics. Antibiotics reduce pain at 2 days (NNT 15) Consider antibiotics (2 to 3 days) if: <2 years AND bilateral otitis media (NNT 4) or marked otoscopic signs and 3 symptoms All ages with otorrhea (NNT 3) Immediate prescribing may be appropriate for the following groups: otorrhoea <2 years with bilateral acute otitis media Haemophilus is an extracellular pathogen so macrolides (e.g., erythromycin), which concentrate intracellularly, are less effective therapy.

Otitis media (acute) child doses

Drug and dose (listed in order of preference) ACETIC ACID spray (EarCalm) 1 spray TDS, or PREDNISOLONE + NEOMYCIN ear drops 3 drops TDS ANTIBIOTIC TREATMENT NOT ROUTINELY RECOMMENDED If antibiotic is required, AMOXICILLIN 40-90mg/kg/day in 3 divided doses up to 1 gram TDS, or CLARITHROMYCIN <8kg - 7.5mg/kg BD 8-11kg 62.5mg BD 12-19kg 125mg BD 20-29kg 187.5mg BD 30-40kg 250mg BD 2nd line - CO-AMOXICLAV 1-6yrs - 156mg TDS 6-12yrs - 312mg TDS

Duration (days) 5

5 5

LOWER RESPIRATORY TRACT Lower respiratory tract infection (including acute bronchitis) in otherwise healthy individuals

Exacerbations of COPD

Community acquired pneumonia

Antibiotics are not routinely indicated. Consider prescribing an antibiotic if the person has a significantly impaired ability to fight infection (e.g., immunocompromised status, cancer, or physical frailty) or if acute bronchitis is likely to significantly worsen a pre-existing condition (e.g. heart failure, angina, or diabetes). Alternative antibiotics may be used on the basis of sputum results. 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 Assess the person's need for admission by determining CRB65 score: Confusion (AMT<8) Respiratory rate > 30/minute Age >65 years BP systolic <90 or diastolic 60 Score 0, suitable for home treatment Score 1-2, hospital assessment or admission Score 3-4, urgent hospital admission Give immediate Benzylpenicillin 1.2 grams IM or Amoxicillin 1 gram oral if delayed admission or life-threatening Antibiotics should be given for exacerbations that present with an acute deterioration with worsening symptoms (cough, increased sputum volume or change in viscosity, increased sputum purulence with or without increasing wheeze, breathlessness, haemoptysis) and/or systemic upset. Sputum samples should be taken to guide therapy. Need long course of 10 to 14 days.

ANTIBIOTIC TREATMENT NOT ROUTINELY RECOMMENDED If antibiotics are required, AMOXICILLIN 500mg TDS, or DOXYCYCLINE 200mg stat, then 100mg daily AMOXICILLIN 500mg TDS, or DOXYCYCLINE 200mg stat, then 100mg daily, or CLARITHROMYCIN 500mg BD 5 5

5 5 5

If CRB65=0 AMOXICILLIN 500mg TDS, or DOXYCYCLINE 200mg stat, then 100mg daily, or CLARITHROMYCIN 500mg BD If CRB65=1 & AT HOME AMOXICILLIN 500mg TDS AND CLARITHROMYCIN 500mg BD, or DOXYCYCLINE 200mg stat, then 100mg daily

5 5 5 5-7 5-7

Bronchiectasis

Antibiotic choice should be based on previous culture results. Consider need for anti-pseudomonal cover if not responding, or Pseudomonas growth from the sputum. If culture negative send sample for Aspergillus

14

EYES Bacterial conjunctivitis

Treat if severe, as most are viral or self-limiting. Bacterial conjunctivitis is unilateral and also selflimiting. It is characterised by red eye with mucopurulent, not watery discharge. 65% resolve on placebo by day 5. STD: unilateral inclusion conjunctivitis usually with urethritis (causative agent: C. trachomatis).

CHLORAMPHENICOL eye drops 1 drop every 2 hours for 2 days, then 4 hourly (whilst awake) for up to 1 week; eye ointment at night If pregnant or history of blood dyscrasia use FUSIDIC ACID BD Chlamydial: DOXYCYCLINE 100mg BD, or AZITHROMYCIN 1 gram stat (treat the sex partner as well) Commence ACICLOVIR eye ointment, applied 5 times a day

7 7

Ocular Herpes simplex infection

Urgent ophthalmic referral necessary. In recurrent infection treatment may be initiated but this must be done in consultation with ophthalmologist. Avoid topical steroids and remove contacts lenses.

