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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
Formulary

Metronidazole 400 mg BD for 7 days OR 2 g STAT* dose
Note there is greater relapse with 2 g dose

If pregnant or unable to abstain from alcohol: Metronidazole 0.75% vaginal gel 5 g applicatorful at night for 5 nights OR Clindamycin 2% cream 5 g PV at night for 7 nights

Avoid Metronidazole 2 g dose in pregnancy.

*Warning Avoid in pregnancy

Refer to GUM or Sexual Health Services if diagnosis is uncertain or the infection is recurrent or troublesome.
 
Link  BASHH
Link  BNFC Clindamycin
Link  BNFC Metronidazole
   
Candida balanitis
Formulary
Clotrimazole cream 1%. Apply 2-3 times a day for 2 weeks
Check for underlying problems
 
Link  BNFC Clotrimazole
   
Candidiasis, vaginal
Formulary

Fluconazole* 150 mg oral STAT dose OR
Clotrimazole pessary 500 mg OR Clotrimazole 10 % vaginal cream NOCTE STAT

AND Clotrimazole 1% cream TDS for 7 days

In pregnancy: avoid oral azoles and use Clotrimazole 500 mg pessary NOCTE STAT (without applicator) and 1% cream TDS for 7 days

*Warning Avoid in pregnancy

Investigate recurrent cases (4 or more episodes annually) and refer if appropriate.

 

 
Link  BASHH
Link  BNFC Clotrimazole
Link  BNFC Fluconazole
   
Chlamydia infection
Formulary

First line: Doxycycline* 100 mg BD for 7 days

Second line: Azithromycin† 1 g STAT, followed by 500 mg OD for 2 days

If at risk of pregnancy or breastfeeding:

  • Azithromycin† 1 g STAT, followed by 500 mg OD for 2 days
  • (recommended first line, most effective, but off-label) OR
  • Erythromycin 500 mg QDS for 7 days OR
  • Erythromycin 500 mg BD for 14 days OR
  • Amoxicillin 500 mg TDS for 7 days

Pregnant patients should be given a test of cure 3 weeks after completing therapy, regardless of the antibiotic used, due to lower cure rate in pregnancy.

For suspected epididymitis in men: Ofloxacin 200 mg BD 14 days OR
Doxycycline 100 mg BD 14 days

If risk of rectal infection: Doxycycline* 100 mg BD for 7 days
For example, all women, and men who have sex with men. Patients and any partners should be referred to GUM even if treated locally.

*Warning Avoid in pregnancy

† The use of azithromycin is appropriate for the treatment of chlamydia in pregnancy

Doxycycline* is now recommended first line. Emerging co-infection with macrolide resistant Mycoplasma genitalium is likely due to widespread use of azithromycin†.

Treat partners and refer to local Sexual Health or GU service.

Look for signs of PID or epididymitis and refer to appropriate guidance.

Offer and encourage full STI screening. If gonorrhoea is not excluded, use of azithromycin† alone may contribute to the development of resistance.

Advise patients to refrain from any sexual activity until they and their partner(s) have completed treatment or, in the case of Azithromycin, one week after the STAT dose.

Note May be asymptomatic or mild symptoms of infection

 
Link  BASHH
Link  SIGN
Link  BNFC Doxycycline
Link  BNFC Azithromycin
Link  BNFC Erythromycin
Link  BNFC Amoxicillin
   
Endometritis, postpartum or following gynaecological procedure or surgery
Formulary

New or changed and offensive discharge within 10 days post partum or post-gynae procedure: Co-amoxiclav 500/125 mg TDS for 7 days

In non-severe penicillin allergy: Cefalexin 500 mg TDS AND Metronidazole 400 mg TDS for 7 days

Refer patients with significant systemic symptoms or if symptoms fail to improve after 7 days
 
Link  BNFC Cefalexin
Link  BNFC Co-amoxiclav
Link  BNFC Metronidazole
   
Epididymitis or epididymo orchitis
Formulary

If > 35 years old and there is low suspicion of STI treat empirically.

