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 Formulary Chapter 27: Antimicrobial guide - Full Chapter
Notes:

Coronavirus guidance

Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.

The list of resources will be updated as new material becomes available so please check back regularly for updates.

The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.

Antimicrobial guide

Self-care

Treatments marked as [OTC] are available to buy from pharmacies. Patients can be advised to purchase them as self-care where appropriate.

 

 Details...
27.06  Upper respiratory tract infections
 note 

 

Upper respiratory tract infections

 

Influenza

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

Antivirals are not recommended for healthy adults.

At risk patients include: pregnant (and up to 2 weeks post-partum); children under 6 months; adults 65 years or older; chronic respiratory disease (including COPD and asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; chronic neurological, renal or liver disease; diabetes mellitus, morbid obesity (BMI > 40).

PHE or DH will advise when influenza is considered to be circulating in the community. To check the current situation, please log onto PHE.

Treat at risk patients when influenza is circulating in the community or in a care home where influenza is likely. Treatment must be started within 48 hours of symptoms.

Treatment: oseltamivir 75 mg BD for 5 days.

Prophylaxis: oseltamivir 75 mg OD for 10 days.

Reduced dose of oseltamivir is required if CrCl < 60 mL/minute.

With severe immunosuppression, treatment will be dependent on the main circulating strain. Please see advice from PHE.

Last updated: Dec 2019

 
   
Labyrinthitis

Antibiotics not indicated.

Last updated: Dec 2019

 
   
Laryngitis, acute

Antibiotics not indicated.

Last updated: Dec 2019

 
   
Otitis externa, acute

Caution: topical neomycin has been known to cause ototoxicity and must not be used if there is a suspicion of ear drum perforation.

If cellulitis or disease extends outside ear canal, or systemic signs of ear infection, start oral antibiotic and refer to exclude malignant otitis externa.

Laboratory diagnosis: not indicated unless there are signs of cellulitis.

First line: analgesia for pain relief and apply localised heat (such as a warm flannel).

Second line: [OTC] acetic acid 2% (Ear Calm®) 1 spray TDS for 7 days

Third line: topical neomycin sulphate with corticosteroid (Betnesol-N®, Otomize®, Otosporin®) 3 drops TDS (1 spray TDS for Otomize®) for 7 days.

Tympanic membrane perforation: ciprofloxacin 2 mg/ml (Cetraxal®) ear drops 0.25 ml twice a day for 7 days (off-label use).

If cellulitis or extensive infection to outside of ear canal: flucloxacillin 500 mg QDS for 7 days.

Penicillin allergy: clarithromycin 500 mg BD for 7 days.

Last updated: Dec 2019

 
   
Otitis media, acute

Evidence does not support routine use of antibiotics. Consider back up prescription for antibiotics.

Acute otitis media (AOM) resolves in 60% of cases in 24 hours without antibiotics, which only reduce pain at 2 days (NNT 15) and do not prevent deafness. 80% of cases will resolve within 72 hours.

Offer immediate antibiotic to:

  • People who are systemically unwell but do not require admission.
  • People at high risk of serious complications because of significant heart, lung, renal, liver or neuromuscular disease, immunosuppression or cystic fibrosis, and young children who were born prematurely.

Depending on severity, consider offering immediate antibiotic prescription to:

  • Children younger than 2 years of age with bilateral AOM.
  • Otorrhoea in all ages.

Laboratory diagnosis: not routinely indicated.

TARGET respiratory tract infection leaflet

NICE acute otitis media 2-page visual summary

Optimise analgesia.

First line: amoxicillin 500 mg TDS for 5 days.

Penicillin allergy: clarithromycin 500 mg BD for 5 days or
erythromycin (preferred in pregnancy) 500 mg QDS for 5 days.

Second line: co-amoxiclav 500/125 mg TDS for 5 days.

Last updated: Dec 2019

 
   
Parotid gland infection

Caution: suppurative parotitis is potentially life threatening. Most patients require initial IV antibiotic treatment.

Ensure patient is hydrated.

If oral treatment is considered appropriate: flucloxacillin 1 g QDS for 14 days and
metronidazole 400 mg TDS for 14 days.

Penicillin allergy: clindamycin 450 mg QDS for 14 days.

Last updated: Dec 2019

 
   
Scarlet fever

Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Vulnerable individuals (immunocompromised, the comorbid, or those with skin disease) are at increased risk of developing complications.

Notify the local Public Health England (PHE) centre once a working diagnosis of scarlet fever is made.

Optimise analgesia and give safety netting advice.

First line: phenoxymethylpenicillin 500 mg QDS for 10 days.

Penicillin allergy: clarithromycin 500 mg BD for 5 days.

Last updated: Dec 2019

 
   
Sinusitis, acute

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

Symptoms < 10 days: no antibiotic.

Symptoms with no improvement > 10 days: no antibiotic or back up antibiotic if several of the following are present: discoloured or purulent nasal discharge, severe localised unilateral pain, fever or marked deterioration after initial milder phase.

Serious signs and symptoms: immediate antibiotic.

Refer to hospital if signs and symptoms of acute sinusitis associated with any of the following:

  • Severe systemic infection.
  • Intraorbital or periorbital complications including periorbital oedema or cellulitis, a displaced eyeball, double vision, ophthalmoplegia, or newly reduced visual acuity.
  • Intracranial complications including swelling over the frontal bone, symptoms or signs of meningitis, severe frontal headache or focal neurological signs.

TARGET respiratory tract infection leaflet

NICE Sinusitis 2-page visual summary

First line: phenoxymethylpenicillin 500 mg QDS for 5 days.

Penicillin allergy: doxycycline 200 mg on day 1, then 100 mg daily for 5 days in total or
clarithromycin 500 mg BD for 5 days or
erythromycin (preferred in pregnancy) 500 mg QDS or 1000 mg BD for 5 days.

Second line (or first line if systemically very unwell or high risk of complications): co-amoxiclav 500/125 mg TDS for 5 days.

Advise paracetamol or ibuprofen for pain.

Consider high-dose nasal corticosteroid (off-label use): mometasone 100 micrograms (2 sprays) into each nostril twice a day for at least one month depending on the disease course.

Chronic sinusitis: antibiotics are not routinely indicated except for acute exacerbations. Complex cases managed by secondary care.

Last updated: Dec 2019

 
   
Sore throat, acute

Avoid antibiotics: 82% of cases resolve in seven days without, and pain is only reduced by 16 hours.

Use FeverPAIN or Centor to assess symptoms:

  • FeverPAIN 0-1 or Centor 0-2: no antibiotic.
  • FeverPAIN 2-3: no or back-up antibiotic.
  • FeverPAIN 4-5 or Centor 3-4: immediate or back-up antibiotic.

Systemically very unwell or high risk of complications: immediate antibiotic or refer to secondary care.

Take a throat swab only in persistent or relapsed infections lasting 3-4 weeks.

TARGET respiratory tract infection leaflet

NICE sore throat 2-page visual summary

Consider self-care and safety netting or a back-up prescription.

First choice: phenoxymethylpenicillin 500 mg QDS or 1000 mg BD for 10 days.

Severe symptoms: phenoxymethylpenicillin 1000 mg QDS for 10 days.

Penicillin allergy: clarithromycin 500 mg BD for 5 days or
erythromycin (preferred in pregnancy) 500 mg QDS or 1000 mg BD for 5 days.

Last updated: Aug 2020

 
   
27.07  Lower respiratory tract infections
 note 

 

Lower respiratory tract infections

 

Bronchiectasis (non-cystic fibrosis), acute exacerbation

Empirical antibiotics should be started if there is worsening cough, increased sputum volume, viscosity or purulence, or increased breathlessness while awaiting sputum microbiology. If previous culture results are available, treat based on sensitivities.

People who may be at higher risk of treatment failure include people who’ve had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.

Where a person is receiving a long-term antibiotic, treatment should be with an antibiotic from a different class. Do not routinely offer antibiotic prophylaxis to prevent exacerbations. Seek specialist advice for preventing exacerbations in people with repeated acute exacerbations.

Note: low doses of penicillins are more likely to lead to resistance. Do not use fluoroquinolones (ciprofloxacin, ofloxacin) first line because they may have long term side effects and there is poor pneumococcal activity. Reserve all fluoroquinolones (including levofloxacin) for proven resistant organisms.

Laboratory diagnosis: send a sputum sample for culture and susceptibility testing.

NICE bronchiectasis (non-CF) 3-page visual summary

When current susceptibility data is available, choose antibiotics accordingly.

Select a course length based on severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment.

First choice (empirical): amoxicillin (preferred in pregnancy) 500mg TDS for 7‑14 days or
doxycycline 200 mg on day 1, then 100 mg daily for 7-14 days in total or
clarithromycin 500mg BD for 7-14 days.

Alternative (empirical) for people at higher risk of treatment failure: co‑amoxiclav 500/125mg TDS for 7-14 days or
levofloxacin (consider safety issues, off-label use) 500 mg OD or BD for 7‑14 days.

Last updated: Dec 2019

 
   
COPD, acute exacerbation

Many exacerbations are not caused by bacterial infections so will not respond to antibiotics.

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath, or increased sputum volume, or both. Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months.

Where a person is receiving a long-term antibiotic for prophylaxis, treatment should be with an antibiotic from a different class.

Antibiotics are less effective if only one symptom present.

Note: low doses of penicillins are more likely to lead to resistance. Do not use fluoroquinolones (ciprofloxacin, ofloxacin) first line because they may have long term side effects and there is poor pneumococcal activity. Reserve all fluoroquinolones (including levofloxacin) for proven resistant organisms.