21

Condition Corneal abrasions ORAL Mucosal ulceration and inflammation

Comments If corneal ulcer - Urgent ophthalmic referral is necessary. Temporary pain and swelling relief can be attained with saline mouthwash(tsp in glass of warm water)

Drug and dose (listed in order of preference) CHLORAMPHENICOL eye ointment BD CHLORHEXIDINE 0.2% mouthwash, rinse mouth for 1 minute BD with 5ml diluted with equal volume of water, or HYDROGEN PEROXIDE 6%, 15mls in glass of warm water TDS AMOXICILLIN 500mg TDS, or PHENOXYMETHYLPENICILLIN 500mg-1 gram QDS If penicillin allergic, or in severe infection METRONIDAZOLE 200mg TDS NYSTATIN 100,000 units QDS, or MICONAZOLE gel, 5mL QDS
(miconazole interacts with statins and anticoagulants)

Duration (days) 5

Until lesion resolves of less pain allows oral hygiene 5 5

Dental abscess

Advise urgent dental consultation, as repeated courses of antibiotics for abscess are not appropriate. Antibiotics are only recommended if there are: signs of severe infection systemic symptoms high risk of complications Otherwise, regular analgesia should be first option until a dentist can be seen.

5 7 7

Oral thrush

Acute necrotising ulcerative gingivitis Pericoronitis

Refer to dentist for scaling and oral hygiene advice, after starting antibiotic Refer to dentist for irrigation and debridement. If persistent swelling or systemic symptoms, use metronidazole GASTRO-INTESTINAL INFECTIONS H.pylori infection Tetracycline 500mg four times a day may be used instead of amoxicillin in penicillin-allergic patients. Resistance to clarithromycin or to metronidazole is much more common than to amoxicillin and can develop during treatment. Do not use clarithromycin or metronidazole if used for any infection in the past year. Giardiasis Recurrence is high even with optimal treatment, therefore follow-up with a stool sample is advised. Threadworms 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. Antibiotics not usually indicated. Discuss any intended treatment with microbiologist. Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 500mg single dose, unlicensed indication) to people travelling to remote areas in whom an episode of infective diarrhoea could be dangerous. Stop unnecessary antibiotics and/or PPIs. 70% respond to metronidazole in 5 days, 92% in 14 days. Admit if severe: Temperature >38.5C WCC >15 Rising creatinine Signs/symptoms of severe colitis

If immunosuppressed, consider fluconazole 50-100mg OD for 7 to 14 days METRONIDAZOLE 200mg TDS METRONIDAZOLE 200mg TDS

3 3

Triple-therapy: LANSOPRAZOLE 30mg BD plus AMOXICILLIN 1 gram BD plus either CLARITHROMYCIN 500mg BD, or METRONIDAZOLE 400mg BD METRONIDAZOLE 200mg TDS for 7 days is the most tolerable and effective doses; 400mg TDS for 5 days or 2 grams daily for 3 days MEBENDAZOLE 100mg (mebendazole is not licensed for children under 2 years, use piperazine instead) Antibiotic treatment not routinely recommended Fluid replacement essential

3-7 depending on the doses One dose repeat in two weeks

Acute gastroenteritis Travellers diarrhoea

C.difficile infection

METRONIDAZOLE 400mg TDS for 1st and 2nd episodes VANCOMYCIN 125mg QDS for 3rd episode/severe or type 027

10-14 10-14

URINARY TRACT Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic bacteriuria: it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely. Co-amoxiclav is alternative in patients with low GFR. Nitrofurantoin should not be used if GFR is <60mL/min/1.73m2 or trimethoprim if GFR is <15mL/min/1.73m2. Cystitis in women Routine urine culture unnecessary for simple cystitis in TRIMETHOPRIM 200mg BD, or 3 adult women. NITROFURANTOIN MR 100mg BD 3 (Note that trimethoprim may cause a rise in Further diagnosis should be made on basis of serum creatinine especially in pre-existing symptoms and dipstick analysis (see HPA guidance). Co-amoxiclav is alternative in patients with low GFR (see above) TRIMETHOPRIM 200mg BD, or NITROFURANTOIN MR 100mg BD Co-amoxiclav is alternative in patients with low GFR (see above)
renal impairment due to competition for renal excretion)

UTI in men

7 7

Condition UTI or confirmed asymptomatic bacteriuria in pregnant women

Comments Screening requires a urine sample to be sent to microbiology for microscopy and culture, dip stick testing alone is not adequate

UTI in children

Pyelonephritis Epididymo-orchitis

< 3 months, immediate paediatric referral > 3 months with acute pyelonephritis/upper UTI, consider referral to paediatric specialist, treat with antibiotics > 3 months with cystitis/lower UTI, treat. If still unwell after 24 to 48 hours, child should be reassessed Culture required. Screen for chlamydia.

