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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...
27.10  Expand sub section  Gastrointestinal infections
 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

 
   
 ....
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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