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 Formulary Chapter 27: Antimicrobial Guide - Full Chapter
27.08  Expand sub section  Respiratory Tract Infections
 note 

Respiratory Tract Infections

Prescribers should be aware of the need to check previous positive microbiology of patients before prescribing for a chest infection and treat the possibility of multi-resistant organisms (e.g. MRSA) accordingly. MRSA carriers with chest infections given amoxicillin or clarithromycin (sometimes multiple courses) don’t always get better and sometimes get worse including bacteraemia.

Management of acute bronchitis in otherwise healthy adults

See NICE CG69 Respiratory tract infections (self-limiting): prescribing antibiotics. This guideline covers prescribing antibiotics in primary care to children (aged 3 months and older), young people and adults with self-limiting respiratory tract infections (RTIs).

Recommendations

  • Exclude pneumonia as a likely diagnosis using patient history and physical examination.
  • Do NOT use quinolone (Ciprofloxacin*, Ofloxacin*) first line due to poor pneumococcal activity.
  • Provide a patient information leaflet explaining the limitations of antibiotics for this indication. More than 90% of cases of acute bronchitis do not have a bacterial cause.
  • Purulent sputum can arise from either viral or bacterial infection. The presence of purulent sputum is not a predictor of bacterial infection.
  • Consider using a back-up (delayed) prescription for antibiotics
  • Immunisation against pneumococcal infection and annual immunisation against influenza infection should be offered to all at-risk patients including patients over 65 years.

In children

NICE CG160 Fever in under 5s may be used to aid the diagnosis of acute bronchitis.

*Warning Avoid in pregnancy

Management of lower respiratory tract infection

When a clinical diagnosis of community-acquired pneumonia is made in primary care, determine whether patients are at low, intermediate or high risk of death using the CRB-65 score.

Further information is available in NICE CG69 Respiratory tract infections (self-limiting)

The CRB-65 score may be used as a tool to predict the severity of community-acquired pneumonia in adults.
Each criterion scores 1:

  • Confusion (recent);
  • Respiratory rate ≥ 30/min;
  • BP systolic < 90 or diastolic ≤ 60;
  • Age ≥ 65;

Patients are stratified for risk of death as follows:

  • Score 0: low risk (< 1% mortality risk), suitable for home treatment;
  • Score 1-2: intermediate risk (1 to 10% mortality risk), hospital assessment or admission
  • Score 3-4: high risk (>10% mortality risk), urgent hospital admission
Asthma, acute viral exacerbations
Formulary
 

Antibiotics not indicated

Symptomatic treatment only

 
   
Bronchiectasis, infective exacerbation
Formulary
Discuss with appropriate specialist
Always send a sputum sample
 
   
Bronchiolitis or croup in children
Formulary
 

Antibiotics not indicated

Symptomatic treatment only

 
   
Chronic obstructive pulmonary disease, acute infective exacerbations
Formulary

Amoxicillin 500 mg TDS for 5 days OR
Doxycycline* 200 mg STAT then 100 mg OD for 5 days in total OR
Clarithromycin* 500 mg BD for 5 days

If at risk of resistance: Co-amoxiclav 500/125 mg TDS for 5 days

*Warning Avoid in pregnancy

Treat if dyspnoea with changes in sputum i.e. increase and purulence.

Antibiotics are less effective if only one symptom present.

Risk factors for antibiotic resistance: severe COPD (MRC > 3), comorbid disease, frequent exacerbations, antibiotics in last 3 months.

Obtain sputum sample wherever possible (before second-line antibiotic used).

For further information refer to the links in the left column.

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.

 
Link  PMAPC (2015). AZITHROMYCIN tablets for prevention of exacerbations
of COPD and bronchiectasis in selected high-risk patients

Link  NICE (2010). Chronic obstructive pulmonary disease in over 16s:
diagnosis and management [CG101]

Link  Global Initiative for Chronic Obstructive Lung Disease (GOLD): Reports, 2018
   
Cough and cold, viral
Formulary
 

Antibiotics not indicated

Symptomatic treatment only. Cough may persist for several weeks

 
   
Cough or bronchitis, acute
Formulary

Likely to be viral and does not require antibiotics

First line: self-care and safety netting advice

If antibiotics are indicated:

  • Second line: Amoxicillin 500 mg TDS for 5 days
  • Penicillin allergy: Doxycycline* 200 mg STAT then 100 mg daily for 5 days in total

*Warning Avoid in pregnancy

Antibiotics have little benefit if no co-morbidity.

