1st choice - Flucloxacillin 1g QDS 5 days

2nd choice - Clindamycin 450mg QDS for 5 days

• Arrange x-ray to rule out osteomyelitis
• Collect and send any bone fragments to microbiology for culture and sensitivity
• Whilst results of x-ray awaited, treat any signs or symptoms of soft tissue infection using the Tameside local office guidelines guidelines. If the infection does not respond to treatment liaise with microbiology.
• Refer patient to High Risk Foot Team for assessment and treatment plan advice (email: integrated.diabetes@tgh.nhs.uk)

If radiology report diagnoses osteomyelitis:

Liaise with microbiology around individualised treatment plan for patient.

Dr H Sacho 0161 922 4086 or contact via hospital switchboard (0161 922 6000)

Dr P F Unsworth 0161 922 6500 or contact via hospital switchboard

Monitor patient’s wound at least weekly until healing achieved/ conservative plan set

Please Note:

Patient may need MRI to affected area if complex case/lack of clarity

Flucloxacillin 1g QDS

Penicillin allergy

Clindamycin 450mg QDS

Typical treatment duration:

4 weeks for septic arthritis and 6 weeks for osteomyelitis

Phenoxymethylpenicillin 500mg QDS or 1g BD (QDS) when severe for 5 days. (10 days for scarlet fever).

Penicillin allergy

Clarithromycin 500mg BD for 5 days. (10 days for scarlet fever).

First line treatment should be with:

Eardrops containing an anaesthetic and an analgesic

Phenazone 40 mg/g with lidocaine 10 mg/g (Otigo)

Apply 4 drops two or three times a day for up to 7 days. Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea

Treatment for adults (for children see BNF for doses)

Amoxicillin 500mg TDS for 5 days or 1g TDS for 3 days

Penicillin allergy

Clarithromycin 500mg BD for 5 days

Treatment for adults (for children see CBNF for doses)

Amoxicillin 500 mg TDS for 5 days (1g if severe)

Penicillin allergy

Doxycycline 200 mg STAT then 100 mg OD for 5 days in total.

Doxycycline must NOT be prescribed for children under 12 years, or for pregnant or breast-feeding women.

If failure to respond to the above first line antibiotics use

Co-amoxiclav 625 mg TDS for 5 days

Penicillin allergy

Clarithromcyin 500 mg BD for 5 days

Cefalexin 1g TDS for 10 days.

Penicillin allergy

Ciprofloxacin 500mg BD for 7 days.

1st line: Co-trimoxazole 960mg BD for 14 days.

2nd line: Ciprofloxacin 500mg BD for 14 days.

3rd line: Doxycycline 100mg BD for 14 days.

In sexually active young men consider a diagnosis of Chlamydia trachomatis or gonorrhoea. Refer all men for investigation by a specialist after recovery to exclude a structural cause.

This is not routinely required for every patient. However, for those patients that are truly symptomatic of a UTI and require a catheter change (rather than just removal) and there is concern regarding introduction of bacteria during the change (due to previous medical history or traumatic catheter change), then antibiotics can be given to reduce the incidence of bacteraemia.

Any antibiotic therapy for these patients should be based on previous known urine sensitivities and ideally a specimen be sent for urinalysis BEFORE any antibiotic therapy is started for resolution of the UTI.

Urine specimens should ALWAYS be taken from the sampling port and NOT the catheter bag. Refer to the Trust Urinary catheterisation and catheter care management adults policy for guidance on best practice.

Urinary catheterisation prophylaxis for those patients with urethritis, where Staph aureus has been isolated, and require a catheter change.

For further advice on individual patients contact Urology Specialist Nurses 0161 922 6696, Infection Prevention Nurses on 0161 922 6194 or the Consultant Microbiologist on 0161 922 4086 / 6500.

Antibiotic treatment:

If behavioural and personal hygiene measures do not reduce incidence of UTI, antibiotic treatment may be considered from one of the following recommendations below:

• Each episode of UTI may be treated by a healthcare professional as it occurs.
• Patient/carer initiated antibiotic treatment is a cost-effective and safer alternative (in terms of avoiding the development of CDI and antibiotic resistance) compared to continuous antibiotic prophylaxis. This entails self-administration of single high-dose antibiotic treatment; however, if symptoms persist, treatment could continue for up to 3 days, but often 1 or 2 days are sufficient. This should be considered in patients who are compos mentis and are capable of recognising the symptoms of UTI. The patient should be counselled on how and when to self-treat. Antibiotics should be reviewed every 6 months.
• Antibiotic prophylaxis with either trimethoprim 100mg or nitrofurantoin 50mg nocte (provided there is sensitivity to these antibiotics) may be considered where it may be impractical for patients or carers to initiate antibiotics appropriately however antibiotics must be reviewed at least every 6 months. The patient should be counselled on adverse effects and the risk of antibiotic resistance developing.
• If related to sexual intercourse consider a single dose of antibiotic post coital (off-label use). Trimethoprim 200mg or nitrofurantoin 100mg stat may be given after taking into account sensitivity results. Antibiotics should be reviewed every 6 months.

For patients who develop and continue to have symptoms of UTI whilst taking antibiotic prophylaxis or treating a UTI, they should be advised to seek medical help.

Nitrofurantoin 100mg MR BD for 3 days (nitrofurantoin 50mg QDS may be an alternative if supply issues with MR preparations).

Nitrofurantoin is contraindicated in patients with an eGFR of ≤45ml/min; however it maybe used with caution in patients with eGFR 30-44ml/min provided the duration of treatment does not exceed 7 days

OR

Pivmecillinam 400mg STAT then 200mg TDS for 3 days (this is a penicillin)

If the above two options are not suitable for patients then please use MSU results to guide treatment or discuss with Microbiologist on 0161 922 4086/6500 or mobile via switch 0161 922 6000

If a patient is penicillin allergic (anaphylaxis) and has poor renal function whereby other antibiotic options can't be used then Fosfomycin (prescribe as Monuril) 3g STAT once only can be given.

We have high levels of resistance (50%) to co-amoxiclav of E coli. Pivecillinam has shown to be effective against E coli and is also a recommended choice in the PHE guidelines. The resistance to this drug is low in our local population at 16%. Cephalosporins have high sensitivity rates in Tameside.

Extended - spectrum Beta-lactamase enzymes (ESBLs) in gram-negative bacilli such as E. coli are increasing, and these ESBL-producing E. coli are multi-resistant but remain sensitive to nitrofurantoin. Consider a diagnosis of Chlamydia trachomatis in sexually active young women (in which case urine or endocervical specimens should be submitted for Chlamydia PCR assay).

Trimethoprim dosed as in cBNF for 3 days

An alternative antibiotic should be used if the child is already on trimethoprim prophylaxis (in which case the trimethoprim should be stopped), has had it in the last 3months, or has had previous infections resistant to it e.g.

Cefalexin dosed as in cBNF for 3 days

Penicillin allergy

Nitrofurantoin dosed as in c BNF for 3 days

For children who are 3 months or older and have cystitis or lower UTI NICE guidance CG54 suggests 3 days treatment for lower UTI. However if the child is still unwell after 24 - 48 hours, therapy needs reviewing and if there is no alternative diagnosis, send urine for culture.

For children who are under 3 months or children with upper UTI/pyelonephritis refer immediately to a paediatric specialist.

Infants and children with recurrent UTIs should be referred for assessment by a paediatric specialist.

1st choice: Pivmecillinam 400mg STAT for the first dose followed by 200mg TDS thereafter for 7 days.

2nd choice: Nitrofurantoin 100mg MR BD for 7 days (nitrofurantoin 50mg QDS may be an alternative if supply issues with MR preparations)

Nitrofurantoin is contraindicated in patients with an eGFR of ≤45ml/min however it may be used with caution in patients with eGFR 30-44ml/min provided the duration of treatment does not exceed 7 days.

ORAL TREATMENT:

1st line: Nitrofurantoin 100mg MR BD - AVOID AT TERM (from 37 weeks).

2nd line: Pivmecillinam 400mg STAT then 200mg TDS (this is a penicillin-containing antibiotic)

3rd line: Cefalexin 500mg TDS - avoid if penicillin allergy anaphylaxis.

Treatment duration is a total of 7 days.

Cefalexin has been chosen as first line choice as we have high levels of E coli sensitive to this antibiotic in our local population and it also concentrates well in the urine. It is of utmost importance that UTI in pregnancy is treated promptly and effectively. We can be confident that this is the case if cephalexin is used in this population.

Short term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus. Nitrofurantoin i s contraindicated in patients with an eGFR of ≤45ml/min however it may be used with caution in patients with eGFR 30-44ml/min provided the duration of treatment does not exceed 7 days.

Do not routinely offer antibiotics if there are no signs or symptoms of spreading cellulitis.

Be aware that people may wish to consider oral antihistamines (in those over 1 year old) to help relieve itching.

