Tameside & Glossop Antibiotics Guidelines Web App

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Infected Olecrenon Bursitis

Bursitis occurs when the bursa is irritated and inflamed and is generally classified as.

Non-septic (most common) - sterile inflammation resulting from various causes including trauma or overuse.

Septic - infection resulting from seeding of the bursal sac with micro-organisms, usually bacteria. Olecranon bursitis is more common in:

Athletes who play sports which involve repetitive overhead throwing or elbow flexion and extension.
People in jobs which involve risk of regular elbow trauma or pressure on the bursa. For example gardeners and mechanics.
Young or middle-aged men.

Most cases of olecranon bursitis resolve without complications; however, recurrent episodes may occur especially after recurrent minor trauma.

1st choice - Flucloxacillin 1g QDS 5 days

2nd choice - Clindamycin 450mg QDS for 5 days

Osteomyelitis

Osteomyelitis could be suspected if the following are seen:

Wound probing to bone
sequestrated bone removed from wound
static ulceration not responding to treatment (first address soft tissue infection, mechanical causes, ischaemia, co-morbidities)
history of soft tissue infection increases suspicion
“Sausage toe”

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

Pharyngitis / Sore Throat / Tonsillitis

Acute Cough

Be aware that an acute cough:

is usually self-limiting and gets better within 3 to 4 weeks without antibiotics
is most commonly caused by a viral upper respiratory tract infection, such as a cold or flu
can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial
can also have other infective or non-infective causes.

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

Influenza

For further information on management of seasonal influenza please see NICE guidance

Please note this service is provided by Public Health Laboratory Manchester

Influenza diagnostic service for General Practice

INTRODUCTION

Public Health Laboratory Manchester provides a testing service for respiratory viral infections, including Influenza.
Primary Care leads will be notified by email once the enhanced service is operational. This will be when Influenza is circulating, either nationally (by CMO notification) or locally, whichever is sooner.

SAMPLES

If patients are producing sputum, please collect a sample in sputum pot.
For patients who are not producing sputum: Please send nose and throat swabs, combined in a single vial of virus transport medium (VTM). Please use one flocked swab to swab the nose and another one to swab the throat and then place both in a single vial of VTM.
If virus transport medium is not available, specimens can be taken using dry cotton or Dacron-tipped swabs but they should not be sent in charcoal transport medium.

REQUESTS

Respiratory virus testing, including Influenza can be requested on GP ICE.

RESULTS

Between Monday and Friday routine respiratory virus results will generally be available within 24 hours of receipt in the laboratory. Results for samples received after 09.00 on Saturday or during Sunday will be available on the following Monday.
Positive results will be telephoned to the requesting location during the following hours: 08.30-17.00 Monday to Friday and 08.30 to 12.30 on Saturday.
A dedicated mobile phone number (07973 870099) will be available (08:30 to 17:00 seven days a week) for chasing urgent results.

ADDITIONAL CONTACT DETAILS

For further information during normal working hours (Mon-Fri 9am-5pm and Saturday 09.00-12.30) please contact the laboratory (0161 2768854 Option 1).
Outside of normal working hours the duty consultant virologist can be contacted for urgent clinical and operational advice via the hospital switchboard (01612761234).

The current Department of Health advice should be followed.

Annual vaccination is essential for all those at risk of influenza.

Treatment is recommended when all of the following apply:

Influenza is known to be circulating in the community (indicated by national surveillance schemes).
The patient is in an ‘at-risk’ group.
The patient presents with influenza-like illness and can begin treatment within 48 hours of the onset of symptoms.

Oseltamivir 75mg BD for 5 days

Zanamivir 10 mg (2 inhalations via diskhaler) BD for 5 days (caution in asthma and COPD; there is a risk of bronchospasm so a short- acting bronchodilator should be available).

Prophylaxis is normally not considered in at-risk groups who have been vaccinated against seasonal influenza at least 14 days before exposure.
Prescribe an antiviral drug for post-exposure prophylaxis if all of the following circumstances apply:
- The national surveillance scheme indicates that influenza is circulating.
- The person has been exposed to a person (in the same household or residential setting) with an influenza-like illness.
- The person is in an 'at risk' group (see below for more information) and has not been adequately protected by vaccination, that is:
  - They have not been vaccinated since the previous influenza season.
  - The vaccination is not well matched to the circulating strain.
  - There has been less than 14 days between vaccination and date of contact with influenza.
- The person is able to start treatment within 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir).
  - Treatment after 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir) is an off-label use and should be done on specialist advice only.

Prophylaxis is also recommended for residents in chronic care establishments (regardless of influenza vaccination) using oseltamivir within 48 hours of influenza-like illness being present in the establishment.

Oseltamivir 75mg OD for 10 days (within 48 hours of contact)

Zanamivir 10mg (via diskhaler) OD for 10 days (within 36 hours of contact)

Chronic respiratory disease, including:
- Chronic obstructive pulmonary disease, including chronic bronchitis and emphysema, bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis, and bronchopulmonary dysplasia.
- Asthma that requires continuous or repeated use of inhaled corticosteroids or with previous exacerbations requiring hospital admission.
- Children who have previously been admitted to hospital for lower respiratory tract disease.
Chronic heart disease, including congenital heart disease, hypertension with cardiac complications, chronic heart failure, and individuals requiring regular medication or follow up for ischaemic heart disease.
Chronic kidney disease, including nephrotic syndrome, chronic renal failure, and renal transplantation.
Chronic liver disease, including cirrhosis, biliary atresia, and chronic hepatitis.
Chronic neurological disease, including stroke and transient ischaemic attack.
Diabetes, including type 1 diabetes and type 2 diabetes (requiring oral hypoglycaemic drugs or a controlled diet).
Immunosuppression due to disease or treatment, including:
- People undergoing chemotherapy (or radiotherapy) leading to immunosuppression.
- People with asplenia or splenic dysfunction.
- HIV infection (all stages).
- Individuals treated with, or likely to be treated with, systemic steroids for more than 1 month at dosages equivalent to 20 mg prednisolone daily (at any age) or, for children weighing less than 20 kg, a dose of 1 mg or more per kg body weight per day.
Morbid obesity (body mass index of 40 or more).

Consideration should also be given to:

People living in long-stay residential or nursing homes.
People who receive a carer’s allowance or care for disabled or elderley people, whose welfare may be at risk if the carer falls ill.

Pertussis (Whooping Cough)

There is increased pertussis activity in England and it is advised that the following actions should be taken:

Immunise: all infants must be immunised at the correct time to ensure they are protected as early as possible and prevent spread to vulnerable infants.
Notify: suspected cases must be reported to PHE North West on 0344 225 0562.
Treat: follow treatment recommendations by the PHE at: https://www.gov.uk/government/collections/pertussis-guidance-data-and-analysis
Test: the specimen taken will depend on the time of presentation. For patients presenting within 14 days of onset of cough, take a per nasal swab. For patients presenting after 14 days of onset of cough, take blood for serology.

Please can the following form also be completed and faxed or emailed to PHE

Registered medical practitioner notification form

Pharyngitis / Sore Throat / Tonsillitis

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.

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).

Otitis Media

Many cases are viral and otitis media resolves in 60% of cases without antibiotics within 24 hours. You need to treat 15 children aged over 2 years to get pain relief in one child, at 2 days. A poor outcome is unlikely if there is no vomiting and the temperature is below 38.5ºC. Recent evidence suggests that antibiotics seem to be most beneficial in children younger than 2 years of age with bilateral acute otitis media, and in children with both acute otitis media and otorrhoea.

Non-antimicrobial treatments

Offer regular doses of paracetamol or ibuprofen for pain. Use the right dose for the age or weight of the child at the right time, and use maximum doses for severe pain

Consider eardrops containing an anaesthetic and an analgesic for pain if an immediate antibiotic is not given, and there is no eardrum perforation or otorrhoea decongestants or antihistamines

Evidence on antibiotics Antibiotics make little difference to the number of children whose symptoms improve

Antibiotics make little difference to the number of children with recurrent infections, short-term hearing loss or perforated eardrum

Complications (such as mastoiditis) are rare with or without antibiotics. Possible adverse effects include diarrhoea and nausea.

Groups who may be more likely to benefit from antibiotics

• Children and young people with acute otitis media and otorrhoea (discharge following eardrum perforation) Children under 2 years with acute otitis media in both ears

2-3 days treatment may be sufficient so parents can stop the antibiotics before the end of the course if their child has recovered.

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

Otitis Externa

First use aural toilet and analgesics.

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

First line: Acetic acid 2% (e.g. Earcalm available over the counter) 1 spray TDS 7 days

Second line: Neomycin sulphate with corticosteroid (e.g. Otomize ear spray, 1 puff TDS or Betnesol N ear drops 3 drops TDS) 7 days min to 14 days max.

Advise patient to apply tragal pressure to help remove the debris.

AVOID IF PERFORATED TYMPANIC MEMBRANE.

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

Acute Rhinosinusitis

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

Reserve antibiotics for those with severe or persistent (10 days plus) symptoms. Steam inhalations will encourage drainage and can give relief. Use adequate analgesia. Consider delayed or immediate antibiotic when purulent nasal discharge.

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

Acute Pyelonephritis

Bacterial Prostatitis

Catheter-associated UTI

Recurrent UTI

Uncomplicated UTI in Females

UTI in Children

UTI in Males

UTI in pregnancy

Acute Pyelonephritis

Pyelonephritis is inflammation of the kidney which usually results from bacterial infection. It is important to differentiate pyelonephritis (upper urinary tract infection) from cystitis (lower urinary tract infection) in order to treat the patient appropriately. Pyelonephritis triggers a systemic response and symptoms include: fever, rigors, flank pain, nausea, vomiting and costovertebral angle tenderness, whereas symptoms of cystitis are more localised to the area of infection i.e. the bladder and include dysuria, urinary bladder frequency and urgency,and suprapubic pain.

Cefalexin 1g TDS for 10 days.

Penicillin allergy

Ciprofloxacin 500mg BD for 7 days.

Bacterial Prostatitis

Send a MSU off for culture and prescribe empiric antibiotics. Review antibiotic therapy when sensitivity results come back (refer to urologist).

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.

Catheter-associated UTI

Catheter-associated UTI occurs when bacteria in a catheter bypass the body's defence mechanisms and enter the bladder.
The longer a catheter has been in place the more likely bacteria will be found in the urine
Treatment is only needed for symptomatic catheter-associated UTI (apart from in pregnancy)
Removing or changing the catheter (especially if it has been in place for longer than 7 days) should be strongly considered.
Catheters should be reviewed and removed rather than changed if possible

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.

Recurrent UTI

Recurrent urinary tract infection (UTI) in adults is defined as repeated UTI with frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months.

Comprehensively assess the problem and refer to a specialist urologist or gynaecologist (for female patients).

Behavioural and personal hygiene measures:

Patients should be given advice about behavioural and personal hygiene measures to reduce the risk of UTI, such as:

- drinking enough fluids to avoid dehydration

- not delaying habitual and post-coital urination

- wiping from front to back after defaecation

- not douching or wearing occlusive underwear.

Cranberry products and D-mannose:

Some women find these effective, but there is currently poor evidence to support this and patients should be warned about the sugar content of these products if relevant. Cranberry products should be avoided by patients on warfarin.

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.

Uncomplicated UTI in Females

If there is fever, flank or back pain then it is likely to be an upper UTI and antibiotic treatment for 7 - 14 days is needed, (see pyelonephritis section).

If symptoms are mild the woman may wish to consider not taking antibiotics and simply increase her fluid intake as UTIs often resolve spontaneously in a few days.

If the woman has more than 3 typical symptoms of a UTI, and no vaginal discharge, then treat empirically with antibiotics as below.

If the woman has 2 or less, or mild symptoms, obtain a urine sample. If the urine is NOT cloudy this gives a 97% negative predictive value, so do not treat unless other risk factors of infection are present.

If urine is cloudy then perform a urine dipstick test containing nitrite and leucocyte esterase impregnated reagent. If the results are negative for leucocytes and nitrites then there is a 95% negative predictive value. If both are positive, or nitrite or leucocyte esterase are positive, then treat. However, if only leucocytes are positive only treat if symptoms are severe and send urine for culture.

DO NOT PERFORM URINE DIPSTICK TESTS IN THOSE OVER THE AGE OF 65 YEARS

1st choice: Pivmecillinam 400mg STAT for the first dose followed by 200mg TDS for 3 days (this is a penicillin)

2nd choice: 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

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).

UTI in Children

Send a MSU for culture and rule out or manage associated conditions (e.g. constipation, urinary tract obstruction). In a child over 60 days old with mild symptoms or another possible cause a urine dipstick test can be performed. If negative for nitrites and leucocyte esterase, antibiotics can be delayed until culture results become available. With moderate symptoms start antibiotics and review treatment when the culture results are back.

NICE guidelines also state that the locally agreed choices should be followed.

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.

UTI in Males

Always send a MSU off to the lab for culture. Consider a diagnosis of prostatitis and refer if necessary. In sexually active young men with urinary symptoms consider Chlamydia trachomatis and other sexually transmitted infections.

DO NOT PERFORM URINE DIPSTICK TESTS IN THOSE OVER THE AGE OF 65 YEARS

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.

UTI in Pregnancy

A MSU (mid stream urine sample) should be sent off for culture at the first antenatal visit, as asymptomatic bacteriuria can be associated with pyelonephritis and premature delivery. If the patient presents with signs of a UTI send off a MSU for culture.

Treat empirically until sensitivity data comes back. Repeat the MSU 7 days after treatment has been completed to ensure the infection has been eradicate.

ORAL TREATMENT:

1st line: Pivmecillinam 400mg STAT then 200mg TDS (this is a penicillin-containing antibiotic)

2nd line: Nitrofurantoin 100mg MR BD - AVOID AT TERM (from 37 weeks).

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.

Acne

Cellulitis

Chicken Pox

Dermatophyte Infection of the Skin

Diabetic Foot Infection

Fungal Nail Infections

Human and Animal Bites

Impetigo

Insect Bites and Stings

Leg Ulcers / Pressure Sores

Scarlet Fever

shingles

Strep Group A

Mastitis

Hidradenitis Suppurativa

Insect Bites and Stings

Please note that 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:

That skin redness and itching are common and may last for up to 10 days
Avoid scratching as this may help reduce inflammation and the risk of infection
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.

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

Human and Animal Bites

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

Antibiotic prophylaxis is recommended for all wounds under 72 hours old even if there is no sign of infection. Consider if tetanus prophylaxis is needed. Assess the HIV, hepatitis B and C and syphillis risk and if necessary discuss with a Consultant in Communicable Disease Control.

If the skin is not broken just clean it, but if the skin is broken irrigate it with warm, running water. Send the patient to ED if severe.

Check tetanus status and immunise if necessary. Prophylaxis is advised for puncture wounds, any bite involving the hand, face, foot, joint tendon or ligament, and in immunocompromised, diabetic, asplenic or elderley patients.

If treating an insect bite then treat as cellulitis. True cellulitis is a systemic infection and you would expect some systemic signs and symptoms, please ensure an infection is confirmed as all insect bites do not need to be treated with antibiotics. (See cellulitis for treatment of infected insect bites)

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.

Cellulitis

True cellulitis is a systemic infection and you would expect some systemic signs and symptoms.

This treatment also applies if there is spreading cellulitis resulting from an insect bite (please ensure an infection is confirmed as all insect bites do not need to be treated with antibiotics).

If there is history of exposure to fresh water, i.e. rivers or streams (Aeromonas hydrophilia) at the site add ciprofloxacin (750 mg twice daily 7 days) and if there is history of exposure to salt water (Vibrio vulnificus) add doxycycline (200mg stat then 100mg daily 7 days total).

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

Please refer to the full guidance distributed for the community IV cellulitis pathway

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.

Cellulitis Antibiotic Formulary (Treat only until acute inflammation disappears)
ERON CLASS I
Antibiotic	Route	Dose	Frequency	Duration	Review
Flucloxacillin	Oral	1g	QDS	3 days	Day 4
In penicillin allergy:
Clarithromycin	Oral	500mg	B.D.	3 days	Day 4
ERON CLASS II
Oral treatment
Antibiotic	Route	Dose	Frequency	Duration	Review
Flucloxacillin Plus Clindamycin	Oral Oral	1g 450mg	QDS QDS	3 days 3 days	Day 4 Day 4
In penicillin allergy:
Clindamycin	Oral	450mg	QDS	3 days	Day 4
IV treatment
Flucloxacillin via Elastomeric pump	IV	8g	24 hours	3 days	Day 4
In the case of chemical phlebitis From pump-Change to Clindamycin	Oral	450mg	Q.D.S.	3 days	Day 4
In penicillin allergy:
Teicoplanin
If 50-70kg	IV	Day 1 = 800mg	Stat	3 days	Day 4
If 50-70kg	IV	Day 2 & 3 = 10mg/kg	Once daily	3 days	Day 4
If > 70kg	IV	Day 1 = 12mg/kg	Stat	3 days	Day 4
If > 70kg	IV	Day 2 & 3 = 10mg/kg	Once daily	3 days	Day 4
Do pre-dose level before 4^th dose and if outside the therapeutic range, discuss with Microbiologist/Antibiotic Pharmacist before resuming treatment.
If eGFR<30ml/min dose of teicoplanin should be obtained from Antibiotic Pharmacist.

Dermatophyte Infection of the Skin

Take skin scrapings for culture. Topical azoles, clotrimazole 1 % or miconazole 2 %, are useful if you are not sure if there is Candida or dermatophyte infection. The azoles can take 4–6 weeks to work. Topical terbinafine 1% although more expensive can work with in a week. Consider oral treatment only if disease is extensive or severe (however, consider referral) or if topical treatment has failed. Discuss scalp infections with a specialist

Diabetic Foot Infection

The recommendations for treatment of DFI have been made following discussion with Abigail Hall (High Risk Foot Team Podiatrist) and Dr Haris Rathur (Consultant for Adult Medicine).

Refer to Diabetes Service

email: integrated.diabetes@tgh.nhs.uk (Contact High Risk Foot Podiatry on0161 922 4888)

All patients with Diabetic Foot Ulcers MUST be under the care of a Podiatrist

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

Leg Ulcers / Pressure Sores

Bacteria will always be present and therefore culture swabs of deeper tissues should be taken and not slough or necrotic tissue. Systemic antibiotics are only indicated if there is evidence of clinical infection (e.g. increasing pain, pyrexia, spreading cellulitis, tissue induration, enlarging ulcer).

In the absence of systemic features of infection, only topical treatment without the addition of systemic antibiotic is indicated for these patients

Refer adults with an infected leg ulcer to hospital if they have any symptoms or signs suggesting a more serious illness or condition, such as sepsis, necrotising fasciitis or osteomyelitis.

In consultation with the community tissue viability team, either:

Flamazine (silver sulphadiazine) cream for non-exudative wounds

Apply at every dressing change

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)

Shingles (Herpes Zoster)

Antivirals should be started within 72 hours of onset of the rash.

They should be used in adults over 50 years, in the immunocompromised, in anyone with ophthalmic involvement, in anyone in severe, acute pain or with an extensive rash; they can also be used in people who are likely to come in close contact with “at risk” groups (e.g. immunocompromised, pregnancy).

Specialist advice should be sought for immunocompromised patients.

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

2. Valaciclovir 1g TDS for 7 days

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).

Strep A Group Infection

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 Pharyngitis / Tonsillitis section in primary care guidelines.

Penicillin allergy

Clarithromycin 500mg BD for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Pharyngitis / Tonsillitis section in primary care guidelines.

Impetigo

In those with uncomplicated impetigo

Explain the diagnosis and provide written information.

A patient information leaflet on Impetigo can be downloaded from the British Association of Dermatologists website at www.bad.org.uk.
Reassure the person that impetigo usually heals completely without scarring, and that serious complications are rare.
Advise the person that hygiene measures are important to aid healing and stop infection spreading to other areas of the body and to other people.
Recommend that the person:
- Washes affected areas with soap and water.
- Washes their hands regularly, in particular after touching a patch of impetigo.
- Avoids scratching affected areas.
- Avoids sharing towels, face cloths, and other personal care products and thoroughly cleans potentially contaminated toys and play equipment.
Inform the person of Public Health England exclusion recommendations:
- Children and adults should stay away from school and other childcare facilities or work until lesions are healed, dry and crusted over or 48 hours after initiation of antibiotics.
- Food handlers are required by law to inform employers immediately if they have impetigo.
Ensure optimal treatment of any pre-existing skin conditions such as eczema, head lice, scabies or insect bites.

Mupirocin should be reserved for MRSA. If widespread or long standing impetigo use systemic antibiotics.

Do not offer combination treatment with a topical and oral antibiotic to treat impetigo.

Ensure a review is undertaken to ensure sustained improvement or the need to escalate treatment.

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:

Age	Dose
1 month to 1 year	62.5mg - 125mg QDS
2 years to 9 years	125mg - 250mg QDS
10 years to 17 years	250mg - 500mg QDS

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:

Age	Dose
1 month to 1 year	62.5mg - 125mg QDS
2 years to 9 years	125mg - 250mg QDS
10 years to 17 years	250mg - 500mg QDS

If child weighs over 50kg use adult doses.

Penicillin allergy

Clarithromycin 500mg BD for 5 days

(see BNFc for doses in children)

Acne

Topical treatment

In mild acne initial treatment should consist of topical benzoyl peroxide or a topical retinoid. Topical antibiotics may be used in moderate acne, or where there is treatment failure or intolerance to treatment in mild acne. Topical antibiotics should be used in combination with benzoyl peroxide (if tolerated) as this combination is more effective than using either drug in isolation, and because it limits the development of antibiotic resistance. Topical antibiotics should not be combined with topical retinoids as this combination may promote bacterial resistance.

Topical antibiotic treatment should not be used long-term and should be stopped after 6-8 weeks. Consider switching to benzoyl peroxide at this point.

Oral treatment

Oral antibiotics may be considered in patients where topical treatment is not tolerated, there is moderate acne on the shoulders or back where it may be extensive or difficult to reach, or if there is a significant risk of scarring or pigment changes. Oral antibiotics may be combined with topical benzoyl peroxide or a topical retinoid, or both if tolerated. Oral and topical antibiotics should not be prescribed for concomitant use. Oral antibiotics may need to continue for 3 months before a response to treatment is seen.

Lymecycline 408mg OD

If not tolerated or pregnant/breastfeeding:

Erythromycin 500mg BD

Fungal Nail Infections

If you suspect a dermatophyte infection of the proximal fingernail or toenail, take nail clippings for fungal culture. Only start treatment if infection is confirmed by the laboratory. This condition is rare in children so refer them for specialist advice.

For superficial infections only

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

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

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.

Chicken Pox

Always seek specialist advice for treatment and prophylaxis in pregnant women. For advice during normal working hours, contact the Clinical Virology department at Central Manchester University Hospitals on 0161 276 8853, and for clinical advice out of hours, telephone 0161 276 1234 and ask for the duty Consultant Virologist.

In healthy adults and children with uncomplicated chickenpox no antiviral treatment is recommended. Antivirals are indicated in all patients who are immunocompromised and always seek specialist advice for these patients. If the patient is severely immunocompromised they will need hospital referral for intravenous aciclovir as well as varicella zoster immunoglobulin. Antivirals should be used in an adult with clinical toxicity within 24 hours of onset of the rash using the same doses as in shingles.