Laboratory testing: obtain sputum sample for culture wherever possible. Review antibiotic choice with culture result.

NICE COPD (acute exacerbations) 2-page visual summary

First line: amoxicillin 500mg TDS for 5 days or
doxycycline 200 mg on day 1, then 100 mg daily for 5 days in total or
clarithromycin 500mg BD for 5 days.

Second line: use alternative first choice.

Alternative for people at higher risk of treatment failure: co-amoxiclav 500/125 mg TDS for 5 days or
levofloxacin (consider safety issues) 500mg OD for 5 days or
if unable to use any other antibiotic and only after discussion with a specialist, co‑trimoxazole 960mg BD for 5 days.

Note: azithromycin may be recommended by a respiratory specialist for prevention of exacerbation of COPD. This recommended long-term use is for its immunomodulatory and lung remodelling properties and not its anti-infective action.

Last updated: Dec 2019

 
   
Cough, acute

Acute cough with upper respiratory tract infection: no antibiotic.

Acute bronchitis: no routine antibiotic. Antibiotics of little benefit if there is no co morbidity.

Acute cough and higher risk of complications (at face-to-face examination): immediate or back-up antibiotic.

Acute cough and systemically very unwell (at face to face examination): immediate antibiotic.

Do not offer a mucolytic, an oral or inhaled bronchodilator, or an oral or inhaled corticosteroid unless otherwise indicated.

TARGET respiratory tract infection leaflet

NICE cough (acute) 2-page visual summary

First line: self-care and safety netting advice. Symptoms can last 3 weeks.

First line antibiotic: doxycycline 200 mg on day 1, then 100 mg daily for 5 days in total.

Alternative first line antibiotic: amoxicillin (preferred in pregnancy) 500 mg TDS for 5 days or
clarithromycin 500mg BD for 5 days or
erythromycin (preferred in pregnancy) 500 mg QDS or 1000 mg BD for 5 days.

Last updated: Dec 2019

 
   
Perichondritis

Perichondritis confined to the pinna can be managed in primary care, but cellulitis spreading across the face needs referral to the local ENT unit and often results in admission for intravenous antibiotics due to the risk of haematogenous intracranial spread.

Most frequent causative agent is Pseudomonas aeruginosa. Less frequently Staphylococcus aureus can also be involved.

Consider referring patient to ENT due to risk of complications such as abscess formation or necrosis. Often associated with ear piercing, foreign body has to be removed.

First line: ciprofloxacin 500 mg BD for 7 days.

In cases of cellulitis: refer and consider addition of flucloxacillin 500 mg QDS or
clindamycin 300 mg QDS until ENT assessment.

Last updated: Dec 2019

 
   
Pneumonia, aspiration

First line: metronidazole 400mg TDS for 7 days and
amoxicillin 500mg TDS for 7 days.

Penicillin allergy: clarithromycin 500 mg BD for 7 days and
metronidazole 400 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Pneumonia, community-acquired

Assess severity in adults based on clinical judgement guided by mortality risk score (CRB65).

  • Low severity – CRB65 0 – suitable for home treatment.
  • Moderate severity – CRB65 1 or 2 – consider hospital assessment.
  • High severity – CRB65 3 or 4 – urgent hospital admission. If patient refuses, consider referral to Hospital@Home or contact microbiology.

CRB65 score is calculated by giving 1 point for each of the following prognostic features:

  • Confusion (new onset).
  • Respiratory rate ≥ 30 /min.
  • BP systolic < 90 mmHg or diastolic ≤ 60 mmHg.
  • Age ≥ 65.

Alternative first choice antibiotics should be considered if the first choice antibiotic is unsuitable, for example, for penicillin allergy or an atypical pathogen is suspected.

Laboratory diagnosis: send sputum for culture and sensitivity if CRB > 2 and managed in the community.

NICE pneumonia (community acquired) 3-page visual summary

Review antibiotic treatment after 5 days with the aim to stop. If slow clinical response, consider extending the course length. If clinical deterioration, consider hospital admission.

Low severity, first choice: amoxicillin 500 mg TDS for 5 days (higher doses can be used, see BNF).

Low severity, alternative first choice: doxycycline 200 mg on day 1, then 100 mg daily for 5 days in total or
clarithromycin 500 mg BD for 5 days or
erythromycin (preferred in pregnancy) 500 mg QDS for 5 days.

Moderate severity, first choice: amoxicillin 500 mg TDS for 5 days (higher doses can be used, see BNF) and
either clarithromycin 500 mg BD for 5 days or erythromycin (preferred in pregnancy) 500 mg QDS for 5 days.

Moderate severity, alternative first choice: doxycycline 200 mg on day 1, then 100 mg daily for 5 days in total or
clarithromycin 500 mg BD for 5 days.

Last updated: Aug 2020

 
   
Tuberculosis

TB care should be provided directly by an infectious diseases or respiratory physician with experience in managing the disease. TB medications are dispensed by TB specialist doctors and nurses from community and hospital clinics. TB medications are not routinely prescribed or dispensed by other primary care providers. In the occasional circumstances where this is required, arrangements can be made in partnership with the TB clinical and specialist nursing team.

Important: TB drugs have many recognised drug interactions, side effects, and cautions. This is particularly important when the TB drugs are not prescribed or dispensed in primary care, as the drugs may not be recorded in the GP clinical system or pharmacy patient medication records and so alerts may not be issued.

TB drugs are occasionally used for other non-TB indications.

Laboratory diagnosis: if TB or mycobacterium suspected, send 3 early morning sputum samples for AFB testing.

Discuss with specialist.

Last updated: Dec 2019

 
   
Whooping cough

Note: confirmed cases of pertussis should be notified to Public Health England, but treatment should be commenced as soon as possible and not withheld until advice is sought.

Laboratory testing

  • < 2 weeks from symptom onset, throat, pernasal, or nasopharyngeal swab for PCR and culture.
  • Between 2 and 3 weeks from symptom onset, throat, pernasal or nasopharyngeal swab for PCR and culture. Serology may also be sent.
  • > 3 weeks from symptom onset, serology (or oral fluid kit for children aged 2-17 years – discuss with local health protection team).

Treatment should be given to:

  • any person in whom the clinician suspects pertussis infection or
  • any person with an acute cough lasting for ≥ 14 days without an apparent cause plus one or more of the following:
    • paroxysms of coughing,
    • post-tussive vomiting,
    • inspiratory whoop.

First line: clarithromycin 500 mg BD for 7 days.

Macrolide allergy: co-trimoxazole (not in pregnancy) 960 mg BD for 7 days.

Last updated: Dec 2019

 
   
27.08  Urinary tract infections
 note 

 

Urinary tract infections

 

Non-pregnant women with uncomplicated lower UTI

Consider offering a back-up (delayed) antibiotic prescription for low severity symptoms and low risk of complications.

TARGET UTI leaflet

NICE UTI (lower) 3-page visual summary

First line: if eGFR ≥ 45 ml/minute, nitrofurantoin 100 mg MR BD for 3 days or
if there is low risk of resistance, trimethoprim 200 mg BD for 3 days.

Alternative: if not used 1st line, nitrofurantoin 100 mg MR BD for 3 days (if eGFR ≥ 45 ml/minute) or
pivmecillinam 400 mg STAT then 200 mg TDS for a total of 3 days or
fosfomycin 3 g single dose sachet.

Trimethoprim resistance and a liquid formulation is required: cefalexin 500 mg TDS for 3 days.

Last updated: Dec 2019

 
   
Non-pregnant women with complicated lower UTI

UTI may be complicated due to an abnormal genitourinary tract or impaired host defences:

  • Stent or splint (urethral, ureteral, renal) or nephrostomy.
  • Post-void residual urine of > 100 ml.
  • An obstructive uropathy of any aetiology (upper and lower urinary tracts), e.g., bladder outlet obstruction (including neurogenic urinary bladder), stones and tumour.
  • Vesicoureteric reflux or other functional abnormalities.
  • Urinary tract modifications/deviation, such as an ileal loop or pouch.
  • Chemical or radiation injuries of the uroepithelium.
  • Peri- and postoperative UTI, including renal transplantation.
  • Poorly controlled diabetes.
  • Immunosuppression.

TARGET UTI leaflet

NICE UTI (lower) 3-page visual summary

First line: cefalexin 500 mg TDS 7 days.

Alternative: with culture results and susceptibility, co-amoxiclav 500/125 mg TDS for 7 days or
with culture results and susceptibility, trimethoprim 200 mg BD for 14 days or
ciprofloxacin 500 mg BD 7 days.

Last updated: Dec 2019

 
   
Pregnant women with symptomatic lower UTI

Send urine for culture and review antibiotic choice with results; change antibiotic if bacteria are resistant regardless of treatment response.

TARGET UTI leaflet

NICE UTI (lower) 3-page visual summary

First line: avoid at term, * nitrofurantoin 100 mg MR BD for 7 days (if eGFR ≥ 45 ml/minute).

* May cause neonatal haemolysis. Avoid from 37 weeks of pregnancy.

Alternative: with culture results and susceptibility, amoxicillin 500 mg TDS for 7 days or
if eGFR < 45 ml/min and non-severe penicillin allergy, cefalexin 500 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Pregnant women with asymptomatic bacteriuria

Screen for bacteriuria.

Confirm clearance of infection 7 days after completing treatment and request a follow-up MSU at each antenatal clinic appointment.