If signs and symptoms of infection treat as cellulitis

Co-amoxiclav 625 mg TDS for 5 days

Penicillin allergy

Doxycycline 200mg po for the first dose then 100mg po bd for 5 days

Animal and human bites to the hand including clenched fist injuries ('fight-bite') are at greater risk for development of complications associated with infection particularly septic arthritis, osteomyelitis and tendon sheath infection.

These patients would require hospital admission for intravenous antibiotic treatment as well as orthopaedic review with assessment of surgical intervention including joint washout and tissue debridement.

Flucloxacillin 1g QDS for 5 days

Penicillin allergy

Clindamycin 450mg QDS for 5 days

Co-amoxiclav 625 mg TDS for 10 days.

Penicillin allergy

Clindamycin 450mg po QDS for 10 days.

If the patient is febrile and acutely ill, refer to hospital for IV treatment.

Presence of at least 2 of the following:

local swelling, erythema, local tenderness or pain, local warmth, purulent discharge.

Local infection involving only skin and subcutaneous tissue. If erythema, must be <2cm around ulcer

Flucloxacillin 1g QDS for a maximum of 5 days (review after 3 days)

Penicillin allergy

Clarithromycin 500mg BD for a maximum of 5 days (review after 3 days)

as above plus erythema > 2cm but <5cm, or involving structures deeper than skin and subcutaneous tissues.

Co-amoxiclav 625mg TDS for a maximum of 5 days (review after 3 days)

Spreading cellulitis (> 5cm from the wound), ascending lymphangitis, deep tissue abscess formation with or without systemic inflammatory response syndrome

arrange admittance into hospital for IV antibiotics

Note: Systemic infection may sometimes manifest with sepsis syndrome including fever, vomiting, hypotension, deranged blood glucose levels and confusion. It is important to note that patients with ischaemia and neuropathy may not mount an appropriate inflammatory response, but nevertheless be extremely ill.

National Institute of Health and Care Excellence (NICE), (2015). Diabetic foot problems: prevention and management, NICE guideline 19. http://www.nice.org.uk/guidance/ng19/chapter/1-Recommendations#diabetic-foot-infection-2

Lipsky, B.A., Berendt, A.R., Cornia, P.B., Pile, J.C., Peters, E.J.G., Armstrong, D.G.… Senneville, E. (2012) 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. CID 2012, 54:132-164

In consultation with the community tissue viability team, either:

Flamazine (silver sulphadiazine) cream for non-exudative wounds

Apply at every dressing change

OR

Medicinal honey (Mesitran soft ointment dressing) for wounds with an exudate

Apply at every dressing change

If these ulcers are complicated by systemic features of infection (as above), give:

Co-amoxiclav 625mg TDS for 5 days and then review - if the systemic symptoms of infection have resolved, stop antibiotics and continue topical treatment

For penicillin allergy options please contact Consultant Microbiology on 0161 922 4086(or mobile via switchboard 0161 922 6000)

1. Aciclovir 800 mg orally five times a day for 7 days

2. Valaciclovir 1g TDS for 7 days

or

3. Famciclovir 250mg TDS for 7 days

Aciclovir is by far the cheapest antiviral. If compliance is an issue valaciclovir or famciclovir can be given less frequently but these drugs are much more expensive (provided aciclovir is prescribed generically).

Topical agent - for people with localised non-bullous impetigo who are not systemically unwell or at high risk of complications

Hydrogen peroxide 1% cream (Crytacide) apply 2-3 times a day for 5 days

Although other topical antiseptics are available for treating superficial skin infections, no evidence was found for using them to treat impetigo.

If hydrogen peroxide 1% cream is unsuitable, then fusidic acid 2% (apply TDS for 5 days) may be considered as an alternative

Offer a short course of a topical or oral antibiotic for people with widespread non-bullous impetigo who are not systemically unwell or at high risk of complications

Topical

Fusidic acid 2% apply TDS for 5 days

Oral options

Flucloxacillin 1g QDS for 5 days

Children:

If child weighs over 50kg use adult doses.

Penicillin allergy

Clarithromycin 500mg BD for 5 days

Bullous impetigo or impetigo in people who are systemically unwell or at high risk of complications

Offer a short course of an oral antibiotic for:

• all people with bullous impetigo
• people with non-bullous impetigo who are systemically unwell or at high risk of complications.

Oral options

Flucloxacillin 1g QDS for 5 days

Children:

If child weighs over 50kg use adult doses.

Penicillin allergy

Clarithromycin 500mg BD for 5 days

(see BNFc for doses in children)

Lymecycline 408mg OD

If not tolerated or pregnant/breastfeeding:

Erythromycin 500mg BD

For superficial infections only

Amorolfine 5 % nail lacquer 1–2 times a week for 6 months (fingers) or 12 months (toes)

or

Terbinafine 250 mg OD for 6–12 weeks (fingers) or 3–6 months (toes)

or

For infections with yeasts and non-dermatophyte moulds use pulsed Itraconazole 200 mg BD for 7 days repeated monthly. For fingernails use 2 courses and for toenails use 3 courses.

Rarely idiosyncratic liver reactions occur with terbinafine. Tell patients to watch for signs of liver toxicity.

Itraconazole should be avoided in patients at risk of heart failure and in patients taking statins (risk of myopathy) and it can also cause liver toxicity.

1st choice Chloramphenicol 0.5 % eye drops 1 drop 2 hourly for 2 days, reducing to 4 hourly as the infection improves

plus

Chloramphenicol 1% eye ointment at night

However treatment with eye drops alone may be sufficient.

2nd choice (ONLY if chloramphenicol not effective or unsuitable) Fusidic acid 1 % eye drops 1 drop BD

Continue both for 48 hours after resolution of symptoms

Swab the eye for culture and sensitivity if the infective conjunctivitis is not resolving after 7 days of treatment. Swab all people who are sexually active for gonococcal and chlamydial infection who have conjunctivitis that persists for 14 days despite treatment.

Please note that there as recently been a significant price increase of fusidic acid eye drops. Please ensure it is only prescribed as a second choice when absolutely necessary and chloramphenicol is not suitable

Treatment for adults (for children see CBNF for doses)

Benzylpenicillin 1.2g – ideally IV but IM if a vein cannot be accessed

Penicillin allergy (rash)

Cefotaxime 1g – ideally IV but IM if a vein cannot be accessed

Penicillin allergy (Anaphylaxis)

Chloramphenicol 1g - IV

Indications for antibiotic prophylaxis

Antibiotic prophylaxis should be offered to the following:

• Close contacts - those who have had prolonged close contact with the case in a household type setting during the seven days before onset of illness. Examples of such contacts would be those living and/or sleeping in the same household, pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence.
• Transient contacts - those who have had transient close contact with a case only if they have been directly exposed to large particle droplets/secretions from the respiratory tract of a case around the time of admission to hospital.

Close contact does NOT include:

• staff and children attending same nursery or crèche
• students/pupils in same school/class/tutor group
• work or school colleagues
• friends
• residents of nursing/residential homes
• kissing on cheek or mouth (intimate kissing would normally bring the contact into the close, prolonged contact category)
• food or drink sharing or similar low level of salivary contact
• attending the same social function
• travelling in next seat on same plane, train, bus, or car (in the absence of intense exposure to nasopharyngeal secretions).

Prevention of secondary cases

Chemoprophylaxis should be prescribed following discussion with the specialist team at the PHE North West on 0344 225 0562 within office hours and via Tameside Hospital switchboard out of hours–ask for the PHE North West on call.

Tameside General Hospital will arrange the supply of antibiotic prophylaxis for household contacts of patients treated there.

For other useful numbers please see https://www.gov.uk/emergency-contacts-public-health

1st line:

Adult: Ciprofloxacin 500mg po as a single dose for an adult.

Neonate: Ciprofloxacin 30mg/kg (max. per dose 125mg) po for 1 dose.

Child 1 month–4 years: Ciprofloxacin 30mg/kg (max. per dose 125mg) po for 1 dose.

Child 5–11 years: Ciprofloxacin 250mg po for 1 dose.

Child 12–17 years: Ciprofloxacin 500mg po for 1 dose.

Ciprofloxacin in pregnancy

A single dose of ciprofloxacin can be used for the prevention of secondary cases of meningococcal meningitis/bacteraemia in pregnancy.

Or if unable to take ciprofloxacin or if contraindicated,

2nd line:

Adult: Rifampicin 600mg po every 12 hours for 2 days.

Neonate - 11 months: Rifampicin 5mg/kg po every 12 hours for 2 days.

Child 1–11 years: Rifampicin 10mg/kg po every 12 hours (max. per dose 600mg), for 2 days.

Child 12–17 years: Rifampicin 600mg po every 12 hours for 2 days.

Or if rifampicin is contraindicated,

3rd line: Ceftriaxone 250mg IM stat dose (125mg in a child under 12yrs)

(NB not licensed for this indication).

Further advice can be sought from Greater Manchester Health Protection Unit 0161 786 6710 or via switchboard out of hours.