If likely enteric organisms: Ciprofloxacin 500 mg BD for 14 days OR Ofloxacin 200 mg BD for 14 days

Sexual history is imperative.

If < 35 years old or if high suspicion of sexually transmitted infection at any age refer to GUM or Sexual Health services.

Submit MSU

Recent investigations or catheterisation are risk factors.

All patients with sexually transmitted epididymo-orchitis should be screened for other sexually transmitted infections. Sexual partners will also need treatment and screening.

All patients with urinary tract pathogen confirmed epididymo-orchitis should be investigated for structural abnormalities and urinary tract obstruction by a urologist.

 
   
Episiotomy or Caesarean section wound infection
Formulary

Co-amoxiclav 500/125 mg TDS for 7 days

In non-severe penicillin allergy: Cefalexin 500 mg TDS AND Metronidazole 400 mg TDS for 7 days

 
 
   
Gonorrhoea
Formulary
 
Refer all people with suspected gonorrhoea to a GUM clinic or other local specialist sexual health service for culture, treatment, and partner notification.
 
   
Herpes, genital (primary cases only)
(Refer all patients to GUM/Sexual Health Service for virological confirmation. Phone local department same day)
Formulary
Aciclovir 400 mg TDS for 5 days

Treat if suspected based on clinical appearance and history.

It may be preferable to initiate treatment in primary care if there would be a delay of > 24 hours until the patient was assessed in GUM or Sexual Health Service.

 
Link  BASHH
Link  BNFC Aciclovir
   
Pelvic sepsis or pelvic inflammatory disease
(Under review)
Formulary

Metronidazole 400 mg BD for 14 days AND
Ofloxacin* 400 mg BD for 14 days

*Warning Avoid in pregnancy

Consider Chlamydia infection. MUST be referred to GUM or Sexual Health Services for contact tracing and follow-up.

It may be preferable to initiate treatment in primary care if there would be a delay of > 24 hours until the patient was assessed by GUM or Sexual Health Service.

If gonorrhoea likely, refer to GUM or Sexual Health Service.

Consider gynaecological referral if systemically unwell.

 

 
Link  BASHH 2019 update
Link  BNFC Metronidazole
Link  BNFC Ofloxacin
   
Trichomoniasis
Formulary

Metronidazole 400 mg BD orally for 7 days OR 2 g STAT* dose

In pregnancy or breastfeeding:
Avoid 2 g single dose of Metronidazole. Consider Clotrimazole 100 mg pessary at night for 6 nights for symptom relief. Clotrimazole has no activity against Trichomonas and should only be considered if Metronidazole is refused. Important alleviating symptoms without treating the infection will only delay accessing treatment and risk complications and onward transmission.

*Warning Avoid in pregnancy

MUST be referred to GUM or Sexual Health Services for contact tracing and follow-up. Sexual partners should be treated simultaneously.
 
Link  BASHH
Link  BNFC Clotrimazole
Link  BNFC Metronidazole
   
Vaginal discharge in children
Formulary
Be guided by swab and culture sensitivity as often unexpected pathogens such as H influenzae, pneumococci or group A streptococci are present.
Consider all possible causes including foreign bodies and abuse. If abuse suspected refer urgently to paediatricians and consider safeguarding issues.
 
   
27.12  Skin Infections
 note 

Skin infections

With moderate or severe signs of infection, or failure to respond to first line treatment, consider swabbing the wound for culture and sensitivity. Review empirical antibiotic choice when culture results become available. Please include any recent antimicrobial therapy on the request.

 

Acne rosacea (may co-exist with acne vulgaris)
Formulary

First line: Metronidazole cream 0.75% applied daily for 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

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

*Warning Avoid in pregnancy

Avoid topical Benzoyl peroxide

Refer to dermatology specialist patients who have failed to respond to two courses of 6 months oral treatment.