NICE UTI (lower) 3-page visual summary

Based on culture results and susceptible bacteria

Avoid at term, * nitrofurantoin 100 mg MR BD for 7 days (if eGFR ≥ 45 ml/minute) or
amoxicillin 500 mg TDS for 7 days or
non-severe penicillin allergy, cefalexin 500 mg TDS for 7 days.

* May cause neonatal haemolysis. Avoid from 37 weeks of pregnancy.

Last updated: Dec 2019 

 
   
Adult men with lower UTI

Send MSU for culture and susceptibility testing. Consider urology referral to screen out an underlying cause.

Consider alternative diagnoses including pyelonephritis or acute prostatitis if not responded to first choice antibiotic.

NICE UTI (lower) 3-page visual summary

First line: if eGFR ≥ 45 ml/minute, nitrofurantoin 100 mg MR BD for 7 days or
trimethoprim 200 mg BD for 7 days.

Alternative with culture results and susceptibility: pivmecillinam 400 mg STAT then 200 mg TDS for a total of 7 days or
non-severe penicillin allergy, cefalexin 500 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Pyelonephritis (upper urinary tract), acute

Refer to hospital patients with severe systemic infection. Consider referring those who are: dehydrated or unable to take oral fluids; pregnant; at risk of complicated UTI.

NICE pyelonephritis 3-page visual summary

First line: cefalexin 500 mg TDS for 7 days or
with culture results and susceptibility, co-amoxiclav 500/125 mg TDS for 7 days or
with culture results and susceptibility, trimethoprim 200 mg BD 14 days or
ciprofloxacin 500 mg BD for 7 days.

In pregnancy: low threshold for hospitalisation, cefalexin 500 mg TDS for 7 days.

Last updated: Aug 2020 

 
   
Prostatitis, acute

Refer severe systemic infection (any of the high-risk criteria from the NICE guideline on sepsis), or complications, such as acute urinary retention or suspected prostatic abscess, or symptoms that are not improving 48 hours after starting the antibiotic.

Review antibiotic treatment after 14 days and either stop or continue for a further 14 days if needed based on history, examination findings, urine or blood tests.

If antibiotic choices are not suitable, discuss alternative options with a local microbiologist. Ofloxacin may be preferable if a sexually transmitted infection is suspected.

NICE prostatitis 2-page visual summary

First line: ciprofloxacin 500 mg BD for 14 days then review or
ofloxacin 200 mg BD for 14 days then review.

Alternative: with culture results and susceptibility, trimethoprim 200 mg BD for 14 days then review or
only after discussion with a specialist, co-trimoxazole 960 mg BD for 14 days then review.

Last updated: Dec 2019 

 
   
Catheter-associated urinary tract infection

Definition of catheter associated UTI
At least two of the following with no other recognised cause or
at least one of the following and a positive urine culture and no other recognised cause: fever (> 38 °C); suprapubic tenderness; altered mental status; malaise; lethargy; tenderness over the kidneys; pelvic pain; acute haematuria.

There is a high incidence of bacteriuria with long-term catheters. Antibiotics do not eliminate bacteria but leads to resistant organisms. Send urine culture and treat only if bacteriuria is associated with systemic symptoms (e.g. pyrexia, rigor) or pyelonephritis is likely.

Do not dipstick catheter urine.

Do not use the presence or absence of odorous or cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from catheter associated UTI.

Do not use pyuria as an indicator for catheter associated UTI.

Refer patients with severe systemic infection to hospital. Consider referring those who are dehydrated or unable to take oral fluids, pregnant, at risk of complicated UTI, or suffering recurrent catheter associated UTIs.

Do not use prophylactic antibiotics for catheter changes unless there is a history of catheter change associated UTI or trauma.

Nitrofurantoin is not suitable and unlikely to be effective if there is clinical suspicion of upper UTI – treat with antibiotics used for pyelonephritis.

Laboratory diagnosis: intermittent self-catheterisation specimens should be labelled as “MSU”.

NICE catheter-associated UTI 2-page visual summary

Supportive measures

  • Check that the catheter drains correctly and is not blocked.
  • If the catheter has been in place for > 7 days, consider changing it before or when starting antibiotic treatment.
  • Ensure high fluid intake or when this cannot be assured perform regular bladder washout using 0.9% saline.
  • Review the need for continued catheterisation.

First line: no clinical suspicion of upper UTI, nitrofurantoin 100 mg MR BD for 7 days (if eGFR ≥ 45 ml/minute) or
if there is low risk of resistance, trimethoprim 200 mg BD for 7 days or
with culture results and susceptibility, amoxicillin 500 mg TDS for 7 days.

Alternative: pivmecillinam 400 mg STAT then 200 mg TDS for a total of 7 days.

Suspected upper UTI: follow antibiotic choices as pyelonephritis.

In pregnancy: cefalexin 500 mg TDS for 7 days.

Last updated: Dec 2019

 
   
Recurrent urinary tract infection

Recurrent UTI is two proven UTIs in six months or three in 12 months.

Consider urology referral to screen out an underlying cause.

Use single dose prophylaxis only where there is a well-defined trigger. Confirm eradication of previous uropathogen by a negative culture before starting long term prophylaxis.

Consider the risk of pulmonary, hepatic and neurological toxicity. Perform baseline spirometry, LFT and renal function tests before prescribing long-term nitrofurantoin.

Amoxicillin has higher resistance rates and is not licensed for preventing UTIs.

NICE recurrent UTI 2-page visual summary

Give advice on behavioural and personal hygiene measures and self-care to reduce the risk of UTI before considering prophylaxis.

Choose from these agents based on previous sensitivities.

If behavioural or self-care measure fail: if eGFR ≥ 45 ml/minute, nitrofurantoin 100 mg single dose when exposed to a trigger or 100 mg at night or
trimethoprim 200 mg single dose when exposed to a trigger or 100 mg at night.

Alternative: amoxicillin 500 mg single dose when exposed to a trigger or 250 mg at night (unlicensed) or
cefalexin 500 mg single dose when exposed to a trigger or 125 mg at night.

Review at three months and stop at six months.

Last updated: Aug 2020

 
   
27.09  Meningitis
 note 

 

Meningitis

 

Suspected meningococcal disease

Transfer all patients to hospital immediately.

If there is time before hospital admission, if suspected meningococcal septicaemia or non-blanching rash, give IV benzylpenicillin as soon as possible.

Do not give IV antibiotics if there is a definite history of anaphylaxis; rash is not a contraindication. Give IM only if venous access cannot be found.

First line: IV or IM benzylpenicillin 1.2 g STAT

Penicillin allergy (not anaphylaxis): IV or IM cefotaxime 1 g STAT

Last updated: Dec 2019 

 
   
Prevention of secondary case of meningitis

Only prescribe following advice from Public Health Doctor. To contact PHE North West Health Protection Team Cheshire and Merseyside phone 0344 225 0562 option 1.

Expert advice is available for managing clusters of meningitis. Please alert the appropriate organisation to any cluster situation.

Out of hours Public Health England phone 0151 434 4819 ask for public health on call.

Last updated: Dec 2019

 
   
27.10  Gastrointestinal infections to top
 note 

 

Gastrointestinal Infections

 

Campylobacter

Notifiable to Public Health England. Antibiotic therapy is not usually indicated unless patient is systemically unwell.

Consider antibiotics in patients with:

  • Severe symptoms (high fever, bloody diarrhoea, > 8 stools/day).
  • Immunocompromise.
  • Worsening symptoms.
  • Symptoms lasting longer than 7 days.

If the symptoms are severe or prolonged, take advice from the consultant gastroenterologist or consultant microbiologist.

Encourage fluid intake. Consider oral rehydration salt solution for adults at increased risk of a poor outcome.

If antibiotic treatment is considered appropriate: clarithromycin 250-500 mg BD for 7 days.

Last updated: Dec 2019 

 
   
Candidiasis, oral

Oral candidiasis is rare in immunocompetent adults. Consider undiagnosed risk factors, including HIV. Consider offering testing for HIV in unexplained or severe or recurrent cases.

Topical azoles are more effective than topical nystatin. Topical treatments should not be swallowed immediately but kept in the mouth as long as possible.

Check carefully for drug interactions with both miconazole oral gel and fluconazole.

Laboratory testing: mouth swabs only indicated in severe or recurrent infection.

First choice: miconazole 20 mg/g oral gel 2.5ml QDS for 7 days. Continue for 7 days after symptoms have cleared.

If not tolerated: nystatin 100,000 units/ml suspension 1 ml QDS (half in each side) for 7 days. Continue for 2 days after symptoms have cleared.

Severe or extensive candidiasis: fluconazole capsules 50 mg OD for 7 days. For persistent infection continue for a further 7 days.

HIV, immunocompromised or unusually difficult infection: fluconazole capsules 100 mg OD for 7 days. For persistent infection continue for a further 7 days.

Last updated: Dec 2019 

 
   
Cholecystitis, acute

Caution: hospital admission is usually recommended as serious complications can occur.

Provide symptomatic relief prior to admission.

Only if treatment in the community is appropriate

First choice: co-amoxiclav 500/125 mg TDS for 7 days.

Penicillin allergy: ciprofloxacin 500 mg BD for 7 days and
metronidazole 400 mg TDS for 7 days.

Last updated: Dec 2019 

 
   
Clostridioides difficile

Risk assess the requirement for antibiotics, PPIs, and anti-peristaltic agents. Discontinue use where possible.

Definition of severe: temperature > 38.5 °C, white cell count > 15 x 10^9 /L, rising creatinine, or signs and symptoms of severe colitis.