References:

Public Health England. Guidance for the public health management of meningococcal disease in the UK. February 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/688835/Public_health_management_of_meningococcal_disease_guidelines.pdf

Metronidazole 400mg BD for 7 days

or

Metronidazole 2g STAT

or

Metronidazole vaginal gel 0.75% 5g nightly for 5 nights

or

Clindamycin 2 % vaginal cream 5g nightly for 7 nights (expensive)

During pregnancy /breastfeeding avoid high dose regimens of metronidazole (2g stat dose). During lactation metronidazole enters breast milk and can alter the taste of breast milk, therefore avoid oral treatment in lactating women and use topical treatment instead.

1st line: Doxycycline 100mg BD for 7 days

2nd line:Azithromycin 1g STAT, followed by 500mg once daily for 2 days

In pregnancy/breast feeding:

Azithromycin 1g STAT, followed by 500mg once daily for 2 days

Due to the lower cure rate in pregnancy, a test for cure should be performed at least 5 weeks after treatment (6 weeks with azithromycin).

Patients should be advised to avoid sexual contact for a week after treatment, even if using a condom, to prevent the risk of re-infection.

Due to chlamydial infection:

Ceftriaxone 1g IM stat then Doxycycline 100mg po bd for 14 days.

Refer to Tameside & Glossop centre for sexual health for contact tracing.

Due to Gram negative enteric organisms (urinary pathogens):

1st line: Co-trimoxazole 960mg po bd for 10 days.

2nd line: Ciprofloxacin 500mg po bd for 10 days

or

ofloxacin 200mg po bd for 14 days.

3rd line: Doxycycline 100mg BD for 10 days.

Cefalexin 1g TDS plus clindamycin 450mg QDS for 5 days.

Note: cephalosporins can be given in penicillin allergy with a rash.

Penicillin allergy (anaphylaxis):

Co-trimoxazole 960mg BD plus clindamycin 450mg QDS for 5 days.

Ceftriaxone 1g IM single dose

followed by

Metronidazole 400mg BD plus Doxycycline 100mg BD for 14 days.

The above regimen is suitable for patients with penicillin allergy, where the nature of the allergy is a rash.

Penicillin allergy (anaphylaxis):

Metronidazole 400mg BD plus Ofloxacin 400mg BD for 14 days.

(AVOID this regimen if high risk of gonococcal disease due to quinolone resistance).

Doxycycline must NOT be prescribed for pregnant or breast - feeding women

Metronidazole 400mg BD for 7 days

or

Metronidazole 2g stat

Consider clotrimazole for symptom relief (not cure) if metronidazole declined. During pregnancy avoid high dose regimens of metronidazole (2g stat dose)

Amoxicillin 1g TDS for 3 days (or amoxicillin 500mg TDS for 5 days)

Penicillin allergy

Doxycycline 200 mg STAT then 100 mg OD for 5 days (or Doxycycline 200 mg STAT then 100 mg BD for 3 days)

Doxycycline must NOT be prescribed for children under 12 years, or for pregnant or breast-feeding women.

Please ensure response to treatment is reviewed after 7 days at the very most. DO NOT routinely offer two weeks of antibiotics without adequate review. NICE (2019) guidance gives the duration of 7-14 as a guide and up to weeks may be required for some patients. However, adequate review is crucial when treating exacerbation of bronchiectesis to ensure the patient is responding and not deteriorating.

1. Amoxicillin 1g TDS (or amoxicillin 500mg TDS if less than 50kg) for 7-14 days

or

Penicillin allergy (or alternative regime if amoxicillin not suitable)

2. Doxycycline 200 mg STAT then 100 mg OD for 7-14 days (or Doxycycline 200 mg STAT then 100 mg BD)

If there is inadequate clinical response to amoxicillin and/or doxycyline, co-amoxiclav 625 mg TDS for 7-14 days can be tried as an alternative antibiotic.

It is recommended that only hospital consultants should commence long-term antibiotic prophylaxis for bronchiectesis patients and that those patients who would benefit are carefully selected and closely monitored with regular follow ups.

There has been some recent information circulated on this from the medicines management team. All patients issued with a rescue pack should ONLY be done so after a proper clinical assessment and the patient should be issued with an individualised and detailed care plan – so they are aware of what actions need to be taken.

Please refrain from conducting practice-wide searches and sending out rescue pack prescriptions to all on the COPD or asthma registers. This is inappropriate and the medicines supply chain will be unable to cope with such increased demand, meaning those actually requiring rescue medication will not be able to source it.

COVID19 is a viral infection and so the advice stands as for all other respiratory viral pathogens. If patients are unwell then they are advised to seek medication attention.

1. Amoxicillin 1g TDS for 3 days (or amoxicillin 500mg TDS if less than 50kg for 5 days)

or

Penicillin allergy (or alternative regime if amoxicillin not suitable)

2. Doxycycline 200 mg STAT then 100 mg OD for 5 days (or Doxycycline 200 mg STAT then 100 mg BD for 3 days)

If there is inadequate clinical response to amoxicillin and/or doxycyline, co-amoxiclav 625 mg TDS for 5 days can be tried as an alternative antibiotic. However, the diagnosis should also be reviewed to ensure that exacerbation is indeed bacterial in nature, as up to 50% of acute exacerbation of COPD are due to a viral cause.

It is recommended that only hospital consultants should commence long-term antibiotic prophylaxis for COPD patients and that those patients who would benefit are carefully selected and closely monitored with regular follow ups.

The current COVID19 pandemic has highlighted the risk faced by older adults who are more susceptible to complications as a result of pneumonia.

Comorbidities, impaired immunity and frailty, including a reduced ability to cough and to clear secretions from the lungs, can all contribute to this complication.

Viruses are thought to cause around 50% of cases of pneumonia. Viral pneumonia is generally less severe than bacterial pneumonia but can act as a precursor to it. Preventing any pneumonia in older adults is preferable to treating it.

Where physical examination and other ways of making an objective diagnosis are not possible, the clinical diagnosis of CAP of any cause in an adult can be informed by other clinical signs or symptoms such as:

• temperature above 38 ^oC
• respiratory rate above 20 breaths per minute
• heart rate above 100 beats per minute
• new confusion

Use of NEWS2 score in the community for predicting the risk of clinical deterioration may be useful.

Prevention of CDI relies on ensuring that patients do not become susceptible through disruption of their normal gut flora and on preventing as far as possible their exposure to the organism. These approaches are implemented through careful measures to control antibiotic usage and through routine infection control procedures.

Enterobacteriaceae are a large family of bacteria that usually live harmlessly in the gut of all humans and animals. However, these organisms are also some of the most common causes of urinary tract infections, intra-abdominal and bloodstream infections. They include species such as E coli, Klebsiella and Enterobacter.

Carbapenems are a group of penicillin-like antibiotics. Until now, they have been the antibiotics that we could always rely upon to treat infections caused by Enterobacteriaceae. Carbapenemases are enzymes that destroy carbapenem antibiotics, conferring resistance to the bacteria. Carbapenemases are made by a small but growing number of Enterobacteriaceae, with resistance able to transfer between bacterial species.

In the last 5 years England has seen a rapid increase in the incidence of infection and colonisation by multi-drug resistant carbapenemase-producing organisms. This reflects similar problems worldwide and indicates the urgent need for guidance, particularly on infection prevention and control management.

Useful resources:

https://www.gov.uk/government/news/phe-carbapenemase-producing-enterobacteriaceae-toolkit-published

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/329232/CPE_Acute_Trust_Toolkit_Relevant_Literature_and_Resources.pdf

https://www.gov.uk/government/publications/carbapenemase-producing-enterobacteriaceae-early-detection-management-and-control-toolkit-for-acute-trusts

• Avoid inappropriate or excessive antibiotic therapy and prophylaxis.
• Ensure antibiotics are given at the correct dosage and for an appropriate duration.
• Limit the use of glycopeptide antibiotics (vancomycin and teicoplanin) to situations where their use has been shown to be appropriate. If possible, prolonged courses of glycopeptide therapy should be avoided.
• Reduce the use of broad-spectrum antibiotics, particularly third-generation cephalosporins and fluoroquinolones, to what is clinically appropriate.
• Instituting antibiotic stewardship programmes in healthcare facilities, key components of which include the identification of key personnel who are responsible for this, surveillance of antibiotic resistance and antibiotic consumption, and prescriber education. To combat resistance, the Tameside local Clinical Lead for Infection prevention recommends that:
• For community patients, repeated topical therapies should not be prescribed.
• Community patients need not be re-screened, unless they are pre-operative and there is direction to the GP in the form of a ‘treatment and screening protocol’ from the hospital that is planning the surgery.
• Community patient’s wounds need not be swabbed unless there are clinical signs of infection, (Consultation can be sought from the Tameside local office Tissue Viability Nurse Specialist).
• Advice on good personal and home hygiene must be given to promote a reduction in MRSA colonisation.