 
Link  BNFC Doxycycline
Link  BNFC Metronidazole
Link  BNFC Oxytetracycline
   
Acne vulgaris
Formulary

First line: Self care

Second line: 6 – 8 weeks single topical treatment
benzoyl peroxide 5% (Acnecide®) OD – BD
OR topical retinoid* (Differin®) thinly OD

Third line: 12 weeks dual treatment
topical benzoyl peroxide with clindamycin (Duac®) OD
OR topical benzoyl peroxide with retinoid* (Epiduo®) OD
OR topical second line treatment co-prescribed with oral antibiotics

DO NOT USE TOPICAL AND ORAL ANTIBIOTICS TOGETHER

If treatment failure/severe: add oral antibiotic, consider referral
Tetracycline* 500 mg BD for 6 - 12 weeks OR
Doxycycline* 100 mg OD for 6 - 12 weeks OR
Lymecycline* 408 mg OD for 6 - 12 weeks

*Warning Avoid in pregnancy

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.

 

 
Link  CKS Acne vulgaris
Link  BNFC Rosacea and Acne
Link  BNFC Adapalene
Link  BNFC Benzoyl peroxide
Link  BNFC Clindamycin
Link  BNFC Lymecycline
Link  BNFC Tetracycline
   
Bites  (human or animal)
(treatment and prophylaxis;
refer serious bites, especially in children, to AED
)
Formulary

Co-amoxiclav 500/125 mg TDS for 7 days

In penicillin allergy:

Human: Metronidazole 400 mg TDS plus Clarithromycin* 500 mg BD for 7 days

Animal: Doxycycline* 100 mg BD plus Metronidazole 400 mg TDS for 7 days

Children under 12 years with confirmed penicillin allergy: Azithromycin for 7 days plus Metronidazole for 7 days.

Give prophylaxis for any of the following bite or puncture wounds:

  • to the hand, foot, face, joint, tendon, ligament
  • in immunocompromised, diabetic, asplenic, or cirrhotic patients
  • in the presence of prosthetic valve or joint
  • any cat bite.

*Warning Avoid in pregnancy

Adequate wound toilet is essential and the mainstay of treatment. Consider surgical debridement if required.

Assess rabies risk for animal bites occurring abroad.

Assess tetanus immunisation status.

Assess HIV and Hepatitis B and C risk for human bites.

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

Note Consider risk of blood borne virus transmission. Further guidance available from Public Health England.

 
Link  CKS Bites
Link  PHE Infectious diseses
Link  BNFC Azithromycin
Link  BNFC Co-amoxiclav
Link  BNFC Doxycycline
Link  BNFC Metronidazole
   
Boils
Formulary

If cellulitis has been excluded antibiotics not indicated.

Drainage is advised.

Also, see recurrent boils

 
   
Boils, recurrent (associated with carriage of Staph. aureus)
Formulary

Topical antiseptic for one week, see MRSA bacteraemia

Mupirocin 2% nasal ointment BD for 5 days

Swabs to confirm nasal carriage of Staphylococcus aureus. Ask for PVL testing to be carried out. Mupirocin resistance should be discussed with a specialist.

 
Link  BNFC Mupirocin
   
Candida-associated angular stomatitis / cheilitis
(Refer to dental surgeon)
Formulary
Miconazole 2% cream 2 - 4 times daily continuing for 2 days after lesions healed
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.
 
Link  BNFC Miconazole
   
Cellulitis and Erysipelas
Formulary

Erysipelas or Class I cellulitis - patient afebrile and healthy other than cellulitis: Flucloxacillin 500 mg QDS for 7 days

Severe infection: Flucloxacillin 1 g QDS for 7 days (unlicensed)

Known colonisation with MRSA: Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

Penicillin allergy and on statins: Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total

If unresolving: Clindamycin 300 mg QDS for 7 days

*Warning Avoid in pregnancy

Class II cellulitis – patient febrile and ill, or comorbidity, admit for intravenous treatment, or use OPAT: consider admission if febrile and unwell. Outpatient Parenteral Antimicrobial Therapy may be available for those assessed for suitability for the service according to strict criteria. See OPAT

Class III cellulitis – if toxic appearance, admit.

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

Review response to treatment after 7 days. If slow response, continue for further 7 days.

 

 
Link  BLS Cellulitis
Link  CREST Cellulitis
Link  BNFC Clarithromycin
Link  BNFC Flucloxacillin
   
Cellulitis, facial (non-dental)
Formulary

Co-amoxiclav 500/125 mg TDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

*Warning Avoid in pregnancy

Review response to treatment after 7 days. If slow response, continue for further 7 days.