For people with swallowing difficulties: vancomycin powder is licensed for oral use and can be used to prepare a solution for oral or enteral use. Reconstitute one 500 mg vial with 10 ml of water for injection. Write the date and time on a label and attach label to the reconstituted vial. Withdraw 2.5 ml (125 mg) from the reconstituted vial and mix in 30 ml of water. Store remaining reconstituted vial in fridge. Discard after 24 hours. One 500 mg vial provides four 125 mg doses (one day’s treatment).

Laboratory testing: stool specimen for C. difficile toxin detection. If toxin is not detected but there is evidence of a toxigenic strain of C. difficile (reported with a comment that it's a "potential toxin producer"), treatment for infection should be commenced only if no other likely cause for the patient's diarrhoea.

First episode and not severe: oral vancomycin 125 mg QDS for 10 days.

Second episode or severe first episode (or known type 027): oral vancomycin 125 mg QDS for 10 days.

Following a discussion with a gastroenterologist or microbiologist: oral vancomycin may be titrated up to 500 mg QDS.

More than two episodes or deteriorating clinically: contact consultant microbiologist for advice on the possible use of fidaxomicin. Refer to BNF Fidaxomicin for dosing information.

Last updated: Aug 2020 

 
   
Diarrhoea or gastroenteritis

Food poisoning is notifiable to Public Health England. Usually viral and self‑limiting. Antibiotics only tend to prolong the carrier state, do not shorten the duration of illness and may be contraindicated.

Laboratory testing, send a stool specimen if:

  • Patient is systemically unwell.
  • There is blood or pus in the stool. Sample essential.
  • Patient is immunocompromised.
  • History of recent hospitalization or antibiotic treatment or both.
  • Recent foreign travel to anywhere other than Western Europe, North America, Australia, or New Zealand.
  • Persistent diarrhoea and giardiasis are suspected.
  • There is uncertainty about the diagnosis of gastroenteritis.
  • Advised by Public Health England.

Encourage fluid intake. Consider oral rehydration salt solution for those at increased risk of a poor outcome.

Antimotility agents (e.g. loperamide) should only be considered for short term management of symptoms (1-2 days) in the absence of fever or bloody diarrhoea.

Review and stop any prokinetic treatment.

Last updated: Dec 2019

 
   
Diverticulitis, exacerbations

Treatment of uncomplicated diverticulitis includes a low residue diet and bowel rest. Antibacterial drugs are recommended only when the patient presents with signs of infection or is immunocompromised; there is no evidence to support routine administration.

Consider admission for severe cases. Review within 48 hours or sooner if symptoms deteriorate. Arrange admission if symptoms persist or deteriorate.

Laboratory testing: stool specimen only if infectious complication suspected to exclude bacterial gastroenteritis.

NICE diverticular disease 2-page visual summary

Suspected infection or immunocompromised: co-amoxiclav 500/125 mg TDS for 5 days.

Non-severe penicillin allergy: cefalexin 500 mg TDS for 5 days and
metronidazole 400 mg TDS for 5 days.

Severe penicillin allergy: ciprofloxacin 500 mg BD for 5 days and
metronidazole 400 mg TDS for 5 days.

Last updated: Dec 2019 

 
   
Giardiasis

Consider ‘blind’ treatment of family contacts only if they are symptomatic.

Encourage fluid intake. Consider oral rehydration salt solution for adults at increased risk of a poor outcome.

Suspected or confirmed giardia: metronidazole 2 g OD for 3 days or 400 mg TDS for 5 days. 

Last updated: Dec 2019

 
   
Helicobacter pylori

Always test for H. pylori using stool antigen testing before giving antibiotics. Treat all positives if known duodenal ulcer, gastric ulcer, or low grade MALToma.

Do not offer eradication for gastro-oesophageal reflux disease.

Do not use clarithromycin, metronidazole or a fluoroquinolone if used in the past year for any infection.

Retest for H. pylori using a breath or stool test post duodenal ulcer, post gastric ulcer, or relapse after second line therapy. Consider referral for endoscopy and culture.

Laboratory testing: stool antigen testing.

Always use a PPI. Always treat for 7 days or MALToma for 14 days.

First line: PPI BD and
amoxicillin 1000 mg BD and
either clarithromycin 500 mg BD or metronidazole 400 mg BD.

Penicillin allergy: PPI BD and
clarithromycin 500 mg BD and
metronidazole 400 mg BD.

Penicillin allergy and previous clarithromycin: PPI BD and
bismuth subsalicylate 525 mg QDS (use Pepto-Bismol chewable tablets 2 QDS) and
metronidazole 400 mg BD and
tetracycline 500 mg QDS.

Second line: PPI BD and
amoxicillin 1000 mg BD and
either clarithromycin 500 mg BD or metronidazole 400 mg BD (whichever was not used first line).

Previous clarithromycin and metronidazole: PPI BD and
amoxicillin 1000 mg BD and
tetracycline 500 mg QDS (or, if tetracycline cannot be used, levofloxacin 250 mg BD).

Penicillin allergy and no previous fluoroquinolone: PPI BD and
metronidazole 400 mg BD and
levofloxacin 250 mg BD.

Penicillin allergy and previous fluoroquinolone: PPI BD and
bismuth subsalicylate 525 mg QDS (use Pepto-Bismol chewable tablets 2 QDS) and
metronidazole 400 mg BD and
tetracycline 500 mg QDS.

Last updated: Dec 2019 

 
   
Salmonella

Notifiable to Public Health England. For most cases antibiotic treatment is not indicated.

If systemically unwell, immunocompromised, or prosthetic vascular grafts seek microbiology advice. If they are a food handler seek Public Health England advice.

Laboratory testing: stool specimen. Please indicate if patient has had recent travel.

Encourage fluid intake. Consider oral rehydration salt solution for adults at increased risk of a poor outcome.

Last updated: Dec 2019

 
   
Threadworm

Washing hands and scrubbing nails before eating and after visiting the toilet are essential. A bath in the morning removes ova laid overnight.

Treat all household contacts at the same time and advise hygiene measures for two weeks:

hand hygiene; pants at night; morning shower, including perianal area and

wash sleepwear, bed linen, and dust, vacuum on day one.

Laboratory diagnosis: laboratory confirmation not usually indicated. Discuss with local microbiology laboratory if required.

First line: mebendazole 100 mg STAT 1 dose. Repeat in 2 weeks if persistent.

In pregnancy (at least in the first trimester): only hygiene measures for 6 weeks.

Last updated: Dec 2019

 
   
Travellerís diarrhoea

Standby treatment for traveller’s diarrhoea must not be prescribed at NHS expense. Consider standby antimicrobial only for patients at high risk of severe illness or visiting high-risk areas.

Prophylaxis is rarely, if ever, indicated.

Laboratory testing: stool specimen.

Standby (private prescription only): azithromycin 500 mg OD for 3 days.

Prophylaxis or treatment: bismuth subsalicylate 525 mg QDS for 2 days (use Pepto Bismol chewable tablets 2 QDS).

Last updated: Dec 2019

 
   
27.11  Genital Tract Infections
 note 

Genital tract infections

Sexual Health Wirral

Website: sexualhealthwirral.nhs.uk
Appointment number: 03001 235474 - Professional advice = Option 2
Address: Gemini Centre, St Catherine’s Health Centre, Derby Road, Birkenhead, CH42 0LQ

 

Bacterial vaginosis

If symptomatic, empirical treatment is recommended. Oral metronidazole is as effective as topical treatment and is more cost effective. Less relapse with 7 days oral metronidazole treatment than 2 g stat dose at 4 weeks.

Pregnant or breastfeeding: avoid 2 g stat dose.

Treating partners does not reduce relapse.

Advise: do not use vaginal douches, bubble bath, shower gel or shampoo in the bath or strong detergents to wash your underwear.

Laboratory testing: bacterial vaginosis can be diagnosed by high-vaginal swab and Gram stain performed by the laboratory. The presence of clue-cells is diagnostic of bacterial vaginosis. Note bacterial vaginosis can be asymptomatic – the coincidental finding of clue cells in asymptomatic patients does not require treatment.

First line: oral metronidazole 400 mg BD for 7 days or 2 g STAT dose.

If pregnant or unable to abstain from alcohol: metronidazole 0.75% vaginal gel one 5 g applicatorful at night for 5 nights or alternatively
clindamycin 2% cream 5 g PV at night for 7 nights.

After first line treatment is ineffective or not tolerated as an alternative to clindamycin: dequalinium chloride vaginal tablet 10 mg inserted at night for 6 nights. 

Last updated: Feb 2021

 
   
Balanitis

Check for any underlying problems.

Avoid soap, bubble bath or other irritant. Instead advise use of a soap substitute. Advise that topical imidazole preparations may damage latex condoms and diaphragms.

If inflammation is causing discomfort, consider prescribing topical hydrocortisone 1% cream or ointment for up to 14 days in addition.

Laboratory diagnosis: penile swab if pus present

Candida: clotrimazole 1% cream BD/TDS until symptoms settle or for up to 14 days or
oral fluconazole 150 mg STAT dose.

Bacterial: oral flucloxacillin 500 mg QDS for 7 days.

Penicillin allergy: oral clarithromycin 250 mg BD for 7 days.

Anaerobic (Gardnerella): oral metronidazole 400 mg BD for 7 days.

Last updated:

 
   
Candidiasis, vaginal

All topical and oral azoles give over 80% cure.

Concurrent vulvitis: add 2% clotrimazole cream.
If treating with clotrimazole 500 mg pessary, prescribing a Combi pack is less expensive than separate prescriptions for pessary and cream.