Prevention of CDI relies on ensuring that patients do not become susceptible through disruption of their normal gut flora and on preventing as far as possible their exposure to the organism. These approaches are implemented through careful measures to control antibiotic usage and through routine infection control procedures.

Malathion 0.5 % aqueous solution

Apply to dry hair and scalp, wash off after 12 hours and repeat in 7 days. 200 ml should be sufficient for an adult to have 2 treatments.

Treatment failure maybe due to resistance, reinfection from another household member or poor treatment technique.

Rub into dry hair and scalp, allow to dry naturally, shampoo off after 8 hours (or overnight); repeat after 7 days.

Wash the hair with ordinary shampoo and apply plenty of conditioner. Untangle the hair with an ordinary comb and then work through the hair in sections with a louse detection comb drawing downwards from root to tip ensuring the whole head of hair is worked through.

Remove lice and eggs from the comb by wiping or washing the comb. Four sessions at 4 day intervals are needed over 2 weeks. The process should continue until no live lice are found on 3 consecutive sessions.

Mebendazole (over 2 years) 100 mg as a single dose repeat in 2 weeks

if infection persists or if under 2 years

Piperazine and sennosides sachet: 3 - 12 months 2.5 ml spoon (from sachet in water), 1 - 6 years 5ml spoon repeat in 2 weeks.

There is information in the cBNF on mebendazole dosing from 6 months of age. However this is unlicensed so the patient information leaflet may cause alarm to the parent.

Cefalexin 1g TDS for 5 days.

Penicillin allergy (anaphylaxis):

Co-trimoxazole 960mg BD plus Metronidazole 400mg TDS for 5 days.

Full dose PPI (proton pump inhibitor) BD

plus

Amoxicillin 1g and Clarithromycin 500mg BD / Metronidazole 400mg BD

Penicillin allergy and no prior treatment

Full dose PPI BD

plus

Clarithromycin 500mg BD and Metronidazole 400mg BD

Penicillin allergy & previous treatment/exposure to clarithromycin or levofloxacin

Full dose PPI BD

plus

Bismuth subsalicylate 525mg QDS (this is pepto-bismol and is blacklisted in the drug tariff. If treatment is required with this regimen then patient will have to buy this over-the-counter. Please inform the patient of this)

plus

Metronidazole 400mg BD and Tetracycline 500mg QDS

Please note

Full dose PPI BD refers to:

Omeprazole 20mg BD or Lansoprazole 30mg BD

Relapse & previous treatment with metronidazole and clarithromycin

Full dose PPI (proton pump inhibitor) BD

plus

Amoxicillin 1g BD

plus

Tetracycline 500mg QDS or Levofloxacin 250mg BD

Miconazole oral gel 2.5ml QDS. Treatment should continue for at least 7 days after lesions have healed.

If not suitable or failure to respond,

Nystatin suspension 1ml QDS usually for 7 days (continued for at least 48 hours after lesions have healed).

If the patient is using an inhaled corticosteroid assess inhaler technique. Advise the patient to brush teeth or rinse mouth with water (do not swallow) after using the inhaled corticosteroid. Use of a spacer can reduce the deposition of the drug on oromucosal surfaces and use of the lowest maintenance dose also reduces likelihood of oral candidiasis. If the patient wears dentures give advice on oral hygiene measures to prevent recurrence.

Systemic treatment should be offered if the patient does not respond to topical treatment, the infection is extensive or severe, or if the patient is immunocompromised.

Fluconazole 50mg OD for 7 - 14 days maximum.

Unusually difficult infections may need up to 100mg OD and immunocompromised patients may need treatment for longer than 14 days

• Arrange x-ray to rule out osteomyelitis
• Collect and sent any bone fragments to microbiology for culture and sensitivity
• Whilst results of x-ray awaited, treat any signs or symptoms of soft tissue infection using the Tameside local guidelines. If the infection does not respond to treatment liaise with microbiology.
• Refer patient to High Risk Foot Team for assessment and treatment plan advice (email: integrated.diabetes@tgh.nhs.uk)

If radiology report diagnoses osteomyelitis:

Liaise with microbiology around individualised treatment plan for patient.

Dr H Sacho 0161 922 4086 or contact via hospital switchboard (0161 922 6000)

Dr P F Unsworth 0161 922 6500 or contact via hospital switchboard

Monitor patient’s wound at least weekly until healing achieved/ conservative plan set

Please Note:

Patient may need MRI to affected area if complex case/lack of clarity

Flucloxacillin 1g QDS

Penicillin allergy

Clindamycin 450mg QDS

Typical treatment duration:

4 weeks for septic arthritis and 6 weeks for osteomyelitis

Be aware that some people may wish to try the following self-care treatments, which have limited evidence of some benefit for the relief of cough symptoms:

• honey (in people aged over 1 year)
• pelargonium (a herbal medicine; in people aged 12 and over)
• over-the-counter cough medicines containing the expectorant guaifenesin (in people aged 12 and over)
• over-the-counter cough medicines containing cough suppressants, except codeine, (in people aged 12 and over who do not have a persistent cough, such as in asthma, or excessive secretions).

For people with an acute cough who are identified at a face-to-face clinical examination as systemically very unwell, offer an immediate antibiotic prescription

Be aware that people with an acute cough may be at higher risk of complications if they:

• have a pre-existing comorbidity, such as significant heart, lung, renal, liver or neuromuscular disease, immunosuppression or cystic fibrosis
• are young children who were born prematurely
• are older than 65 years with 2 or more of the following criteria, or older than 80 years with 1 or more of the following criteria: － hospitalisation in previous year － type 1 or type 2 diabetes － history of congestive heart failure － current use of oral corticosteroids.

Reassess people with an acute cough if their symptoms worsen rapidly or significantly, taking account of:

• alternative diagnoses, such as pneumonia
• any symptoms or signs suggesting a more serious illness or condition, such as cardiorespiratory failure or sepsis
• previous antibiotic use, which may have led to resistant bacteria.

Doxycycline 200 mg on first day, then 100 mg once a day

Amoxicillin 500mg - 1g three times a day

Clarithromycin 500 mg twice a day

Review at day 3 and do not exceed total duration of treatment by 5 days in total

Phenoxymethylpenicillin 500mg QDS or 1g BD (QDS) when severe for 5 days. (10 days for scarlet fever).

Penicillin allergy

Clarithromycin 500mg BD for 5 days. (10 days for scarlet fever).

Amoxicillin 500mg TDS or 1g TDS review after 72 hours

Penicillin allergy

Clarithromycin 500mg BD review after 72 hours

treatment should exceed 5 days

Amoxicillin 1g TDS review after 72 hours

Penicillin allergy

Doxycycline 200 mg STAT then 100 mg OD

Doxycycline must NOT be prescribed for children under 12 years, or for pregnant or breast-feeding women.

Penicillin allergy

Clarithromycin 500 mg BD for 7 days

Treatment should not exceed 5 days in total

Cefalexin 1g TDS for 5 days.

Penicillin allergy (anaphylaxis):

Co-trimoxazole 960mg BD plus Metronidazole 400mg TDS for 5 days.

Miconazole oral gel 2.5ml QDS. Treatment should continue for at least 7 days after lesions have healed.

If not suitable or failure to respond,

Nystatin suspension 1ml QDS usually for 7 days (continued for at least 48 hours after lesions have healed).

If the patient is using an inhaled corticosteroid assess inhaler technique. Advise the patient to brush teeth or rinse mouth with water (do not swallow) after using the inhaled corticosteroid. Use of a spacer can reduce the deposition of the drug on oromucosal surfaces and use of the lowest maintenance dose also reduces likelihood of oral candidiasis. If the patient wears dentures give advice on oral hygiene measures to prevent recurrence.

Systemic treatment should be offered if the patient does not respond to topical treatment, the infection is extensive or severe, or if the patient is immunocompromised.

Fluconazole 50mg OD for 7 - 14 days maximum.

Unusually difficult infections may need up to 100mg OD and immunocompromised patients may need treatment for longer than 14 days

Cefalexin 1g TDS for 7-10 days.

Penicillin allergy

Ciprofloxacin 500mg BD for 7 days.

1st line: Co-trimoxazole 960mg BD for 14 days.

2nd line: Ciprofloxacin 500mg BD for 14 days.

3rd line: Doxycycline 100mg BD for 14 days.

In sexually active young men consider a diagnosis of Chlamydia trachomatis or gonorrhoea. Refer all men for investigation by a specialist after recovery to exclude a structural cause.

This is not routinely required for every patient. However, for those patients that are truly symptomatic of a UTI and require a catheter change (rather than just removal) and there is concern regarding introduction of bacteria during the change (due to previous medical history or traumatic catheter change), then antibiotics can be given to reduce the incidence of bacteraemia.

Any antibiotic therapy for these patients should be based on previous known urine sensitivities and ideally a specimen be sent for urinalysis BEFORE any antibiotic therapy is started for resolution of the UTI.