Orbital cellulitis: urgent referral to hospital

 

 
Link  BNFC Clarithromycin
Link  BNFC Co-amoxiclav
   
Chickenpox (Varicella zoster)
Formulary

Children: antiviral treatment not recommended if < 14 years.

Adults and adolescents ≥14 years: consider prescribing valaciclovir 1 g TDS for 7 days if within 24 hours of rash onset, particularly for people with severe chickenpox (severe pain, dense rash, oral rash, secondary household case) or those at increased risk of complications, such as smokers, pregnant women, chronic diseases (neurological, hepatic, renal, pulmonary, cardiac, diabetes mellitus), morbid obesity (BMI = 40).

Varicella zoster virus (VZV) is highly communicable.

Admit patient urgently if immunocompromised.

Seek urgent advice from obstetrician for pregnant women with chickenpox.

Contacts of VZV (chickenpox or shingles): for babies under one month of age, non-immune pregnant women and immunocompromised contacts maybe offered immunoglobulin - contact virologist or microbiologist urgently for advice.

 
Link  PHE Varicella
Link  BNFC Valaciclovir
   
Dermatophyte infection: nail
Formulary

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

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. Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists. Encourage self-care with over the counter medicines for self limiting conditions.
 
Link  BNFC Terbinafine
Link  BNFC Itraconazole
   
Dermatophyte infection: scalp
Formulary

First line: Ketoconazole 2% shampoo. Apply twice weekly for two to four weeks

Second line: Terbinafine 250 mg OD for 4 weeks.

Seek specialist advice before considering antifungal treatment in children

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

 
Link  BNFC Ketoconazole
Link  BNFC Terbinafine
   
Dermatophyte infection: skin
Formulary

Most cases: Terbinafine 1% cream BD

If candida possible: Clotrimazole 1% cream BD

Both for 1 to 2 weeks and then 1 to 2 weeks after healing (a total of 4 to 6 weeks)

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

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 (e.g. scalp ringworm or nail disease); in severe or extensive skin fungal infections (e.g. moccasin-type athlete’s foot); in skin infections refractory to initial treatment; when the diagnosis is uncertain.

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

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

 
Link  BNFC Terbinafine
   
Herpes, genital
Formulary
 
See Genital Tract infections
 
   
Herpes, oral
Formulary

Cold sores do not normally require antiviral treatment. The mainstay for primary acute oral herpes stomatitis is oral fluids.

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

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

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

 
Link  CKS Herpes simplex, oral
Link  BNFC Aciclovir
   
Impetigo or eczema with visible signs of infection
Formulary

As resistance is increasing, topical treatment should only be used when a few localised lesions are present:
Fusidic acid cream TDS for 5 days OR for MRSA lesions only: topical Mupirocin 2% ointment TDS for 5 days.

For more extensive infection: Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days OR for MRSA only: Doxycycline* 200 mg OD on day 1 followed by 100 mg OD for another 6 days (i.e. 7 days in total)

*Warning Avoid in pregnancy

Advise on the importance of personal hygiene e.g. not to share communal items such as towels, flannels etc. Avoid topical steroids or long-term topical antibiotic use. Further advice may be obtained from the community infection control nurse.

 
Link  PHE Childcare settings
Link  BNFC Clarithromycin
Link  BNFC Doxycycline
Link  BNFC Flucloxacillin
Link  BNFC Fusidic acid
Link  BNFC Mupirocin
   
Ingrowing toenail infection
Formulary

Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

*Warning Avoid in pregnancy

Wound debridement and swab.

Lateral nail ablation recommended when infection settled if the problem is recurrent.

 
Link  BNFC Clarithromycin
Link  BNFC Flucloxacillin
   
Lice, body
Formulary

Malathion 0.5% aqueous solution

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

 
Link  BNFC Malathion
   
Lice, crab or pubic
Formulary

Malathion 0.5% aqueous solution

Apply to all hairy parts of the body. Repeat after 7 days. Consider other sexually transmitted infections.