If pregnant: avoid oral azoles and may need a longer duration of treatment, usually about 7 days to clear the infection.

Laboratory diagnosis: not indicated unless severe or recurrent infection

First line: [OTC] oral fluconazole 150 mg STAT dose or
[OTC] clotrimazole 500 mg pessary STAT dose or
[OTC] clotrimazole 100 mg pessary at night for 6 nights.

In pregnancy: clotrimazole 100 mg pessary at night for 6 nights (without applicator).

Recurrent (> 4 episodes per year): oral fluconazole 150 mg every 72 hours for 3 doses, then 150 mg dose once a week for 6 months maintenance. 

Last updated: Jan 2020

 
   
Chlamydia trachomatis / urethritis

Offer and encourage full STI screening to patients aged 15 to 24 years for chlamydia annually, and on change of sexual partner. If positive, treat patient and partner, and refer to GUM or local sexual health clinic.

Advise to refrain from sexual activity until doxycycline course is complete or for 7 days after treatment with azithromycin. Test for reinfection 3-6 months following treatment if under 25 years or for over 25 years and high risk. 

Test of cure: test of cure is required at least three weeks after the end of a course of azithromycin for people who are pregnant or breastfeeding, and in cases of allergy or intolerance. 

Symptomatic urethritis: consider referring to GUM to test for Mycoplasma genitalium and Gonorrhoea (see separate sections).

Laboratory testing: if suspected chlamydia, send chlamydia nucleic acid amplification test (NAAT) in viral transport media.

Non-pregnant
First line: doxycycline 100 mg BD for 7 days.

Second line: azithromycin 1 g STAT dose, then 500 mg OD for 2 days (3 days total).

Third line: ofloxacin 200 mg BD or 400 mg OD for 7 days. 

Pregnant/breastfeeding/allergy/intolerance
First line: azithromycin 1 g STAT dose, then 500 mg OD for 2 days (3 days total). 

Second line: erythromycin 500 mg QDS for 7 days or
amoxicillin 500 mg TDS for 7 days. 

Last updated: Feb 2021

 
   
Endometritis, postpartum or following gynaecological procedure or surgery

Endometritis is a potentially severe postpartum infection that most often requires hospitalisation and IV antibiotic treatment.

Mild cases and late onset postpartum endometritis (>7 days) usually can be treated with PO antibiotics.

In late onset cases Chlamydia testing is required.

Refer patients with significant systemic symptoms or if symptoms fail to improve after 7 days

Chlamydia negative
First choice: co-amoxiclav 500/125 mg TDS for 7 days.

Non-severe penicillin allergy: cefalexin 500 mg TDS for 7 days and
metronidazole 400 mg TDS for 7 days. 

Severe penicillin allergy: clindamycin * 450 mg QDS for 7 days
* Clindamycin is present in breast milk. Use with caution in breastfeeding women. Infant needs to be monitored for effects on the gastrointestinal flora such as diarrhoea and candidiasis.

Chlamydia positive
If breastfeeding: metronidazole 400 mg TDS for 7 days and
either erythromycin 500 mg QDS for 7 days or azithromycin 1000 mg STAT then 500 mg OD for 2 days (total 3 days).

If not breastfeeding: doxycycline 100 mg BD for 7 days and
metronidazole 400 mg TDS for 7 days

Last updated: Jan 2020

 
   
Epididymitis

Usually in men over 35 years with low risk of STI. If under 35 years or STI risk, refer to GUM or local sexual health clinic.

Laboratory testing: all patients with sexually transmitted epididymitis should be screened for other STI infections. Sexual partners will also need treatment and screening.

Occasionally an MSU is useful identifying the causative agent (non-STI aetiologies)

First line: doxycycline 100 mg BD for 14 days or
ofloxacin 200 mg BD for 14 days or
ciprofloxacin 500 mg BD for 10 days.

Last updated: Jan 2020

 
   
Episiotomy or Caesarean section wound infection

Refer patients with moderate or severe symptoms or if symptoms fail to improve after 7 days. If there is clinical deterioration or no response then admission for IV antibiotics should be considered.

If the woman is colonised with MRSA or thought to be at high risk (e.g. healthcare professional), then discuss with microbiology.

Breastfeeding: antibiotics listed can be used in breastfeeding when used short term. 

First line: co-amoxiclav 500/125 mg TDS for 7 days.

Non-severe penicillin allergy: cefalexin 500 mg TDS for 7 days and
metronidazole 400 mg TDS for 7 days.

Severe penicillin allergy: clindamycin * 450 mg QDS for 7 days
* Clindamycin is present in breast milk. Use with caution in breastfeeding women. Infant needs to be monitored for effects on the gastrointestinal flora such as diarrhoea and candidiasis.

Severe penicillin allergy and clindamycin is not suitable: erythromycin 500 mg QDS for 7 days and
metronidazole 400 mg TDS for 7 days

Last updated: Jan 2020

 
   
Genital herpes simplex

Advise: saline bathing, analgesia, or topical lidocaine for pain, and discuss transmission.

First episode: treat within 5 days if new lesions or systemic symptoms and refer to GUM. May need to start treatment in primary care if there would be a delay of > 24 hours until patient will be assessed in GUM or sexual health clinic.

Recurrent: if attacks are infrequent (< 6 attacks per year) use self-care if mild or give an immediate short course of treatment. If attacks are frequent (> 6 attacks per year), or causing psychological distress, or affecting the person’s social life consider suppressive treatment.

Pregnancy: seek specialist advice.

First episode treatment: oral aciclovir 400 mg TDS for 5 days or
valaciclovir 500 mg BD for 5 days

Recurrent treatment: oral aciclovir 800 mg TDS for 2 days or
valaciclovir 500 mg BD for 3 days or
famciclovir 1 g BD for 1 day (expensive)

Suppressive treatment: oral aciclovir 400 mg BD or
valaciclovir 500 mg once a day or
famciclovir 250 mg BD (expensive)

If breakthrough reoccurrence occurs, the dose should be increased. Seek microbiology advice.

Continue treatment for a maximum of one year, then stop and reassess reoccurrence (for a minimum of 2 reoccurrences). Consider restarting treatment in people with high rates of reoccurrence with advice from microbiology.

Last updated: Jan 2020

 
   
Gonorrhoea

Antibiotic resistance is now very high. Test of cure is essential.

Refer to GUM or sexual health clinic for advice and treatment. 

Last updated: Jan 2020

 
   
Pelvic inflammatory disease

Refer women and sexual contacts to GUM or local sexual health clinic.

Exclude: ectopic pregnancy, appendicitis, endometriosis, UTI, irritable bowel, complicated ovarian cyst, functional pain.

Moxifloxacin has greater activity against likely pathogens, but always test for Gonorrhoea, Chlamydia, and M. genitalium.

Ceftriaxone for intramuscular administration: 1 g ceftriaxone should be dissolved in 3.5ml of 1% lidocaine injection BP and given by deep IM injection. 

First line (GUM clinic): ceftriaxone I.M. 1 g STAT dose and
oral metronidazole 400 mg BD for 14 days and
doxycycline 100 mg BD for 14 days.

Second line: oral metronidazole 400 mg BD for 14 days and
ofloxacin 400 mg BD for 14 days.

Alternative second line: moxifloxacin alone 400 mg OD for 14 days.

M.genitalium PID: moxifloxacin 400 mg OD for 14 days.

Last updated: Jan 2020

 
   
Trichomoniasis

All patients: refer patients to GUM or local sexual health clinic for contact tracing and follow-up. Sexual partners should be treated simultaneously.

Laboratory diagnosis: trichomonas culture, if transport is delayed, leave at room temperature. Do not refrigerate samples for culture. Delays over 24 hours are undesirable for culture.

First line: oral metronidazole 400 mg BD for 7 days or 2 g * STAT dose (more adverse effects).
* Avoid high dose metronidazole in pregnancy.

In pregnancy: if metronidazole refused consider for symptom control, clotrimazole 100 mg pessary at night for 6 nights (without applicator). 

Last updated: Jan 2020

 
   
27.12  Skin Infections
 note 

Skin infections

 

Acne rosacea

May co-exist with acne vulgaris. Avoid topical benzoyl peroxide. Refer to dermatology specialist patients who have failed to respond to two courses of 6 months oral treatment.

First line: metronidazole cream 0.75% applied daily for 8 weeks.

Alternative before oral antibiotics: ivermectin 10 mg/g (Soolantra) cream applied daily. Review at 8 weeks.

Second line: oxytetracycline 500 mg BD for 3-6 months. Repeat courses if necessary or
doxycycline 100 mg OD. Review at 12 weeks. Note: unlicensed; photosensitivity reported.

Pregnancy: use topical metronidazole or contact dermatology.

Last updated: Jan 2020

 
   
Acne vulgaris

Self-care advice: wash with mild soap or cleanser and lukewarm water not more than twice a day; avoid vigorous scrubbing and excessive use of makeup and cosmetics; benzoyl peroxide is a useful topical over-the-counter preparation, refer to minor ailments scheme if appropriate.

If topical treatment ineffective or acne is moderate to severe, oral antibiotics are preferred. Consider swab in failure of clinical response.

Severe acne, cases unresponsive to prolonged antibiotics, the presence of scarring or psychological problems should be referred to a dermatologist.

Treatment with oral antibiotics alone is not recommended.

First line: self-care.