Urine specimens should ALWAYS be taken from the sampling port and NOT the catheter bag. Refer to the Trust Urinary catheterisation and catheter care management adults policy for guidance on best practice.

Urinary catheterisation prophylaxis for those patients with urethritis, where Staph aureus has been isolated, and require a catheter change.

For further advice on individual patients contact Urology Specialist Nurses 0161 922 6696, Infection Prevention Nurses on 0161 922 6194 or the Consultant Microbiologist on 0161 922 4086 / 6500.

Antibiotic treatment:

If behavioural and personal hygiene measures do not reduce incidence of UTI, antibiotic treatment may be considered from one of the following recommendations below:

• Each episode of UTI may be treated by a healthcare professional as it occurs.
• Patient/carer initiated antibiotic treatment is a cost-effective and safer alternative (in terms of avoiding the development of CDI and antibiotic resistance) compared to continuous antibiotic prophylaxis. This entails self-administration of single high-dose antibiotic treatment; however, if symptoms persist, treatment could continue for up to 3 days, but often 1 or 2 days are sufficient. This should be considered in patients who are compos mentis and are capable of recognising the symptoms of UTI. The patient should be counselled on how and when to self-treat. Antibiotics should be reviewed every 6 months.
• Antibiotic prophylaxis with either trimethoprim 100mg or nitrofurantoin 50mg nocte (provided there is sensitivity to these antibiotics) may be considered where it may be impractical for patients or carers to initiate antibiotics appropriately however antibiotics must be reviewed at least every 6 months. The patient should be counselled on adverse effects and the risk of antibiotic resistance developing.
• If related to sexual intercourse consider a single dose of antibiotic post coital (off-label use). Trimethoprim 200mg or nitrofurantoin 100mg stat may be given after taking into account sensitivity results. Antibiotics should be reviewed every 6 months.

For patients who develop and continue to have symptoms of UTI whilst taking antibiotic prophylaxis or treating a UTI, they should be advised to seek medical help.

Nitrofurantoin 100mg MR BD for 3 days (nitrofurantoin 50mg QDS may be an alternative if supply issues with MR preparations).

Nitrofurantoin is contraindicated in patients with an eGFR of ≤45ml/min; however it maybe used with caution in patients with eGFR 30-44ml/min provided the duration of treatment does not exceed 7 days

OR

Pivmecillinam 400mg STAT then 200mg TDS for 3 days (this is a penicillin)

If the above two options are not suitable for patients then please use MSU results to guide treatment or discuss with Microbiologist on 0161 922 4086/6500 or mobile via switch 0161 922 6000

If a patient is penicillin allergic (anaphylaxis) and has poor renal function whereby other antibiotic options can't be used then Fosfomycin (prescribe as Monuril) 3g STAT once only can be given.

We have high levels of resistance (50%) to co-amoxiclav of E coli. Pivecillinam has shown to be effective against E coli and is also a recommended choice in the PHE guidelines. The resistance to this drug is low in our local population at 16%. Cephalosporins have high sensitivity rates in Tameside.

Extended - spectrum Beta-lactamase enzymes (ESBLs) in gram-negative bacilli such as E. coli are increasing, and these ESBL-producing E. coli are multi-resistant but remain sensitive to nitrofurantoin. Consider a diagnosis of Chlamydia trachomatis in sexually active young women (in which case urine or endocervical specimens should be submitted for Chlamydia PCR assay).

1st choice: Pivmecillinam 400mg STAT for the first dose followed by 200mg TDS thereafter for 7 days.

2nd choice: Nitrofurantoin 100mg MR BD for 7 days (nitrofurantoin 50mg QDS may be an alternative if supply issues with MR preparations)

Nitrofurantoin is contraindicated in patients with an eGFR of ≤45ml/min however it may be used with caution in patients with eGFR 30-44ml/min provided the duration of treatment does not exceed 7 days.

Metronidazole 400mg BD for 7 days

or

Metronidazole 2g STAT

or

Metronidazole vaginal gel 0.75% 5g nightly for 5 nights

or

Clindamycin 2 % vaginal cream 5g nightly for 7 nights (expensive)

During pregnancy /breastfeeding avoid high dose regimens of metronidazole (2g stat dose). During lactation metronidazole enters breast milk and can alter the taste of breast milk, therefore avoid oral treatment in lactating women and use topical treatment instead.

Clotrimazole 10% vaginal cream 5g single dose

or

Clotrimazole pessary 500mg as a single dose

If topical treatment fails or the patient prefers oral preparation:

Fluconazole 150mg orally STAT

In pregnancy avoid oral azole and use intravaginal treatment for 7 days:

Clotrimazole pessary 100mg at night for 6 nights

(This slightly shorter treatment duration is considered acceptable by PHE as that is the number of pessaries in one original pack of clotrimazole 100mg pessaries).

or

Miconazole 2% cream 5g BD as intravaginal application for 7 days

In pregnancy the use of an applicator to insert pessaries should be avoided and insertion by hand is preferable.

The patient should be instructed to wash hands before insertion. For intravaginal creams where use of an applicator cannot be avoided, care must be taken to avoid injuring the cervix.

Due to chlamydial infection:

Ceftriaxone 1g IM stat then Doxycycline 100mg po bd for 14 days.

Refer to Tameside & Glossop centre for sexual health for contact tracing.

Due to Gram negative enteric organisms (urinary pathogens):

1st line: Co-trimoxazole 960mg po bd for 10 days.

2nd line: Ciprofloxacin 500mg po bd for 10 days

or

ofloxacin 200mg po bd for 14 days.

3rd line: Doxycycline 100mg BD for 10 days.

Cefalexin 1g TDS plus clindamycin 450mg QDS for 5 days.

Note: cephalosporins can be given in penicillin allergy with a rash.

Penicillin allergy (anaphylaxis):

Co-trimoxazole 960mg BD plus clindamycin 450mg QDS for 5 days.

Amoxicillin 1g TDS for 3 days (or amoxicillin 500mg TDS only if body weight less than 50kg)

Penicillin allergy

Doxycycline 200 mg STAT then 100 mg BD for 3 days

Doxycycline must NOT be prescribed for children under 12 years, or for pregnant or breast-feeding women.

Please ensure response to treatment is reviewed after 7 days at the very most. DO NOT routinely offer two weeks of antibiotics without adequate review. NICE (2019) guidance gives the duration of 7-14 as a guide and up to weeks may be required for some patients. However, adequate review is crucial when treating exacerbation of bronchiectesis to ensure the patient is responding and not deteriorating.

1. Amoxicillin 1g TDS (or amoxicillin 500mg TDS if less than 50kg) for 7-14 days

or

Penicillin allergy (or alternative regime if amoxicillin not suitable)

2. Doxycycline 200 mg STAT then 100 mg OD for 7-14 days (or Doxycycline 200 mg STAT then 100 mg BD)

If there is inadequate clinical response to amoxicillin and/or doxycyline, co-amoxiclav 625 mg TDS for 7-14 days can be tried as an alternative antibiotic.

It is recommended that only hospital consultants should commence long-term antibiotic prophylaxis for bronchiectesis patients and that those patients who would benefit are carefully selected and closely monitored with regular follow ups.

We have become aware of some posts on social media “advising” patients to contact their GP if they have asthma or COPD for a rescue pack.

There has been some recent information circulated on this from the medicines management team. All patients issued with a rescue pack should ONLY be done so after a proper clinical assessment and the patient should be issued with an individualised and detailed care plan – so they are aware of what actions need to be taken.

Please refrain from conducting practice-wide searches and sending out rescue pack prescriptions to all on the COPD or asthma registers. This is inappropriate and the medicines supply chain will be unable to cope with such increased demand, meaning those actually requiring rescue medication will not be able to source it.

COVID19 is a viral infection and so the advice stands as for all other respiratory viral pathogens. If patients are unwell then they are advised to seek medication attention.

1. Amoxicillin 1g TDS for 3 days (or amoxicillin 500mg TDS if less than 50kg for 5 days)

or

Penicillin allergy (or alternative regime if amoxicillin not suitable)

2. Doxycycline 200 mg STAT then 100 mg OD for 5 days (or Doxycycline 200 mg STAT then 100 mg BD for 3 days)

If there is inadequate clinical response to amoxicillin and/or doxycyline, co-amoxiclav 625 mg TDS for 5 days can be tried as an alternative antibiotic. However, the diagnosis should also be reviewed to ensure that exacerbation is indeed bacterial in nature, as up to 50% of acute exacerbation of COPD are due to a viral cause.

It is recommended that only hospital consultants should commence long-term antibiotic prophylaxis for COPD patients and that those patients who would benefit are carefully selected and closely monitored with regular follow ups.

The current COVID19 pandemic has highlighted the risk faced by older adults who are more susceptible to complications as a result of pneumonia.

Comorbidities, impaired immunity and frailty, including a reduced ability to couggh and to clear secretions from the lungs, can all contribute to this complication.