Aciclovir 800mg orally five times for 7 days

Mastitis

Lactational

Most cases of lactational mastitis are not caused by an infection and do not require antibiotics. Advice is to take paracetamol or ibuprofen to reduce pain and fever, drink plenty of fluids, rest and apply a warm compress. Breastfeeding: oral antibiotics are safe and appropriate, where indicated. Women should continue feeding, including from the affected breast and be advised to monitor the child for adverse drug reactions e.g. diarrhoea and thrush.

Non-Lactation

If immediate admission or referral is not indicated then prescribe an oral antibiotic for all women with non-lactational mastitis. Advise the woman to seek immediate medical advice if symptoms worsen or fail to settle after 48 hours of antibiotic treatment.

Flucloxacillin 1g QDS for 10 days

Penicillin allergy (if rash)

Cefalexin 1g TDS for 10 days

If symptoms fail to settle after 48 hours of first-line antibiotic treatment:

Check that the woman has taken the antibiotic correctly.
Consider the possibility of an alternative diagnosis (such as breast cancer or a breast abscess) and the need for admission or referral.
- If an abscess is suspected, be aware that malaise and fever may have subsided if antibiotics have been started.

If truly penicillin allergic then please contact Consultant Microbiologist or Antibiotic Specialist Pharmacists for advice

Scarlet Fever

See Tonsillitis section on the Upper Respiratory Infection page

Hidradenitis suppurativa

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

Clindamycin 300mg BD

Plus

Rifampicin 300mg BD

for about 10 – 12 weeks

Conjuctivitis

Only treat if severe, as most cases are viral or self limiting and 65% tend to resolve on placebo by day 5. Bacterial conjunctivitis is usually unilateral and also self limiting. It is characterised by mucopurulent red eyes and not watery discharge.

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

Meningitis

Rapid transfer to hospital remains the highest priority whether or not penicillin is given – minutes are precious. Provided it does not cause a delay in admission, benzylpenicillin should be administered as soon as meningococcal disease is suspected. PHE recommends all GPs carry benzylpenicillin and it should be given whilst transfer to hospital is being arranged.

If a patient with suspected meningitis without a non-blanching rash cannot be transferred to hospital urgently, antibiotics should also be given. Benzylpenicillin is the antibiotic of choice however cefotaxime can be given in penicillin allergy. NICE guidance states, ‘a history of a rash following penicillin is not a contraindication.’ However if there is a clear history of anaphylaxis after a previous dose of penicillin or cephalosporin arrange urgent transfer without administering antibiotics.

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

Consider a diagnosis of Chlamydia infection in anyone who is (or has been) sexually active who presents with a genital infection.

To identify Chlamydia infection first catch urine sample after holding urine in bladder for at least 1 hour, can be sent to the laboratory at Tameside General Hospital. A test for Chlamydia on first catch urine is very reliable and the specimen is also tested for gonorrhoea. Gonorrhoea positive cases should be referred for management by a GUM clinic where swabs for culture and sensitivity will betaken and contact tracing will be carried out.

Refer patients to Locala Sexual Health on 0161 507 9460 for contact tracing and further management

Bacterial Vaginosis

Candidiasis

Chlamydia

Epididymo - Orchitis

Gonorrhoea

Infected Bartholin's Cyst/Abcess

Pelvic Inflammatory Disease

Trichomoniases

Bacterial Vaginosis

A seven day course of metronidazole is slightly more effective than 2g stat.

Clindamycin gel is expensive but is a useful alternative if metronidazole cannot be tolerated

Metronidazole 400mg BD for 7 days

Metronidazole 2g STAT

Metronidazole vaginal gel 0.75% 5g nightly for 5 nights

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.

Candidiasis

Many products are available over the counter, so check whether the patient has already self-treated. Systemic treatments are best reserved for failures of topical treatment and for patients who prefer oral treatment to topical.

Clotrimazole 10% vaginal cream 5g single dose

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).

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.

Chlamydia

It is recommended that management of Chlamydia should be undertaken at Ashton Primary Care Sexual Health Clinic.

The majority of sexually transmitted infection (STI) guidelines have until recently recommended a 1g single dose of azithromycin or 7 days of doxycycline as standard treatment for uncomplicated urogenital and oral chlamydia infection. Mycoplasma genitalium is emerging as a significant sexually transmitted pathogen and coinfection rates of 3%-15% with chlamydia have been reported. Recent data demonstrate an increasing prevalence of macrolide resistance in Mycoplasma genitalium , likely due to the widespread use of azithromycin to treat STIs, and the limited availability of diagnostic tests for Mycoplasma genitalium.

As a consequence of its potential to select for macrolide resistance in Mycoplasma genitalium and its inadequacy as a treatment for rectal CT, the British Association for Sexual Health and HIV (BASHH) no longer recommends azithromycin for treatment of uncomplicated chlamydia infection at any site, regardless of the gender of the infected individual.

Doxycycline 100mg bd for 7 days is now recommended as first line treatment for uncomplicated urogenital, pharyngeal and rectal chlamydia infections, with test of cure (TOC) for diagnosed rectal infections

Test of cure (TOC )is not routinely recommended for uncomplicated genital chlamydia infection, because residual, non-viable chlamydial DNA may be detected by NAAT for 3–5 weeks following treatment.

TOC is recommended in pregnancy, where poor compliance is suspected and where symptoms persist.

Contacts of chlamydia positive patients should be treated immediately rather than waiting for a positive result. A urine specimen must be taken before treatment is commenced.

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.

Epididymo-Orchitis

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

ofloxacin 200mg po bd for 14 days.

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

Gonorrhoea

Because of varying antibiotic sensitivities gonorrhoea can be difficult to treat, and a test of cure is important. It is recommended that management of gonorrhoea should be undertaken at Ashton Primary Care Sexual Health Clinic, particularly in a climate of emerging antibiotic resistance.

Infected Bartholin's cyst/abscess

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.

Pelvic Inflammatory Disease

Take appropriate specimens for chlamydia and gonococci then give a choice of treatment regimen as indicated below. Note that all Gonorrhoea positive cases should be referred for treatment to a GUM clinic.

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

Trichomoniasis

As this is a sexually transmitted infection treatment of the partner is important. Other sexually transmitted infections may be present as well as Trichomonas. Refer to GUM clinic for confirmation of diagnosis, treatment and partner notification. There is emerging evidence that pregnant women with Trichomoniasis should be treated, but there is no alternative to Metronidazole. Wait until the second trimester before treating with 400mg twice daily for 7 days.

Metronidazole 400mg BD for 7 days

Metronidazole 2g stat

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

Many infections are viral but the principal bacterial pathogens in acute lower respiratory tract infections are Streptococcus pneumoniae (which is the most common cause of community-acquired pneumonia), Haemophilus influenzae and atypical organisms such as Legionella and Mycoplasma. Staphylococcus aureus lower respiratory infections can occur as a complication following influenza. Pseudomonas may be isolated from sputum cultures but, in the community, this would usually reflect colonisation and should not be treated; it may be helpful to discuss with a microbiologist if in doubt. Avoid use of low dose amoxicillin which may encourage bacterial resistance. Note that excessive use of quinolones (e.g. ciprofloxacin) and co-amoxiclav is implicated in development of MRSA and Clostridium difficile infections.

Acute Bronchitis

Acute Exacerbation of Bronchiectasis

Acute Exacerbation of COPD

Community-Acquired Pneumonia

Acute Bronchitis

Systematic reviews indicate antibiotics have marginal benefits in otherwise healthy adults. Explain to patients why they have not been prescribed antibiotics. Consider prescribing antibiotics for people who have a pre-existing co-morbid condition that impairs their ability to deal with infection or is likely to deteriorate with acute bronchitis. Consider immediate antibiotics in patients over 80 years old and ONE of: hospitalisation in past year, oral steroids, diabetic, congestive heart failure OR over 65 years with 2 of the above.

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.

Acute Exacerbation of Bronchiectasis

An acute exacerbation of bronchiectasis is sustained worsening of symptoms from a person’s stable state.

When choosing antibiotics, take account of:

the severity of symptoms
previous exacerbations, hospitalisations and risk of complications
previous sputum culture and susceptibility results.

NICE (2019) recommends to send a sputum sample for culture and susceptibility testing and then offer an antibiotic. Also, when results of sputum culture are available:

review choice of antibiotic
only change antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving, using narrow spectrum antibiotics when possible.

Refer to hospital if the person has any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis).

Seek specialist advice if:

symptoms do not improve with repeated courses of antibiotics
bacteria are resistant to oral antibiotics
the person cannot take oral medicines (to explore giving intravenous antibiotics at home or in the community if appropriate)

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

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 Legionella is suspected: Add Clarithromycin 500mg BD for 7-14 days to amoxicillin

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.

Acute exacerbation of COPD

About up to 50% of cases are viral, 30-50% are bacterial and the rest are undetermined. Antibiotics are not indicated in the absence of purulent/mucopurulent sputum especially if not associated with increased dyspnoea or clinical toxicity.

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.

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)

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 Legionella is suspected: Add Clarithromycin 500mg BD for 5 days to amoxicillin

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.

Community-acquired Pneumonia

The intensity of pneumonia in the community can be assessed using the CRB65 score; each factor scores one point:

confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place, or time);
a raised respiratory rate (30 breaths per minute or more);
a low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg);
age 65 years or over.

Score 1 or 2: intermediate risk (1-10% mortality risk).

Score 3 or 4: high risk (more than 10% mortality risk)

For life-threatening illness or where hospital admission is likely to be delayed, give intravenous Benzylpenicillin 1.2g (give intramuscular if a vein cannot be found) or oral Amoxicillin 1g immediately.

If it is felt that blood cultures are required, due to severity of illness, then the patient should be referred to secondary care. It is vital that blood cultures are taken by someone who is appropriately trained to do so, reducing the chances of contamination.

NB: it is recognised that due to increased remote consultations it may not always be possible to obtain a BP reading. Some patients may have suitable equipment at home, assisting the clinician in making an assesment. The antibiotic choices have been amended to help with this in this current climate.

CRB score	Antibiotic choice (5 day treatment)
CRB = 0	Amoxicillin 1g TDS OR Clarithromycin 500mg BD
CRB = 1-2	Amoxicillin 1 g TDS PLUS Clarithromycin 500mg BD OR Doxycycline 200 mg STAT then 100 mg BD (suitable for penicillin allergy)
CRB = 3-4	Consider urgent hospital admission

Post influenzal pneumonia can be due to S. aureus which usually requires hospital admission because of the clinical severity of staphylococcal pneumonia. Following recovery consider pneumococcal vaccination.

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.

Introduction

Key DoH Recommendations

Prevention & Treatment of HCAIs

Introduction

In December 2003 The Department of health published a National Plan that set out the actions to control the transmission of Healthcare Associated Infections, Winning Ways: Working Together to reduce Healthcare Associated Infections in England. ‘Action area Five’ of the plan refers to the ‘Prudent use of Antibiotics’. The key issue states that: ‘Indiscriminate and inappropriate use of antibiotics to treat infection within a clinical service promotes the emergence of antibiotic resistant organisms and ‘super bug’ strains.

Key DoH Recommendations

Antibiotics normally to be used only after a treatable infection has been recognised or there is a high degree of suspicion of infection.
Choice of antibiotic normally to be governed by local information about trends in antibiotic resistance or a known sensitivity of the organism.
Antibiotics only to be taken by patients over the prescribed period at the correct dose.
Prescription of the antibiotics for children to be carefully considered; they are often unnecessarily prescribed for common viral infections and the child is subsequently more likely to develop antibiotic resistance.
Support for prudent antibiotic prescribing to be provided by clinical pharmacists, medical microbiologists and infectious disease physicians.
Antibiotics to be used for prevention of infection only where benefit has been proven.
Narrow-spectrum antibiotics to be preferred to the broad-spectrum groups.

Prevention of HCAIs

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.

For the purpose of preventing CDI, the main component of an antibiotic policy should be:

The avoidance of unnecessary antibiotic use.
The use of narrow spectrum antibiotics whenever the causative pathogen is known.
Review of “blind” empiric antibiotic therapy as soon as the causative pathogen has been identified.
Avoidance, wherever possible, of the use of antibiotic ‘cocktails.’
Regular (daily if possible) prescription review to ensure that antibiotics are discontinued as soon as possible.

If a patient is deemed suitable for intravenous antibiotic therapy they may be treated at home with intravenous antibiotics in accordance with the OPAT pathways. If CDI is known to be a problem;

It should be noted that parenteral aminoglycosides (e.g. gentamicin), when given alone, have seldom been associated with CDI, although their potential serious toxicity must be recognised.
Consideration should be given to whether the intramuscular or intravenous route should be used, since parenteral antimicrobials can be less likely than oral preparations to predispose to CDI.

For further information on the prevention and control of CDI, please refer to the Infection Prevention Team on 0161 922 6194, C.difficile Policy or contact the Microbiologist, for advice on individual cases if required.

It is important to exclude non-infectious causes of diarrhoea, such as laxatives, high-energy feeds or inflammatory bowel disease. Usual diarrhoeal pathogens, notably Salmonella, Shigella, Campylobacter, E coli 0157 should be tested for.

Consideration should be given to the possibility of norovirus (depending on the time of year).

Treatment should be initiated after receiving a positive result from a stool sample if the diarrhoea is not settling within about 72 hours and the decision to treat should be based on the clinical condition of the patient, i.e. either acutely ill or otherwise well despite their diarrhoea. It is important to palpate the abdomen which in the acutely ill patient would be tender with distension versus soft, non-tender, not distended in the patient who is well. Withdraw antibiotics if possible. Mild cases will often resolve without treatment if antibiotics are stopped. Consider stopping PPIs if possible.

Metronidazole 400 mg TDS for 3 to 10 days depending on clinical response.

Consider also a probiotic yoghurt drink (Actimel) 100ml twice a day for 7 days.

Refractory disease:

Vancomycin 125 mg QDS for 3 to 10 days depending on clinical response.

Antibiotics can be stopped for CDI as soon as the diarrhoea settles and the patient is not acutely ill or debilitated and there is no abdominal pain or tenderness. Good hygiene is important to prevent re-infection; patients should wash their hands after using the toilet and before eating with soap and water. Patients who do not respond to the above treatment can be discussed with the hospital microbiologists.

As the lab is now located at MRI for Tameside they will automatically test for clostridium difficile toxin if the stool fits a certain criteria. Another positive toxin test will count as another case for Tameside local office.

If a patient has previously been tested positive for CDI and symptoms have now recurred please contact the Infection Prevention Team on 0161 922 6194

Consultant Microbiologist on 0161 922 4086 (Dr Sacho) / 0161 922 6500 (Dr Unsworth)

BEFORE sending another sample for advice.

This is to ensure whether a repeat sample is required.

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.

Effective control measures are less well understood than for other types of antibiotic resistant bacteria for example C. difficile. Until we know more about how to control these bacteria it is suggested that;
All care establishments should ensure that hand washing and other infection control procedures are rigorously enforced. Visitors and patients should also practice good hand hygiene
In some circumstances patients with ESBL producing bacteria will be isolated whilst in hospital to prevent spread to others
Individuals known to be colonised should not share a room with someone with a urinary catheter or IV line.
Minimising the use of antibiotics is crucial in helping reduce spread.
Thorough cleaning should also be undertaken to maintain a clean and safe environment
For further information on the prevention and control of ESBL infections, please refer to the Tameside local office Infection Prevention Service.

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 Tissue Viability Nurse Specialist).
Advice on good personal and home hygiene must be given to promote a reduction in MRSA colonisation.

For further information on the prevention and control of MRSA colonisation / infections, please refer to the Tameside local Infection Prevention Service MRSA Policy or contact the Microbiologist, or the Tameside local Infection Prevention Service staff, for advice on individual cases, if required.

The need for systemic antibiotic therapy should be considered in immunocompromised patients or those with severe disease, based on clinical judgement and local susceptibilities of strains. It is important to ensure empiric treatment also provides cover against Streptococcus pyogenes. Contact the Microbiologist for advice, if required.

Headlice

Scabies

Threadworm (Enterobius Vermicularis)

Headlice

Advise the individual or parent to use detection combing on wet or dry hair to confirm head lice infestation. All close contacts and household members should be checked. Only the presence of live lice confirms infestation and then treatment is necessary. There are 3 treatment options, none of which are 100 % effective, which can be discussed with the patient or parent.

1. Insecticide

2. Dimeticone

3. Wet combing

The latter 2 options are suitable in pregnancy and breastfeeding.

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.

Scabies

Treat the patient and all members of the household, close contacts and sexual contacts with a topical insecticide within 24 hours.

Permethrin 5 % dermal cream

should be used as first line treatment. Most adults should only need one tube of cream. The cream should be washed off after 8–12 hours.

Malathion 0.5 % aqueous solution

can be used second line if permethrin is unsuitable (e.g. if the patient is allergic to chrysanthemums) and washed off after 24 hours.

If any treated areas are washed during the application time, the cream/lotion must be reapplied. The insecticide should be applied twice with applications one week apart. Treat the whole body including scalp, face, neck, ears and under the nails. Treating the face and scalp is important in the immunocompromised, very young and elderley. Refer if there is crusted scabies or if there have been multiple treatment failures.

Threadworm (Enterobius Vermicularis)

Treat both the patient and all household members unless contraindicated. Good hygiene is very important in breaking the lifecycle of the worms:

Hands should be washed after using the toilet and nails should be kept short.
Showering or bathing in the morning, washing around the anus, is recommended.
Underpants should be worn at night in bed and changed every morning
Sleepwear and bedding should be washed
Dusting and vacuuming of the surroundings (especially bedrooms) should be done and damp-dusting of the bathroom.

Hygiene methods should be used for 2 weeks if drug treated; in those who do not receive drug treatment ,e.g. under 3 months, pregnant or breastfeeding women, they should be continued for 6 weeks.

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.

Clostridioides Difficile Infection

Diverticulitis

Eradication of Helicobacter Pylori

Gastroenteritis

Oral Candidiasis (Oral Thrush)

Threadworm

Travellers Diarrhoea

Clostridioides Difficile

Vancomycin 125mg QDS for 3 to 10 days depending on clinical response.

Refractory disease:

Metronidazole 400mg TDS for 3 to 10 days depending on clinical response.

Diverticulitis

Cefalexin 1g TDS for 5 days.

Penicillin allergy (anaphylaxis):

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

Helicobacter Pylori

Eradication is beneficial in duodenal ulcers, gastric ulcers and low grade MALT lymphoma but not in GORD.

In non ulcer dyspepsia only 8 % of patients benefit.

13Ca urea breath test or stool antigen test are the favoured diagnostic tests. The tests require a 4 week washout period for antibiotics and a 2 week washout period for PPIs.

PHE guidance recommends that clarithromycin, metronidazole or quinolone should not be used if the patient has received these antibiotics in the past year for any infection.

Treatment duration:

7 days in total, but 14 days in MALToma

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

Gastroenteritis

Check the patient’s travel, food, hospitalisation and antibiotic history (CDI).

Fluid replacement is the mainstay of treatment. Antibiotic therapy is not usually indicated because food -borne associated gastroenteritis is usually a self-limiting condition, and treatment only reduces diarrhoea by 1–2 days and can cause antibiotic resistance.

Initiate antibiotics, on the advice of the microbiologist, if the patient is systemically unwell (ongoing pyrexia, diarrhoea, dehydration, and clinical toxicity). If the patient has suspected food poisoning or CDI, send a stool specimen to the lab. These conditions can then be treated according to the results.

7 days in total, but 14 days in MALToma

Oral Candidiasis (Oral Thrush)

Oral candidiasis tends to occur most commonly in babies, people who wear dentures or use inhaled corticosteroids and in immunocompromised patients. Antibiotic use can also predispose to the development of oral candidiasis.

If a patient has oral thrush and is otherwise healthy treatment should be given.

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

Threadworm

See Threadworm section on the Parasites page

Traveller's Diarrhoea

Pre-travel: provide advice on prevention and consider vaccination if appropriate. A ‘just in case’ course of antibiotics may be carried by people travelling to remote areas and for people in whom an episode of infective diarrhoea could be dangerous. If used in this way Azithromycin 500mg OD for 3 days should be prescribed.

This should be prescribed as a private prescription and not on an NHS FP10 prescription. If quinolone resistance is high e.g. South Asia consider bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis for 2 days.

There is also a drug called Rifaximin available which is indicated for the treatment of travellers' diarrhoea that is not associated with any of:

Fever
Bloody diarrhoea
Eight or more unformed stools in the previous 24 h
Occult blood or leucocytes in the stool.

Dose of Rifaximin is 200mg TDS for 3 days. This can also be used as an alternative especially in areas of high quinolone resistance.

Post-travel: send a stool sample to the lab for culture if the patient is systemically unwell or symptoms persist, obtain advice from microbiologist before initiating empiric treatment. If the patient is very ill admit to hospital.

Osteomyelitis Suspected

Osteomyelitis could be suspected if the following are seen:

Wound probing to bone
sequestrated bone removed from wound
static ulceration not responding to treatment (first address soft tissue infection, mechanical causes, ischaemia, co-morbidities)
history of soft tissue infection increases suspicion
“Sausage toe”

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

Acute Cough

Acute Rhinosinusitis

Influenza

Otitis Externa

Otitis Media

Pharyngitis

Acute Cough

Be aware that an acute cough:

is usually self-limiting and gets better within 3 to 4 weeks without antibiotics
is most commonly caused by a viral upper respiratory tract infection, such as a cold or flu
can also be caused by acute bronchitis, a lower respiratory tract infection, which is usually a viral infection but can be bacterial
can also have other infective or non-infective causes.

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

Influenza

For further information on management of seasonal influenza please see NICE guidance

Please note this service is provided by Public Health Laboratory Manchester

Influenza diagnostic service for General Practice

INTRODUCTION

Public Health Laboratory Manchester provides a testing service for respiratory viral infections, including Influenza.
Primary Care leads will be notified by email once the enhanced service is operational. This will be when Influenza is circulating, either nationally (by CMO notification) or locally, whichever is sooner.

SAMPLES

If patients are producing sputum, please collect a sample in sputum pot.
For patients who are not producing sputum: Please send nose and throat swabs, combined in a single vial of virus transport medium (VTM). Please use one flocked swab to swab the nose and another one to swab the throat and then place both in a single vial of VTM.
If virus transport medium is not available, specimens can be taken using dry cotton or Dacron-tipped swabs but they should not be sent in charcoal transport medium.

REQUESTS

Respiratory virus testing, including Influenza can be requested on GP ICE.

RESULTS

Between Monday and Friday routine respiratory virus results will generally be available within 24 hours of receipt in the laboratory. Results for samples received after 09.00 on Saturday or during Sunday will be available on the following Monday.
Positive results will be telephoned to the requesting location during the following hours: 08.30-17.00 Monday to Friday and 08.30 to 12.30 on Saturday.
A dedicated mobile phone number (07973 870099) will be available (08:30 to 17:00 seven days a week) for chasing urgent results.

ADDITIONAL CONTACT DETAILS

For further information during normal working hours (Mon-Fri 9am-5pm and Saturday 09.00-12.30) please contact the laboratory (0161 2768854 Option 1).
Outside of normal working hours the duty consultant virologist can be contacted for urgent clinical and operational advice via the hospital switchboard (01612761234).

The current Department of Health advice should be followed.

Annual vaccination is essential for all those at risk of influenza.

Treatment is recommended when all of the following apply:

Influenza is known to be circulating in the community (indicated by national surveillance schemes).
The patient is in an ‘at-risk’ group.
The patient presents with influenza-like illness and can begin treatment within 48 hours of the onset of symptoms.