Drug and dose (listed in order of preference) AMOXICILLIN 500mg TDS, or NITROFURANTOIN MR 100mg BD, or CEFALEXIN 500mg TDS for 7 days, or TRIMETHOPRIM 200mg BD for 7 days (unless folate deficient or taking folate antagonist [e.g. antiepileptic or proguanil]) TRIMETHOPRIM 4mg/kg BD (max 200mg), or CEFALEXIN 1 month-1 year - 125mg BD 1 5 years - 125mg TDS 5 - 12years - 250mg TDS CO-AMOXICLAV 625mg TDS, or CIPROFLOXACIN 500mg BD DOXYCYCLINE 100mg BD Add IM CEFTRIAXONE 500mg stat if there likelihood of sexually transmitted pathogen

Duration (days) 7 7 7 7

3 (lower) 7-10 if upper UTI

7-10 10-14

GENITAL SYSTEM Vaginal candidiasis

Clotrimazole and fluconazole are available over-thecounter. 7 day course recommended during pregnancy. Fluconazole is contra-indicated in pregnancy. Usually associated with anaerobes, recurrence is frequent, but is not a sexually transmissible infection (STI). Do not retest if symptoms resolve. In pregnancy 7 days of clindamycin gel recommended. In pregnancy testing should be repeated after 1 month to ensure cure achieved. Advise sexual abstinence until the infected woman and her partner(s) have both completed the course of treatment. If treatment with single-dose azithromycin is given, then sexual abstinence for the following 7 days is advised.
(Azithromycin has been used for 20 years, during which time a number of studies have shown that there is no increased risk of adverse effects associated with using the drug during pregnancy. It is significantly more effective and better tolerated than the alternative agents (erythromycin and amoxicillin), but its use is more limited).

CLOTRIMAZOLE pessaries 500mg, or 200mg FLUCONAZOLE 150mg METRONIDAZOLE 400mg BD, or 2 grams stat, or METRONIDAZOLE vaginal gel, 0.75% daily apply at night CLINDAMYCIN vaginal gel, 2% daily apply at night DOXYCYCLINE 100mg BD, or AZITHROMYCIN 1 gram (not licensed for use in pregnancy, see comments)

1 3 Stat dose 7 5 7 7 stat

Bacterial vaginosis

Chlamydia

Trichomoniasis Gonorrhoea - uncomplicated Pelvic inflammatory disease

Pregnant woman must be retested after 5 weeks after completing therapy (6 weeks if azithromycin used). Refer to GUM clinic for contact tracing. Refer to GUM may be associated with other STDs. Increasing resistance Refer to GUM clinic for contact tracing and screening for other sexually transmitted diseases. Refer to GUM. Tests essential for gonococcus and chlamydia.

METRONIDAZOLE 400mg BD CEFTRIAXONE IM 500mg stat and AZITHROMYCIN 1 gram stat CEFTRIAXONE IM 500mg stat followed by DOXYCYCLINE 100mg BD and METRONIDAZOLE 400mg BD or OFLOXACIN 400mg BD and METRONIDAZOLE 400mg BD CIPROFLOXACIN 500mg BD, or TRIMETHOPRIM 200mg BD ACICLOVIR 200mg five times a day Antibiotics not indicated for uncomplicated disease PODOPHYLLOTOXIN applied twice daily for three consecutive days, repeated at weekly intervals if necessary for a total of 4 to 5 courses Liquid nitrogen if small number of low volume warts or keratinized FLUCLOXACILLIN 500mg QDS, or CLARITHROMYCIN 500mg BD

7 stat 14

14 14 14 5

Acute prostatitis Genital herpes Bartholins gland infection Genital warts

Send MSU for culture and start antibiotics. 2 week course may prevent chronic prostatitis. Screening for low risk patients may be done in practice. Higher risk should be referred to GUM. May be associated with STD consider screening. Screening for co-existent STD indicated. Podophyllotoxin is contra-indicated in pregnancy.

WOUND AND SKIN INFECTION Cellulitis If afebrile and well other than cellulitis oral therapy is - limb adequate. If febrile and unwell admit or arrange for IV antibiotics (flucloxacillin or clarithromycin, as approved under PCT Cellulitis pathway). If river or seawater exposure discuss with microbiologist. Early referral necessary if not responding to treatment.