Viruses are thought to cause around 50% of cases of pneumonia. Viral pneumonia is generally less severe than bacterial pneumonia but can act as a precursor to it. Preventing any pneumonia in older adults is preferable to treating it.

Where physical examination and other ways of making an objective diagnosis are not possible, the clinical diagnosis of CAP of any cause in an adult can be informed by other clinical signs or symptoms such as:

• temperature above 38 ^oC
• respiratory rate above 20 breaths per minute
• heart rate above 100 beats per minute
• new confusion

Use of NEWS2 score in the community for predicting the risk of clinical deterioration may be useful.

Doxycycline 200 mg STAT then 100 mg BD for 72 hours and review

Doxycycline must NOT be prescribed for children under 12 years, or for pregnant or breast-feeding women

Co-amoxiclav 625 mg TDS - review every 72 hours and treatment duration should not exeed 5 days.

Penicillin allergy

Doxycycline 200mg po for the first dose then 100mg po bd - review every 72 hours and treatment duration should not exceed 5 days.

Animal and human bites to the hand including clenched fist injuries ('fight-bite') are at greater risk for development of complications associated with infection particularly septic arthritis, osteomyelitis and tendon sheath infection.

These patients would require hospital admission for intravenous antibiotic treatment as well as orthopaedic review with assessment of surgical intervention including joint washout and tissue debridement.

Flucloxacillin 1g QDS and review every 72 hours

Penicillin allergy

Clindamycin 450mg QDS and review every 72 hours

DO NOT PRESCRIBE FOR LONGER THAN 72 HOURS AT A TIME

Co-amoxiclav 625 mg TDS plus clindamycin 450mg QDS for 10 days (ensure review every 72 hours)

Penicillin allergy

If rash - Cefalexin 1g TDS plus clindamycin 450mg QDS for 10 days (ensure review every 72 hours)

If anaphylaxis - Levofloxacin 500mg BD plus clindamycin 450mg QDS for 10 days

A total of 10 days of antibiotic treatment to cover both Group A Strep and Staph aureus would be required in order to prevent recurrence

If the patient is febrile and acutely ill, refer to hospital for IV treatment.

Presence of at least 2 of the following:

local swelling, erythema, local tenderness or pain, local warmth, purulent discharge.

Local infection involving only skin and subcutaneous tissue. If erythema, must be <2cm around ulcer

Flucloxacillin 1g QDS for a maximum of 5 days (review every 72 hours)

Penicillin allergy

Clarithromycin 500mg BD for a maximum of 5 days (review every 72 hours)

as above plus erythema > 2cm but <5cm, or involving structures deeper than skin and subcutaneous tissues.

Co-amoxiclav 625mg TDS for a maximum of 5 days (review every 72 hours)

Spreading cellulitis (> 5cm from the wound), ascending lymphangitis, deep tissue abscess formation with or without systemic inflammatory response syndrome

arrange admittance into hospital for IV antibiotics

Note: Systemic infection may sometimes manifest with sepsis syndrome including fever, vomiting, hypotension, deranged blood glucose levels and confusion. It is important to note that patients with ischaemia and neuropathy may not mount an appropriate inflammatory response, but nevertheless be extremely ill.

National Institute of Health and Care Excellence (NICE), (2015). Diabetic foot problems: prevention and management, NICE guideline 19. http://www.nice.org.uk/guidance/ng19/chapter/1-Recommendations#diabetic-foot-infection-2

Lipsky, B.A., Berendt, A.R., Cornia, P.B., Pile, J.C., Peters, E.J.G., Armstrong, D.G.… Senneville, E. (2012) 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. CID 2012, 54:132-164

In consultation with the community tissue viability team, either:

Flamazine (silver sulphadiazine) cream for non-exudative wounds

Apply at every dressing change

OR

Medicinal honey (Mesitran soft ointment dressing) for wounds with an exudate

Apply at every dressing change

If these ulcers are complicated by systemic features of infection (as above), give:

Co-amoxiclav 625mg TDS for 72 hours and then review - if the systemic symptoms of infection have resolved, stop antibiotics and continue topical treatment. If not fully reolved then prescription can continue but review, at least every 72, hours is a must. Treatment should not generall continue for longer than 6 days. If unresolving after 6 days please contact the Consultant Microbiologist as below.

For penicillin allergy options please contact Consultant Microbiology on 0161 922 4086 or 6500 (or mobile via switchboard 0161 922 6000)

Aciclovir 800 mg orally five times a day for 7 days

Infection Control Measures

Only a person who has not had chickenpox or varicella vaccine is susceptible to chickenpox infection from a person active shingles; however spead is via direct skin contact with the lesions and not via the respiratory route as is the case with chickenpox. Infection prevention measures are therefore primarily aimed at skin contact precautions.

The person with shingles is infectious until lesions have crusted over; howver if the rash is covered then the risk of transmission is very low.

First line treatment should be with:

Eardrops containing an anaesthetic and an analgesic

Phenazone 40 mg/g with lidocaine 10 mg/g (Otigo)

Apply 4 drops two or three times a day for up to 7 days. Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea

Amoxicillin 1g po tds for 3 days.

Penicillin allergy

Clarithromycin 500mg po bd for 3 days.

Most infections are caused by viruses; most uncomplicated cases resolve without antibiotic treatment.

Amoxicillin 1g po tds for 3 days.

Penicillin allergy

Doxycycline 200mg po stat on day 1, then 100mg po od days 2 and 3.

(not due to group A Streptococci)

No Antibiotics required

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

Use FeverPAIN Score:

Fever in last 24h, purulence, attend rapidly under 3d, severely inflamed tonsils, no cough or coryza

Score 0-1: 13-18% streptococci, use NO antibiotic strategy;

2-3: 34-40% streptococci, use 3 day back-up antibiotic;

>4: 62-65% streptococci, use immediate antibiotic if severe, or 48hr short back-up prescription

A positive throat swab culture growing Streptococcus Group A, together with clinical features of acute pharyngotonsillitis almost certainly indicates infection.

If you have taken a throat swab before prescribing antibiotics and it is reported negative for Streptococcus Group A do not prescribe antibiotics, and if antibiotics have already been commenced, discontinue them.

Streptococcus A throat swab POC testing can be a rapid way to determine bacterial vs viral sore throat and consideration should be given to this method of testing especially in the urgent care or walk-in setting.

Ceftriaxone1g IM stat(administer in A&E) - do not give if allergic to penicillin (anaphylaxis)

plus

Doxycycline 100mg po bd for 14 days

plus

Metronidazole 400mg po bd for 14 days.

Avoid tetracyclines in pregnancy.

Refer to Tameside & Glossop centre for sexual health for contact tracing.

Antibiotic treatment:

Cefalexin 1g po tds plus clindamycin 450mg po qds for 5 days

Note: cephalosporins can be given in penicillin allergy with a rash.

Penicillin allergy (anaphylaxis):

Co-trimoxazole 960mg po bd plus clindamycin 450mg po qds for 5 days.

Due to chlamydial infection:

Ceftriaxone 1g IM stat then Doxycycline 100mg po bd for 14 days.

Refer to Tameside & Glossop centre for sexual health for contact tracing.

Due to Gram negative enteric organisms (urinary pathogens):

1st line: Co-trimoxazole 960mg po bd for 10 days.

2nd line: Ciprofloxacin 500mg po bd for 10 days

or

ofloxacin 200mg po bd for 14 days.

3rd line: Doxycycline 100mg BD for 10 days.

Amoxicillin 1g po tds for 3 days.

Penicillin allergy

Doxycycline 200mg po stat on day 1, then 100mg po od days 2 and 3.

Only if associated with systemic symptoms/constitutional involvement.

Amoxicillin 1g po tds for 3 days.

Penicillin allergy

Doxycycline 200mg po stat on day 1, then 100mg po od days 2 and 3.

Amoxicillin 1g po tds for 3 days.

Penicillin allergy

Clarithromycin 500mg po bd for 3 days.

Flucloxacillin 1g po qds for 3 days.

Penicillin allergy

Clarithromycin 500mg po bd for 3 days.

Co-amoxiclav 625mg po tds for 10 days.

Penicillin allergy

Clindamycin 450mg po qds for 10 days.

Duration must be 10 days in order to include adequate duration of treatment of Strep group A

Note: see also section below under the heading animal and human bites to the hand including clenched fist injuries.

Tetanus Prophylaxis

See tetanus prophylaxis in the 'Medical Prophylaxis Guideline' section.

Co-amoxiclav 625mg po tds for 5 days.

Penicillin allergy

Doxycycline 200mg po for the first dose then 100mg po bd for 5 days.

Animal and human bites to the hand including clenched fist injuries ('fight-bite') are at greater risk for development of complications associated with infection particularly septic arthritis, osteomyelitis and tendon sheath infection.

These patients would require hospital admission for intravenous antibiotic treatment as well as orthopaedic review with assessment of surgical intervention including joint washout and tissue debridement.