Oseltamivir 75mg BD for 5 days

Zanamivir 10 mg (2 inhalations via diskhaler) BD for 5 days (caution in asthma and COPD; there is a risk of bronchospasm so a short- acting bronchodilator should be available).

Prophylaxis is normally not considered in at-risk groups who have been vaccinated against seasonal influenza at least 14 days before exposure.
Prescribe an antiviral drug for post-exposure prophylaxis if all of the following circumstances apply:
- The national surveillance scheme indicates that influenza is circulating.
- The person has been exposed to a person (in the same household or residential setting) with an influenza-like illness.
- The person is in an 'at risk' group (see below for more information) and has not been adequately protected by vaccination, that is:
  - They have not been vaccinated since the previous influenza season.
  - The vaccination is not well matched to the circulating strain.
  - There has been less than 14 days between vaccination and date of contact with influenza.
- The person is able to start treatment within 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir).
  - Treatment after 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir) is an off-label use and should be done on specialist advice only.

Oseltamivir 75mg OD for 10 days (within 48 hours of contact)

Zanamivir 10mg (via diskhaler) OD for 10 days (within 36 hours of contact)

Chronic respiratory disease, including:
- Chronic obstructive pulmonary disease, including chronic bronchitis and emphysema, bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis, and bronchopulmonary dysplasia.
- Asthma that requires continuous or repeated use of inhaled corticosteroids or with previous exacerbations requiring hospital admission.
- Children who have previously been admitted to hospital for lower respiratory tract disease.
Chronic heart disease, including congenital heart disease, hypertension with cardiac complications, chronic heart failure, and individuals requiring regular medication or follow up for ischaemic heart disease.
Chronic kidney disease, including nephrotic syndrome, chronic renal failure, and renal transplantation.
Chronic liver disease, including cirrhosis, biliary atresia, and chronic hepatitis.
Chronic neurological disease, including stroke and transient ischaemic attack.
Diabetes, including type 1 diabetes and type 2 diabetes (requiring oral hypoglycaemic drugs or a controlled diet).
Immunosuppression due to disease or treatment, including:
- People undergoing chemotherapy (or radiotherapy) leading to immunosuppression.
- People with asplenia or splenic dysfunction.
- HIV infection (all stages).
- Individuals treated with, or likely to be treated with, systemic steroids for more than 1 month at dosages equivalent to 20 mg prednisolone daily (at any age) or, for children weighing less than 20 kg, a dose of 1 mg or more per kg body weight per day.
Morbid obesity (body mass index of 40 or more).

Consideration should also be given to:

People living in long-stay residential or nursing homes.
People who receive a carer’s allowance or care for disabled or elderley people, whose welfare may be at risk if the carer falls ill.

Pharyngitis / Sore Throat / Tonsillitis

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.

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).

Otitis Media

The best option is to use pain relief for 24 hours (ibuprofen or paracetamol) before deciding if antibiotics are needed. Consider a delayed prescription to use if symptoms don’t improve in 24 hours.

2-3 days treatment may be sufficient so parents can stop the antibiotics before the end of the course if the patient has recovered.

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

Penicillin allergy

Clarithromycin 500mg BD review after 72 hours

treatment should exceed 5 days

Otitis Externa

First use aural toilet and analgesics.

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

First line: Acetic acid 2% (e.g. Earcalm available over the counter) 1 spray TDS 7 days

Second line: Neomycin sulphate with corticosteroid (e.g. Otomize ear spray, 1 puff TDS or Betnesol N ear drops 3 drops TDS) 7 days min to 14 days max.

Advise patient to apply tragal pressure to help remove the debris.

AVOID IF PERFORATED TYMPANIC MEMBRANE.

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

Acute Rhinosinusitis

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

Clostridioides Difficile Infection

Diverticulitis

Gastroenteritis

Oral Candidiasis (Oral Thrush)

Threadworm

Clostridioides Difficile

Vancomycin 125mg QDS for 3 to 10 days depending on clinical response.

Refractory disease:

Metronidazole 400mg TDS for 3 to 10 days depending on clinical response.

Diverticulitis

Cefalexin 1g TDS for 5 days.

Penicillin allergy (anaphylaxis):

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

Gastroenteritis

Check the patient’s travel, food, hospitalisation and antibiotic history (CDI).

7 days in total, but 14 days in MALToma

Oral Candidiasis (Oral Thrush)

If a patient has oral thrush and is otherwise healthy treatment should be given.

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).

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

Threadworm

Treat both the patient and all household members unless contraindicated. Good hygiene is very important in breaking the lifecycle of the worms:

Hands should be washed after using the toilet and nails should be kept short.
Showering or bathing in the morning, washing around the anus, is recommended.
Underpants should be worn at night in bed and changed every morning
Sleepwear and bedding should be washed
Dusting and vacuuming of the surroundings (especially bedrooms) should be done and damp-dusting of the bathroom.

Hygiene methods should be used for 2 weeks if drug treated; in those who do not receive drug treatment ,e.g. under 3 months, pregnant or breastfeeding women, they should be continued for 6 weeks.

Acute Pyelonephritis

Bacterial Prostatitis

Catheter-associated UTI

Recurrent UTI

Uncomplicated UTI in Females

UTI in Males

Acute Pyelonephritis

Cefalexin 1g TDS for 7-10 days.

Penicillin allergy

Ciprofloxacin 500mg BD for 7 days.

Bacterial Prostatitis

Send MSU for culture and prescribe empiric antibiotics. Ensure that antibiotic therapy is reviewed whilst the patient remains in the intermediate care setting and if not improvement then a different diagnosis is sought.

Ensure antibiotics are reviewed when results are available and alter/stop therapy accordingly.

Refer to Urology if needed

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.

Catheter-associated UTI

Catheter-associated UTI occurs when bacteria in a catheter bypass the body's defence mechanisms and enter the bladder.
The longer a catheter has been in place the more likely bacteria will be found in the urine
Treatment is only needed for symptomatic catheter-associated UTI (apart from in pregnancy)
Removing or changing the catheter (especially if it has been in place for longer than 7 days) should be strongly considered.
Catheters should be reviewed and removed rather than changed if possible

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.

Recurrent UTI

Recurrent urinary tract infection (UTI) in adults is defined as repeated UTI with frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months.

Comprehensively assess the problem and refer to a specialist urologist or gynaecologist (for female patients).

Behavioural and personal hygiene measures:

Patients should be given advice about behavioural and personal hygiene measures to reduce the risk of UTI, such as:

- drinking enough fluids to avoid dehydration

- not delaying habitual and post-coital urination

- wiping from front to back after defaecation

- not douching or wearing occlusive underwear.

Cranberry products and D-mannose:

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.

Uncomplicated UTI in Females

If there is fever, flank or back pain then it is likely to be an upper UTI and antibiotic treatment for 7 - 14 days is needed, (see pyelonephritis section).

If symptoms are mild the woman may wish to consider not taking antibiotics and simply increase her fluid intake as UTIs often resolve spontaneously in a few days.

If the woman has more than 3 typical symptoms of a UTI, and no vaginal discharge, then treat empirically with antibiotics as below.

If urine is cloudy then perform a urine dipstick test (if under 65 years of age) containing nitrite and leucocyte esterase impregnated reagent. If the results are negative for leucocytes and nitrites then there is a 95% negative predictive value. If both are positive, or nitrite or leucocyte esterase are positive, then treat. However, if only leucocytes are positive only treat if symptoms are severe and send urine for culture.

Do not use dipstick testing in patients over the age of 65. If symptomatic of a UTI then send a urine specimen for testing and base any antibiotic treatment on this result. If empiric treatment is required because patient is symptomatic REVIEW this once MSU results available.

1st choice: Pivmecillinam 400mg STAT for the first dose followed by 200mg TDS for 3 days (this is a penicillin)

2nd choice: Nitrofurantoin 100mg MR BD for 3 days (nitrofurantoin 50mg QDS may be an alternative if supply issues with MR preparations).

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.

UTI in Males

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)

Consider a diagnosis of Chlamydia infection in anyone who is (or has been) sexually active who presents with a genital infection.

Refer patients to Locala Sexual Health on 0161 507 9460 for contact tracing and further management

Bacterial Vaginosis

Candidiasis

Epididymo - Orchitis

Infected Bartholin's Cyst/Abcess

Bacterial Vaginosis

A seven day course of metronidazole is slightly more effective than 2g stat.

Clindamycin gel is expensive but is a useful alternative if metronidazole cannot be tolerated

Metronidazole 400mg BD for 7 days

Metronidazole 2g STAT

Metronidazole vaginal gel 0.75% 5g nightly for 5 nights

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

Candidiasis

Clotrimazole 10% vaginal cream 5g single dose

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).

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.

Epididymo-Orchitis

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

ofloxacin 200mg po bd for 14 days.

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

Infected Bartholin's cyst/abscess

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.

Acute Bronchitis

Acute Exacerbation of Bronchiectasis

Acute Exacerbation of COPD

Community-Acquired Pneumonia

Hospital-Acquired Pneumonia

Acute Bronchitis

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.

Acute Exacerbation of Bronchiectasis

An acute exacerbation of bronchiectasis is sustained worsening of symptoms from a person's stable state..

When choosing antibiotics, take account of:

the severity of symptoms
previous exacerbations, hospitalisations and risk of complications
previous sputum culture and susceptibility results.

NICE (2019) recommends to send a sputum sample for culture and susceptibility testing and then offer an antibiotic. Also, when results of sputum culture are available:

review choice of antibiotic
only change antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving, using narrow spectrum antibiotics when possible.

Refer to hospital if the person has any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis).

Seek specialist advice if:

symptoms do not improve with repeated courses of antibiotics
bacteria are resistant to oral antibiotics
the person cannot take oral medicines (to explore giving intravenous antibiotics at home or in the community if appropriate)

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

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 Legionella is suspected: Add Clarithromycin 500mg BD for 7-14 days to amoxicillin

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.

Acute Exacerbation of COPD

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.

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.

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)

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 Legionella is suspected: Add Clarithromycin 500mg BD for 5 days to amoxicillin

Community-acquired Pneumonia

The intensity of pneumonia in the community can be assessed using the CRB65 score; each factor scores one point:

confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place, or time);
a raised respiratory rate (30 breaths per minute or more);
a low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg);
age 65 years or over.

Score 1 or 2: intermediate risk (1-10% mortality risk).

Score 3 or 4: high risk (more than 10% mortality risk)

CRB score	Antibiotic choice (5 day treatment)
CRB = 0	Doxycycline 200 mg STAT then 100 mg BD (suitable for penicillin allergy) OR Amoxicillin 1 g TDS
CRB = 1-2	Doxycycline 200 mg STAT then 100 mg BD (suitable for penicillin allergy) OR Amoxicillin 1 g TDS PLUS Clarithromycin 500mg BD
CRB = 3-4	Co-amoxiclav 625mg TDS PLUS Clarithromycin 500mg BD Levofloxacin 500mg BD if penicillin allergic

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.

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.

Hospital-acquired Pneumonia

Hospital-acquired pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after hospital admission and is not incubating at hospital admission.

Early-onset (occurring within 4 days of admission) HAP is usually caused by the same bacteria and viruses as CAP and has a good prognosis.

Late-onset (starting 5 days or more after admission) HAP has a worse prognosis and is usually caused by microorganisms that are acquired from the hospital environment. Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA) and other nonpseudomonal Gram-negative bacteria are the most common causes.

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

Sepsis

Diagnosis of possible sepsis relies on clinical judgment. Healthcare professionals assessing people with clinical deterioration due to likely infection, or in those who are acutely unwell with no clear cause should consider the possibility of sepsis.

They should:

a. take into account the patient's history and risk factors alongside clinical assessment

b. Make a clinical assessment that includes measurement of physiological variables (temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation) that can be used to stratify the severity of illness.

NEWS (the National Early Warning Score) provides an appropriate framework for risk stratification in adults in acute care. The National Quality Board strongly endorses the use of NEWS in adult patients as the standardised system for assessment of the severity of acute illness and communication of this between healthcare practitioners. NEWS is recommended for use in hospitals including mental health hospitals and in ambulance services and in prison healthcare.

NEWS has not yet received NICE support for use in primary care, pending further evidence of its value in this setting. The National Quality Board and NICE have recommended further evaluation of the use of NEWS in primary care and recognises the value of a "common language" across the NHS in England to communicate the severity of a patient's acute illness.

A diagnosis of sepsis should be considered in patient with a NEWS2 score of 5 or more. Patients with a NEWS2 score of less than 5 might also have or develop sepsis.

Clinicians assessing patients with a NEWS2 score of less than 5 should still be aware of the risk of sepsis and should specifically look for: a single NEWS parameter of 3; non-blanching rash/mottled/ashen/cyanotic skin; responds only to voice or pain, or unresponsive; not passed urine in last 18 hours/urine output<0.5 ml/kg/hr; lactate 2+ as any of these indicators suggest the possibility of underlying infection and sepsis.

Human and Animal Bites

Cellulitis

Dermatophyte Infection of the Skin

Diabetic Foot Infection

Leg Ulcers / Pressure Sores

shingles

Strep Group A

Human and Animal Bites

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

If the skin is not broken just clean it, but if the skin is broken irrigate it with warm, running water. Send the patient to ED if severe.

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.

Cellulitis

True cellulitis is a systemic infection and you would expect some systemic signs and symptoms.

This treatment also applies if there is spreading cellulitis resulting from an insect bite (please ensure an infection is confirmed as all insect bites do not need to be treated with antibiotics).

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

Please refer to the full guidance distributed for the community IV cellulitis pathway

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.

Dermatophyte Infection of the Skin

Diabetic Foot Infection

The recommendations for treatment of DFI have been made following discussion with Abigail Hall (High Risk Foot Team Podiatrist) and Dr Haris Rathur (Consultant for Adult Medicine).

Refer to Diabetes Service

email: integrated.diabetes@tgh.nhs.uk (Contact High Risk Foot Podiatry on 0161 922 4888)

All patients with Diabetic Foot Ulcers MUST be under the care of a Podiatrist

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

Leg Ulcers / Pressure Sores

In the absence of systemic features of infection, only topical treatment without the addition of systemic antibiotic is indicated for these patients

In consultation with the community tissue viability team, either:

Flamazine (silver sulphadiazine) cream for non-exudative wounds

Apply at every dressing change

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)

Shingles (Herpes Zoster)

Antivirals should be started within 72 hours of onset of the rash.

Specialist advice should be sought for immunocompromised patients.

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.

Strep A Group Infection

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.

Amoxicillin 1g po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Pharyngitis / Tonsillitis section in intermediate care guidelines.

Penicillin allergy

Clarithromycin 500mg BD for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see Pharyngitis / Tonsillitis section in intermediate care guidelines.

Dental Abscess

Ear, Nose and Throat Infections

Genital Tract

Lower Respiratory Tract Infections

Skin and Soft Tissue

Urinary Tract Infection

Dental Abscess

Amoxicillin 1g po tds for 3 days.

Penicillin allergy

Clindamycin 450mg po qds for 3 days.

Ear, Nose and Throat Infections

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.

Penicillin V 1g po qds for 5 days. Treatment duration will be longer in more complicated infections such as Scarlet fever (at least 10 days).

Penicillin allergy (rash)

Cefalexin 1g po tds for 5 days. Treatment duration will be longer in more complicated infections such as Scarlet fever (at least 10 days).

Penicillin allergy (anaphylaxis)

Clarithromycin 500mg po bd for 5 days. Treatment duration will be longer in more complicated infections such as Scarlet fever (at least 10 days).

Genital Tract Infections

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

ofloxacin 200mg po bd for 14 days.

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

Lower Respiratory Tract Infections

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.

Skin & Soft Tissue

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.

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.

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:

That skin redness and itching are common and may last for up to 10 days
Avoid scratching as this may help reduce inflammation and the risk of infection
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.

TREATMENT SHOULD ONLY BE COMMENCED BY A DERMATOLOGIST IN SECONDARY CARE

Clindamycin 300mg BD

Plus

Rifampicin 300mg BD

for about 10 – 12 weeks

Urinary Tract Infection

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.

Dental Abscess

Ear, Nose and Throat Infections

Lower Respiratory Tract Infections

Skin and Soft Tissue

Urinary Tract Infection

Dental Abscess

Amoxicillin po tds for 3 days.

Penicillin allergy

Clindamycin po qds for 3 days.

Ear, Nose and Throat Infections

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

Group A Streptococcus positive

Penicillin V po qds for 5 days. Treatment duration will be longer in more complicated infections such as scarlet fever (at least 10 days).

Penicillin allergy (rash)

Cefalexin po tds for 5 days. Treatment duration will be longer in more complicated infections such as scarlet fever (at least 10 days).

Penicillin allergy (anaphylaxis)

Clarithromycin po bd for 5 days. Treatment duration will be longer in more complicated infections such as scarlet fever (at least 10 days).

Lower Respiratory Tract Infections

Amoxicillin po tds for 3 days.

Penicillin allergy

Clarithromycin po bd for 3 days.

Skin & Soft Tissue

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.

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.

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:

That skin redness and itching are common and may last for up to 10 days
Avoid scratching as this may help reduce inflammation and the risk of infection
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.

Urinary Tract Infection

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.

Intravascular Cannula Infections

Multi-Drug Resistant Organisms

Sepsis Syndrome

Intravascular Cannula Infections

For peripherally-inserted cannulae:

Flucloxacillin 2g IV 6 hourly.

Penicillin allergy:

Teicoplanin 10mg/kg IV stat then 10mg/kg iv 12 hourly for 2 further doses then once daily thereafter.

Before commencing antibiotic treatment blood for microbiologic culture should be taken using careful aseptic technique. Blood sampling should be from both the intravascular cannula as well as from a peripheral vein.

For centrally placed intravascular catheters (internal jugular, subclavian, Hickman, Tessio central catheters):

Teicoplanin 10mg/kg IV stat then 10mg/kg iv 12 hourly for 2 further doses then once daily thereafter.

Multi-Drug Resistant Organisms

Multi drug resistant Gram negative organisms including Carbapenemase-producing enterobacteriaceae (CPE)

Tigecycline 100mg IV stat dose, followed by 50mg IV 12 hourly

plus

Gentamicin 5mg/kg IV single, stat dose (4mg/kg in patients > 70 yrs).

If resistant to gentamicin give Amikacin 15mg/kg IV single, stat dose.

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

Sepsis Syndrome

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.

This includes all febrile immunocompromised patients.

Antibiotic treatment

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

If severely ill and hypotensive add:

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

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

Note: Do not give gentamicin to patients who have received platinum based chemotherapy (oxaliplatin, carboplatin, cisplatin) in the last 7 days due to increased risk of nephrotoxicity and ototoxicity.

Penicillin allergy (rash)

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

If severely ill and hypotensive add:

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

If severely ill and hypotensive add:

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.

Compound/Open Fractures

Prosthetic Joint Infection

Septic Arthritis and Osteomyelitis

Compound/Open Fractures

Empiric antibiotic treatment

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

Penicillin allergy (rash)

IV treatment: cefuroxime 1.5g IV stat followed by 1.5g IV 8 hourly.

Penicillin allergy (anaphylaxis)

IV treatment: Co-trimoxazole 960mg IV stat followed by 960mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 600mg IV 6 hourly.

Further antibiotic management should be based on microbiologic culture results.

Prosthetic Joint Infection

The commonest organism affecting prothetic joints is Staph epidermidis as well as other coagulase negative Staphylococci such as Staph hominis, Staph haemolyticus, Staph warneri as well as numerous others.

Other less commonly encountered bacteria include Staph aureus, Streptococci, Entercocci, enteric Gram negative bacilli, Pseudomonas aeruginosa and Propionibacteria.

Empiric IV treatment:

IV treatment: Teicoplanin IV 10mg/kg 12 hourly for 3 doses followed by 10mg/kg once daily thereafter plus oral rifampicin 300mg po BD.

NOTE:

Once culture results are available contact Microbiology for advice regarding further antibiotic management based on sensitivites and for the most appropriate regimen in terms of IV treatment, oral step down and treatment duration for the organism isolated.

Septic Arthritis and Osteomyelitis

Treatment duration for septic arthritis is 4 weeks.

Treatment duration for osteomyelitis is 6 weeks.

Antibiotic treatment

IV treatment: Flucloxacillin 2g IV stat followed by 2g IV 6 hourly.

Oral step down: Flucloxacillin 2g po qds. If not tolerated at this dose reduce to 1.5g or 1g po qds.

Penicillin allergy

IV treatment: Clindamycin 1.2g IV stat followed by 900mg IV 6 hourly.

Oral step down: Clindamycin 450mg po qds.

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.

Anaerobic infection

Anaerobic infection should be suspected in the following patients:

Immunocompromised
Diabetics
Recent trauma with devitalised tissue
IV drug abusers

Antibiotic treatment

IV treatment:

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

plus

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.

Oral step down: Co-amoxiclav 625mg po tds plus clindamycin 450mg po qds.

Penicillin allergy

IV treatment:

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

plus

Co-trimoxazole 960mg IV stat followed by 960mg IV 12 hourly

plus

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

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

Endocarditis

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.

See section on therapeutic Drug Monitoring for guidance on the dose and the monitoring of drug plasma levels of aminoglycosides (such as gentamicin) and glycopeptides (such as vancomycin).

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.

Vancomycin 1g IV 12 hourly plus gentamicin 1mg/kg IV 8 hourly plus rifampicin 450mg IV 12 hourly.

Vancomycin and gentamicin doses should be modified according to renal function and plasma vancomycin and gentamicin levels.

In patients who have existing renal impairment or who develop renal function deterioration while receiving this combination, the following alternative agents should be considered:

Vancomycin 1g IV 12 hourly plus ceftriaxone 1g IV 12 hourly plus rifampicin 450mg IV 12 hourly - only suitable if penicillin allergy (rash). This combination cannot cannot be given to patients who have anaphylaxis to penicillin.

Vancomycin 1g IV 12 hourly plus ciprofloxacin 400mg IV 12 hourly plus rifampicin 450mg IV 12 hourly.

See section on therapeutic Drug Monitoring for guidance on the dose and the monitoring of drug plasma levels of aminoglycosides (such as gentamicin) and glycopeptides (such as vancomycin).

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

Treatment duration is 6 weeks or longer.

Haemophilus Influenzae

Listeria

Meningitis - Empiric Treatment

Meningococcus

Pneumococcus

Viral Meningitis/Encephalitis

Meningitis - Empiric Treatment

Ceftriaxone 2g IV stat followed by 2g IV 12 hourly

plus

Amoxicillin 2g stat followed by 2g IV 4 hourly if Listeria suspected.

Listeria should be suspected in:

elderley patients
neonates
patients with alcohol dependency
immunosuppressed patients (particularly those with solid tumours)
diabetic patients

See section on Listeria.

If herpes simplex virus meningitis/encephalitis is suspected add aciclovir 10mg/kg IV 8 hourly. For more details see section on viral meningitis/encephalitis below.

Penicillin allergy:

Chloramphenicol 1g IV stat followed by 1g IV 6 hourly

plus

Moxifloxacin 400mg IV stat followed by 400mg IV OD

plus

Co-trimoxazole 1.44g IV stat followed by 1.44g 12 hourly (if Listeria suspected).

If herpes simplex virus meningitis/encephalitis is suspected add aciclovir 10mg/kg IV 8 hourly. For more details see section on viral meningitis/encephalitis.

Review antibiotic treatment once microbiologic culture results become available

Consider adjunctive treatment with dexamethasone (particularly if pneumococcal meningitis suspected in adults); starting before or with first dose of antibiotic. Avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery.

