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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  Expand sub section  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

 
   
 ....
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.  

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