 
Link  BNFC Malathion
   
Lice, head
(Only treat if live moving lice are found or black or brown eggs, not empty white egg cases)
Formulary

Wet combing AND
Dimeticone 4% OR Malathion 0.5% aqueous solution

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 different insecticides for subsequent course following treatment failure. Avoid shampoos and do not use insecticides as prophylaxis

 
Link  CKS Head Lice
Link  BNFC Dimeticone
Link  BNFC Malathion
   
Lyme disease
Formulary

First line: Doxycycline* 100 mg BD for 21 days

Alternative: Amoxicillin 1 g TDS for 21 days

Prophylaxis, low risk: antibiotic not recommended, give safety netting advice

Prophylaxis, high risk: Doxycycline* 200 mg STAT

*Warning Avoid in pregnancy

Treat erythema migrans. Suspected Lyme disease with focal symptoms, uveitis, or cardiac complications should be disused with a specialist.

Prophylaxis is not routinely recommended in Europe. Risk increased if high prevalence area and the longer tick is attached to the skin. Only give prophylaxis within 72 hours of tick removal. Give safety netting advice about erythema migrans and other possible symptoms that may occur within one month of tick removal.

 
Link  BMJ (2018) Infographic
Link  NICE (2018) NG95
Link  BNFC Amoxicillin
Link  BNFC Doxycycline
   
Mastitis
Formulary

Flucloxacillin 500 mg QDS for 14 days if clinical evidence of infection.

In penicillin allergy: Erythromycin 500 mg QDS for 14 days

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

 
Link  CKS Mastitis and breast abscess
   
Post-operative wound infections
Formulary

Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

*Warning Avoid in pregnancy

Infection within 30 days of surgery should be referred back to the responsible Trust.

Swab wound for culture and sensitivity. Consider nature of the operation and likely pathogens including MRSA status.

Consider hospital admission and discuss with a medical microbiologist.

Post-operative infections involving a prosthetic implant avoid prescribing antibiotics and refer urgently back to the surgeon.

 
Link  BNFC Flucloxacillin
Link  BNFC Clarithromycin
   
Scabies
Formulary

Permethrin 5% dermal cream applied for 12 hours.

Apply to the whole body from ear and chin downwards and under nails. Do not apply after a hot bath.

It is important that ALL household and sexual contacts (previous 2 months) should also be treated at the same time (within 24hrs).

Apply 2 treatments 1 week apart

If allergic to permethrin, Malathion 0.5% aqueous solution, 2 applications 1 week apart

Infants aged less than 2 years and the elderly aged over 65 years require head and face application (avoiding eyes) initially. Unlicensed use in less than 2 months of age, refer to paediatric dermatologist.

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 patient institutionalised refer to Community Infection Prevention and Control Team

 
Link  NHS Scabies
Link  BNFC Malathion
Link  BNFC Permethrin
   
Scabies, crusted (Norwegian)
Formulary

Rare. Treat as for scabies but include head and neck.

Refer to Dermatology for specialist advice including prescribing oral ivermectin (unlicensed).

 
   
Shingles (Varicella zoster)
Formulary

Antiviral treatment not recommended if < 50 years

Treat if ≥ 50 years (PHN rare if < 50 years) or one or more of the following: active ophthalmic lesions, Ramsey Hunt, eczema, non-truncal involvement (e.g. meningitis), moderate or severe pain, moderate or severe rash if within 72 hours of rash.

First line: Valaciclovir 1 g TDS for 7 days

Alternative (expensive): Famciclovir 500 mg TDS for 7 days OR Famciclovir 750 mg BD for 7 days

Refer to ophthalmologist urgently if ocular involvement.

Antiviral treatment if not within 72 hours of rash: consider up to one week after rash onset if high risk of severe shingles or complications (continued vesicle formation, older age, immunocompromised, severe pain).

 
Link  PCDS Herpes zoster
   
Superficial skin and soft tissue infections, Paronychia
Formulary

Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

If infection due to MRSA, use Doxycycline* 100 mg BD for 7 days
Use sensitivity results to guide therapy.

