| Formulary Chapter 27: Antimicrobial guide - Full Chapter
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| 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.
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| Details... |
| 27.11 |
Genital Tract Infections |
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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
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Bacterial vaginosis
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Formulary
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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.
* Avoid in pregnancy
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| Refer to GUM or Sexual Health Services if diagnosis is uncertain or the infection is recurrent or troublesome. |
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 BASHH
 BNFC Clindamycin
BNFC Metronidazole
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Candida balanitis
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Formulary
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| Clotrimazole cream 1%. Apply 2-3 times a day for 2 weeks |
| Check for underlying problems |
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BNFC Clotrimazole
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Candidiasis, vaginal
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Formulary
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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
* Avoid in pregnancy
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| Investigate recurrent cases (4 or more episodes annually) and refer if appropriate. |
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BASHH
BNFC Clotrimazole
BNFC Fluconazole
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Chlamydia infection
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Formulary
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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.
* Avoid in pregnancy
† The use of azithromycin is appropriate for the treatment of chlamydia in pregnancy
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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
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BASHH
SIGN
BNFC Doxycycline
BNFC Azithromycin
BNFC Erythromycin
BNFC Amoxicillin
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Endometritis, postpartum or following gynaecological procedure or surgery
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Formulary
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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
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| Refer patients with significant systemic symptoms or if symptoms fail to improve after 7 days |
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BNFC Cefalexin
BNFC Co-amoxiclav
BNFC Metronidazole
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Epididymitis or epididymo orchitis
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Formulary
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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
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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.
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Episiotomy or Caesarean section wound infection
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Formulary
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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
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Gonorrhoea
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Formulary
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| Refer all people with suspected gonorrhoea to a GUM clinic or other local specialist sexual health service for culture, treatment, and partner notification. |
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Herpes, genital (primary cases only)
(Refer all patients to GUM/Sexual Health Service for virological confirmation. Phone local department same day)
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Formulary
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| Aciclovir 400 mg TDS for 5 days |
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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.
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BASHH
BNFC Aciclovir
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Pelvic sepsis or pelvic inflammatory disease
(Under review)
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Formulary
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Metronidazole 400 mg BD for 14 days AND
Ofloxacin* 400 mg BD for 14 days
* Avoid in pregnancy
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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.
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BASHH 2019 update
BNFC Metronidazole
BNFC Ofloxacin
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Trichomoniasis
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Formulary
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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.
* Avoid in pregnancy
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| MUST be referred to GUM or Sexual Health Services for contact tracing and follow-up. Sexual partners should be treated simultaneously. |
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BASHH
BNFC Clotrimazole
BNFC Metronidazole
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Vaginal discharge in children
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Formulary
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| 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. |
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Traffic Light Status Information
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Description |
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Medicines considered suitable for non-specialist prescribing in primary or secondary care. |
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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. |
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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 patient’s dose and condition is stable
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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 patient’s dose and condition is stable
(4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care
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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. |
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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.
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Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care. |
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Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. |
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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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