Meningococcus

Meningococcal meningitis is caused by Neisseria meningitidis, a Gram negative diplococcus.

Antibiotic treatment:

Benzylpenicillin 2.4g IV stat followed by 2.4g IV every 4 hours.

Penicillin allergy (rash):

Ceftriaxone 2g IV stat followed by 2g IV 12 hourly.

Penicillin allergy (anaphylaxis):

Chloramphenicol 1g IV stat followed by 1g IV 6 hourly.

Duration of therapy is 7 days.

Elimination of nasopharyngeal carriage:

After treatment with benzylpenicillin give oral rifampicin 600mg twice a day for 2 days before hospital discharge to eliminate nasopharyngeal carriage; or ciprofloxacin 500mg oral as a single dose before discharge. Patients treated with ceftriaxone or moxifloxacin would not require follow up rifampicin or ciprofloxacin treatment on discharge.

Pneumococcus

Pneumococcal meningitis is caused by Strep pneumoniae, a Gram positive diplococcus.

Antibiotic treatment:

Ceftriaxone 2g IV stat followed by 2g IV 12 hourly.

If the organism is penicillin-sensitive on culture results change to benzylpenicillin 2.4g IV every 4 hours instead of ceftriaxone.

Duration of antibiotic therapy is 10-14 days then review.

If the organism is resistant to penicillin and cephalosporin discuss with the Consultant Microbiologist.

Penicillin allergy - anaphylaxis:

Moxifloxacin 400mg IV stat followed by 400mg IV OD.

Duration of antibiotic therapy is 10-14 days then review.

Listeria

Listeria should be suspected in:

elderley patients
neonates
patients with alcohol dependency
immunosuppressed patients (particularly those with solid tumours)
diabetic patients

Antibiotic treatment:

Note: Listeria is resistant to all cephalosporins.

Amoxicillin 2g IV stat followed by 2g IV 4 hourly

plus

Gentamicin 5mg/kg IV once daily (for the first week of treatment). If the patient is > 70 years dose should be 4mg/kg IV once daily.

See section on therapeutic Drug Monitoring for guidance on the monitoring of gentamicin levels and also for guidance on gentamicin dose calculation if the patient is obese.

Treatment duration is 21 days.

Penicillin allergy:

Co-trimoxazole 1.44g IV 12 hourly.

Treatment duration is 21 days.

Haemophilus Influenzae

Haemophilus influenzae meningitis is rare nowadays due to Hib vaccination.

Antibiotic treatment

Ceftriaxone 2g IV 12 hourly.

Penicillin allergy

Moxifloxacin 400mg IV once daily.

Duration of therapy is 10 days.

Elimination of nasopharyngeal carriage

For H. influenzae type b, after treatment with chloramphenicol give rifampicin 600mg po OD for 4 days before hospital discharge to eliminate nasopharyngeal carriage.

Viral Meningitis/Encephalitis

Most cases of viral meningitis ("aseptic" meningitis) are due to enteroviruses such as Coxsackie and ECHO viruses, which is usually a self-limiting infection and does not require specific antiviral treatment.

A CSF sample should be sent for viral PCR testing at Manchester Royal Infirmary laboratory.

If the test is negative for Herpes simplex viruses types 1 and 2 and Varicella zoster virus, stop treatment with aciclovir because this agent is not effective against enteroviruses.

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)

Dental

Antibiotic treatment

Oral treatment: Amoxicillin 1g po tds.

IV treatment: Amoxicillin 1g IV 8 hourly.

Penicillin allergy:

Oral treatment: Clindamycin 450mg po qds.

IV treatment: Clindamycin 600mg IV 6 hourly.

Acute Mastoiditis

Deep Neck Space Abscess

Epiglottitis / Supraglottitis

Malignant / Necrotising Otitis Externa

Otitis Externa

Otitis Media

Parotitis

Perichondritis

Post-Tonsillectomy Bleed

Sinusitis

Superficial Neck Abscess

Suppurating Neck Nodes

Tonsillitis / Quinsy

Acute Mastoiditis

IV treatment:

Ceftriaxone 2g IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Penicillin allergy (anaphylaxis):

Moxifloxacin 400mg IV once daily plus clindamycin 600mg IV 6 hourly.

Deep Neck Space Abscess

IV treatment: co-amoxiclav 1.2g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Oral step down: co-amoxiclav 625mg po TDS plus clindamycin 450mg po QDS.

Penicillin allergy (anaphylaxis):

IV treatment: cefuroxime 1.5g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Oral step down: cefalexin 1g po TDS plus clindamycin 450mg po QDS.

Penicillin allergy (anaphylaxis):

IV treatment: co-trimoxazole 960mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Oral step down: co-trimoxazole 960mg po BD plus clindamycin 450mg po QDS.

Epiglottitis / Supraglottitis

IV treatment: Ceftriaxone 2g IV 12 hourly.

Oral step down: Cefalexin 1g po tds (can be used in penicillin allergy where reaction is rash)

Penicillin allergy (anaphylaxis)

IV treatment:

Moxifloxacin 400mg IV OD

Oral step down:

Moxifloxacin 400mg po OD.

Since the introduction of Hib vaccination in childhood this infection is rarely caused by Haemophilus influenzae.

Treatment duration: 7-10 days.

Malignant/necrotising otitis externa

IV treatment: Tazocin 4.5g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Also give topical ciprofloxacin 0.3% drops 3 drops QDS into the affected ear(s).

Oral treatment: ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Also give topical ciprofloxacin 0.3% drops 3 drops QDS into the affected ear(s).

Penicillin allergy (rash):

IV treatment: ceftazidime 2g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Also give topical ciprofloxacin 0.3% drops 3 drops QDS into the affected ear(s).

Oral treatment: ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Also give topical ciprofloxacin 0.3% drops 3 drops QDS into the affected ear(s).

Penicillin allergy (anaphylaxis):

IV treatment: ciprofloxacin 400mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Also give topical ciprofloxacin 0.3% drops 3 drops QDS into the affected ear(s).

Oral treatment: ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Also give topical ciprofloxacin 0.3% drops 3 drops QDS into the affected ear(s).

Otitis Externa

First use aural toilet and analgesics.

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

First line: Acetic acid 2% (e.g. Earcalm available over the counter) 1 spray TDS 7 days

Second line: Neomycin sulphate with corticosteroid (e.g. Otomize ear spray, 1 puff TDS or Betnesol N ear drops 3 drops TDS) 7 days min to 14 days max.

Advise patient to apply tragal pressure to help remove the debris.

AVOID IF PERFORATED TYMPANIC MEMBRANE.

If fungal infection suspected:

Clotrimazole 1% drops.

Otitis Media

Amoxicillin 1g po tds

Clarithromycin 500mg po bd.

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

Parotitis

See Parotitis section on the Head and Neck page

Perichondritis

IV treatment: Tazocin 4.5g IV 8 hourly.

Oral treatment: ciprofloxacin 500mg po bd

If systemically unwell 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 (rash):

IV treatment: ceftazidime 2g IV 8 hourly.

Oral treatment: ciprofloxacin 500mg po bd.

Penicillin allergy (anaphylaxis):

IV treatment: ciprofloxacin 400mg IV 12 hourly.

Oral treatment: ciprofloxacin 500mg po bd.

Post-Tonsillectomy Bleed

IV treatment: co-amoxiclav 1.2g IV 8 hourly.

Oral step down: co-amoxiclav 625mg po TDS.

Penicillin allergy (rash):

IV treatment: cefuroxime 1.5g IV 8 hourly.

Oral step down: cefalexin 1g po TDS.

Penicillin allergy (anaphylaxis):

IV treatment: clindamycin 600mg IV 6 hourly.

Oral step down: clarithromycin 500mg po bd.

Sinusitis

Many cases of sinusitis are viral and two thirds will resolve without antibiotics.

Only treat those with persistent symptoms and purulent discharge lasting at least one week or if symptoms are severe. Treat those at high risk of serious complications notably immunosuppressed patients and those with cystic fibrosis.

Amoxicillin 1g po tds

Doxycycline 200mg po stat then 100mg po bd.

Superficial Neck Abscess

The mainstay of treatment is incision and drainage.

Flucloxacillin 1g po QDS.

Penicillin allergy:

Clindamycin 450mg po QDS.

Suppurating Neck Nodes

IV treatment: co-amoxiclav 1.2g IV 8 hourly.

Oral step down: co-amoxiclav 625mg po TDS.

If no better add clindamycin 600mg IV 6 hourly to IV treatment with co-amoxiclav.

Oral step down: co-amoxiclav 625mg po TDS plus clindamycin 450mg po QDS.

Penicillin allergy (anaphylaxis):

IV treatment: cefuroxime 1.5g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Oral step down: cefalexin 1g po TDS plus clindamycin 450mg po QDS.

Penicillin allergy (anaphylaxis):

IV treatment: co-trimoxazole 960mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Oral step down: co-trimoxazole 960mg po BD plus clindamycin 450mg po QDS.

Tonsillitis / Quinsy

Strep Group A (Beta-haemolytic streptococcal) pharyngotonsillitis

Most throat infections are caused by viruses and do not require antibiotic treatment. Consider antibiotic treatment if there is:

a history of valvular heart disease
systemic clinical toxicity
peritonsillar abscess (quinsy)
immunocompromised patient.

Antibiotic treatment

Oral treatment: Phenoxymethylpenicillin (penicillin V) 1g po QDS.

IV treatment: Benzylpenicillin 1.2g IV 6 hourly.

Treatment duration is 5 days however this may be longer in more complicated infections such as quinsy or scarlet fever (usually at least 10 days).

Penicillin allergy (rash)

Oral treatment: Cefalexin 1g po tds.

IV treatment: Cefuroxime 1.5g IV 8 hourly

Treatment duration is 5 days however this may be longer in more complicated infections such as quinsy or scarlet fever (usually at least 10 days).

Penicillin allergy (anaphylaxis)

Oral treatment: Clarithromycin 500mg po bd.

IV treatment: Clindamycin 600mg IV 6 hourly (this is preferred for IV treatment in order to avoid risk of macrolide associated phlebitis with IV clarithromycin).

Treatment duration is 5 days however this may be longer in more complicated infections such as quinsy or scarlet fever (usually at least 10 days).

Facial / Orbital Cellulitis

Purulent Conjuctivitis

Facial / Orbital Cellulitis

See Facial / Orbital Cellulitis section on the Skin and Soft Tissue page

Purulent Conjuctivitis

Chloramphenicol eye drops / ointment.

* Chloramphenicol eye drops and ointment is contra-indicated in patients under 2 years old as it contains boron which may affect future fertility.

Invasive Candidiasis

Oropharyngeal Candidiasis

Vaginal / Penile Candidiasis

Invasive Candidiasis

For blood culture positive Candida species:

1st line: Fluconazole 400mg IV stat followed by 200mg IV 12 hourly for 2 weeks.

Repeat blood cultures after 48 hours of treatment to ensure elimination of the organism from the bloodstream.

2nd line: Caspofungin 70mg IV stat followed by 50mg IV once daily (for body weight over 80kg give 70mg IV once daily) for 2 weeks.

Repeat blood cultures after 48 hours of treatment to ensure elimination of the organism from the bloodstream.

Follow up antifungal agent sensitivity results from the laboratory to ensure treatment is appropriate.

Oropharyngeal Candidiasis

1st line: Nystatin oral suspension 1ml QDS for 7 days.

If patient does not respond to above treatment or cannot take orally but has NG/PEG access:

2nd line: Fluconazole 100mg po once daily for up to 7 days.

For severe thrush (oropharyngeal, laryngeal, oesophageal) or if no response to the treatment above:

Fluconazole 200mg IV 12 hourly for 48 hours.

Vaginal / Penile Candidiasis

Vaginal/penile candidiasis

1st line: Topical clotrimazole 2% cream to be applied tds plus clotrimazole 500mg pessary single stat dose once only.

2nd line: Fluconazole 150mg po single stat dose once only.

In severe/unresponsive vaginal candidiasis: Fluconazole 200mg IV 12 hourly for 48 hours.

Acute Pancreatitis

Appendicitis

Biliary Tract Infections

Campylobacter Enteritis

Clostridioides Difficile

Diverticulitis

Enteric Fever (Typhoid / Paratyphoid)

Gastroenteritis

Liver Abscess

Non-Typhoidal Salmonellosis

Peritoneal Dialysis Peritonitis

Peritonitis

Shigellosis

Spontaneous Bacterial Peritonitis

Variceal Bleeding with Cirrhosis

Acute Pancreatitis

Antibiotic treatment is NOT indicated for acute uncomplicated pancreatitis. Antibiotic treatment is only indicated in necrotising pancreatitis or pseudocyst formation in which secondary infection has occurred.

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.

Appendicitis

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 clindamycin (to cover both Strep milleri and anaerobes) 900mg IV 8 hourly.

Oral treatment: Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Billary Tract Infections

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.

Campylobacter Enteritis

Antibiotics are not indicated in uncomplicated cases; however if antibiotic treatment is necessary such as in severe or relapsing illness:

1st line: Azithromycin 500mg po od for 3 days.

2nd line: Ciprofloxacin 500mg po bd for 3 days (note there is increasing resistance to ciprofloxacin in Campylobacter organisms).

Clostridioides Difficile

Stop offending antibiotics if possible.
Stop proton pump inhibitors if possible.
Antibiotics should be given until the diarrhoea has resolved or is resolving, but can be continued for up to 10 days.

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.

Diverticulitis

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.

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 500mg po bd plus metronidazole 400mg po tds.

Enteric Fever (Typhoid / Paratyphoid)

Antibiotic treatment

Empiric therapy: Ceftriaxone 2g IV od for 14 days.

If organism is susceptible: Ciprofloxacin orally if possible 500mg bd; otherwise 400mg IV bd, for a total of 7 to 10 days.

Enteric fever from Indian subcontinent, Middle-East, and South-East Asia may be multiply-antibiotic-resistant and susceptibility should be tested. If infection occurs after travel to these areas give:
Azithromycin 1g po stat on the first day followed by 500mg po od thereafter (unlicensed indication). Treat for a total of 5 to 7 days. This may be an option in mild or moderate disease caused by multidrug-resistant organisms.

Gastroenteritits

Antibiotics are usually not indicated in uncomplicated/mild cases which are self-limiting and do not require antibiotic treatment.

Liver Abscess

The antibiotic treatment below should be used until abscess is drained and culture and sensitivity results are available to guide further antibiotic treatment.

Antibiotic treatment:

1st line: Piperacillin/tazobactam 4.5g IV 8 hourly.

Penicillin allergy (rash):

Cefuroxime 1.5g IV 8 hourly.

Penicillin allergy (anaphylaxis):

Ciprofloxacin 400mg IV 12 hourly plus clindamycin 1.2g IV stat then 900mg IV 8 hourly.

Treatment duration: The duration of antibiotics will depend on the patient's clinical response and the adequacy of drainage. Parenteral therapy should be given initially. If the patient improves and fever and leukocytosis resolves, the patient can be stepped down to oral antibiotics guided by culture and sensitivity results. The typical duration of treatment is 4 to 6 weeks of total antibiotic therapy including IV and oral antibiotics.

Non-Typhoidal salmonellosis

If the patient is asymptomatic or the illness is mild, antibiotics are not indicated.

Treatment should be given to the following patients:

infants less than one year old
patients over 50 years old
immunocompromised patients
patients with vascular grafts or prosthetic joints
patients with Salmonella bacteraemia
patients with haemoglobinopathy (such as sickle cell disease)
patients with clinical toxicity who are hospitalised with fever and severe diarrhoea.

Antibiotic treatment:

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

If IV treatment needed: Co-trimoxazole 960mg IV 12 hourly.

2nd line: Azithromycin 500mg po od.

If IV treatment needed: Azithromycin 500mg IV once daily.

3rd line: Ciprofloxacin 500mg po bd.

If IV treatment needed: Ciprofloxacin 400mg IV 12 hourly.

4th line: Ceftriaxone 2g IV once daily.

Peritoneal Dialysis Peritonitis

Peritoneal dialysis-associated peritonitis

Discuss with Renal unit at Central Manchester.

Peritonitis

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 patient's with penicillin allergy (rash).

Penicillin allergy (anaphylaxis):

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

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

In severe cases and those requiring critical care

Piperacillin/tazobactam 4.5g IV 8 hourly plus metronidazole 500mg IV 8 hourly.

Penicillin allergy (rash):

Meropenem 1g IV 8 hourly plus metronidazole 500mg IV 8 hourly.

Penicillin allergy (anaphylaxis):

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

Shigellosis

Antibiotics are not indicated in uncomplicated disease. Treat according to sensitivities.

Antibiotic treatment

1st line: Co-trimoxazole 960mg po bd for 3 days.

2nd line: Amoxicillin 1g po tds for 3 days.

3rd line: Ciprofloxacin 500mg po bd for 3 days.

In children amoxicillin or trimethoprim may be used if the organism is sensitive. Ciprofloxacin or azithromycin (unlicensed indication) are alternatives.

Spontaneous Bacterial Peritonitis

Treatment:

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

Penicillin allergy:

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

Prophylaxis after initial episode of SBP: Ciprofloxacin 500mg po od.

Variceal Bleeding with Cirrhosis

Antibiotic treatment:

Cefuroxime 1.5g IV 8 hourly.

Penicillin allergy (anaphylaxis):

Ciprofloxacin 400mg IV 12 hourly.

Bacterial Vaginosis

Infected Bartholin's cyst/abscess

Bacterial Vaginosis

Metronidazole 400mg BD for 7 days

Metronidazole 2g STAT

Metronidazole vaginal gel 0.75% 5g nightly for 5 nights

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

Infected Bartholin's cyst/abscess

Antibiotic treatment:

Oral treatment: cefalexin 1g po tds plus clindamycin 450mg po qds.

IV treatment: cefuroxime 1.5g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

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

Penicillin allergy (anaphylaxis):

Oral treatment: co-trimoxazole 960mg po bd plus clindamycin 450mg po qds.

IV treatment: co-trimoxazole 960mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Facial / Orbital Cellulitis

Parotitis

Facial / Orbital Cellulitis

Antibiotic treatment

IV treatment: Co-amoxiclav 1.2g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Co-amoxiclav 625mg po tds plus clindamycin 450mg po qds.

If intracranial extension of infection is suspected give: ceftriaxone 2g IV stat then 2g IV 12 hourly plus clindamycin 1.2g IV stat plus 900mg IV 8 hourly.

Penicillin allergy (rash)

IV treatment: Ceftriaxone 2g IV 12 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Cefalexin 1g po tds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treatment: Levofloxacin 500mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Levofloxacin 500mg po bd plus clindamycin 450mg po qds.

If intracranial extension of infection is suspected give: moxifloxacin 400mg IV stat followed by 400mg IV once daily plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

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

Parotitis

IV treatment: Flucloxacillin 2g IV 6 hourly (note Staph aureus is the most common cause of acute suppurative parotitis).

Oral step down: Flucloxacillin 1g po qds.

Penicillin allergy (rash):

IV treatment: Cefuroxime 1.5g IV 8 hourly.

Oral step down: Cefalexin 1g po tds.

Penicillin allergy (anaphylaxis):

IV treatment: Clindamycin 600mg IV 6 hourly.

Oral step down: Clindamycin 450mg po qds.

Post-Partum Endometritis

Antibiotic treatment:

This combination is also suitable for penicillin allergy (rash).

IV treatment: Cefuroxime 1.5g IV stat then 1.5g IV 8 hourly plus metronidazole 500mg IV stat then 500mg IV 8 hourly

Oral step down: Cefalexin 1g po tds plus metronidazole 400mg po tds.

Penicillin allergy (anaphylaxis)

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

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

Antibiotic treament should cover for Strep Group A puerperal sepsis as well as for histotoxic clostridia (Clostridium perfringens).

Antibiotic treament

IV treatment:

Piperacillin/tazobactam 4.5g IV stat, then 4.5g IV 8 hourly.

plus

Clindamycin 1.2g IV stat, plus 900mg IV 8 hourly.

plus

Gentamicin 5mg/kg 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 tds plus clindamycin 450mg po qds.

Penicillin allergy

IV treatment:

Ciprofloxacin 400mg IV stat, then 400mg IV 12 hourly

plus

Clindamycin 1.2g IV stat, then 900mg IV 8 hourly.

plus

Gentamicin 5mg/kg 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: Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Acute Exacerbation of Asthma

Aspiration Pneumonia

Empyema

Infective Exacerbation of COPD

Influenza

Pneumonia

PVL-Producing Staph Aureus Pneumonia

Acute Exacerbation of Asthma

If respiratory infection is suspected in acute exacerbation of asthma, antibiotic treatment should follow the pneumonia guidelines..

See section on Treatment of pneumonia

Aspiration Pneumonia

IV treatment: Co-amoxiclav 1.2g IV 8 hourly.

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Penicillin allergy (rash):

IV treatment: Cefuroxime 1.5g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Penicillin allergy (anaphylaxis):

IV treatment: Co-trimoxazole 960mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

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

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Penicillin allergy (rash):

IV treatment: Ceftazidime 2g IV 8 hourly plus clindamycin 600mg IV 6 hourly.

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Penicillin allergy (anaphylaxis):

IV treatment: Levofloxacin 500mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Empyema

Empiric antibiotic treatment should be modified by culture results.

IV treatment: Co-amoxiclav 1.2g IV 8 houly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Co-amoxiclav 625mg po tds plus clindamycin 450mg po qds.

Penicillin allergy (rash):

IV treatment: Cefuroxime 1.5g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Cefalexin 1g po tds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis):

IV treatment: Levofloxacin 500mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Levofloxacin 500mg po bd plus clindamycin 450mg po qds.

Duration of treatment depends on the clinical response of the patient but may need to be continued for a number of weeks.

Empiric antibiotic treatment should be modified by culture results.

IV treatment: Piperacillin/tazobactam 4.5g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Levofloxacin 500mg po bd plus clindamycin 450mg po qds.

Penicillin allergy (rash):

IV treatment: Ceftazidime 2g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Levofloxacin 500mg po bd plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis):

IV treatment: Levofloxacin 500mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Levofloxacin 500mg po bd plus clindamycin 450mg po qds.

Duration of treatment depends on the clinical response of the patient but may need to be continued for a number of weeks.

Infective Exacerbation of COPD

Infective exacerbation of chronic obstructive pulmonary disease (COPD)

Degree of severity of COPD exacerbation is based on the following criteria (BAP65 score) each scoring one if present:

B = Blood urea > 9mmol/L

A = Altered mental state

P = Pulse > 109/min

65 = Age > 65 years

Mild Infection (BAP65 = 0-1)

Amoxicillin po 1g tds, if IV treatment necessary give amoxicillin 1g IV 8 hourly.

Severe Infection (BAP65 = 2-3)

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

IV treatment: Co-amoxiclav 1.2g IV 8 hourly.

Penicillin allergy:

Mild infection (BAP65 = 0-1)

Clarithromycin 500mg po bd if IV treatment necessary give co-trimoxazole 960mg IV 12 hourly due to risk of macrolide associated phlebitis with IV clarithromycin.

Severe Infection (BAP65 = 2-3)

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

IV treatment: Co-trimoxazole 960mg IV 12 hourly.

Prophylaxis

If a patient is deemed as being suitable for long-term antibiotic prophylaxis refer the patient to the respiratory physicians.

Influenza

It is important to treat severely unwell patients with antiviral drugs where possible. Public Health England (PHE) recommends the early use of antivirals for patients with proven or suspected seasonal influenza who are in high risk groups or who are considerably unwell, (even if not in a high risk group);

Risk factors for complicated influenza are:

Neurological, hepatic, renal, pulmonary and chronic cardiac disease.

