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... |
27.12 |
Skin Infections |
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Skin infections
With moderate or severe signs of infection, or failure to respond to first line treatment, consider swabbing the wound for culture and sensitivity. Review empirical antibiotic choice when culture results become available. Please include any recent antimicrobial therapy on the request.
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Acne rosacea (may co-exist with acne vulgaris)
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Formulary
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First line: Metronidazole cream 0.75% applied daily for 8 weeks
Second line: Oxytetracycline* 500 mg BD for 3-6 months. Repeat courses if necessary OR Doxycycline*100 mg OD. Review at 12 weeks Note unlicensed; photosensitivity reported
Alternative before oral antibiotics: Ivermectin 10 mg/g (Soolantra) cream applied daily. Review at 8 weeks
* Avoid in pregnancy
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Avoid topical Benzoyl peroxide
Refer to dermatology specialist patients who have failed to respond to two courses of 6 months oral treatment.
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BNFC Doxycycline
BNFC Metronidazole
BNFC Oxytetracycline
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Acne vulgaris
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Formulary
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First line: Self care
Second line: 6 – 8 weeks single topical treatment benzoyl peroxide 5% (Acnecide®) OD – BD OR topical retinoid* (Differin®) thinly OD
Third line: 12 weeks dual treatment topical benzoyl peroxide with clindamycin (Duac®) OD OR topical benzoyl peroxide with retinoid* (Epiduo®) OD OR topical second line treatment co-prescribed with oral antibiotics
DO NOT USE TOPICAL AND ORAL ANTIBIOTICS TOGETHER
If treatment failure/severe: add oral antibiotic, consider referral Tetracycline* 500 mg BD for 6 - 12 weeks OR Doxycycline* 100 mg OD for 6 - 12 weeks OR Lymecycline* 408 mg OD for 6 - 12 weeks
* Avoid in pregnancy
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Self-care advice: wash with mild soap or cleanser and lukewarm water not more than twice a day; avoid vigorous scrubbing and excessive use of makeup and cosmetics; benzoyl peroxide is a useful topical over-the-counter preparation, refer to minor ailments scheme if appropriate.
If topical treatment ineffective or acne is moderate to severe, oral antibiotics are preferred. Consider swab in failure of clinical response.
Severe acne, cases unresponsive to prolonged antibiotics, the presence of scarring or psychological problems should be referred to a dermatologist.
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CKS Acne vulgaris
BNFC Rosacea and Acne
BNFC Adapalene
BNFC Benzoyl peroxide
BNFC Clindamycin
BNFC Lymecycline
BNFC Tetracycline
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Bites (human or animal) (treatment and prophylaxis; refer serious bites, especially in children, to AED)
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Formulary
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Co-amoxiclav 500/125 mg TDS for 7 days
In penicillin allergy:
Human: Metronidazole 400 mg TDS plus Clarithromycin* 500 mg BD for 7 days
Animal: Doxycycline* 100 mg BD plus Metronidazole 400 mg TDS for 7 days
Children under 12 years with confirmed penicillin allergy: Azithromycin for 7 days plus Metronidazole for 7 days.
Give prophylaxis for any of the following bite or puncture wounds:
- to the hand, foot, face, joint, tendon, ligament
- in immunocompromised, diabetic, asplenic, or cirrhotic patients
- in the presence of prosthetic valve or joint
- any cat bite.
* Avoid in pregnancy
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Adequate wound toilet is essential and the mainstay of treatment. Consider surgical debridement if required.
Assess rabies risk for animal bites occurring abroad.
Assess tetanus immunisation status.
Assess HIV and Hepatitis B and C risk for human bites.
Penicillin allergy: review at 24 and 48 hours, as not all pathogens are covered.
Note Consider risk of blood borne virus transmission. Further guidance available from Public Health England.
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CKS Bites
PHE Infectious diseses
BNFC Azithromycin
BNFC Co-amoxiclav
BNFC Doxycycline
BNFC Metronidazole
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Boils
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Formulary
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If cellulitis has been excluded antibiotics not indicated.
Drainage is advised.