See Animal and Human bites section under bite wounds for treatment recommendations.

Tetanus Prophylaxis

See tetanus In the medical prophylaxis section.

Clean/non-contaminated laceration

A laceration caused by a clean object e.g. a knife, does not require antibiotics. The wound should be cleaned and protected from becoming infected.

Infected laceration

If a previously clean laceration becomes infected, the most likely organism is Staph aureus and therefore this should be treated as cellulitis. Please refer to section on cellulilitis above.

Contaminated/infected laceration

If a laceration is contaminated it should be treated as follows:

Co-amoxiclav 625mg po tds for 5 days.

Penicillin allergy (rash):

Cefalexin 1g po tds for 5 days.

Penicillin allergy (anaphylaxis):

Co-trimoxazole 960mg po bd plus clindamycin 450mg po qds for 5 days.

See sore throat in Ear, Nose and Throat section

Strep Group A infections can be clinically classified into 2 main groups:

• Non-invasive and treatable with oral antibiotics in the GP/outpatient setting and includes:
  • Pharyngotonsillitis
  • Cellulitis
  • Skin and wound infections (such as impetigo and chronic leg ulcers)
  • Scarlet fever (toxin mediated infection).
• Invasive and potentially life-threatening including:
  • Necrotizing fasciitis
  • Bacteraemia (including bacteraemic pneumonia)
  • Facial erysipelas
  • Streptococcal toxic shock syndrome.

Differentiation between non-invasive and invasive Strep Group A infection is important for appropriate clinical management. Because of the potential for non-invasive Strep Group A infections to be become invasive all clinical laboratory culture proven Strep Group A infections must be treated with antibiotics as follows:

Amoxicillin 1g po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Strep Group A Pharyngo-tonsillitis section, under ENT - Sore throat section in the A&E guideline).

Penicillin allergy (rash)

Cefalexin 1g po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Strep Group A Pharyngo-tonsillitis section, under ENT - Sore throat section in the A&E guideline).

Penicillin allergy (anaphylaxis)

Clarithromycin 500mg po bd for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Strep Group A Pharyngo-tonsillitis section, under ENT - Sore throat section in the A&E guideline).

A rapid-onset skin reaction is likely to be an inflammatory or allergic reaction rather than an infection.

Most insect bites or stings will not require antibiotics.

Advise patients:

1. That skin redness and itching are common and may last for up to 10 days
2. Avoid scratching as this may help reduce inflammation and the risk of infection
3. They should seek medical help if symptoms worsen significantly at any time or they become systemically unwell

Do not routinely offer antibiotics if there are no signs or symptoms of spreading cellulitis.

Patients may wish to consider oral antihistamines (in those over 1 year old) to help relieve itching.

If signs or symptoms of infection are present, treat as cellulitis. See cellulitis tab above.

Hidradenitis suppurativa is a chronic inflammatory suppurative disease of the apocrine sweat glands causing painful, inflamed nodules and sterile abscesses. Consider this if only the groin and the axillae are involved.

It can cause painful, chronic, scarring skin condition that leads to the formation of lumps (nodules), abscesses, and draining channels in the skin. It often affects certain areas of the body including the armpits, breasts, groins and genitals, and bottom. The exact cause is unknown, but the disorder involves inflammation around the hair follicles in these areas. There is an association with smoking, being overweight, and other medical problems including arthritis, inflammatory bowel disease, and diabetes mellitus. Hidradenitis suppurativa has a significant impact on patients’ quality of life.

TREATMENT SHOULD ONLY BE COMMENCED BY A DERMATOLOGIST IN SECONDARY CARE

Pivmecillinam 400mg po stat for the first dose followed by 200mg po tds thereafter for 3 days.

Penicillin allergy

Nitrofurantoin M/R 100mg po bd for 3 days.

Acute pyelonephritis is an infection of one or both kidneys usually resulting from ascending urinary tract infection. A urine specimen MUST be sent to the laboratory for microbiologic culture and sensitivity prior to commencing antibiotic treatment.

1st line: Cefalexin 1g po tds for 10 days - this is suitable in penicillin allergy (rash).

2nd line: Ciprofloxacin 500mg po bd for 7 days.

1st line: Pivmecillinam 400mg po stat for the first dose followed by 200mg po tds thereafter for 7 days.

2nd line: Nitrofurantoin M/R 100mg po bd for 7 days.

ORAL TREATMENT:

1st line: Nitrofurantoin 100mg MR BD - AVOID AT TERM (from 37 weeks).

2nd line: Pivmecillinam 400mg STAT then 200mg TDS (this is a penicillin-containing antibiotic)

3rd line: Cefalexin 500mg TDS - avoid if penicillin allergy anaphylaxis.

Treatment duration is a total of 7 days.

1st line: Co-trimoxazole 960mg BD for 14 days.

2nd line: Ciprofloxacin 500mg BD for 14 days.

3rd line: Doxycycline 100mg BD for 14 days.

And refer to Urologist.

First line treatment should be with:

Eardrops containing an anaesthetic and an analgesic

Phenazone 40 mg/g with lidocaine 10 mg/g (Otigo)

Apply 4 drops two or three times a day for up to 7 days. Use only if an immediate oral antibiotic prescription is not given, and there is no eardrum perforation or otorrhoea

No antibiotics required unless clinically toxic

Amoxicillin po tds for 3 days.

Penicillin allergy

Clarithromycin po bd for 3 days.

No antibiotics required unless clinically toxic.

Amoxicillin po tds for 3 days.

Penicillin allergy

Clarithromycin po bd for 3 days.

(not due to group A Streptococci)

No antibiotics required

Amoxicillin po tds for 3 days.

Penicillin allergy

Clarithromycin po bd for 3 days.

Flucloxacillin po qds for 3 days.

Penicillin allergy

Clarithromycin po bd for 3 days.

Co-amoxiclav po tds for 10 days.

Penicillin allergy

Clindamycin po qds for 10 days.

Duration must be 10 days in order to include adequate duration of treatment of Strep group A

Note: see also section below under the heading animal and human bites to the hand including clenched fist injuries.

Tetanus Prophylaxis

See tetanus prophylaxis in the 'Medical Prophylaxis Guideline' section.

Co-amoxiclav po tds for 5 days.

Penicillin allergy

Co-trimoxazole po BD plus clindamycin po QDS for 5 days.

Animal and human bites to the hand including clenched fist injuries ('fight-bite') are at greater risk for development of complications associated with infection particularly septic arthritis, osteomyelitis and tendon sheath infection.

These patients would require hospital admission for intravenous antibiotic treatment as well as orthopaedic review with assessment of surgical intervention including joint washout and tissue debridement.

See Animal and Human bites section under Animal and human bite wounds for treatment recommendations.

Tetanus Prophylaxis

See tetanus In the medical prophylaxis section.

Clean/non-contaminated laceration

A laceration caused by a clean object e.g. a knife, does not require antibiotics. The wound should be cleaned and protected from becoming infected.

Infected laceration

If a previously clean laceration becomes infected, the most likely organism is Staph aureus and therefore this should be treated as cellulitis. Please refer to section on cellulilitis above.

Contaminated/infected laceration

If a laceration is contaminated it should be treated as follows:

Co-amoxiclav po tds for 5 days.

Penicillin allergy (rash):

Cefalexin po tds for 5 days.

Penicillin allergy (anaphylaxis):

Co-trimoxazole po bd plus clindamycin po qds for 5 days.

See tonsillitis in Ear, Nose and Throat section

Strep Group A infections can be clinically classified into 2 main groups:

• Non-invasive and treatable with oral antibiotics in the GP/outpatient setting and includes:
  • Pharyngotonsillitis
  • Cellulitis
  • Skin and wound infections (such as impetigo and chronic leg ulcers)
  • Scarlet fever (toxin mediated infection).
• Invasive and potentially life-threatening including:
  • Necrotizing fasciitis
  • Bacteraemia (including bacteraemic pneumonia)
  • Facial erysipelas
  • Streptococcal toxic shock syndrome.

Differentiation between non-invasive and invasive Strep Group A infection is important for appropriate clinical management. Because of the potential for non-invasive Strep Group A infections to be become invasive all clinical laboratory culture proven Strep Group A infections must be treated with antibiotics as follows:

Amoxicillin po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Strep Group A Pharyngo-tonsillitis section, under ENT - Sore throat section in the A&E guideline).

Penicillin allergy (rash)

Cefalexin po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Strep Group A Pharyngo-tonsillitis section, under ENT - Sore throat section in the A&E guideline).

Penicillin allergy (anaphylaxis)

Clarithromycin po bd for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Strep Group A Pharyngo-tonsillitis section, under ENT - Sore throat section in the A&E guideline).

A rapid-onset skin reaction is likely to be an inflammatory or allergic reaction rather than an infection.

Most insect bites or stings will not require antibiotics.