Diabetes mellitus.

Immunosuppression.

Age over 65 years.

Pregnancy (including up to two weeks post partum)

Morbid obesity (BMI >=40).

Check the Trust intranet for the latest version of this guideline.

For more detailed guidance see:

Antiviral Guidance PDF

Treatment should be commenced within 48 hours of symptom onset.

Oseltamivir 75mg po BD for 5 days.

If the patient is unable to take orally or oseltamivir is not suitable for other reasons:

Zanamivir 10 mg (2 inhalations via diskhaler) BD for 5 days (caution in asthma and COPD: there is a risk of bronchospasm so a short-acting bronchodilator should be available).

Prophylaxis is normally not considered in at-risk groups (see below for these groups) who have been vaccinated against seasonal influenza at least 14 days before exposure.
Prescribe an antiviral drug for post-exposure prophylaxis if all of the following circumstances apply:
- The national surveillance scheme indicates that influenza is circulating.
- The person has been exposed to a person (in the same household or residential setting) with an influenza-like illness.
- The person is in an 'at risk' group (see below for these groups) and has not been adequately protected by vaccination, that is:
  - They have not been vaccinated since the previous influenza season.
  - The vaccination is not well matched to the circulating strain.
  - There has been less than 14 days between vaccination and date of contact with influenza.
- The person is able to start treatment within 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir).
  - Treatment after 48 hours of this contact (for oseltamivir) or 36 hours of this contact (for zanamivir) is an off-label use and should be done on specialist advice only.

Oseltamivir 75mg OD for 10 days (within 48 hours of contact)

Zanamivir 10mg (via diskhaler) OD for 10 days (within 36 hours of contact).

At risk groups include the following:

Chronic respiratory disease, including:
- Chronic obstructive pulmonary disease, including chronic bronchitis and emphysema, bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis, and bronchopulmonary dysplasia.
- Asthma that requires continuous or repeated use of inhaled corticosteroids or with previous exacerbations requiring hospital admission.
- Children who have previously been admitted to hospital for lower respiratory tract disease.
Chronic heart disease, including congenital heart disease, hypertension with cardiac complications, chronic heart failure, and individuals requiring regular medication or follow up for ischaemic heart disease.
Chronic kidney disease, including nephrotic syndrome, chronic renal failure, and renal transplantation.
Chronic liver disease, including cirrhosis, biliary atresia, and chronic hepatitis.
Chronic neurological disease, including stroke and transient ischaemic attack.
Diabetes, including type 1 diabetes and type 2 diabetes (requiring oral hypoglycaemic drugs or a controlled diet).
Immunosuppression due to disease or treatment, including:
- People undergoing chemotherapy (or radiotherapy) leading to immunosuppression.
- People with asplenia or splenic dysfunction.
- HIV infection (all stages).
- Individuals treated with, or likely to be treated with, systemic steroids for more than 1 month at dosages equivalent to 20 mg prednisolone daily (at any age) or, for children weighing less than 20 kg, a dose of 1 mg or more per kg body weight per day.
Morbid obesity (body mass index of 40 or more).

Consideration should also be given to:

People living in long-stay residential or nursing homes.
People who receive a carer’s allowance or care for disabled or elderley people, whose welfare may be at risk if the carer falls ill.

Pneumonia

Degree of severity of pneumonia is based on the following criteria (CURB65 score) each scoring one if present:

C = confusion (new or Mental Test Score < 8)

U = urea >7mmol/l

R = resp. rate 30/min

B = BP: SBP < 90mmHg and/or DBP < 60mmHg

65 = Age > 65 years

IMPORTANT SPECIMENS TO BE SUBMITTED TO THE LABORATORY:

1) Urine for Legionella and Pneumococcal antigen

2) Respiratory secretions (sputum or throat/nasal swab placed in viral transport medium) for:

a) Respiratory virus PCR

style="color: #000000"> b) Mycoplasma pneumoniae PCR

3) Sputum for culture (if patient is expectorating)

4) Blood cultures (if clinical sepsis present).

5) Respiratory secretions (sputum or throat/nasal swab placed in viral transport medium) for Pneumocystis jirovecii PCR if indicated (immunocompromised patients).

LOW-SEVERITY (CURB65=0 TO 1), OUTPATIENT TREATMENT, OR ADMITTED FOR OTHER ILLNESS:

Amoxicillin 1g po tds.

If penicillin allergic

Clarithromycin 500mg po BD.

Moderate-severity (CURB65=2):

Oral treatment: Amoxicillin 1g po tds plus clarithromycin 500mg po bd.

If penicillin allergic

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd

If unable to take orally and IV treatment needed:
IV treatment: Amoxicillin 1g IV 8 hourly plus clarithromycin 500mg IV 12 hourly.

Note: Clarithromycin can be given IV; however oral administration is preferred because of risk of severe clarithromycin-associated phlebitis when given IV.

Oral stepdown: Amoxicillin 1g po tds plus clarithromycin 500mg po bd.

If penicillin allergy (rash):

IV treatment: Cefuroxime 1.5g IV 8 hourly plus clarithromycin 500mg IV 12 hourly.

Note: Clarithromycin can be given IV; however oral administration is preferred because of risk of severe clarithromycin-associated phlebitis when given IV.

Oral step down: Doxycycline 200mg po stat for the first dose then 100mg po bd as a single agent. (Stop other antibiotics as clarithromycin plus doxycycline constitutes duplicative treatment).

If penicillin allergy (anaphylaxis)

Note: penicillin anaphylaxis is very rare

IV treatment: Levofloxacin 500mg IV 12 hourly.

Oral step down: Doxycycline 200mg po stat for the first dose then 100mg po bd as a single agent. (Stop other antibiotics as clarithromycin plus doxycycline constitutes duplicative treatment).

High-severity (CURB65=3-5):

Co-amoxiclav 1.2g IV 8 hourly plus clarithromycin 500mg po bd.

Note: Clarithromycin can be given IV; however oral administration is preferred because of risk of severe clarithromycin-associated phlebitis when given IV.

Oral step down: Doxycycline 200mg po stat for the first dose then 100mg po bd as a single agent. (Stop other antibiotics as clarithromycin plus doxycycline constitutes duplicative treatment).

Penicillin allergy (rash):

IV treatment: Cefuroxime 1.5g IV 8 hourly plus clarithromycin 500mg IV 12 hourly:

Oral step down: Doxycycline 200mg po stat for the first dose then 100mg po bd as a single agent. (Stop other antibiotics as clarithromycin plus doxycycline constitutes duplicative treatment).

Penicillin allergy (anaphylaxis):

IV treatment: Levofloxacin 500mg IV 12 hourly.

Oral step down: Doxycycline 200mg po stat for the first dose then 100mg po bd (as a single agent).

In suspected or confirmed pneumococcal pneumonia antibiotic treatment may need to continue for 7-10 days in the more severely ill patient.

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

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Penicillin allergy (rash):

IV treatment: Ceftazidime 2g IV 8 hourly.

Oral treatment: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Penicillin allergy (anaphylaxis):

IV treatment: Levofloxacin 500mg IV 12 hourly.

Oral step down: Doxycycline 200mg po stat for the first dose then 100mg po bd.

Please note: Levofloxacin for hospital-acquired pneumonia is unlicensed use.

PVL-Producing Staph Aureus Pneumonia

Panton-Valentine leucocidin producing Staph. aureus-associated pneumonia

IV treatment:

Linezolid 600mg IV 12 hourly

plus

Rifampicin 600mg IV 12 hourly.

Oral treatment:

Linezolid 600mg po bd

plus

Rifamipicin 600mg po bd.

Treatment duration is for 10 to 14 days.

Chlamydia

Epididymo-Orchitis

Gonorrhoea

Mycoplasma Genitalium

Non-Specific Urethritis

Pelvic Inflammatory Disease

Syphilis

Refer patients to Locala Sexual Health on 0161 507 9460 for contact tracing and further managment.

Chlamydia

1st line : Doxycycline 100mg po bd for 7 days. (note sunlight sensitivity)

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 or re-infection.

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

Epididymo-Orchitis

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

Ofloxacin 200mg po bd for 14 days.

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

Gonorrhoea

Ceftriaxone 1g intramuscularly as a single dose (with lignocaine as directed)

Same treatment in pregnancy and breastfeeding.

Ceftriaxone 1g intramuscularly as a single dose plus azithromycin 1g po stat once only.

Single dose treatment in uncomplicated infection.

Refer to Tameside & Glossop centre for sexual health for partner notification.

Gonorrhoea may be associated with Chlamydia infection and therefore always treat for Chlamydia infection concomitantly.

Mycoplasma Genitalium

1st line: Doxycycline 100mg po bd for 7 days (note sunlight sensitivity) followed by azithromycin 1g po single stat then 500mg po od for 2 days.

2nd line:Moxifloxacin 400mg po od for 7 days.

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

Non-Specific Urethritis

1st line. Ceftriaxone 1g IM stat (to cover for Gonorrhoea)

plus

Doxycycline 100mg po bd for 7 days (note sunlight sensitivity) followed by azithromycin 1g po single stat then 500mg po od for 2 days (to cover for Chlamydia and Mycoplasma genitalium).

2nd line. Ceftriaxone 1g IM stat (to cover for Gonorrhoea)

plus

Moxifloxacin 400mg po od for 7 days(to cover for Chlamydia and Mycoplasma genitalium).

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

Pelvic Inflammatory Disease

Ceftriaxone 1g intramuscular or intravenous stat dose once only plus

Doxycycline 100mg po bd plus

Metronidazole 400mg po bd

Treatment duration is 14 days.

Avoid tetracyclines in pregnancy

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

IV treatment:

Ceftriaxone 2g IV once daily plus doxycycline 100mg po bd.

Followed by oral treatment with: Doxycycline 100mg po bd plus metronidazole 400mg po bd.

If patient is allergic to or cannot tolerate doxycycline:

IV treatment:

Ceftriaxone 1g IV stat dose once only plus Levofloxacin 500mg IV 12 hourlyplus metronidazole 500mg IV 8 hourly.

Followed by oral treatment with: Levofloxacin 500mg po bd plus metronidazole 400mg po bd.

If pregnant:

Ceftriaxone 2g IV once daily plus clindamycin 900mg IV 8 hourly.

Followed by oral treatment with: azithromycin 250mg od plus metronidazole 400mg po bd.

Treatment duration is 14 days in total including both IV and oral treatment.

NOTE: If patients fail to respond to treatment with the above antibiotic regimens, please contact the Antimicrobial Management Team for further guidance.

Syphilis

Refer to Tameside & Glossop centre for sexual health (gum clinic) for contact tracing and further management.

Incubating + primary, secondary or early latent syphilis

Benzathine penicillin 2.4MU IM stat

Penicillin allergy: Doxycycline 100mg po bd 14 days

Benzathine penicillin 2.4MU IM weekly x3 (day 1,8 +15)

Bite Wounds

Cellulitis

Clostridial Myonecrosis (Gas Gangrene)

Diabetic Foot Infections

Erysipelas

Facial / Orbital Cellulitis

Invasive Strep Group A Infections (iGAS)

Necrotizing Fasciitis

Non-invasive Strep Group A Infections.

Scarlet Fever

Shingles

Wound Infections

Bite Wounds

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

Tetanus Prophylaxis

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

Antibiotic treatment

Oral treatment: Co-amoxiclav 625mg po tds.

IV treatment (if cannot take orally): Co-amoxiclav 1.2g IV 8 hourly.

Penicillin allergy

Oral treatment: Doxycycline 200mg po for the first dose then 100mg po bd.

IV treatment (if cannot take orally): Co-trimoxazole 960mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Antibiotic treatment

IV treatment: Co-amoxiclav 1.2g IV 8 hourly.

Penicillin allergy

IV treatment: Co-trimoxazole 960mg IV 12 hourly plus clindamycin 600mg IV 6 hourly.

Cellulitis

Flucloxacillin 1g po qds.

Penicillin allergy

Clindamycin 300mg po qds.

Antibiotic treatment:

IV treatment: Flucloxacillin 2g IV stat followed by 2g IV 6 hourly.

Oral step down: Flucloxacillin 1g po qds.

Penicillin allergy

IV treatment: Clindamycin 600mg IV 6 hourly.

Oral step down: Clindamycin 450mg po qds.

Clostridial Myonecrosis (Gas Gangrene)

Antibiotic treatment

IV treatment: Benzypenicillin 2.4g IV stat followed by 2.4g IV 4 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral step down: Amoxicillin 2g po tds plus clindamycin 450mg po qds.

Penicillin allergy (rash)

IV treatment: Cefuroxime 1.5g IV stat followed by 1.5g IV 6 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral step down: Cefalexin 1g po tds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treatment: Chloramphenicol 1g IV stat followed by 1g IV 6 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

See section on therapeutic Drug Monitoring for guidance on the dose and the monitoring of drug plasma levels of glycopeptides (such as vancomycin).

Oral step down: Chloramphenicol 500mg po qds plus clindamycin 450mg po qds.

Diabetic Foot Infections

Diabetic foot infections in a large measure follow the antibiotic treatment guidelines of wound infections, however consultation of the Clinical guidelines for the in-patient management of diabetic foot infections is also advised.

Erysipelas

Erysipelas is caused by Strep Group A.

Antibiotic treatment

IV treatment: Benzylpenicillin 1.2 g IV stat followed by 1.2g IV 6 hourly.

Oral treatment: Amoxicillin 1g po tds.

Penicillin allergy (rash)

IV treatment: Cefuroxime 1.5g IV stat followed by 1.5g IV 8 hourly.

Oral treatment: Cefalexin 1g po tds.

Penicillin allergy (anaphylaxis)

IV treatment: Clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Clindamycin 450mg po qds.

A total of 10 days of antibiotic treatment would be required in order to prevent recurrence of infection by Group A Strep.

Facial / Orbital Cellulitis

See Facial / Orbital cellulitis in head and neck section.

Invasive Group A Strep Infections (iGAS)

Management of Invasive Group A Strep (iGAS) Infections is as follows:

Invasive Group A Strep infections include:

Strep Group A bacteraemia
Bacteraemic spreading cellulitis with a well-demarcated intensely erythematous edge
Bacteraemic facial erysipelas
Necrotizing fasciitis.
Pneumonia and empyema.
Strep Group A toxic shock syndrome.
Bacteraemic puerperal sepsis.

Management:

1) Antibiotic treatment with: high dose benzylpenicillin 2.4g IV stat, then 2.4g IV 4 hourly plus high dose clindamycin 1.2g IV stat, then 1.2g IV 6 hourly.

Oral step down: amoxicillin 2g po tds plus clindamycin 450mg po qds.

Penicillin allergy (rash)

IV treatment: cefuroxime 1.5g IV stat followed by 1.5g IV 6 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral step down: cefalexin 1g po qds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treatment: linezolid 600mg IV stat followed by 600mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral step down: linezolid 600mg po bd plus clindamycin 450mg po qds.

2) Urgent surgical review in cases of:

Necrotizing fasciitis
Thoracic empyema.

3) Consider immunoglobulin administration in a single dose of 400mg/kg IV stat

iGAS is a notifiable condition and must be reported to Public Health England (tel: 0344 225 0562).

Necrotizing Fasciitis

Necrotising fasciitis due to Strep Group A

Antibiotic treatment

IV treatment: benzylpenicillin 2.4g IV stat followed by 2.4g IV 4 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly

Oral step down: amoxicillin 2g po tds plus clindamycin 450mg po qds.

Penicillin allergy (rash)

IV treatment: cefuroxime 1.5g IV stat followed by 1.5g IV 6 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral step down: cefalexin 1g po qds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treatment: linezolid 600mg IV stat followed by 600mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral step down: linezolid 600mg po bd plus clindamycin 450mg po qds.

Polymicrobial necrotizing fasciitis is caused by mixed aerobic and anaerobic bacteria.

Antibiotic treatment

IV treatment: Piperacillin/Tazobactam 4.5g IV stat followed by 4.5g IV 6 hourly (QDS) plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral treament: Co-amoxiclav 625mg po tds plus clindamycin 450mg po qds.

Penicillin allergy (rash)

IV treatment: Ceftazidime 2g IV stat followed by 2g IV 8 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral treatment: Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treatment: Ciprofloxacin 400mg IV stat followed by 400mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 1.2g IV 6 hourly.

Oral treatment: Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

Non-Invasive Strep Group A Infections

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

Non-invasive and treatable with oral antibiotics 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.

Amoxicillin 1g po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see section on Tonsillitis in the inpatient guideline).

Penicillin allergy (rash)

Cefalexin 1g po tds for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see section on Tonsillitis in the inpatient guideline).

Penicillin allergy (anaphylaxis)

Clarithromycin 500mg po bd for 10 days. (NOTE: for treatment of Strep Group A tonsillitis see section on Tonsillitis in the inpatient guideline).

Scarlet Fever

See Tonsillitis section on the ENT page

Shingles

Oral treatment: Aciclovir 800mg five times a day for 7 days.

IV treatment: Aciclovir 5mg/kg 8 hourly for 5 days.

If the patient is immunocompromised:

Oral treatment: Aciclovir 800mg five times a day continued for 2 days after crusting of lesions (usually 10 days).

IV treatment: Aciclovir 10mg/kg 8 hourly for 5 days.

Infection control measures:

Only a person who has not had chickenpox or varicella vaccine in the past (i.e. is non-immune) is susceptible to chickenpox infection from a person with active shingles; however spread 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; however if the rash is covered then the risk of transmission is very low.

References:

British National Formulary. Available at URL: https://www.medicinescomplete.com/mc/bnf/current/ [Accessed: 23/08/16]

NICE Clinical Knowledge Summaries. Shingles. (May 2013).

Wound Infections

Wound infections include surgical site infections, chronic skin ulcers and infected pressure sores.

For superficial surgical site infections the commonest aetiologic organism is Staph aureus and treatment should follow the cellulitis guideline. See section on Cellulitis

For deep surgical site infection antibiotic treatment should cover the organisms associated with that anatomic site such as the GI tract and respiratory tract. See section on Surgical prophylaxis and use the same antibiotics recommended for surgical prophylaxis to treat deep surgical site infections.

The duration of antibiotic treatment depends on the clinical response.

In the ABSENCE of spreading cellulitis, induration or constitutional symptoms associated with the lesion, NO systemic antibiotic treatment would be required, and TOPICAL/LOCAL MANAGEMENT of the lesion would be more appropriate. Topical treatment includes maintenance of good wound toilet together with application of appropriate dressings in consultation with the tissue viability department. Local management of the wound includes surgical debridement, vascular surgical assessment as well as close diabetic monitoring.

Antibiotic treatment

IV treatment: Co-amoxiclav 1.2g IV 8 hourly.

Oral treatment: Co-amoxiclav 625mg po tds.

Penicillin allergy (rash)

IV treatment: Cefuroxime 1.5g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treatment: Cefalexin 1g po tds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treament: Ciprofloxacin IV 400mg stat followed by 400mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly.

Oral treament: Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

If clinical toxicity is present i.e. sepsis syndrome (SIRS plus invasive infection):

IV treatment: Piperacillin/tazobactam 4.5g IV stat followed by 4.5g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly plus gentamicin 5mg/kg (4mg/kg if > 70 years) IV single stat dose once only. (4mg/kg if > 70 years.) Max dose 400mg

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

Penicillin allergy (rash)

IV treatment: Cefuroxime 1.5g IV 8 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly plus gentamicin 5mg/kg (4mg/kg if > 70 years) IV single stat dose once only. (4mg/kg if > 70 years.) Max dose 400mg

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

Oral treatment: Cefalexin 1g po tds plus clindamycin 450mg po qds.

Penicillin allergy (anaphylaxis)

IV treament: Ciprofloxacin IV 400mg stat followed by 400mg IV 12 hourly plus clindamycin 1.2g IV stat followed by 900mg IV 8 hourly plus gentamicin 5mg/kg (4mg/kg if > 70 years) IV single stat dose once only.

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

Oral treament: Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds.

In the elderley (>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 there is dysuria, the patient is systemically unwell or pyelonephritis is likely.

A urine specimen MUST be sent to the laboratory for microbiologic culture and sensitivity prior to commencing antibiotic treatment for urinary tract infection.
Follow up culture and sensitivity results to review the choice of antibiotic.
Change the antibiotic according to susceptibility results if the bacteria are resistant.
Use narrow spectrum antibiotics wherever possible.

Acute Bacterial Prostatitis (Non-STI)

Acute Pyelonephritis

Chronic Bacterial Prostatitis

Recurrent UTI

Urinary Catheter Associated UTI

Urinary Tract Infections

Urosepsis

UTI in Pregnancy

Acute Bacterial Prostatitis (Non-STI)

Ensure any sexually transmitted infections are excluded.

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

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

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

Acute Pyelonephritis

1st line: Cefuroxime 1.5g IV 8 hourly then cefalexin 1g po tds for a total 10 days.

2nd line: Ciprofloxacin 400mg IV 12 hourly then 500mg po bd for a total of 7 days.

Chronic Bacterial Prostatitis

Only treat if a bacterial etiology has been confirmed as chronic prostatitis has a large inflammatory component and antibiotics may not always be indicated.

1st line: Co-trimoxazole 960mg po bd for 4 weeks.

2nd line: Ciprofloxacin 500mg po bd for 4 weeks.

3rd line: Doxycycline 100mg po bd for 4 weeks.

Refer to Urologist.

Recurrent UTI

Recurrent urinary tract infections (UTI) in adults is defined as repeated UTI with frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months.

Comprehensively assess the problem and refer to a specialist urologist or gynaecologist (for female patients).

Behavioural and personal hygiene measures:

Patients should be given advice about behavioural and personal hygiene measures to reduce the risk of UTI, such as:

- drinking enough fluids to avoid dehydration

- not delaying habitual and post-coital urination

- wiping from front to back after defaecation

- not douching or wearing occlusive underwear.

Cranberry products and D-mannose:

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.

Urinary Catheter Associated UTI

Urinary-catheter associated UTI should be treated as an acute urinary tract infection - for antibiotic treatment recommendations see UTI section .

Note: If the patient is asymptomatic, i.e. no local urinary or systemic manifestations of infection, no antibiotic treatment is required.

Urine dipstick testing should not be routintely carried out in patients with long term indwelling catheters. This is because there is no relationship between the level of pyruria (white cells in the urine) and infection in people with indwelling catheters. The presence of the catheter induces pyuria without the presence of infection so using urine dipstick testing for UTI in these patients may produce false positive results. If a patient is symptomatic of UTI, a urine specimen must be taken from the catheter tubing not the bag and sent to the microbiology lab for culture and sensitivity.

Unless contraindicated, urinary catheter-associated infection will always require change of catheter. For the procedure of changing the catheter, antibiotic administration should take place just prior to the replacement of the catheter in order to prevent bacteraemic spread of pathogens. For recommendations on which antibiotic to give when changing the catheter please see section on Urinary catheterisation prophylaxis on the surgical prophylaxis page

Urinary Tract Infections

Patients over 65 years of age

If the patient is over 65 years of age, do not carry out urine dipstick analysis for diagnosis of urinary tract infection. This is not a reliable diagnostic test for patients in this age group as up to half of patients in this age group will have the presence of leucocytes and nitrites in the absence of infection - known as asymptomatic bacteriuria. Diagnosis should be based on clinical signs and symptoms as follows:

new onset dysuria alone or 2 or more of the following: pyrexia new frequency/urgency new incontinence new/worsening delirium/debility new suprapubic pain visible haematuria.