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Also, see recurrent boils
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Boils, recurrent (associated with carriage of Staph. aureus)
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Formulary
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Topical antiseptic for one week, see MRSA bacteraemia
Mupirocin 2% nasal ointment BD for 5 days
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Swabs to confirm nasal carriage of Staphylococcus aureus. Ask for PVL testing to be carried out. Mupirocin resistance should be discussed with a specialist.
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BNFC Mupirocin
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Candida-associated angular stomatitis / cheilitis (Refer to dental surgeon)
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Formulary
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Miconazole 2% cream 2 - 4 times daily continuing for 2 days after lesions healed |
Commonly associated with denture stomatitis. May be seen in nutritional deficiency or HIV infection. If failure to respond to 1–2 weeks of treatment investigate the possibility of underlying disease. |
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BNFC Miconazole
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Cellulitis and Erysipelas
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Formulary
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Erysipelas or Class I cellulitis - patient afebrile and healthy other than cellulitis: Flucloxacillin 500 mg QDS for 7 days
Severe infection: Flucloxacillin 1 g QDS for 7 days (unlicensed)
Known colonisation with MRSA: Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
Penicillin allergy and on statins: Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total
If unresolving: Clindamycin 300 mg QDS for 7 days
* Avoid in pregnancy
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Class II cellulitis – patient febrile and ill, or comorbidity, admit for intravenous treatment, or use OPAT: consider admission if febrile and unwell. Outpatient Parenteral Antimicrobial Therapy may be available for those assessed for suitability for the service according to strict criteria. See OPAT
Class III cellulitis – if toxic appearance, admit.
If river or sea water exposure, discuss with a microbiologist.
Review response to treatment after 7 days. If slow response, continue for further 7 days.
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BLS Cellulitis
CREST Cellulitis
BNFC Clarithromycin
BNFC Flucloxacillin
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Cellulitis, facial (non-dental)
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Formulary
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Co-amoxiclav 500/125 mg TDS for 7 days
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
* Avoid in pregnancy
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Review response to treatment after 7 days. If slow response, continue for further 7 days.
Orbital cellulitis: urgent referral to hospital
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BNFC Clarithromycin
BNFC Co-amoxiclav
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Chickenpox (Varicella zoster)
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Formulary
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Children: antiviral treatment not recommended if < 14 years.
Adults and adolescents ≥14 years: consider prescribing valaciclovir 1 g TDS for 7 days if within 24 hours of rash onset, particularly for people with severe chickenpox (severe pain, dense rash, oral rash, secondary household case) or those at increased risk of complications, such as smokers, pregnant women, chronic diseases (neurological, hepatic, renal, pulmonary, cardiac, diabetes mellitus), morbid obesity (BMI = 40).
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Varicella zoster virus (VZV) is highly communicable.
Admit patient urgently if immunocompromised.
Seek urgent advice from obstetrician for pregnant women with chickenpox.
Contacts of VZV (chickenpox or shingles): for babies under one month of age, non-immune pregnant women and immunocompromised contacts maybe offered immunoglobulin - contact virologist or microbiologist urgently for advice.
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PHE Varicella
BNFC Valaciclovir
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Dermatophyte infection: nail
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Formulary
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First line: Terbinafine 250 mg OD Fingers: 6 weeks Toes: 12 weeks
Second line: Itraconazole 200 mg BD for one week per month Fingers: 2 courses Toes: 3 courses
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Send nail clippings to the laboratory. Treat only if laboratory confirms infection. Oral terbinafine is more effective than oral azole. If candida or non dermatophyte infection is confirmed use oral itraconazole. Topical nail lacquer is not as effective. Patients should be re-evaluated 3–6 months after treatment initiation and further treatment should be given if the disease persists. Encourage self-care with over the counter medicines for self limiting conditions. |
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BNFC Terbinafine
BNFC Itraconazole
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Dermatophyte infection: scalp
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Formulary
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First line: Ketoconazole 2% shampoo. Apply twice weekly for two to four weeks
Second line: Terbinafine 250 mg OD for 4 weeks.