In children (mild)

< 1 month: Cefalexin

> 1 month and older: Flucloxacillin capsules (depending on age and ability to swallow) OR Cefalexin.

*Warning Avoid in pregnancy

Wound debridement if suspected foreign body and swab.

Empirical antibiotic treatment

 
Link  BNFC Clarithromycin
Link  BNFC Cefalexin
Link  BNFC Flucloxacillin
Link  BNFC Doxycycline
   
Ulcer, diabetic foot
(grade 0 or 1)
Formulary

Mild infection in patients previously untreated with antibiotics: Flucloxacillin 1 g QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

If MRSA-positive: Doxycycline* 100 mg BD

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

If treatment failure or chronic infection

Consider referral to secondary care (see decision triggers)

Co-amoxiclav 520/125 mg TDS

In penicillin allergy or MRSA carriage: seek advice from a Medical Microbiologist

*Warning Avoid in pregnancy

Refer all patients immediately to the community podiatry team as per local guidance stating clearly that the patient has diabetes and a new ulcer.

Decision triggers for referral

  1. New foot ulceration
  2. Recurrent foot ulceration
  3. Unexplained foot pain, swelling and deformity
  4. Cellulitis of the foot
  5. Suspected osteomyelitis of the toes
  6. Suspected Charcot neuroarthropathy
  7. Severe neuropathic pain
  8. Deteriorating foot ulcer, despite earlier assessment by MDT

Clinical emergency

  1. Critical limb ischaemia
  2. Acute Charcot suspected
  3. Spreading cellulitis
  4. Gangrene
  5. Significantly deteriorating foot ulceration

This list is not exhaustive, use clinical judgement

 
Link  NWCSCN Foot care
Link  BNFC Clarithromycin
Link  BNFC Co-amoxiclav
Link  BNFC Doxycycline
Link  BNFC Flucloxacillin
Link  BNFC Metronidazole
   
Ulcer, leg
Formulary

Flucloxacillin 500 mg QDS for 7 days

Severe infection: Flucloxacillin 1 g QDS for 7 days (unlicensed)

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

If slow response, continue for a further 7 days

*Warning Avoid in pregnancy

Ulcers are always colonised. Check MRSA status. Antibiotics do not improve healing unless active infection. If active infection, send pre treatment swab. Review antibiotics after culture results.

Signs of active infection: cellulitis, increased pain, pyrexia, purulent exudate, odour

Refer to local district nurse team as per local guidance.

 
Link  PHE Venous leg ulcer
Link  BNFC Clarithromycin
Link  BNFC Flucloxacillin
   
27.13  Eye infections
 note 

Eye infections

 

Blepharitis
Formulary

First line: self-care

Second line: Chloramphenicol 1% ointment BD 6 week trial

Third line: Oxytetracycline* 500 mg BD for 4 weeks then 250 mg BD for 8 weeks OR
Doxycycline* 100 mg OD for 4 weeks then 50 mg OD for 8 weeks

*Warning Avoid in pregnancy

When no antibiotic given advise self-care: lid hygiene including warm compresses, lid massage and scrubs, gentle washing, and avoiding cosmetics.

Second line: topical antibiotics if hygiene measures are ineffective after 2 weeks.

Signs of Meibomian gland dysfunction, or acne rosacea: consider oral antibiotics.

 

 
Link  BNFC Chloramphenicol
   
Conjunctivitis
Formulary

First line: self-care

Second line for bacterial infection: continue self care. 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)

Third line: Fusidic acid 1% gel BD

Treat for 48 hours after resolution

Treat if severe, as most viral or self-limiting. 65% of cases resolve on placebo by day 5

When no antibiotic given advise self-care: bathe or clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water, to remove crusting. Explain red flags for urgent review and advise the person to seek further help if symptoms persist beyond 7 days.

For neonatal infections: treatment not indicated; advise cleaning only and take a swab for Chlamydia

 
Link  BNFC Chloramphenicol
Link  BNFC Fusidic acid
   
Orbital cellulitis
Formulary
 
Urgent referral to hospital
 
   
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
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

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.  

netFormulary