A urine specimen should be taken before antibiotic treatment is commenced.

Patients under 65 years of age

For patients under 65 years of age a preliminary diagnosis of urinary tract infection is made by performing a urine dipstick analysis: Both leucocyte esterase and nitrite should be positive for a diagnosis of urinary tract infection to be made, although in a minority of urinary tract infections (such as enterococcal infections) nitrites may be negative. A urine specimen MUST be sent to the laboratory for microbiologic culture and sensitivity.

Uncomplicated lower urinary tract infection (cystitis) implies no evidence of pyelonephritis (i.e. upper tract disease) or urosepsis (i.e. sytemic involvement of infection = SIRS).

Oral treatment:

1st line: Pivmecillinam 400mg stat for the first dose then 200mg TDS for 3 days.

2nd line: Nitrofurantoin M/R 100mg BD for 3 days

IV treatment: Cefuroxime 1.5g IV stat, followed by 1.5g IV 8 hourly for 2 further doses (3 doses in total).

Where nitrofurantoin is not suitable and the patient is allergic to penicillin see below.

Penicillin allergy (rash)

Oral treatment: Cefalexin 1g po stat, followed by 1g po 8 hourly for a further 2 doses (3 doses in total).

IV treatment: Cefuroxime 1.5g IV stat, followed by 1.5g IV 8 hourly for 2 further doses (3 doses in total).

Penicillin allergy (anaphylaxis)

Oral treatment: Fosfomycin 3g po stat (one dose only).

IV treatment: Ciprofloxacin 400mg, IV, stat followed by 400mg, IV, 12 hours later (2 doses in total).

Oral treatment:

1st line: Pivmecillinam 400mg for the first dose then 200mg TDS.

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

IV treatment: Cefuroxime 1.5g IV 8 hourly.

Men with upper UTI should be referred to a urologist.

Where nitrofurantoin is not suitable and the patient is allergic to penicillin see below.

Penicillin allergy (rash)

Oral treatment: Cefalexin 500mg po tds.

IV treatment: Cefuroxime 1.5g IV 8 hourly.

Penicillin allergy (anaphylaxis)

Oral treatment: Ciprofloxacin 500mg po bd.

IV treatment: Ciprofloxacin 400mg IV 12 hourly

Treatment duration is for up to 7 days. NOTE: in the absence of fever, flank pain, or systemic toxicity, duration of treatment of acute lower urinary tract infection in males can be less than 7 days e.g. even 3 days if the patient has clinically responded to treatment.

Urosepsis

Antibiotic treatment

IV treatment: Cefuroxime 1.5g IV 8 hourly - this is suitable for patients with 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.

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

Penicillin allergy (anaphylaxis)

IV treatment: Ciprofloxacin 400mg IV 12 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.

Oral step down: Ciprofloxacin 500mg po bd.

UTI in Pregnancy

ORAL TREATMENT:

1. Pivmecillinam 400mg STAT for the first dose then 200mg TDS

2.Nitrofurantoin 100mg MR BD - AVOID AT TERM (from 37 weeks).

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

Treatment duration is a total of 7 days.

Repeat MSU 7 days after completion of antibiotic treatment.

IV TREATMENT (if patient is unable to tolerate oral treatment OR there is urosepsis):

Cefuroxime 1.5g IV 8 hourly (oral step down is to cefalexin 1g po tds).

Penicillin allergy (anaphylaxis):

Ciprofloxacin 400mg IV 12 hourly (oral step down is to ciprofloxacin 500mg po bd).

Treatment duration is a total of 7 days.

Repeat MSU 7 days after completion of antibiotic treatment.

Central Line Infection

Neutropenic Sepsis / Oncology Patient

Sepsis

Central Line Infection

Vancomycin IV

Flucloxacillin IV

Penicillin allergy (rash):

Cefuroxime IV

Penicillin allergy (anaphylaxis):

Vancomycin IV

Neutropenic Sepsis / Oncology Patient

Piperacillin/tazobactam IV.

Also give stat gentamicin IV if severely ill.

Penicillin allergy (rash):

Meropenem IV.

Also give stat gentamicin IV if severely ill.

Penicillin allergy (anaphylaxis):

Ciprofloxacin IV plus clindamycin IV.

Also give stat gentamicin IV if severely ill.

Sepsis Syndrome

If there is NO central nervous system involvement (meningitis/encephalitis):

Cefuroxime IV plus a single stat dose of gentamicin IV

Penicillin allergy (anaphylaxis):

Ciprofloxacin IV plus vancomycin IV

If central nervous system involvement suspected (meningitis/encephalitis):

Ceftriaxone IV

Penicillin allergy (anaphylaxis):

Chloramphenicol IV plus co-trimoxazole IV

Neonatal sepsis post delivery:

Benzylpenicillin plus gentamicin

If patient is discharged and admitted with sepsis:

Age <28 days: cefotaxime plus amoxicillin

Age 28 days and over: ceftriaxone plus amoxicillin

Penicillin allergy (anaphylaxis):

Ciprofloxacin plus vancomycin

Septic Arthritis and Osteomyelitis

Flucloxacillin - maximum dose for weight

Penicillin allergy (rash):

Cefuroxime - maximum dose for weight

Penicillin allergy (rash):

Clindamycin - maximum dose for weight.

Treatment duration: minimum 4 - 6weeks.

Aged 3 months and Over

Aged Less than 3 Months

Aged 3 Months and Over

Ceftriaxone IV

Penicillin allergy (anaphylaxis):

Chloramphenicol IV plus co-trimoxazole IV.

Aged Less than 3 Months

Age <28 days: cefotaxime plus amoxicillin

For suspected Herpes simplex virus and Varicella zoster meningitis/encephalitis give: aciclovir IV.

Note aciclovir is not effective against any of the other causes of viral meningitis/encephalitis.

Age 28 days and over: ceftriaxone plus amoxicillin

For suspected Herpes simplex virus and Varicella zoster meningitis/encephalitis give: aciclovir IV.

Note aciclovir is not effective against any of the other causes of viral meningitis/encephalitis.

Acute Lymphadenitis

Acute Mastoiditis

Deep Neck Space Abscess

Dental Infections

Epiglottitis

Facial / Orbital Cellulitis

Otitis Externa

Otitis Media

Peri-Tonsillar / Retropharyngeal Abscess

Post-Tonsillectomy Bleed

Sinusitis

Suppurating Neck Nodes

Tonsillitis

Acute Lymphadenitis

Co-amoxiclav

Penicillin allergy:

Clindamycin

Acute Mastoiditis

Co-Amoxiclav IV - if no improvement add clindamycin IV

Penicillin allergy (rash):

Cefuroxime IV - if no improvement add clindamycin IV

Penicillin allergy (anaphylaxis):

Co-trimoxazole IV plus clindamycin IV

If there are any concerns with regards to intracranial spread of infection give the following:

Ceftriaxone IV plus clindamycin IV

Penicillin allergy (anaphylaxis):

Chloramphenicol IV plus clindamycin IV

Treatment duration is 2 weeks. If there is evidence of mastoid bone osteomyelitis then treatment duration is 4 weeks.

Deep Neck Space Abscess

IV treatment: co-amoxiclav plus clindamycin.

Oral step down: co-amoxiclav plus clindamycin.

Penicillin allergy (anaphylaxis):

IV treatment: cefuroxime plus clindamycin.

Oral step down: cefalexin plus clindamycin.

Penicillin allergy (anaphylaxis):

IV treatment: co-trimoxazole plus clindamycin.

Oral step down: co-trimoxazole plus clindamycin.

Dental Infections

Amoxicillin

Penicillin allergy:

Clindamycin

Epiglottitis

IV treatment:

<28 days: cefotaxime

28 days or older: ceftriaxone

Oral step down: co-amoxiclav

Penicillin allergy (anaphylaxis):

Ciprofloxacin plus clindamycin

Facial / Orbital Cellulitis

See Peri-Orbital / Facial Cellulitis in ophthalmology section.

Otitis Externa

Oral antibiotics are rarely indicated. Topical therapy is the mainstay of treatment:

Acetic acid 2% (EarCalm) 1 spray TDS

Sofradex/Gentisone HC 3 drops TDS

If fungal infection suspected: clotrimazole drops 1%, 3 drops TDS.

Co-amoxiclav PO

Penicillin allergy:

Clarithromycin PO

Cover Pseudomonas aeruginosa

IV treatment: ceftazidime IV plus ciprofloxacin 0.3% eye/ear drops, 3 drops QDS.

Oral step down: ciprofloxacin

Penicillin allergy:

IV treatment: ciprofloxacin IV plus ciprofloxacin 0.3% eye/ear drops, 3 drops QDS.

Oral step down: ciprofloxacin

Otitis Media

No Antibiotics

Less than 2yrs old - amoxicillin 7 days

2yrs and over - amoxicillin 5 days

Penicillin allergy:

Clarithromycin 7 days

Not for antibiotics may trial another course of antibiotics as in severe acute otitis media.

Peri-Tonsillar / Retropharyngeal Abscess

Co-amoxiclav

Penicillin allergy (rash):

Cefuroxime

Penicillin allergy (anaphylaxis):

Ciprofloxacin plus clindamycin.

Post-Tonsillectomy Bleed

IV treatment: co-amoxiclav

Oral step down: co-amoxiclav

Penicillin allergy (rash):

IV treatment: cefuroxime

Oral step down: cefalexin

Penicillin allergy (anaphylaxis):

IV treatment: clindamycin

Oral step down: clarithromycin.

Sinusitis

Amoxicillin

Penicillin allergy:

Clarithromycin

Refer to ENT

Suppurating Neck Nodes

IV treatment: co-amoxiclav

Oral step down: co-amoxiclav

If no better add clindamycin IV to treatment with co-amoxiclav IV.

Oral step down: co-amoxiclav plus clindamycin.

Penicillin allergy (anaphylaxis):

IV treatment: cefuroxime plus clindamycin

Oral step down: cefalexin plus clindamycin

Penicillin allergy (anaphylaxis):

IV treatment: co-trimoxazole plus clindamycin

Oral step down: co-trimoxazole plus clindamycin.

Tonsillitis

No antibiotics/delayed antibiotic prescribing as 90% resolve in 7 days without antibiotics, and pain only reduced by 16 hours.

Note it is most important to submit a THROAT SWAB FOR CULTURE to the laboratory in order to exclude Strep Group A pharyngo-tonsillitis. 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.

Use the following table to assess serious illness in children

Penicillin V (5 days). In more complicated infections such as quinsy and scarlet fever, the duration will be longer (at least 10 days).

Penicillin allergy (rash):

Cefalexin (5 days). In more complicated infections such as quinsy and scarlet fever, the duration will be longer (at least 10 days).

Penicillin allergy (anaphylaxis):

Clarithromycin (5 days). In more complicated infections such as quinsy and scarlet fever, the duration will be longer (at least 10 days).

Appendicitis

Campylobacter Enteritis

Clostridioides Difficile

Necrotizing Enterocolitis

Non-Typhoidal Salmonellosis / Shigella

Peritonitis

Appendicitis

Cefuroxime plus metronidazole

Penicillin allergy (anaphylaxis):

Co-trimoxazole plus clindamycin

Campylobacter Enteritis

Only treat if severe infection or immunocompromised.

<6 months: clarithromycin for 3 days.

6 months and over: azithromycin for 3 days.

Clostridioides Difficile

Metronidazole

Necrotizing Enterocolitis

Benzylpenicillin plus gentamicin plus metronidazole

Penicillin allergy (anaphylaxis):

Co-trimoxazole plus clindamycin

Non-Typhoidal salmonellosis / Shigella

Most infections are self-limiting and no antibiotics are required however in patients who are severely ill empiric antibiotic treatment includes:

Oral treatment:

<6 months: ciprofloxacin PO

6 months or over: azithromycin PO

IV treatment:

Ceftriaxone IV

Penicillin allergy (anaphylaxis):

Co-trimoxazole IV

Peritonitis

Cefuroxime plus metronidazole

Penicillin allergy (anaphylaxis):

Co-trimoxazole plus clindamycin

Acute Bacterial Conjunctivitis

Herpes Simplex Conjunctivitis

Peri-Orbital / Facial Cellulitis

Acute Bacterial Conjunctivitis

Chloramphenicol eye ointment Apply QDS

Herpes Simplex Conjunctivitis

Aciclovir IV plus aciclovir topical.

Refer to Ophthalmologist.

Peri-Orbital / Facial Cellulitis

Co-amoxiclav

Add clindamycin if no improvement

Penicillin allergy (rash):

Cefuroxime

Add clindamycin if no improvement.

Penicillin allergy (anaphylaxis):

Co-trimoxazole plus clindamycin.

Includes risk of intracranial spread.

Age <28 days: cefotaxime plus clindamycin

Age 28 days and over: ceftriaxone plus clindamycin.

Penicillin allergy (anaphylaxis):

age <28 days: co-trimoxazole plus clindamycin

age 28 days and over: chloramphenicol plus clindamycin.

Age <28 days: cefotaxime plus clindamycin

Age 28 days and over: ceftriaxone plus clindamycin.

Penicillin allergy (anaphylaxis):

Ciprofloxacin plus clindamycin.

If risk of intracranial spread

Age <28 days: co-trimoxazole plus clindamycin

Age 28 days and over: chloramphenicol plus clindamycin.

Aspiration Pneumonia

Community-Acquired Pneumonia

Empyema

Hospital-Acquired Pneumonia

Influenza

Aspiration Pneumonia

Co-amoxiclav

Penicillin allergy (rash):

IV treatment: Cefuroxime plus clindamycin

Oral step down: cefalexin plus clindamycin

Penicillin alllergy (anaphylaxis):

Co-trimoxazole plus clindamycin

Community Acquired Pneumonia

Amoxicillin po

Penicillin allergy:

Clarithromycin po

Co-amoxiclav plus clarithromycin

Penicillin allergy:

Clarithromycin

Empyema

IV treatment: cefuroxime plus clindamycin until chest drain removed and patient is afebrile.

Oral step down: cefalexin plus clindamycin.

Minimum 2 weeks duration.

If loculated, 4 weeks duration.

Penicillin allergy (anaphylaxis):

IV treatment: ciprofloxacin plus clindamycin until chest drain removed and patient is afebrile.

Oral step down: ciprofloxacin plus clindamycin.

Minimum 2 weeks duration.

If loculated, 4 weeks duration.

Hospital Acquired Pneumonia

IV treatment: Piperacillin/tazobactam

Oral step down: co-trimoxazole plus clindamycin

Penicillin allergy (rash):

IV treatment: ceftazidime

Oral step down: co-trimoxazole plus clindamycin

Penicillin allergy (anaphylaxis):

IV treatment: co-trimoxazole plus clindamycin

Oral step down: co-trimoxazole plus clindamycin

Influenza

Suspected influenza: fever, coryza, generalised symptoms (headache, malaise, myalgia, arthralgia) when prevalence of high influenza.

1st line: oseltamivir 5 days.

2nd line: zanamivir 5 days.

Animal and Human Bite Wounds

Cellulitis

Erysipelas

Facial / Orbital Cellulitis

Necrotizing Fasciitis

Scarlet Fever

Wound Infections

Animal and Human Bite Wounds

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 guidelines.

Co-amoxiclav

Penicillin allergy:

Co-trimoxazole plus clindamycin

Antibiotic treatment

IV treatment: Co-amoxiclav IV.

Penicillin allergy

IV treatment: Co-trimoxazole IV. plus clindamycin IV.

Cellulitis

Flucloxacillin

Penicillin allergy:

Clindamycin

Erysipelas

Erysipelas is caused by Strep Group A.

Antibiotic treatment

IV treatment: benzylpenicillin

Oral treatment: amoxicillin

Penicillin allergy (rash)

IV treatment: cefuroxime

Oral treatment: cefalexin

Penicillin allergy (anaphylaxis)

IV treatment: clindamycin

Oral treatment: clindamycin

A total of 10 days of antibiotic treatment would be required in order to prevent recurrence of infection by Group A Strep.

Facial / Orbital Cellulitis

See Orbital Cellulitis in section on ophthalmology infections

Necrotizing Fasciitis

Piperacillin/tazobactam plus clindamycin

Penicillin allergy (rash):

Ceftazidime plus clindamycin

Penicillin allergy (anaphylaxis):

Ciprofloxacin plus clindamycin

Scarlet Fever

See Pharyngitis / Tonsillitis in ENT section

Wound Infections

For superficial surgical site infections the commonest aetiologic organism is Staph aureus and treatment should follow the cellulitis guideline. See section on cellulitis.

For deep surgical site infection antibiotic treatment should cover the organisms associated with that anatomic site such as the GI tract and respiratory tract. See section on surgical prophylaxis and use the same antibiotics recommended for surgical prophylaxis to treat deep surgical site infections.

The duration of antibiotic treatment depends on the clinical response.

Antibiotic treatment

IV treatment: co-amoxiclav

Oral treatment: co-amoxiclav

Penicillin allergy (rash)

IV treatment: cefuroxime

Oral treatment: cefalexin

Penicillin allergy (anaphylaxis)

IV treament: co-trimoxazole plus clindamycin

Oral treament: co-trimoxazole plus clindamycin

If clinical toxicity is present i.e. sepsis syndrome (SIRS plus invasive infection):

IV treatment: piperacillin/tazobactam plus clindamycin plus gentamicin IV single stat dose once only.

Oral treatment: cefalexin plus clindamycin.

Penicillin allergy (rash)

IV treatment: cefuroxime plus clindamycin plus gentamicin IV single stat dose once only.

Oral treatment: cefalexin plus clindamycin.

Penicillin allergy (anaphylaxis)

IV treament: ciprofloxacin plus clindamycin plus gentamicin IV single stat dose once only.

Oral treament: ciprofloxacin plus clindamycin.

A urine specimen MUST be sent to the laboratory for microbiologic culture and sensitivity prior to commencing antibiotic treatment for urinary tract infection.
Follow up culture and sensitivity results to review the choice of antibiotic.
Change the antibiotic according to susceptibility results if the bacteria are resistant.
Use narrow spectrum antibiotics wherever possible.

Acute Pyelonephritis

Urinary Tract Infections

Urosepsis

Acute Pyelonephritis

Cefuroxime IV then step down to cefalexin PO. Treat for a total of 10 days.

Penicillin allergy (anaphylaxis):

Co-trimoxazole. Treat for a total of 10 days.

Urinary Tract Infections

1st line:

Cefalexin

2nd line or if penicillin allergy:

Nitrofurantoin tablets (if cannot swallow tablets give 3rd line option)

3rd line:

Ciprofloxacin

Urosepsis

Cefuroxime

If treatment is amenable to oral antibiotics, give cefalexin.

Penicillin allergy (anaphylaxis):

Co-trimoxazole

About these Guidelines:

These guidelines have been revised, rewritten and reformatted by Dr Howard Sacho, Consultant Medical Microbiologist and Infection Control Doctor, and Miss Sarwat Rahman, Antibiotic Specialist Pharmacist.
The intial setting up of this app was constructed by Mrs Saarah Niazi-Ali, Antibiotic Specialist Pharmacist.
Dr Philip Unsworth contributed advice and suggestions to these guidelines.
These Guidelines are regularly updated under the editorship of Miss Sarwat Rahman and Dr Howard Sacho.

Objectives

The primary objective of these guidelines is to:

a. Ensure the most appropriate use of antibacterials

b. Avoid antibiotic abuse and overuse, and the unnecessary prolongation of antibiotic treatment

c. Prevent the development of antibiotic-associated Clostridium difficile infection and MRSA blood stream infection.

d. Promote antibiotic stewardship programmes.

Prior To Commencing Antibiotics

Before commencing antibiotic treatment, the following important issues need to be considered:

Does the patient have a bacterial infection?

Have relevant specimens been collected for laboratory analysis?

Is the patient allergic to any antibiotics and is the history of allergy accurate?

Is parenteral treatment necessary? Use oral route whenever possible - number of antibiotics have good oral bioavailability and are well absorbed from the gastrointestinal (GI) tract such as metronidazole, ciprofloxacin, rifampicin and fluconazole. Unless the patient cannot absorb these agents enterally or has a malfunctioning GI tract, or is hypotensive with the sepsis syndrome, there is no advantage of using any of these drugs intravenously.

Antibiotics should be prescribed intravenously for severe infections such as bacteraemic sepsis, acute pyelonephritis, endocarditis, bacterial meningitis, septic arthritis/osteomyelitis, neutropenic sepsis

All antibiotic treatment should be reviewed daily. If required for longer than 3 days a new prescription is required and should only be prescribed after discussion with the senior clinician in charge of the patient.

Switching from IV to oral (follow on) antibiotic therapy is encouraged if the following conditions are met:

(i) Temperature less than 38 ℃, but preferably normal for at least 24 hours;

(ii) No unexplained tachycardia;

(iii) Signs of clinical improvement;

(iv) Oral fluids tolerated;

(v) No ongoing or potential GI tract absorption problems;

(vi) Infection does not need continued IV therapy to maintain high tissue antibiotic levels, such as would be required in endocarditis, meningitis, or severe soft tissue infection;

(vii) Oral formulation or suitable oral alternative is available.

N.B. Take samples for culture (e.g. blood, pus, urine, sputum, CSF) BEFORE commencing or changing antibiotics, and without delaying start of therapy. For suspected endocarditis take THREE SETS (pairs) of blood cultures of at least 5 ml into each blood culture bottle (i.e. total 30 ml of blood), preferably by separate venepuncture a few minutes apart. In other suspected serious bacteraemic infections, take TWO sets (pairs) of blood cultures of at least 5ml into each blood culture bottle (i.e. 20 ml of blood).

Check the Trust intranet for the latest version of this guideline.

Treat the patient, not the microbiology. The microbiology results need to be interpreted together with the clinical condition of the patient. A positive culture result does not necessarily imply that antibiotic treatment is required. For example chronic leg ulcers and long term indwelling urinary catheters are commonly colonised by bacteria but require no definitive antibiotic treatment. Treatment should depend on clinical infection such as acute cellulitis or underlying osteomyelitis with chronic leg ulcers. Treatment of patients with indwelling urinary catheters should be reserved for those with systemic manifestations infection such as fever, rigors and suprapubic pain. In addition those patients about to undergo instrumentation or surgery of the urinary tract should receive antibiotic prophylaxis just prior to the procedure. Urinary catheters should be removed as soon as they are no longer needed.

In keeping with good antibiotic stewardship strategies antibiotics should NOT be prescribed if there is no clinical or microbiologic evidence of bacterial infection. The majority of sore throats, coughs and colds are generally caused by viruses rather than bacteria, and antibiotics will NOT be beneficial in such cases. Avoid repeated courses of antibiotics where possible. Short course antibiotics are advisable for the majority of acute bacterial infections where as little as 3 days of antibiotic treatment may be sufficient. Use narrow spectrum antibiotics as much as possible such as flucloxacillin to treat Staph. aureus infections and a penicillin for Strep. Group A infections.

Meticulous attention by all staff is warranted with hand washing and use of disposable gloves and aprons when in contact with patients with communicable infections (see Infection Prevention and Control Policy). In addition hand washing by all patients before eating and drinking should be encouraged.

Avoid antimotility agents in patients with diarrhoea until a definitive aetiology has been established.

Preventing emergence of resistant organisms (including Carbapenemase producing Enterobacteriaceae (CPE)).

1. Maintenance of antibiotic stewardship programs directed at preventing antibiotic abuse and overuse.

2. Maintaining a high index of suspicion for patients transferred to this hospital from tertiary care centres such as Central Manchester Foundation Trust, University Hospital South Manchester, and Stepping Hill Hospital.

