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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...
27.07  Expand sub section  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

 
   
 ....
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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