Advise patients:

1. That skin redness and itching are common and may last for up to 10 days
2. Avoid scratching as this may help reduce inflammation and the risk of infection
3. They should seek medical help if symptoms worsen significantly at any time or they become systemically unwell

Do not routinely offer antibiotics if there are no signs or symptoms of spreading cellulitis.

Patients may wish to consider oral antihistamines (in those over 1 year old) to help relieve itching.

If signs or symptoms of infection are present, treat as cellulitis. See cellulitis tab above.

Cefalexin po bd or tds (see cBNF for dosing) for 3 days - This is suitable for patients with penicillin allergy (rash).

If penicillin allergic (anaphylaxis):

Nitrofurantoin po qds for 3 days.

Antibiotic treatment

Cefuroxime 1.5g IV stat followed by 1.5g IV 8 hourly - this is appropriate in penicillin allergy rash

PLUS

Gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg

If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Penicillin allergy (anaphylaxis)

Ciprofloxacin 400mg IV stat followed by 400mg IV 12 hourly

PLUS

Clindamycin 1.2g IV stat followed by 900mg IV 8 hourly

PLUS

Gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg.

If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Antibiotic step down to oral treatment should be based on the antibiotic sensitivity results of the microbiologic culture. Contact Consultant Microbiologist if advice is required.

This includes patients readmitted after recent hospital discharge and hospital inpatients.

Piperacillin/tazobactam 4.5g IV stat followed by 4.5g IV 8 hourly

PLUS

Gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg.

If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Penicillin allergy (rash)

Meropenem 2g IV stat followed by 1g IV 8 hourly

PLUS

Gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg.

If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Penicillin allergy (anaphylaxis)

Ciprofloxacin 400mg IV stat followed by 400mg IV 12 hourly

PLUS

Clindamycin 1.2g IV stat followed by 900mg IV 8 hourly

PLUS

Gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg.

If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Antibiotic step down to oral treatment should be based on the antibiotic sensitivity results of the microbiologic culture. Contact Consultant Microbiologist if advice is required.

The following patients may be at increased risk of infection due to enteric Gram negative bacilli (coliforms):

• Elderley
• Patients with Diabetes
• Patients with rheumatoid arthritis or osteoarthritis
• Patients with underlying malignancy
• Patients receiving systemic steroid treatment

Antibiotic treatment:

IV treatment:

Flucloxacillin 2g IV stat followed by 2g IV 6 hourly

plus

Gentamicin 5mg/kg (4mg/kg if age > 70 years) IV single stat dose once only. If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

plus

Co-amoxiclav 1.2g IV stat followed by 1.2g IV 8 hourly.

Oral step down: Co-amoxiclav 625mg po tds.

Penicillin allergy (rash)

IV treatment:

Cefuroxime 1.5g IV stat followed by 1.5g IV 6 hourly

plus

gentamicin 5mg/kg (4mg/kg if age > 70 years) IV single stat dose once only. If the patient is obese See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Oral step down: Cefalexin 1g po qds.

Penicillin allergy (anaphylaxis)

IV treatment:

Clindamycin 1.2g IV stat followed by 900mg IV 8 hourly

plus

Gentamicin 5mg/kg (4mg/kg if age > 70 years) IV single stat dose once only. If the patient is obese see section on Therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

plus

Ciprofloxacin 400mg IV stat followed by 400mg IV 12 hourly.

Oral step down: Clindamycin 450mg po qds plus ciprofloxacin 500mg po bd.

In acute presentation the organism is likely to be Staph. aureus.

Flucloxacillin 2g IV 6 hourly. (If weight is over 85kg give flucloxacillin 2g IV 4 hourly).

Gentamicin should NOT be added to flucloxacillin for the initial treatment of native valve staphylococcal infective endocarditis.

There is no evidence that the addition of gentamicin results in improved survival, reduced surgery or reduced complications. This recommendation is unchanged from previous guidelines, but since their publication, analysis of data from a randomized controlled trial has confirmed previous findings of increased nephrotoxicity in patients. Furthermore there is no evidence that the addition of sodium fusidate or rifampicin to flucloxacillin offers any advantage in this setting. (Adapted from BSAC and AMH guidelines for the treatment of endocarditis).

Penicillin allergy:

Vancomycin 1g IV 12 hourly (modified according to renal function and plasma vancomyin levels) plus rifampicin 450mg IV 12 hourly.

See section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

When the patient is deemed fit to step down to oral antibiotic treatment contact Microbiology/Antimicrobial Management Team for advice.

Treatment duration is 4 weeks or longer.

Indolent presentation (sub acute bacterial endocarditis) the organisms are likely to be Streptococci.

Amoxicillin 2g IV four hourly plus gentamicin 1mg/kg IV 8 hourly (modified according to renal function and plasma gentamicin levels).

Penicillin allergy (rash):

Vancomycin 1g IV 12 hourly plus ceftriaxone 1g IV 12 hourly - only suitable if penicillin allergy (rash). This combination cannot cannot be given to patients who have anaphylaxis to penicillin.

Penicillin allergy (anaphylaxis):

Vancomycin 1g IV 12 hourly style="color:#000000">plus ciprofloxacin 400mg IV 12 hourly.

Herpes simplex virus type 1 encephalitis

Treatment:

Aciclovir 10mg/kg IV stat followed by 10mg/kg IV 8 hourly for 14 to 21 days.

Calculate dose using Ideal Body Weight in obese patients

IBW = 45.4 +[0.89 x (height {cm} – 152.4)] (+4.5 if male)

Herpes simplex virus type 2 meningitis

Treatment:

Aciclovir 10mg/kg IV 8 hourly, (can switch to oral valaciclovir 1g po tds when patient improves).

Total duration of treatment is 7 days.

Calculate dose using Ideal Body Weight in obese patients

IBW = 45.4 +[0.89 x (height {cm} – 152.4)] (+4.5 if male)

IV treatment: Piperacillin/tazobactam 4.5g IV 8 hourly.

Penicillin allergy (rash):

IV treatment: Ceftazidime 2g IV 8 hourly plus metronidazole 500mg IV 8 hourly.

Penicillin allergy (anaphylaxis):

IV treatment: Ciprofloxacin 400mg IV 12 hourly plus metronidazole 500mg IV 8 hourly.

Antibiotic treatment:

Cefuroxime 1.5g IV 8 hourly then cefalexin 1g po tds - this is suitable for patients with penicillin allergy (rash).

If biliary infection is associated with sepsis syndrome also give gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg

If the patient is obese see section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Penicillin allergy (anaphylaxis):

Ciprofloxacin 400mg IV 12 hourly then ciprofloxacin po 500mg bd.

If biliary infection is associated with sepsis syndrome also give gentamicin 5mg/kg IV as a single stat dose once only (4mg/kg if age > 70 years). Max dose 400mg.

If the patient is obese see section on therapeutic Drug Monitoring for guidance on gentamicin dose calculation.

Note: avoid ceftriaxone due to risk of biliary sludging.

Antibiotic treatment:

IV treatment: Cefuroxime 1.5g IV 8 hourly plus metronidazole 500mg IV 8 hourly - this combination is suitable for patients with penicillin allergy (rash).

Oral treatment: Cefalexin 1g po tds plus metronidazole 400mg po tds - this combination is suitable for patients with penicillin allergy (rash).

Penicillin allergy (anaphylaxis):

IV treatment: Ciprofloxacin 400mg IV 12 hourly plus metronidazole 500mg IV 8 hourly.

Oral treatment: Ciprofloxacin po 500mg bd plus metronidazole 400mg po tds.

Note: avoid ceftriaxone due to risk of biliary sludging.

WCC < 15, absence of rising creatinine and/or colitis.

Mild or resolving cases: No antibiotic treatment.

First episode or first relapse:Vancomycin 125mg po (not IV) QDS.

Second relapse/unresponsive to vancomycin:Metronidazole 400mg po tds (or 500mg IV 8 hourly).

Rapidly rising white cell count (often greater than 30x10*8/L), presence of rising creatinine and/or colitis.

Severe cases: Metronidazole 500mg IV 8 hourly plus vancomycin 500mg po (not IV) qds.

Consideration should also be given to the early administration of intravenous immunoglobulin 400mg/kg stat in cases of severe/life threatening pseudomembranous colitis and toxic megacolon.

If multiple relapses: Fidaxomicin 200mg po bd for 10 days.

FIDAXOMICIN MUST ONLY BE PRESCRIBED ON THE ADVICE OF THE CONSULTANT MICROBIOLOGIST.

Antibiotic treatment:

Oral treatment: Cefalexin 1g po tds - this is suitable for patients with penicillin allergy (rash).

if unable to take orally

IV treatment: Cefuroxime 1.5g IV 8 hourly - this is suitable for patients with penicillin allergy (rash).

Penicillin allergy (anaphylaxis):

Oral treatment: Ciprofloxacin 500mg po bd plus metronidazole 400mg po tds.

If unable to take orally

IV treatment: Ciprofloxacin 400mg IV 12 hourly plus metronidazole 500mg IV 8 hourly.