3. Close liaison and support for clinicians managing these patients from the departments of Microbiology, Infection Prevention and Laboratory Medicine.

The allergy status of all patients should be carefully checked and a careful history of the exact nature of the allergy needs to be determined. If the patient states they are allergic to penicillin they should be asked specifically about their manifestations of the allergy. They may simply report GI symptoms such as nausea or diarrhoea which is NOT an allergic reaction. Only 1-10% of penicillin exposed patients will have an allergic reaction and fewer than 0.05% of these patients will have an anaphylactic reaction.

Assessment of Penicillin Allergy

The following questions are suggested:

How do you know that you are penicillin allergic?
Have you ever taken co-amoxiclav, amoxicillin, ampicillin, flucloxacillin or penicillin V?
What happens to you when you take penicillin?

Pertinent questions for a history of penicillin anaphylaxis should include:

Did you experience tightness in your chest or wheezing (bronchoconstriction)?
Did you feel that there was a lump in your throat and your voice was hoarse (laryngeal oedema)?
Did you feel light-headed or feel like fainting (vascular collapse/shock)?
Was your skin red and face flushed with itching and wheals (urticaria and angiooedema)?

It should be noted that as little as 0.5-6.5% of penicillin-allergic patients will also be allergic to cephalosporins. Where penicillin allergy reaction is a rash cephalosporins, carbapenems and monobactams (aztreonam) may be used with caution. Where the reaction is anaphylaxis all beta-lactam antibiotics (penicillins, cephalosporins, carbapenems and monobactams) should be avoided.

How to prescribe antibiotics appropriately

1) Antibiotics should be prescribed on the antibiotic section of the treatment sheet or on the stat dose section for immediate administration.

2) Stat doses of antibiotics:

It is important to remember that antibiotic treatment should be commenced as soon as a diagnosis of infection is made especially in the acutely ill hospitalised patient. When prescribing the antibiotic if it is not due immediately on the antibiotic section of the chart, a stat dose must be prescribed on the stat dose section for immediate administration.

3) Antibiotic treatment that may be prescribed on the regular side of the treatment sheet includes eye/ear drops and treatment which is given for 4 weeks or more. Examples of conditions for which antibiotics are prescribed for prolonged durations include endocarditis, osteomyelitis, septic arthritis, tuberculosis - if antibiotics are prescribed for prolonged periods on the regular side of the treatment sheet, the indication and the intended duration of the antibiotic course should be stated (e.g. 4 weeks, 6 weeks) however for the vast majority of infections initial antibiotic treatment should continue for no longer than 3 days without prior clinical review.

4) All of the relevant sections on the antibiotic treatment sheet should be filled in correctly. Standard details on a prescription such as the drug name, the dose, frequency and route of administration should be completed. Important details notably the indication for treatment and each date upon which the antibiotic should be given must also be filled in.

5) Antibiotics should be prescribed on the antibiotic chart for 72 hours at a time. At the 72 hour point, antibiotic therapy should be reviewed and a decision made as to whether treatment should be continued, be stopped or changed to another regimen.

6) Antibiotics should be given for the shortest duration possible and stopped when the patient is clinically better unless there is a specific indication (such as endocarditis, pyelonephritis, septic arthritis, osteomyelitis or lung abscess) which requires more prolonged treatment. The durations of treatment for these indications are stated in the guideline. For indications where the duration is not specified in the guideline, antibiotics should be stopped on clinical improvement. In general most antibiotic treatments should not continue for longer than 3 to 5 days. Single day treatment such as for uncomplicated urinary tract infections is completely acceptable.

7) Antibiotic treatments should as far as possible be guided by microbiologic culture and antibiotic sensitivity results. Microbiologic results should be accessed and followed up as soon as they become available – as important as it is to commence empiric antibiotic treatment in the seriously ill patient, it is equally important to:

• obtain appropriate specimens for microbiologic analysis before antibiotic treatment is commenced

• obtain and interpret microbiologic results as soon as they become available.

8) In order to be more therapeutically effective it is important to de-escalate therapy to a narrower spectrum antibiotic once cultures and sensitivity results have become available; however both organ function (renal, hepatic and cardiovascular (haemodynamic stability)) and pharmacokinetics (tissue penetration) should be taken into account when making the step down change from broad to narrow spectrum antibiotics. For example, if treating an uncomplicated UTI (that is no evidence of clinical toxicity) the preference based on how narrow spectrum the antibiotic is would be firstly nitrofurantoin, then trimethoprim, then amoxicillin and then only a broad spectrum antibiotic.

9) Where necessary antibiotic treatment may need to be monitored – please see therapeutic Drug Monitoring for gentamicin and vancomycin monitoring.

10) When antibiotics are stopped, the antibiotic should be crossed off and the section for stopping antibiotics on the treatment sheet should be completed.

Aminoglycosides (such as gentamicin) and glycopeptides (such as vancomycin) require therapeutic drug monitoring, however when aminoglycosides (gentamicin) and glycopeptides (vancomycin) are used together increased nephrotoxicity is an important risk. It is therefore advisable not to use these two agents in combination if alternative effective treatment is available.

Gentamicin can be given using the once daily regimen with the exception of patients receiving gentamicin for the treatment of endocarditis, cystic fibrosis, pancreatitis, and in pregnancy, patients with extensive burns and paediatric patients. For patients who are not suitable for once daily gentamicin dosing, please read the section below 'Gentamicin twice (or three times) a day dosing.' Once daily gentamicin dosing is at least as effective as multiple dose therapy, is no more toxic and makes under-treating less likely and assaying simpler.

GENTAMICIN DOSE AND INTERVAL

For patients under 70 years of age and with normal renal function:

5 mg/kg once daily (max total daily dose must not exceed 400mg),

EXCEPT, in pregnant women, children, endocarditis and the other conditions referred to above - for these patients use the same total daily dose, divided into 2-3 doses per day.

For patients 70 years of age and over with normal renal function:

4 mg/kg once daily

EXCEPT in the conditions referred to above - for these patients use the same total daily dose, divided into 2-3 doses per day.

For patients with abnormal renal function:

For patients with renal impairment give the normal dose to begin with and then dose based on plasma levels. Do not give doses until levels are available from the laboratory in order to avoid toxicity.

Dose calculation for obese patients

Where a patient is obese the dose of gentamicin should be calculated using corrected body weight (CBW). The following steps should be followed in order to calculate CBW.

1. Weigh the patient to obtain actual body weight (ABW)

2. Calculate the ideal body weight (IBW) using the formulas below selected based on gender:

IBW Male (kg) = 50 + (2.3 x number of inches above five feet in height)
IBW Female (kg) = 45.4 + (2.3 x number of inches above five feet in height)

3. Calculate corrected body weight (CBW) using the following formula:

CBW (kg) = IBW + [0.4 x (ABW - IBW)].

For example, an obese male patient who is 6’1” tall and weighs 120kg would result in the following calculation:

IBW = 50 + (2.3 x 13) = 79.9kg

CBW = 79.9 + 0.4 (120 - 79.9) = 95.9kg when calculating dose.

MONITORING OF GENTAMICIN

Monitoring is recommended for all patients in whom it is anticipated that gentamicin will be given for more than 2 days. The main objective is to delay the onset of nephrotoxicity and reduce the risk of ototoxicity. If the patient has adequate renal function do not wait for plasma levels to become available from the laboratory before giving the next dose as this will delay treatment.

Monitoring of plasma levels

For once daily dosing only the pre-dose (trough) plasma concentration should be measured. A clotted blood sample must be taken before the second dose is due. The biochemistry department will test and give the result before the next dose is due. Wait for the test result before giving the second and subsequent doses in patients with renal impairment and patients who have had toxicity with gentamicin. Do NOT wait for the test result for patients who have normal renal function and no signs of gentamicin toxicity as this will delay antibiotic treatment.

If the level is:

Less than 1 mg /litre (therapeutic range) continue with the same dose and check pre-dose levels twice weekly.

Between 1-2 mg/litre give the next dose but check pre-dose level again prior to the next dose.

Greater than 2mg/litre do not give any more. Omit the next dose and repeat levels again after 24 hours. Do not administer any more gentamicin until the level is in the therapeutic range (less than 1mg/litre). The period of time it takes the plasma concentration to drop to a therapeutic level should be used as the time period between doses.

If the patient is very ill or if there are problems monitoring levels please discuss with the microbiologist for an alternative antibiotic regimen.

Duration

Review the need for gentamicin therapy at 72 hours. If it is deemed necessary to continue gentamicin treatment beyond 72 hours discussion with the Consultant Microbiologist.

Twice (or three times) a day dosing

Twice or three times a day dosing may be used, particularly in patients given small doses twice daily for endocarditis. Clotted blood samples should be taken just before and 1 hour after the dose (i.e. trough and peak levels). This should be done at dose 2-4; and earlier if there is renal impairment or other factors associated with increased toxicity. The peak level is needed, in multiple daily dosing, to ensure it is high enough for efficacy.

In endocarditis, aim for trough <1mg/litre and peak 3-5mg/litre.

In other conditions requiring multiple daily doses of gentamicin aim for trough <2mg/litre and peak 5-10mg/litre.

Subsequent monitoring of levels is needed 2-3 times weekly.

If the pre-dose (‘trough’) concentration is high, the interval between doses must be increased. If the post-dose (‘peak’) concentration is high, the dose must be decreased.

Intravenous vancomycin is reserved for severe (bacteraemic) infections due to Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase negative staphylococci (Staph. epidermidis) where there is resistance to flucloxacillin, and when it is indicated as prophylaxis in the penicillin allergic patient, as well as in the treatment of endocarditis including infection with ampicillin-resistant enterococci.

Initial doses, which may have to be altered according to renal function and levels, are 1g IV 12 hourly in patients less than 65 years and 1g IV once daily in patient 65 years and over.

Vancomycin is generally not nephrotoxic if used in the absence of other nephrotoxic drugs such as gentamicin.

Measurement of a single trough concentration just before 2nd to 4th dose is recommended for the following adult patients:

Patients receiving concomitant aminoglycosides
Patients receiving higher than normal doses of vancomycin (i.e. for meningitis)
Patients with rapidly changing renal function
Patients with altered volumes of distribution (burn patients, trauma patients, IV drug abusers)
Patients in whom treatment is failing.

Levels:

Pre dose (trough) concentration 10-15mg/litre

15-20mg/litre for MRSA

Anephric patients receiving haemodialysis should have vancomycin levels done periodically (approximately every 4 to 7 days) to ensure that therapeutic levels are maintained.

Oral vancomycin is effective, but not IV, when used for the treatment of severe C. difficile toxin-positive diarrhoea. It is used as a second line agent to metronidazole in mild C.difficile infection or as a first line agent in severe or relapsing infection. Oral vancomycin is of no use for systemic infections, as it is not significantly absorbed from the GI tract and the only indication for oral vancomycin is in the treatment of Clostridium difficile associated diarrhoea.

Probiotics are live organisms believed to confer health benefits to the host. They are thought to help with food digestion and in maintaining the balance of gut flora. Antibiotic treatment can disturb the natural balance of organisms in the gut by killing beneficial bacteria which can leave the gut open to colonisation and infection by harmful bacteria. Clostridium difficile (C.difficile) is considered to be one of these harmful bacteria and can result in severe diarrhoea, abdominal pain, colitis and pseudomembranous colitis.

Prophylactic

Prophylactic use of probiotics (e.g. Actimel^®) in patients receiving antibiotic treatment

There is moderate quality evidence which suggests that antibiotic-associated diarrhoea can be reduced with the use of probiotic prophylaxis.

In order to prevent the incidence of C.difficile infection, patients who are 65 years or over and are receiving antibiotic treatment for an infection should be given Actimel, one bottle of 100ml, twice a day for the duration of antibiotic treatment and for 7 days after stopping antibiotics.

For patients to receive Actimel, doctors, pharmacists or nurses must show this via a written indication on the medication chart in the regular medicines section.

Contraindications

The following patients should not receive probiotics:

• Patients who are immunosuppressed

• Patients with acute pancreatitis

• Patients who have a dairy allergy

Interactions

Dairy products reduce absorption of oral ciprofloxacin. Patients receiving oral ciprofloxacin should not take Actimel at the same time and a 2 hour interval should be maintained between the administration of these two agents.

Intravenous antibiotic treatment should be reviewed on a daily basis.

Switching from intravenous to oral antibiotic therapy (oral step down) should be undertaken when the following conditions are met:

Temperature less than 38 ℃, but preferably normal for at least 24 hours
Signs of clinical improvement
Oral fluids tolerated
No ongoing or potential GI tract absorption problems
Infection does not require continued IV therapy to maintain high tissue antibiotic levels, such as would be required in endocarditis, meningitis, severe soft tissue infection or septic arthritis/osteomyelitis.
Oral antibiotic formulation or suitable oral alternative is available.

British National Formulary. Available at URL: https://www.medicinescomplete.com/mc/bnf/current/ [Accessed: 07/08/15]
Clostridium difficile infection: How to deal with the problem. DoH and HPA, December 2008. Available at http://www.dh.gov.uk
Updated guidance on the management and treatment of Clostridium difficile infection: guidance on management and treatment. Public Health England. May 2013. Available at http://www.dh.gov.uk
NICE Clinical Guideline 64: Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. (March 2008).
Johns Hopkins POC-IT Center. ABX Guide (2013). Available at URL: http://www.hopkins-abxguide.org [Accessed 07/08/15].
The Sanford Guide (July 2015). Available at URL: http://www.webedition-dva-sanfordguide.com/ [Accessed August 2015].
British National Formulary for children. Available at URL:https://www.medicinescomplete.com/mc/bnfc/current/ [Accessed:21/11/14].
Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008.
Elliott T. S. et al. Policy for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy 2004;54:971-981.
NICE Clinical Guideline 12 COPD: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (February 2004).
British Association for Sexual Health and HIV (BASHH). Clinical Effectiveness Group Policy. (13/07/10) Available at URL: http://www.bashh.org [Accessed: July 2010].
Policy for the Management of Neutropenic Sepsis. Approved by the GMCCN Chemotherapy Tameside local office in January 2009. Due for review in November 2010.
Management of Infection Guidance for primary care for consultation and local adaptation. Produced by the Association of Medical Microbiologists and the Health Protection Agency. Produced 2001, Latest Review March 2010. Available at www.hpa.org.uk
CREST Guidelines on the management of cellulitis in adults (2005). Available at URL: http://www.gain-ni.org/index.php/crest-cellulitis-guidelines (Accessed 5/8/15)
Guidance on minimising infection in patients with an absent or dysfunctional spleen. Health Protection Agency. December 2007. Available at www.hpa.org.uk
Immunisation against infectious disease (2006) The Stationary Office. Updates are available at www.dh.gov.uk/greenbook
NICE Clinical Guideline 139. Infection: Prevention and control of healthcare-associated infections in primary and community care. (March 2012).
ANTIMICROBIAL STEWARDSHIP: “START SMART – THEN FOCUS.” Guidance from Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) 2011.
Guidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (PVL-SA) in England. Health Protection Agency. November 2008. Available at: www.hpa.org.uk
Guidelines for diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. 2011. Available at: http://jac.oxfordjournals.org
Shorr AF, Sun X, Johannes RS, Yaitanes A, Tabak YP. Validation of a novel risk score for severity of illness in acute exacerbations of COPD. Chest 2011;140(5):1177-1183
Test and treat for Helicobacter pylori (HP) in dyspepsia. Quick reference guide for primary care: For consultation and local adaptation (PHE) updated October 2019.

1. In surgical procedures requiring antibiotic prophylaxis it is important to ensure that effective antibiotic concentrations are present in the blood and tissues at the time of the surgical operation.

2. A single stat dose of antibiotic administered at anaesthetic induction is usually sufficient for most indications requiring surgical prophylaxis.

3. A repeat dose of antibiotic should be administered if:

there is blood loss in excess of 1.5 litres for an adult patient - see specific surgery section for each antibiotic.
the duration of the operation is longer than 2 half-lives of the antibiotic used - see specific surgery section for each antibiotic.

Drug	Procedure duration		Blood loss of 1.5L (Give after fluid replacement)
Drug	Over 4 hours	Over 8 hours	Blood loss of 1.5L (Give after fluid replacement)
Gentamicin	-	Repeat original dose if eGFR>60ml/min	Give half of the original dose
Metronidazole	-	Repeat original dose	Repeat original dose
Cefuroxime	Repeat original dose	Repeat original dose	Repeat original dose
Clindamycin	Repeat original dose	Repeat original dose	Give half of the original dose
Co-amoxiclav	Repeat original dose	Repeat original dose	Repeat original dose
Piperacillin/tzobactam (Tazocin)	Repeat original dose	Repeat original dose	Repeat original dose
Flucloxacillin	Repeat original dose	Repeat original dose	Repeat original dose
Ciprofloxacin	-	Repeat original dose	Repeat original dose
Teicoplanin	-	-	Give half of the original dose if 1.5L blood loss within first hour of surgery

4. In cases where infection is already present (such as peritonitis) active treatment of the infection rather than prophylaxis should continue both before and after the surgical procedure.

References:

Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195–283.

Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery. Edinburgh: SIGN; 2014.

Public Health England. Start Smart - Then Focus Antimicrobial Stewardship Toolkit for English Hospitals. March 2015.

Scottish Antimicrobial Prescribing Group (SAPG). Recommendations for re-dosing antibiotics for surgical prophylaxis. October 2018.

Clean Procedures

Clean-Contaminated

Compound/Open Fracture

Dental Endocarditis Prophylaxis

Elective or Emergency Splenectomy

Repeat Dosing Schedule

Urinary Catheterisation Prophylaxis

Vascular Surgery

Clean Procedures

No prophylaxis is indicated except for the implementation of prosthesis, prosthetic joint or orthopedic hardware

Co-amoxiclav 1.2g IV stat, and for a total of 3 doses 8 hourly post-op.

Penicillin allergy (rash)

Cefuroxime 1.5g IV stat, and for a total of 3 doses 8 hourly post-op.

Penicillin allergy (anaphylaxis)

Clindamycin 600mg IV stat, and for a total of 4 doses 6 hourly post-op.

Clean-Contaminated

Cefuroxime 1.5g IV stat plus metronidazole 500mg IV stat

This combination is suitable for patients with penicillin allergy (rash).

For repeat dosing see table in repeat dosing schedule section.

Post-op prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Ciprofloxacin 400mg IV stat plus metronidazole 500mg IV stat.

For repeat dosing see table in repeat dosing schedule section.

Post-op prophylaxis should NOT be given.

Cefuroxime 1.5g IV stat.

This is appropriate for patients with penicillin allergy (rash).

For repeat dosing see table in repeat dosing schedule section.

Post-op prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Ciprofloxacin 400mg IV stat plus metronidazole 500mg IV stat.

For repeat dosing see table in repeat dosing schedule section.

Post-op prophylaxis should NOT be given.

No antibiotic prophylaxis is required in patients undergoing ERCP unless there is evidence of the following:

hepatobiliary-pancreatic obstruction
previous hepatobiliary-pancreatic instrumentation
biliary stasis
pancreatic pseudocyst.

Piperacillin/tazobactam 4.5g IV stat just prior to the procedure.

For repeat dosing see table in repeat dosing schedule section.

Post-op prophylaxis should NOT be given.

Penicillin allergy

Ciprofloxacin 400mg IV stat just prior to the procedure.

For repeat dosing see table in repeat dosing schedule section.

Post-op prophylaxis should NOT be given.

Co-amoxiclav 1.2g IV stat plus clindamycin 600mg IV stat

For repeat dosing see table in repeat dosing schedule section.

Further continuation of antibiotic prophylaxis is not necessary unless it is a complicated surgical procedure in which case antibiotics must not exceed 24 hours post-operatively.

Penicillin allergy (rash)

Cefuroxime 1.5g IV stat plus clindamycin 600mg IV stat

For repeat dosing see table in repeat dosing schedule section.

Further continuation of antibiotic prophylaxis is not necessary unless it is a complicated surgical procedure in which case antibiotics must not exceed 24 hours post-operatively.

Penicillin allergy (anaphylaxis)

Ciprofloxacin 400mg IV stat plus clindamycin 600mg IV stat

For repeat dosing see table in repeat dosing schedule section.

Further continuation of antibiotic prophylaxis is not necessary unless it is a complicated surgical procedure in which case antibiotics must not exceed 24 hours post-operatively.

No antibiotic prophylaxis is indicated in patients with sterile urine. However, in patients with infected urine antibiotic treatment should be administered according to the microbiologic susceptibility pattern. If no microbiologic results are available refer to the section on treatment of urinary tract infections.

Transrectal prostate biopsy/transurethral resection of the prostate (TURP)

Ciprofloxacin 500mg po 12 hours prior to biopsy/procedure and repeated 12 hours after first dose.

In cases of suspected antibiotic resistance to ciprofloxacin give gentamicin 5mg/kg IV stat (4mg/kg if age > 70yrs). Max dose 400mg.

Teicoplanin 400mg IV stat one hour prior to the procedure plus gentamicin 80mg to be infiltrated into the pocket.

PEG insertion prophylaxis

Cefuroxime 1.5g IV stat.

This is appropriate for patients with penicillin allergy (rash).

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Post-op prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Clindamycin 600mg IV stat

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Post-op prophylaxis should NOT be given.

Compound/Open Fractures

Co-amoxiclav 1.2g IV stat followed by 1.2g IV 8 hourly. Treatment duration will depend on the clinical response.

Penicillin allergy (rash)

Cefuroxime 1.5g IV stat followed by 1.5g IV 8 hourly plus clindamycin 600mg IV stat followed by 600mg IV 6 hourly. Treatment duration will depend on the clinical response.

Penicillin allergy (anaphylaxis)

Co-trimoxazole 960mg IV stat followed 960mg IV 12 hourly plus clindamycin 600mg IV stat followed by 600mg IV 6 hourly. Treatment duration will depend on the clinical response.

Dental Endocarditis Prophylaxis

Adults and children with structural cardiac defects at risk of developing infective endocarditis

Healthcare professionals should regard people with the following cardiac conditions as being at risk of developing infective endocarditis:

acquired valvular heart disease with stenosis or regurgitation
valve replacement
structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
previous infective endocarditis
hypertrophic cardiomyopathy
cardiac transplantation recipients who develop cardiac valvulopathy.

Antibiotic prophylaxis

Amoxicillin 2g po stat one hour before the procedure.

Penicillin allergy (rash)

Cefalexin 2g po stat one hour before the procedure.

Penicillin allergy (anaphylaxis)

Clindamycin 600mg po stat one hour before the procedure.

Elective or Emergency Splenectomy

Peri-operative antibiotic prophylaxis is not necessary for splenectomy and should not be given.

Elective or emergency splenectomy

Dual pneumococcal vaccination should be given for maximum protection from pneumococcal infection. The first vaccine should be the 13 valent pneumococcal polysaccharide conjugate vaccine (adsorbed) such as Prevenar 13® administered at least 2 weeks after splenectomy. After 8 weeks, the second vaccine should be administered which is 23 valent pneumococcal polysaccharide vaccine such as Pneumovax® and subsequent booster doses of this vaccine should be given at 5 year intervals thereafter.
A combined Haemophilus influenzae type B (Hib) and meningitis serotype C vaccine called Menitorix® should be given before splenectomy, if possible; or if not, soon after. This should be followed one month later by a single stat dose of meningococcal serotypes A, C, W135 and Y conjugate vaccine which can be administered by the patient's GP if the patient has been discharged before the one month stage. The patient's GP must be informed so that the vaccine can be given timeously.
Influenza vaccine annually (unlicensed use)
Prophylactic antibiotic is recommended (see below).