Second line: 6 – 8 weeks topical therapy
benzoyl peroxide 5% (Acnecide®) OD – BD or
adapalene 0.1% (Differin®) OD [1,4] or
adapalene 0.1% with benzoyl peroxide 2.5% (Epiduo®) OD.

Third line: either add topical clindamycin or consider adding an oral antibiotic
topical benzoyl peroxide 3% with clindamycin 1% (Duac®) OD for 12 weeks or
topical tretinoin 0.025% with clindamycin 1% (Treclin®) OD for 12 weeks or
topical second line treatment with oral antibiotics for 12 weeks.

DO NOT USE TOPICAL ANTIBIOTICS AND ORAL ANTIBIOTICS TOGETHER

Treatment failure or severe: add an oral antibiotic and consider referral
lymecycline 408 mg OD for 6 - 12 weeks or
tetracycline 500 mg BD for 6 - 12 weeks or
doxycycline 100 mg OD for 6 - 12 weeks.

In pregnancy, treatment failure or severe: erythromycin (E/C 250 mg) 500 mg BD

Last updated: Jan 2020

 
   
Bites, human and animal

Consider antibiotic prophylaxis for bites that involve high-risk area such as the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation or
is in a person at risk of a serious wound infection because of a comorbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease).

Human: thorough irrigation is important. Assess risk of tetanus, rabies, and hepatitis B and C.

Penicillin allergy: review all at 24 and 48 hours as not all pathogens are covered.

Laboratory testing: wound swab, please include details of the bite injury to allow optimum detection of pathogens.

NICE Human and animal bites 3-page visual summary

Treatment and prophylaxis: co-amoxiclav 500/125 mg TDS for 7 days.

In penicillin allergy: human and animal, doxycycline 100 mg BD for 7 days and
metronidazole 400 mg TDS for 7 days.

In pregnancy: obtain microbiology advice.

Last updated: Feb 2021

 
   
Boils

Drainage is advised.

Antibiotics are not indicated if cellulitis has been excluded unless the patient is immunocompromised or clinically worsening, or the abscess is > 5 cm. Then give oral antibiotics as per cellulitis treatment guidelines for 5 days. 

Last updated: Jan 2020

 
   
Candida-associated angular stomatitis or cheilitis

Refer to dental surgeon. Commonly associated with denture stomatitis.

May be seen in nutritional deficiency or HIV infection. If failure to respond to 1–2 weeks of treatment investigate the possibility of underlying disease.

Encourage appropriate denture fit and cleaning, and oral hygiene.

Miconazole 2% cream BD-QDS for 7 days then continue for 7 days after lesions healed.

Last updated: Jan 2020

 
   
Cellulitis and erysipelas

Exclude other causes of skin redness (inflammatory reactions or non-infectious causes). Manage underlying conditions such as diabetes, venous insufficiency, eczema and oedema.

Consider taking a swab for culture if skin is broken and uncommon pathogen is suspected, or not responding to antibiotic treatment. A longer course (up to 14 days in total] may be needed but skin takes time to return to normal and full resolution at 7 days is not expected.

Reassessment is needed if symptoms worsen rapidly, or do not start to improve in 2 to 3 days. Refer to hospital if patient is severely unwell or has lymphangitis, or patient has symptoms or signs of a more serious illness such as orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis.

Do not routinely offer antibiotics to prevent recurrent cellulitis or erysipelas.

If river or sea water exposure, discuss with a microbiologist.

Laboratory testing: not usually required.

First line: flucloxacillin 500 mg – 1 g QDS for 7 days.

In severe or not responding cellulitis: co-amoxiclav 500/125 mg TDS 7 days or
clindamycin 300 mg QDS 7 days (can be increased to 450 mg QDS).

Penicillin allergy: clarithromycin 500 mg BD for 7 days or
doxycycline 200 mg on day 1, then 100 mg daily for 7 days in total or
erythromycin (preferred in pregnancy) 500 mg QDS for 7 days.

If MRSA: treat according to sensitivities.

Last updated: Jan 2020

 
   
Cellulitis, facial (non-dental)

Infection around eyes or nose: consider urgent referral to hospital because of potentially serious intracranial complications.

Review response to treatment after 7 days.

If slow response, continue for further 7 days.

Severe penicillin allergy: clinical review at 48 hours as not all pathogens are covered.

Clinical review at 48 hours as not all pathogens are covered.

First line: co-amoxiclav 500/125 mg TDS for 7 days.

Non-severe penicillin allergy: cefalexin 500 mg TDS for 7 days and
metronidazole 400 mg TDS for 7 days

Severe penicillin allergy: clarithromycin 500 mg BD for 7 days and
metronidazole 400 mg TDS for 7 days.

Penicillin allergy in pregnancy: seek microbiology advice.

Last updated: Jan 2020

 
   
Cellulitis, facial (with suspected dental involvement)

Refer to a dental practitioner or maxillofacial department.

Last updated: Jan 2020

 
   
Chickenpox (varicella zoster) and Shingles (herpes zoster)

Pregnant/immunocompromised/neonate: seek urgent specialist advice.

Chickenpox: consider aciclovir if onset of rash < 24 hours and one of the following: > 14 years of age; severe pain; dense/oral rash; taking steroids; smoker.

Give paracetamol for pain relief.

Shingles: treat if > 50 years (PHN rare if <50 years) and within 72 hours of rash, or if 1 of the following: active ophthalmic; Ramsey Hunt; eczema; non-truncal involvement; moderate or severe pain; moderate or severe rash. 

Shingles treatment if not within 72 hours: consider starting antiviral drug up to 1 week after rash onset, if high risk of severe shingles or continued vesicle formation; older age; immunocompromised; or severe pain.

First line for chicken pox and shingles: aciclovir 800 mg five times daily for 7 days.

Alternative if poor compliance: valaciclovir 1 g TDS for 7 days.

Last updated: Jan 2020

 
   
Dermatophyte infection: nail

Encourage self-care with over the counter medicines for self-limiting conditions.

Send nail clippings to the laboratory. Treat only if laboratory confirms infection. Oral terbinafine is more effective than oral azole. If candida or non dermatophyte infection is confirmed use oral itraconazole. Topical nail lacquer is not as effective.

Liver reactions 0.1% to 1% with oral antifungals.

Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists.

First line: terbinafine 250 mg OD

Fingers: 6 weeks
Toes: 12 weeks

Second line: itraconazole 200 mg BD for one week per month

Fingers: 2 courses
Toes: 3 courses

Last updated: Jan 2020

 
   
Dermatophyte infection: scalp

Refer to dermatologist. Send hair and scalp scrapings for laboratory confirmation before commencing systemic therapy. Commence treatment if microscopically positive and review once culture results available. 

First line: terbinafine 250 mg OD for 4 weeks. 

Last updated: Jan 2020

 
   
Dermatophyte infection: skin

Encourage self-care with over the counter medicines for self-limiting conditions.

Refer to a dermatologist if extensive.

Skin scrapings for culture and microscopy are not indicated in cases of uncomplicated athlete’s foot, mild skin ringworm or mild groin infections. Samples for fungal culture are indicated when oral treatment is being considered:

  • Scalp ringworm or nail disease.
  • Severe or extensive skin fungal infections, e.g., moccasin-type Athlete’s Foot
  • Infections refractory to initial treatment.
  • When the diagnosis is uncertain.

Commence treatment if microscopically positive and review once culture results available.

First line: terbinafine 1% cream BD.

If candida possible: clotrimazole 1% cream BD.

Apply cream beyond the margin of the lesions for 1 to 2 weeks. Continue treatment for at least 7 days after lesions have healed.

Intractable and laboratory confirmed infection: oral terbinafine 250 mg OD for 4 weeks. 

Last updated: Aug 2020

 
   
Diabetic foot infection

In diabetes, all foot wounds are likely to be colonised with bacteria.

Diabetic foot infection has at least 2 of:

  • local swelling or induration
  • erythema
  • local tenderness or pain 
  • local warmth
  • purulent discharge

Start antibiotic treatment for people with suspected diabetic foot infection as soon as possible. Take samples for microbiological testing before, or as close as possible to, the start of antibiotic treatment. When microbiological results are available review the choice of antibiotic and change the antibiotic according to results, using a narrow-spectrum antibiotic, if appropriate.

A longer course (up to a further 7 days) may be needed based on clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 7 days is not expected. Review need for continued antibiotics regularly. 

Immediate hospital referral and inform multi-disciplinary foot care service if there are limb- or life-threatening problems: fever; sepsis; limb ischaemia; deep soft tissue infection; bone infection; gangrene.

Mild infection: 0.5 to less than 2 cm erythema; does not involve deeper structures; no signs of systemic inflammatory response. Refer to foot service stating the patient has diabetes and a new ulcer. Reassess if symptoms worsen or fail to improve within 1 to 2 days.

First line: flucloxacillin 500 mg to 1 g four times a day for 7 days (1 g dose is off label).

Alternative: clarithromycin 500 mg twice a day for 7 days or
doxycycline 200 mg on day 1, then 100 mg daily (can be increased to 200 mg daily) for 7 days in total or
erythromycin (preferred in pregnancy) 500 mg four time a day for 7 days.

Consider adding metronidazole 400 mg TDS if anaerobic infection is suspected.

Last updated: Jan 2020

 
   
Herpes simplex

Most cold sores resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12 – 18 hours.

Encourage self-care with over the counter medicines for self-limiting conditions.

If frequent, severe, and predictable triggers: consider oral prophylaxis, aciclovir 400 mg BD for 5 - 7 days.