5 5

- facial

CO-AMOXICLAV 625mg TDS

Condition Surgical wounds, abscesses, mastitis, wound infection

Comments Abscesses should be drained. If wound could be contaminated with soil, faeces or bodily fluids or if infection area has poor vascular supply.

Drug and dose (listed in order of preference) FLUCLOXACILLIN 500mg QDS, or CLARITHROMYCIN 500mg BD CO-AMOXICLAV 625mg TDS, or CLARITHROMYCIN 500mg BD and METRONIDAZOLE 400mg TDS, or CLINDAMYCIN 300mg QDS

Duration (days) 5 5 5 5 5

Leg ulcers and pressure sores Herpes zoster Animal and human bites

Tick bite

Bacteria will always be present. Antibiotics do not improve healing, unless active infection. Culture swabs and antibiotics are only indicated if diabetic or there is evidence of clinical infection such as inflammation/redness/cellulitis, increased pain, purulent exudate, rapid deterioration of ulcer or pyrexia. ACICLOVIR 800mg five times a day, 5 started within 72 hours of onset of rash Human bites should generally be treated with CO-AMOXICLAV 625mg TDS 5 antibiotics if the skin is broken, and consideration given to tetanus, hepatitis B and HIV prophylaxis. If 2nd line the skin is broken following an animal bite, consider Cat, dog and human bites 5 antibiotics if puncture wound, bite to hand, foot, face, DOXYCYCLINE 100mg BD and joint, tendon, ligament or immunocompromised, METRONIDAZOLE 400mg TDS diabetic, asplenic or cirrhotic. Cat bites carry a high Human bites - CLARITHROMYCIN 5 risk of infection and should be treated. 250-500mg BD and Consider tetanus, and, if the bite occurred abroad, METRONIDAZOLE 400mg TDS rabies. Lyme disease prophylaxis is indicated if tick is likely to DOXYCYCLINE 200mg single dose have been attached for >24 hours, or it is obviously engorged. Prophylaxis not indicated if the bite occurred more than 72 hours ago, or if the patient is continually exposed to ticks. Treatment of localised erythema migrans: Treatment of later stages of Lyme disease - discuss with Microbiologist. DOXYCYCLINE 100mg BD, or AMOXICILLIN 500mg TDS; children <8 years Amoxicillin 50mg/kg/day in divided doses for 2 weeks or Erythromycin FLUCLOXACILLIN 500mg QDS, or CLARITHROMYCIN 250mg to 500mg BD FUSIDIC ACID, topical TDS MUPIROCIN, topical TDS TERBINAFINE 250mg daily; fingernails, toenails, ITRACONAZOLE 200mg BD fingernails, (2 courses) toenails, (3 courses) TERBINAFINE cream twice a day CLOTRIMAZOLE cream BD/TDS, 14

Impetigo

For extensive, severe or bullous impetigo, use oral antibiotics Reserve topical antibiotics for very localised lesions to reduce the risk of resistance. Reserve mupirocin (local) for MRSA infections. Take nail clippings. Treatment must only be commenced after mycological confirmation of infection. Topical amorolfine should only be used where infection is confined to the distal edge of the nail in the very early stages of distal and lateral subungual onychomycosis or in superficial white onychomycosis.

5 5 5 5 6 to 12 weeks; 3 to 6 months 7 days monthly

Fungal nail infections

Fungal skin infections - dermatophyte (ringworm) - candida

Terbinafine not licensed in children but listed in BNFc. Clotrimazole is an alternative.

10-14 Continue 12 weeks after affected area has healed

Varicella zoster/chickenpox

Pregnant/immunocompromised/neonate, seek urgent specialist advice Chicken pox: If started < 24 hours of rash and > 14 years or severe pain or dense/oral rash or 2 household case or smoker Shingles: treat if > 50 years and within 72 hours of rash or if active ophthalmic or Ramsey Hunt or eczema. Urgent hospital transfer is primary consideration. Only contra-indication to benzylpenicillin if true penicillin anaphylaxis; use of alternate antibiotics is not recommended.

ACICLOVIR 800mg five times day

CENTRAL NERVOUS SYSTEM Meningitis

BENZYLPENICILLIN, preferably IV, but IM if access difficult Over 10 years, 1.2 grams 1 to 9 years, 600mg Under 1 year, 300mg

stat