Prophylactic antibiotic:

Age 1-11 months: phenoxymethylpenicillin 62.5mg po bd.

Age 1-4 years: phenoxymethylpenicillin 125mg po bd.

Age 5 years and over: phenoxymethylpenicillin 250mg po bd.

Penicillin allergy

Age up to 12 years: clarithromycin as per kg of body weight given as half of total daily dose once daily.

Age 12 years and over: clarithromycin 500mg po od.

At all ages give prophylactic phenoxymethylpenicillin or clarithromycin for at least 2 years or at least up to the age of 18 years.

Rescue antibiotic pack

Patients with asplenia should be given a one day supply of antibiotics (see below) with instructions to start taking immediately if symptoms of infection occur such as fever, feeling unwell or shivering. If a non-blanching rash (=a rash that does not disappear under pressure from a drinking glass) occurs patients should immediately see their GP or report to an A&E department as soon as possible in order to exclude meningococcal disease.

Amoxicillin 1g po tds.

Penicillin allergy (rash):

Cefalexin 1g po tds.

Penicillin allergy (anaphylaxis):

Moxifloxacin 400mg po OD.

Repeat Dosing Schedule

Drug	Procedure duration		Blood loss of 1.5L (Give after fluid replacement)
Drug	Over 4 hours	Over 8 hours	Blood loss of 1.5L (Give after fluid replacement)
Gentamicin	-	Repeat original dose if eGFR>60ml/min	Give half of the original dose
Metronidazole	-	Repeat original dose	Repeat original dose
Cefuroxime	Repeat original dose	Repeat original dose	Repeat original dose
Clindamycin	Repeat original dose	Repeat original dose	Give half of the original dose
Co-amoxiclav	Repeat original dose	Repeat original dose	Repeat original dose
Piperacillin/tzobactam (Tazocin)	Repeat original dose	Repeat original dose	Repeat original dose
Flucloxacillin	Repeat original dose	Repeat original dose	Repeat original dose
Ciprofloxacin	-	Repeat original dose	Repeat original dose
Teicoplanin	-	-	Give half of the original dose if 1.5L blood loss within first hour of surgery

Urinary Catheterisation Prophylaxis

Antibiotic prophylaxis for insertion or removal of a catheter is not routinely recommended. However antibiotic prophylaxis for urinary catheterisation should only be given to patients who:

• have mechanical catheter problems (blockage)

• have infection-related catheter problems (urethral discharge)

• have a history of symptomatic UTI after catheter change

• experience trauma associated with insertion or removal of urinary catheter.

A single stat dose of gentamicin 5mg/kg IV (4mg/kg for patients > 70yrs) should be given once only just prior to catheterisation. Maximum dose should not exceed 400mg.

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

Staph aureus (MSSA & MRSA) urinary catheter-associated urethritis

Staph aureus (MSSA & MRSA) cultured from urine is associated with urinary catheter-related urethral discharge due to catheter-induced urethritis. Therefore catheter change in these circumstances would require antibiotic prophylaxis with teicoplanin 800mg IV single stat dose just prior to the procedure, in order to prevent the serious consequence of Staph aureus bacteraemia.

Vascular Surgery

Co-amoxiclav 1.2g IV stat dose at anaesthetic induction.

For repeat dosing schedule see table in here.

Post-op prophylaxis should NOT be given..

Penicillin allergy (rash)

Cefuroxime 1.5g IV stat dose at anaesthetic induction.

For repeat dosing schedule see table in here.

Post-op prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Clindamycin 600mg IV stat dose at anaesthetic induction.

For repeat dosing schedule see table in here.

Post-op prophylaxis should NOT be given.

2. A single stat dose of antibiotic administered at anaesthetic induction is usually sufficient for most indications requiring surgical prophylaxis.

3. A repeat dose of antibiotic should be administered if:

there is blood loss in excess of 1.5 litres for an adult patient - see specific surgery section for each antibiotic.
the duration of the operation is longer than 2 half-lives of the antibiotic used - see specific surgery section for each antibiotic.

Drug	Procedure duration		Blood loss of 1.5L (Give after fluid replacement)
Drug	Over 4 hours	Over 8 hours	Blood loss of 1.5L (Give after fluid replacement)
Gentamicin	-	Repeat original dose if eGFR>60ml/min	Give half of the original dose
Metronidazole	-	Repeat original dose	Repeat original dose
Cefuroxime	Repeat original dose	Repeat original dose	Repeat original dose
Clindamycin	Repeat original dose	Repeat original dose	Give half of the original dose
Co-amoxiclav	Repeat original dose	Repeat original dose	Repeat original dose
Piperacillin/tzobactam (Tazocin)	Repeat original dose	Repeat original dose	Repeat original dose
Flucloxacillin	Repeat original dose	Repeat original dose	Repeat original dose
Ciprofloxacin	-	Repeat original dose	Repeat original dose
Teicoplanin	-	-	Give half of the original dose if 1.5L blood loss within first hour of surgery

4. In cases where infection is already present (such as peritonitis) active treatment of the infection rather than prophylaxis should continue both before and after the surgical procedure.

References:

Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013; 70: 195–283.

Scottish Intercollegiate Guidelines Network (SIGN). Antibiotic prophylaxis in surgery. Edinburgh: SIGN; 2014.

Public Health England. Start Smart - Then Focus Antimicrobial Stewardship Toolkit for English Hospitals. March 2015.

Scottish Antimicrobial Prescribing Group (SAPG). Recommendations for re-dosing antibiotics for surgical prophylaxis. October 2018.

Gynaecologic Surgery

Caesarean Section

Placental Removal/Perineal Tears

Strep Group B Colonisation

Pyrexia in Labour

Assisted Vaginal Delivery

Gynaecologic Surgery

Cefuroxime 1.5g IV stat plus metronidazole 500mg IV stat

This combination is suitable for patients with penicillin allergy (rash).

For repeat dosing schedule see table above.

Post-op antibiotic prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Clindamycin 900mg IV plus gentamicin 5mg/kg IV stat (dose of gentamicin should NOT exceed 400mg).

For repeat dosing schedule see table above.

Post-op antibiotic prophylaxis should NOT be given.

Caesarean Section

Cefuroxime 1.5g IV stat.

This is suitable in penicillin allergy (rash).

For repeat dosing schedule see table above.

Post-op antibiotic prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Clindamycin 900mg IV plus gentamicin 5mg/kg IV stat (dose of gentamicin should NOT exceed 400mg).

For repeat dosing schedule see table above.

Post-op antibiotic prophylaxis should NOT be given.

Placental Removal / Perineal Tears

Manual removal of placenta and/or suturing of 3rd/4th degree perineal tear

Cefuroxime 1.5g IV stat plus clindamycin 900mg IV stat.

This regimen is suitable in penicillin allergy (rash).

For repeat dosing schedule see table above.

Post-op antibiotic prophylaxis should NOT be given.

In cases of suspected contamination/alternative reasons for requiring oral antibiotics:

Cefalexin 1g po tds plus clindamycin 450mg po qds for 3 days.

Penicillin allergy (anaphylaxis)

Clindamycin 900mg IV stat plus gentamicin 5mg/kg IV stat (dose of gentamicin should NOT exceed 400mg).

For repeat dosing schedule see table above.

Post-op antibiotic prophylaxis should NOT be given.

In cases of suspected contamination/alternative reasons for requiring oral antibiotics:

True/anaphylactic penicillin allergy and breastfeeding:

Ciprofloxacin 500mg po bd plus clindamycin 450mg po qds for 3 days.

True/anaphylactic penicillin allergy and not breastfeeding:

Co-trimoxazole 960mg po BD plus clindamycin 450mg po QDS for 3 days.

Strep Group B Colonisation

Benzylpenicillin 3g IV stat followed by 1.5g IV 4 hourly until delivery.

Further antibiotic prophylaxis should NOT be given post-delivery.

Penicillin allergy

Clindamycin 900 mg IV stat followed by 900mg IV 8 hourly until delivery.

Further antibiotic prophylaxis should NOT be given post-delivery.

Strep Group A Colonisation

Strep group A (Strep pyogenes) in the genital tract at the time of delivery is a risk factor for development of puerperal sepsis.

Antibiotic prophylaxis

Benzylpenicillin 2.4g IV stat followed by 1.2g IV 4 hourly until delivery.

Oral step down post-delivery: amoxicillin 1g po tds.

Complete 10 days of antibiotic treatment including IV already given.

Penicillin allergy

Clindamycin 900 mg IV stat followed by 900mg IV 8 hourly until delivery.

Oral step down (post-delivery): clindamycin 450mg po qds.

Complete 10 days of antibiotic treatment including IV already given.

Pyrexia in Labour

Cefuroxime 1.5g IV stat followed by 1.5g IV 8 hourly

plus

Metronidazole 500mg IV stat followed by 500mg IV 8 hourly.

This regimen is suitable in penicillin allergy (rash).

Continue until clinically settled.

Penicillin allergy (anaphylaxis)

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

plus

Gentamicin 5mg/kg IV stat. (Dose of gentamicin should NOT exceed 400mg). Caution is advised with further dosing of gentamicin because of gentamicin-associated foetal ototoxicity.

Continue until clinically settled (caution with gentamicin).

Assisted Vaginal Delivery

Cefuroxime 1.5g IV stat.

This regimen is suitable in penicillin allergy (rash).

Post-op antibiotic prophylaxis should NOT be given.

Penicillin allergy (anaphylaxis)

Clindamycin 900mg IV stat plus gentamicin 5mg/kg IV stat (dose of gentamicin should NOT exceed 400mg).

Post-op antibiotic prophylaxis should NOT be given.

These guidelines have been produced for General Practitioners in Tameside and Glossop Primary Care Trust as a simple guide to antimicrobial prescribing. Much of the advice has come from Public Health England (PHE) template guidelines and the Clinical Knowledge Summaries service (CKS - the successor to Prodigy) which are both evidence based. However local antibiotic sensitivity data has been used to provide advice specific to the local area at this time.

The Consultant Medical Microbiologists at Tameside and Glossop Acute Services NHS Trust are always happy to help general practice colleagues and are available during office hours on the numbers below.

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 0161 922 6000

To provide a simple, empiric (best guess) approach to the treatment of common infections.
To promote the safe, effective and economic use of antibiotics (and to use antibiotics only if indicated).
To minimise the emergence of bacterial resistance in the community and to prevent the development of antibiotic associated Clostridium difficile infection (CDI).

This guidance is based on the best available evidence at the time and its application must be modified by professional judgement.

Prescribe an antibiotic only when there is likely to be a clear clinical benefit, and most notably when there is a bacterial infection present.
A dose and duration of treatment is suggested - however patients should be treated on an individual basis if infection is severe or recurrent.
Do not prescribe an antibiotic for simple coughs or colds and viral sore throats.
Do not prescribe antibiotics for chronic lower limb ulcers or pressure sores unless there is an associated spreading cellulitis, induration of the tissues, abscess formation or systemic toxicity with constitutional symptoms.
Limit prescribing over the telephone to exceptional cases – rather clinically assess the case first.
Always prescribe antibiotics generically unless it is necessary to state the brand name to ensure the clarity of formulation.
Avoid broad spectrum antibiotics e.g. co-amoxiclav, quinolones and cephalosporins, when narrower spectrum antibiotics are as effective, as they increase the risk of CDI, MRSA and resistant UTIs.
Limit the use of topical antibiotics to selected conditions e.g. Impetigo, fungal skin infections, acne, herpes labialis, especially if they are also available as a systemic preparation.
In pregnancy avoid tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short term use of trimethoprim (theoretical risk in first trimester in patients with a poor diet, as it is a folate antagonist) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause a problem to the foetus. For empiric treatment of UTIs in pregnancy see later in the guidelines.
Clarithromycin is the macrolide of choice due to it being better tolerated and a lower frequency of administration.
Alternatives are usually given in these guidelines for use in penicillin allergy.
If empiric treatment has failed or special circumstances exist contact the Consultant Medical Microbiologists at Tameside General Hospital for advice. See page 3 for contact details.
If samples are sent to the laboratory they should be collected before antibiotic therapy is started. If the patient is already on antibiotics please give a clear drug history on the request form.
Where possible antibiotic treatment should be selected or changed based on microbiologic culture and sensitivity results with a preference for the narrowest spectrum antibiotic where appropriate.
The laboratory usually reports on antibiotic sensitivities for organisms which are thought to be clinically significant, but the clinical picture must always be taken into account before deciding if and how to treat. Treat the patient and not the microbiology result! If you have any queries please speak to either of the Medical Microbiologists.
Prescribing of long-term antibiotic prophylaxis is not encouraged; however it is accepted that a select number of patients, such as COPD or bronchiectasis patients, may benefit from this. Long-term antibiotic prophylaxis should only be commenced by a hospital consultant and the patient should be closely monitored with regular follow ups.

Note to Prescribers about duration of treatment:

In general most antibiotic treatments should not exceed 5 days, and treatment durations for 3 or 4 days may be entirely adequate. However it must be emphasized that the most important determinant for the duration of antibiotic treatment is the clinical response of the patient to therapy. It is vital that patients are educated about their antibiotic treatment and in particular recognising the signs and symptoms of their infection improving. For uncomplicated or infections requiring short duration of treatment with antibiotics, patients should be advised that, although they have been prescribed antibiotics for e .g. 5 days, they c ould stop taking antibiotics e.g. after 3 days if they feel that their symptoms have improved and they are getting better; however, if they are unsure they should consult their doctor. For complicated or infections requiring longer duration of treatment, patients should be advised to complete the prescribed course as advised and explained by their doctor.

PHE Management of infection guidance for primary care for consultation and local adaptation October 2014 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/443046/230415_PHE_Primary_Care_guidance_07_07_15_for_Gateway.pdf
CKS (Evidence Series) Clinical Knowledge Summaries. http://cks.nice.org.uk/#?char=A (accessed August 2015)
BNF Sept 2014 (no 68) and cBNF 2014 -15 www.bnf.org/bnf
Electronic medicines Compendium www.emc.medicines.org.uk
Department of Health. Seasonal flu plan Winter 2011/12. Published May 2011. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127088.pdf
National Institute for Health and Clinical Excellence. Amantadine, oseltamivir and zanamivir for the treatment of influenza (review of NICE technology appraisal guidance 58). Issued Feb 2009.
National Institute for Health and Clinical Excellence. Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza. Issued Sept 2008.
SIGN (2010) Management of sore throat and indications f or tonsillectomy www.sign.ac.uk
MeReC (2006) Bulletin Volume 17 Number 3, The management of common infections in primary care www.npc.co.uk
Rovers MM, Glasziou P, Appelman CL, et al. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006; 368:1429 -1435.
NICE Guidance (2010) Chronic Obstructive Pulmonary Disease www.nice.org.uk
BTS (updated 2004) Guidelines for the Management of Community Acquired Pneumonia in Adults www.Brit-thoracic.org.uk
HPA (2011) Guidance for public health management of meningococcal disease in the UK www.hpa.org.uk
SIGN (2006) Management of suspected bacterial urinary tract infection in adults www.sign.ac.uk
HPA (last reviewed 2011) Diagnosis for UTI quick reference Guide for Primary Care www.hpa.org.uk
NICE (2007) urinary tract infection in children www.nice.org.uk
HPA (last reviewed 2008) Diagnosis of H.pylori Quick Reference Guide for Primary Care www.hpa.org.uk
NICE (2004) CG17 Dyspepsia: managing dyspepsia in adults in primary care. www.nice.org.uk
British Association for Sexual Health and HIV (BASHH) Clinical Effectiveness Group Guidelines. www.bashh.org
NICE. Antibiotic prescribing – especially the broad spectrum antibiotics January 2015.
http://www.guysandstthomas.nhs.uk/resources/about-us/board-minutes/2014-board-papers/april/Board/cpe-briefing.pdf

Department of Health. Resistance to Antibiotics and other Antimicrobial agents; action for the NHS following the Government’s response to the House of Lords Science and Technology Select Committee report. Department of Health; 1999. (Health Service Circular: HSC (99) 049)

Department of Health. Hospital Pharmacy initiative for promoting prudent use of antibiotics in hospitals. London. Department of Health: 2003 (Professional letter. Chief Medical Officer: PLCMO (2003) 3)

Journal of hospital infection (2006) 63S, S1eS 44 Guidelines for the control and prevention of methicillin resistant Staphylococcus aureus (MRSA) in healthcare facilities.

JE Coia a, CG Duckworth b, DI Edwards c, M Farrington d, C Fry e, H Humphreys f *, C Mallaghan g, D R Tucker h, for the Joint Working Party of the British Society of Antimicrobial Chemotherapy, the Hospital Infection Society and the Infection Control Nurses Association.

Dilip Nathwani (DN) (Chair), Marina Morgan (MM), Bob Masterton (RGM), Matthew S Dryden (MD), Barry D Cookson (BDC), Gary French (GF), Deidre Lewis (DL). Working Party Draft 2007

Diagnosis and Principles of Management of MRSA Infections Presenting in The Community: Guidelines for UK Practice Working Party * On Behalf Of The British Society For Antimicrobial Chemotherapy (Bsac).

Health Protection Agency, interim guidance on diagnosis and management of PVL - associated Staphylococcal infections in the UK, 13th march 2007.

Clostridium difficile infection: How to deal with the problem. Guidance from Department of Health/HPA 2008.

International Infection Control Council Best Infection Control Practices for patients with extended spectrum beta-Lactamase Enterobacteriaceae C Friedman, S Callery, Ajeans, P Piaskowski, L Scott (representing the International Infection Control Council) and members of the Best Practices Experts Panel and Reviewer.

ANTIMICROBIAL STEWARDSHIP: “START SMART–THEN FOCUS.” Guidance from Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) 2011

Diphtheria

Elective or Emergency Splenectomy

Endocarditis

Haemophilus Influenza Type B (Hib)

Meningococcal Meningitis or Septicaemia

Prevention of Rheumatic Fever

Spontaneous Bacterial Peritonitis

Tetanus

Whooping Cough (Pertussis)

Diphtheria

Prevention of secondary cases in non-immune patients - for close contacts, in conjunction with immunisation of susceptible individuals:

Adult: Clarithromycin po 500mg bd for 7 days.

Child: see Children's BNF - give for 7 days.

Treat for a further 10 days if nasopharyngeal swabs positive after first 7 days of treatment.

Elective or Emergency Splenectomy

For post-splenectomy prophylaxis please see section titled 'Surgical Prophylaxis.'

Endocarditis

See Dental Endocarditis Prophylaxis in section on Surgical Prophylaxis.

Haemophilus Influenzae type B (Hib)

Haemophilus Influenzae type B (Hib) Meningitis, Epiglottitis or Other Invasive Disease

Rifampicin 600 mg od for 4 days;

Child over 3 months: Rifampicin 20mg/kg od for 4 days, up to a maximum of 600mg daily.

Child between 1- 3 months: Rifampicin 10mg/kg od for 4 days.

If rifampicin is contraindicated or in pregnancy/breastfeeding,

Ceftriaxone [unlicensed indication] IM or IV 1 g od 2 days

Child 1 month–12 years Ceftriaxone 50 mg/kg (max. 1 g) od for 2 days by IV infusion only

Give to all household members irrespective of age where there is an index case of Hib disease and a child less than 4 years.

Report to Public Health England as soon as possible (is a notifiable disease).

Meningococcal Meningitis or Septicaemia

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

1st line:

Adult: Ciprofloxacin 500mg po as a single dose.

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

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

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

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

Ciprofloxacin in pregnancy

A single dose of ciprofloxacin 500mg po 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 to 11 months: Rifampicin 5mg/kg po every 12 hours for 2 days.

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

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

In addition, give rifampicin to the index case (unless they have had treatment with ceftriaxone or moxifloxacin), before discharge from hospital.

Or if rifampicin is contraindicated,

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

(NB not licensed for this indication).

Report to Public Health England as soon as possible (is a notifiable disease).

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

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

References:

Public Health England. Guidance for the public health management of meningococcal disease in the UK. February 2018. Public Health Guidance PDF

Prevention of Rheumatic Fever

Prevention of recurrent attacks (particularly in children):

Phenoxymethylpenicillin po 250mg bd.

For children under 1 year: dose according to body weight.

Penicillin allergy

Age 12 years and over: Clarithromycin 250mg po bd.

For children under 12 years: Dose according to body weight and give half of total daily dose once daily.

Spontaneous Bacterial Peritonitis

Prophylaxis after initial episode of SBP: Ciprofloxacin 500mg po od.

Tetanus

Tetanus prone wounds include:

wounds or burns that require surgical intervention that is delayed for more than six hours

wounds or burns that show a significant degree of devitalised tissue or a puncture-type injury, particularly where there has been contact with soil or manure

wounds containing foreign bodies

compound fractures

wounds or burns in patients who have systemic sepsis.

	Clean Wound	Tetanus-prone Wound
Immunisation status	Vaccine	Vaccine	Human Immunoglobulin
Fully immunised, i.e. has received a total of five doses of vaccine at appropriate intervals	None required	None required	Only if high risk*
Primary immunisation complete, boosters incomplete but up to date	None required (unless next dose due soon and convenient to give now)	None required (unless next dose due soon and convenient to give now)	Only if high risk*
Primary immunisation incomplete or boosters not up to date	A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)	A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)	Yes: one dose of human tetanus immunoglobulin in a different site
Not immunised or immunisation status not known or uncertain	An immediate dose of vaccine followed, if records confirm the need, by completion of a full five-dose course to ensure immunity	An immediate dose of vaccine followed, if records confirm the need, by completion of a full five-dose course to ensure immunity	Yes: one dose of human tetanus immunoglobulin in a different site

* High risk is regarded as heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue.

Whooping Cough (Pertussis)

Prevention of secondary cases:

Adult: Clarithromycin po 500mg bd for 7 days.

Child: see Children's BNF - give for 7 days.

Both nasal and skin/hair treatment must be carried out to ensure MRSA decolonisation is successful.

NASAL DECOLONISATION

Topical intra-nasal mupirocin or chlorhexidine can be effective for nasal decolonisation.

Bactroban® (mupirocin) nasal ointment TDS for 5 days in both nostrils. If mupirocin nasal ointment is not available due to national shortage, give: Octenisan nasal gel to be applied BD for 5 days.

Naseptin nasal cream QDS for 10 days can be used where the strain of MRSA is resistant to mupirocin. NASEPTIN CONTAINS PEANUT OIL - AVOID IN PATIENTS WITH NUT ALLERGY.

The effectiveness of this approach is approximately 60% and may be short lived.

SKIN DECOLONISATION

Using disinfectants while bathing or showering has also been shown to be effective in decolonisation of skin and hair.

Octenisan® wash applied directly to the skin (body, face and hair) once daily and washed off for 5 days.

As there are concerns about development of resistance, it is recommended that topical antibiotic use should be confined to a single course of 5 days.

For further information on the prevention and control of MRSA colonisation / infections, please refer to the Trust policy for the management of MRSA or contact the Infection Prevention Team.

Antibiotic guidelines

Primary / Urgent Care Guidelines

Intermediate Care Guidelines

Hospital Guidelines

Adult Inpatients

Paediatric Inpatients

General Guidance

Prophylaxis

LOW-SEVERITY (CURB65=0 TO 1), OUTPATIENT TREATMENT, OR ADMITTED FOR OTHER ILLNESS:

Moderate-severity (CURB65=2):

High-severity (CURB65=3-5):

Prior To Commencing Antibiotics