Last updated: Jan 2020

 
   
Impetigo and eczema with visible signs of infection

Advise on the importance of personal hygiene, for example, not to share communal items such as towels, flannels, etc.

Do not offer combination treatment with topical and oral antibiotics or extended or repeated use of topical antibiotics.

Refer people with signs or symptoms of more serious illness or if immunocompromised.

  • Bullous impetigo especially children less than 1 year old
  • Recurs frequently
  • Systemically unwell
  • High risk of complications

Recurring impetigo: take a skin swab and consider a nasal swab with treatment for decolonisation.

NICE impetigo 2-page visual summary

Self care: remove the crusts gently and regularly using [OTC] antibacterial liquid soap or skin wash and water.

First choice, non-severe infection: hydrogen peroxide 1% cream TDS for 5 days.

If not suitable and only when a few localised lesions are present
Second choice: fusidic acid 2% cream TDS for 5 days or
if resistance, topical mupirocin 2% TDS for 5 days.

For more extensive infection: flucloxacillin 500mg QDS for 7 days.

In penicillin allergy: clarithromycin 500mg BD for 7 days or
erythromycin (preferred in pregnancy) 500mg QDS for 7 days.

Last updated: Aug 2020

 
   
In-growing toenail infection

Wound debridement and swab. Lateral nail ablation recommended when infection settled if the problem is recurrent.

First line: flucloxacillin 500 mg QDS for 7 days.

In penicillin allergy: clarithromycin 500 mg BD or
erythromycin (preferred in pregnancy) 500 mg QDS for 7 days.

Last updated: Jan 2020

 
   
Leg ulcer

Bacteria will always be present. Check MRSA status.

Antibiotics do not improve healing unless there is an active infection: cellulitis, increased pain, pyrexia.

Reassess if the infection worsens, does not start to improve within 2 to 3 days, or the person becomes systemically unwell or has severe pain. Take account of previous antibiotic use, which may have led to resistant bacteria. Consider sending a sample from the leg ulcer after cleaning. Review treatment choice with culture and sensitivity results.

Refer to local district nurse team as per local guidance. 

If patient is febrile and unwell admit for IV treatment.

First line: flucloxacillin 500 mg QDS for 7 days. If slow response, continue for another 7 days or
if flucloxacillin is unsuitable, doxycycline 200 mg on day 1, then 100 mg daily for 7 days in total.

Penicillin allergy: clarithromycin 500 mg BD for 7 days. If slow response, continue for another 7 days.

Penicillin allergy in pregnancy: erythromycin 500 mg QDS for 7 days.

Last updated: Aug 2020

 
   
Lice - body, crab, or pubic

Consider that other sexually transmitted infections may coexist with this.

Hot wash (50°C) all clothes and bedding or dry clean following first treatment.

Consider self-care.

[OTC] Malathion 0.5% aqueous solution. Apply to all hairy parts of the body. Repeat after 7 days.

Last updated: Jan 2020

 
   
Lice - head

Only treat if live moving lice are found or black or brown eggs, not empty white egg cases. Encourage self-care of this condition.

A course involves two treatments one week apart. Reinfection is more probable than treatment failure. Combs should be thoroughly cleaned after each use.

Use a different product for subsequent courses following treatment failure. Avoid shampoos and do not use insecticides as prophylaxis.

Consider self-care.

Wet combing and either [OTC] dimeticone 4% or [OTC] malathion 0.5% aqueous solution.

Last updated: Jan 2020

 
   
Mastitis, lactational

The most common cause of mastitis is an ineffective attachment at the breast. It is essential that this is corrected otherwise the problem will persist and secondary problems may result despite antibiotic treatment.

Women should continue feeding including from the affected breast. The possibility of hypersensitive reactions must be considered in breast feeding infants.

Surgical drainage may be required.

Laboratory testing: superficial swab of pus if present. Do not send milk specimens.

First line: flucloxacillin 500 mg QDS for 14 days.

Penicillin allergy: erythromycin (preferred in pregnancy and breastfeeding) 500 mg QDS for 14 days or
clarithromycin 500 mg BD for 14 days.

Last updated: Jan 2020

 
   
Perianal abscess

Antibiotics are not an alternative to surgical drainage.

The development of a necrotising, soft-tissue infection is more common in the elderly, patients with diabetes, and immunosuppressed individuals and has been reported to have a mortality between 25% and 35%.

Antibiotics should be used as an adjunctive treatment for patients with diabetes, immuno-compromise, chronic debilitation, older age, history of cardiac valvular disease, or significant associated cellulitis.

Refer for surgical drainage.

Adjunctive treatment or necrotising infection (see key points): co amoxiclav 500/125 mg TDS for 5 days or
both ciprofloxacin 500 mg BD for 5 days and metronidazole 400 mg TDS for 5 days.

Last updated: Jan 2020

 
   
Post-operative wound infections

Consider the site and severity of infection.

A brief course of systemic antimicrobial therapy may be indicated following clean operations on the trunk, head and neck, or extremities.

Post-operative infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract: seek microbiology advice.

Post operative infections following operations on the spine or involving a prosthetic implant: avoid prescribing antibiotics and refer urgently back to the surgeon.

Laboratory testing: swab wound for culture and sensitivity. Consider nature of the operation and likely pathogens including MRSA status. Review treatment with culture and sensitivity results.

Infection within 30 days of surgery should be referred back to the responsible Trust. Low threshold for admission. Discuss with a microbiologist or the on-call surgical team.

If oral treatment is considered appropriate: flucloxacillin 500 mg QDS for 7 days.

Penicillin allergy: clarithromycin 500 mg BD for 7 days.

Penicillin allergy in pregnancy: seek microbiology advice.

Last updated: Jan 2020

 
   
Scabies

Treat whole body from the ear and chin downwards and under nails. If using permethrin and the patient is elderly or immunosuppressed, or if treating with malathion also treat face and scalp.

Treat all home and sexual contacts from the previous 2 months at the same time (within 24 hrs).

Itch may persist for 4-6 weeks following effective treatment. Crotamiton or aqueous cream may be beneficial. Sedative antihistamines may help with nocturnal itch.

Hot wash (50°C) all clothes and bedding or dry clean following first treatment. If the patient is institutionalised refer to the Community Infection Prevention and Control Team.

First line: permethrin 5% cream two applications left on for 12 hours one week apart.

Permethrin allergy: malathion 0.5% aqueous liquid two applications left on for 24 hours one week apart. 

Last updated: Jan 2020

 
   
Scabies, crusted

Refer to dermatology for specialist advice.

Last updated: Jan 2020

 
   
Superficial skin and soft tissue infections, paronychia

Wound debridement if suspected foreign body and swab.

Use sensitivity results to guide therapy.

First line: flucloxacillin 500 mg QDS for 7 days.

In penicillin allergy: clarithromycin 500 mg BD for 7 days.

Penicillin allergy in pregnancy: erythromycin 500 mg QDS for 7 days.

Last updated: Jan 2020

 
   
27.13  Eye infections
 note 

Eye infections

 

Blepharitis

Self-care: initial trial of lid hygiene including warm compresses, lid massage and scrubs, gentle washing, and avoiding cosmetics. Proprietary eyelid wipes and cleansers are available over the counter.

Unresponsive cases may benefit from specialist review for systemic antibiotic, topical steroid, or both. The full course should be provided by the specialist and reviewed accordingly.

First line: self-care.

Second line: if lid hygiene measures are ineffective, chloramphenicol 1% ointment BD for 6 weeks.

Signs of Meibomian gland dysfunction, or acne rosacea: the effectiveness of oral antibiotics for blepharitis has been shown to be inconclusive. The risks and benefits of antibiotic treatment should be weighed. Specialist Ophthalmology advice is required.

Last updated: Jan 2020

 
   
Conjunctivitis

Treat only if severe, as most cases are viral or self-limiting.

Self-care: bathe or clean eyelids with cotton wool dipped in boiled and cooled water to remove crusting.

For mild cases there is no requirement for diagnostic specimens.

Explain red flags for urgent review and advise the person to seek further help if symptoms persist beyond 7 days.

Use topical antibiotics for severe or prolonged infection only. Send a bacterial swab in severe or prolonged cases.

Red flag symptoms for urgent review: eye pain, visible eye trauma, photophobia, reduced visual acuity, unilateral marked redness, contact lens related red eye.

First line: self-care.

Second line for bacterial infection: continue self-care and add
either chloramphenicol 0.5% eye drops 2 hourly for 2 days then reduce frequency or chloramphenicol 1% ointment QDS (or just at night if used with eye drops during the day).

Consider issuing two bottles or tubes in bilateral infection to prevent cross contamination.

Third line: fusidic acid 1% modified-release eye drops BD.

Treat for 48 hours after resolution.

Last updated: Jan 2020

 
   
Orbital cellulitis

Urgent referral to hospital.

Last updated: Jan 2020

 
   
27.14  Dental infections
 note 

 

Suspected dental infections in primary care (outside dental settings)

Non-dental primary care prescribers are not licensed and are not indemnified to treat suspected dental infections

Patients presenting to non-dental primary care services with dental problems should be directed to their regular dentist or, if this is not possible, to the NHS 111 service (in England) who will be able to provide details of how to access emergency dental care. In Cheshire and Merseyside there is also an emergency dental helpline (0161 476 9651) which operates from 9.00 am to 9.30 pm every day including weekends and Bank Holidays.

Note: antibiotics do not cure toothache. First line treatment is with paracetamol or ibuprofen, or both. Codeine has no proven efficacy for toothache.

PHE (2019). Patient information leaflet: antibiotics don’t cure toothache.