Second line: back-up antibiotic with 7 day delay, safety net, advice that symptoms can last 3 weeks.

Consider immediate antibiotics if >80 years of age and one of: hospitalisation in past year; taking oral steroids; insulin-dependent diabetic; congestive heart failure; serious neurological disorder/stroke, or >65 years with two of the above.

Consider CRP if an antibiotic is being considered: no antibiotics if CRP<20mg/L and symptoms for >24 hours; back-up (delayed) antibiotics if 20-100mg/L; immediate antibiotics if >100mg/L.

 
   
Cystic fibrosis
Formulary
 

This service is commissioned by NHS England. Prescribing should not be undertaken in primary care.

 
   
Influenza
Formulary

Treat ‘at risk’ patients when influenza is circulating in the community or in a care home where influenza is likely.

For treatment: Oseltamivir 75 mg BD for 5 days

For prophylaxis: Oseltamivir 75 mg daily for 10 days

Refer to the most recent supporting info from PHE for up to date dosing for children or the BNF for Children.

See PHE advice on the use of antivirals in pregnancy, breastfeeding, hepatic or renal dysfunction and immunosuppression.

Avoid use in otherwise healthy adults.

Treatment must be started within 48 hours of onset of symptoms of ILI.

PHE or DH will advise when influenza is considered to be circulating in the community.

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

To check current situation log onto PHE.

 
Link  PHE: Annual flu programme
Link  BNFC: Oseltamivir
   
Pneumonia, community-acquired in adults
Formulary

Low risk CRB-65 = 0
Amoxicillin 500 mg TDS for 5 days

In penicillin allergy:
Clarithromycin* 500 mg BD for 5 days
OR
Doxycycline* 200 mg STAT then 100 mg OD for 5 days in total

Intermediate risk CRB-65 = 1 and at home
Amoxicillin 500 mg TDS for 7 days AND Clarithromycin* 500 mg BD for 7 days

OR

Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total

*Warning Avoid in pregnancy

For low-risk CAP consider extending antibiotic course for up to 7 – 10 days if no improvement after 3 days.

Explain to patients treated in the community, and when appropriate their families or carers, they should seek further medical advice if symptoms do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening.

Only a small range of pathogens causes CAP, with Streptococcus pneumoniae being the most frequent. The frequency of pathogens can vary in specific patient groups. Mycoplasma infections are less frequent in the elderly.

Administer benzylpenicillin 1.2 g IM/IV or Amoxicillin 1 g orally immediately where the illness is considered to be life-threatening or if there are likely to be a delay (>2 hours) in admission.

 
Link  NICE CG191: Pneumonia in adults: diagnosis and management, December 2014
Link  British Thoracic Society (2009). Guidelines for the Management of
Community Acquired Pneumonia in Adults

   
Pneumonia, community-acquired in children
Formulary

0-3 months

Seek paediatric specialist advice

 

> 3 months

Consider using traffic light assessment tool in the NICE guideline on Feverish Illness in Children to assess the need for admission to hospital

Amoxicillin TDS 5 days

In penicillin allergy: Clarithromycin BD

 
 
Link  BTS: Community acquired pneumonia in children, 2011
Link  NICE CG160: Fever in under 5s: assessment and initial management, August 2017
Link  BNFC: Amoxicillin
Link  BNFC: Clarithromycin
   
Tuberculosis
Formulary
Discuss with specialist

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)

 
Link  BNF: Tuberculosis
   
Whooping cough
Formulary

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.

Clarithromycin* 500 mg BD for 7 days

If allergic to macrolides: Co-trimoxazole 960 mg BD for 7 days (not in pregnancy)

*Warning Avoid in pregnancy

Treatment of children does not affect the duration of illness but may control the spread of infection as untreated children shed organism for many weeks. Non-infectious coughing may continue for several weeks.

Note: 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.

 
Link  PHE: Pertussis: guidance, data and analysis, 31 July 2014
Link  BNFC: Clarithromycin
Link  BNFC: Co-trimoxazole
   
 ....
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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