 

Abscess, dental

Antibiotics are not appropriate in cases where the infection is localised to the peri‑radicular tissues as this indicates that the infection is being adequately managed by the immune system. In these cases, the abscess is mostly isolated from the circulation, resulting in very little antibiotic penetration.

Regular analgesia dosed appropriately should be advised until a dentist can be seen for urgent drainage.

Antibiotics are only required if immediate drainage is not achieved using local measures or in cases of spreading infection (swelling, cellulitis, lymph node involvement) or systemic involvement (fever, malaise) or a high risk of complications.

Patients with severe odontogenic infections (cellulitis, plus signs of sepsis; difficulty in swallowing; impending airway obstruction) should be referred urgently for hospital admission to protect airway, for surgical drainage and for IV antibiotics.

If antibiotics are indicated: amoxicillin 500 mg TDS for up to 5 days. Review at 3 days. Doses can be doubled in severe infection.

Penicillin allergy: clarithromycin 500 mg BD for up to 5 days. Review at 3 days.

If spreading infection (lymph node involvement or systemic signs, that is, fever or malaise): add metronidazole 400 mg TDS for up to 5 days, review at 3 days.

Last updated: Dec 2019

 
   
Mucosal ulceration and inflammation
(simple gingivitis)

There are no indications for the prescribing of systemic antimicrobials for the management of gingivitis.

The primary cause for mucosal ulceration or inflammation (aphthous ulcers; oral lichen planus; herpes simplex infection; oral cancer) needs to be evaluated and treated.

Superficial infections of the mouth are often helped by warm mouthwashes which have a mechanical cleansing effect and cause some local hyperaemia. However, to be effective, they must be used frequently and vigorously.

First line: simple saline mouthwash PRN (half a teaspoon of salt dissolved in a glass of warm water) or

chlorhexidine gluconate 0.2% mouthwash, rinse or gargle with 10ml BD for 1 minute (do not use within 30 minutes of toothpaste) or

hydrogen peroxide 6% solution, dilute 15 ml in half a glass of warm water and rinse or gargle 2-3 times a day for 2-3 minutes.

Always spit out mouthwashes after use. Use until lesions resolve or less pain allows for oral hygiene. Reversible discoloration of teeth and tongue may occur with chlorhexidine mouthwash.

Last updated: Dec 2019

 
   
Necrotising ulcerative gingivitis, acute

Refer to dentist for scaling and hygiene advice.

Prescribe a mouthwash for plaque control.

Only commence metronidazole if there are systemic signs and symptoms.

First line: chlorhexidine gluconate 0.2% mouthwash, rinse or gargle with 10 ml BD for 1 minute (do not use within 30 minutes of toothpaste) or

hydrogen peroxide 6% solution, dilute 15ml in half a glass of warm water and rinse or gargle 2-3 times a day for 2-3 minutes.

Always spit out mouthwashes after use. Use until pain allows for oral hygiene. Reversible discoloration of teeth and tongue may occur with chlorhexidine mouthwash.

If antibiotics are indicated: metronidazole 400 mg TDS for 3 days.

Last updated: Dec 2019

 
   
Pericoronitis
(soft tissues surrounding the crown of a partially erupted tooth)

Refer to dentist for irrigation and debridement.

Use antiseptic mouthwash if pain and trismus limit oral hygiene.

If severe local swelling, systemic symptoms or trismus, prescribe antibiotics.

First line: chlorhexidine gluconate 0.2% mouthwash, rinse or gargle with 10 ml BD for 1 minute (do not use within 30 minutes of toothpaste) or

hydrogen peroxide 6% solution, dilute 15 ml in half a glass of warm water and rinse or gargle 2-3 times a day for 2-3 minutes.

Always spit mouthwashes out after use. Use until pain allows for oral hygiene.

If antibiotics are indicated: metronidazole 400 mg TDS for 3 days or
if metronidazole can’t be used, amoxicillin 500 mg TDS for 3 days.

Last updated: Dec 2019

 
   
Prophylaxis against endocarditis

Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. (NICE CG64, SDCEP, FGDP).

Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures.

Any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing. [NICE CG64]

SDCEP (2018). Antibiotic Prophylaxis Against Infective Endocarditis.

The vast majority of patients at increased risk of infective endocarditis will not be prescribed prophylaxis as per NICE CG64. However, for a very small number of patients, it may be prudent to consider antibiotic prophylaxis (non-routine management), in consultation with the patient and their cardiologist or cardiac surgeon.

Note: GPs would not routinely be involved in this decision or asked to prescribe. This responsibility lies with the dental practitioner.

Last updated: Dec 2019

 
   
27.17  Treatment of Splenectomy Patients to top
 note 

Treatment of Splenectomy Patients

Patients who suffer from asplenia or hyposplenia are at increased risk of overwhelming bacterial infection. Infection is most commonly pneumococcal (Streptococcus pneumoniae) but other organisms such as Haemophilus influenzae type b (Hib) and Neisseria meningitidis may be involved. This risk is greatest in the first two years following splenectomy and is greater amongst children but persists into adult life.

Please check online for most up to date information PHE Green book Chapter 7

Practical schedule for immunising individuals with asplenia, splenic dysfunction or complement disorders (including those receiving complement inhibitor therapy*).

First diagnosed under 1 year of age

Children should be fully immunised according to the national schedule, and should also receive:

  • two doses of MenACWY vaccine at least one month apart during infancy;
  • one additional dose of PCV13* and one dose of MenACWY conjugate vaccine two months after the 12-month vaccinations; and
  • one additional dose of Hib/MenC and one dose of PPV231 after the second birthday.

First diagnosed at 12-23 months of age

If not yet administered, give the routine 12-month vaccines: Hib/MenC, PCV13, MMR and MenB, plus:

  • one additional dose of PCV13* and one dose of MenACWY conjugate vaccine two months after the 12-month vaccinations; and
  • one additional dose of Hib/MenC and one dose of PPV23*,† after the second birthday.

If not already received, two primary doses of MenB vaccine should be given two months apart at the same visit as the other vaccinations.

First diagnosed from two years to under ten years of age

Ensure children are immunised according to the national schedule, and they should also receive:

  • one additional dose of Hib/MenC and one dose of PPV23*; followed by:
  • one dose of MenACWY conjugate vaccine two months later

If not already received, two primary doses of MenB vaccine should be given two months apart at the same visit as the other vaccinations.

First diagnosed at age ten years onwards

Older children and adults, regardless of previous vaccination, should receive:

  • one dose of Hib/MenC and one dose of PPV23*; followed by:
  • one dose of MenACWY conjugate vaccine one month later.

If not already received, two primary doses of MenB vaccine should be given one month apart at the same visit as the other vaccinations.

All patients

Annual influenza vaccine each season

* Patients on Eculizumab (Soliris®) therapy are not at increased risk of pneumococcal disease and do not require PPV23 or additional doses of PCV13
† Patients with splenic dysfunction should receive boosters of PPV at five yearly intervals.

Prophylactic antibiotics should be offered to all patients.

Lifelong antibiotic prophylaxis is appropriate for high-risk groups including those individuals

  • aged less than 16 years or greater than 50 years
  • with inadequate serological response to pneumococcal vaccination,
  • a history of previous invasive pneumococcal disease,
  • splenectomy for underlying haematological malignancy, particularly in the context of on-going immunosuppression.

Low-risk patients should be counselled as to the risks and benefits of prophylaxis, particularly where adherence is an issue.

Lifelong compliance with prophylactic antibiotics is problematic. If the patient does not continue to be at high risk as per the criteria above, the patient must have antibiotic prophylaxis until at least 2 years after splenectomy.

If compliance is a problem, the patient must be advised to have an emergency supply of Amoxicillin or Erythromycin to take in the event of fever as well plus be advised to seek medical attention urgently.

Phenoxymethylpenicillin is preferred unless the cover is also needed against Haemophilus influenza for a child in which case, give Amoxicillin; or if the patient is allergic to penicillin, give Erythromycin.

Phenoxymethylpenicillin Child 1 – 11 months 62.5 mg bd
  Child 1 – 4 years 125 mg bd
  Child 5 – 17 years 250 mg bd
Amoxicillin Child 1 month – 4 years 125 mg bd
  Child 5 -11 years 250 mg bd
  Child 12 – 17 years 500 mg bd
Erythromycin Child 1 month – 1 year 125 mg bd
  Child 2 – 7 years 250 mg bd
  Child 8 – 17 years 500 mg bd

Adapted from BNF for children and PHE guidelines

Other measures to reduce risk include:

  • Patients should be asked to consult if they have a febrile illness and may be given a stock of antibiotics to start treatment by themselves. They should carry a card or Medic-Alert bracelet or necklace, or both.
  • When travelling abroad patients should obtain advice from a reputable travel advice centre (e.g. Liverpool School of Tropical Medicine) to ensure precautions are adequate and up to date.
  • Patients should avoid malaria (which is more severe in asplenic patients) by avoiding malaria areas or, if going to such areas, adhere scrupulously to antimalarial prophylaxis and anti-mosquito precautions.
  • Avoid tick bites as there is a risk of Babesiosis and Lyme disease.
27.21  Sampling guidance
 note 

 

Sampling guidance

Liverpool Clinical Laboratories

This sampling guidance is provided for reference and intended for users of Liverpool Clinical Laboratory services (does not include Wirral). There are differences with other laboratory services and you should follow local guidance. This guide may be adapted for local use.

 

 ....
Key
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Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
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Display tracking information
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Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection. †Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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