Seek specialist advice before considering antifungal treatment in children
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Send hair and scalp scrapings for laboratory confirmation before commencing systemic therapy. Commence treatment if microscopically positive and review once culture results available. Refer to dermatologist
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BNFC Ketoconazole
BNFC Terbinafine
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Dermatophyte infection: skin
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Formulary
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Most cases: Terbinafine 1% cream BD
If candida possible: Clotrimazole 1% cream BD
Both for 1 to 2 weeks and then 1 to 2 weeks after healing (a total of 4 to 6 weeks)
Apply cream beyond the margin of the lesions. Continue treatment for at least 7 days after lesions have healed.
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Refer to a dermatologist if extensive.
Skin scrapings for culture and microscopy are not indicated: in cases of uncomplicated athlete’s foot, mild skin ringworm or mild groin infections. Samples for fungal culture are indicated when oral treatment is being considered (e.g. scalp ringworm or nail disease); in severe or extensive skin fungal infections (e.g. moccasin-type athlete’s foot); in skin infections refractory to initial treatment; when the diagnosis is uncertain.
Commence treatment if microscopically positive and review once culture results available.
Encourage self-care with over the counter medicines for self limiting conditions.
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BNFC Terbinafine
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Herpes, genital
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Formulary
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Herpes, oral
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Formulary
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Cold sores do not normally require antiviral treatment. The mainstay for primary acute oral herpes stomatitis is oral fluids.
If frequent, severe, and predictable triggers: consider oral prophylaxis: aciclovir 400 mg BD for 5 - 7 days
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Most cold sores resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12 - 18 hrs.
Encourage self-care with over the counter medicines for self limiting conditions
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CKS Herpes simplex, oral
BNFC Aciclovir
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Impetigo or eczema with visible signs of infection
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Formulary
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As resistance is increasing, topical treatment should only be used when a few localised lesions are present: Fusidic acid cream TDS for 5 days OR for MRSA lesions only: topical Mupirocin 2% ointment TDS for 5 days.
For more extensive infection: Flucloxacillin 500 mg QDS for 7 days
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days OR for MRSA only: Doxycycline* 200 mg OD on day 1 followed by 100 mg OD for another 6 days (i.e. 7 days in total)
* Avoid in pregnancy
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Advise on the importance of personal hygiene e.g. not to share communal items such as towels, flannels etc. Avoid topical steroids or long-term topical antibiotic use. Further advice may be obtained from the community infection control nurse.
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PHE Childcare settings
BNFC Clarithromycin
BNFC Doxycycline
BNFC Flucloxacillin
BNFC Fusidic acid
BNFC Mupirocin
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Ingrowing toenail infection
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Formulary
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Flucloxacillin 500 mg QDS for 7 days
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
* Avoid in pregnancy
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Wound debridement and swab.
Lateral nail ablation recommended when infection settled if the problem is recurrent.
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BNFC Clarithromycin
BNFC Flucloxacillin
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Lice, body
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Formulary
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Malathion 0.5% aqueous solution
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Hot wash (50°C) all clothes and bedding or dry clean following first treatment.
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BNFC Malathion
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Lice, crab or pubic
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Formulary
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Malathion 0.5% aqueous solution
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Apply to all hairy parts of the body. Repeat after 7 days. Consider other sexually transmitted infections.
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BNFC Malathion
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Lice, head (Only treat if live moving lice are found or black or brown eggs, not empty white egg cases)
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Formulary
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Wet combing AND Dimeticone 4% OR Malathion 0.5% aqueous solution
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Encourage self-care of this condition
A course involves two treatments one week apart.
Reinfection is more probable than treatment failure. Combs should be thoroughly cleaned after each use.
Use different insecticides for subsequent course following treatment failure. Avoid shampoos and do not use insecticides as prophylaxis
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CKS Head Lice
BNFC Dimeticone
BNFC Malathion
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Lyme disease
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Formulary
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First line: Doxycycline* 100 mg BD for 21 days
Alternative: Amoxicillin 1 g TDS for 21 days
Prophylaxis, low risk: antibiotic not recommended, give safety netting advice
Prophylaxis, high risk: Doxycycline* 200 mg STAT
* Avoid in pregnancy
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Treat erythema migrans. Suspected Lyme disease with focal symptoms, uveitis, or cardiac complications should be disused with a specialist.
Prophylaxis is not routinely recommended in Europe. Risk increased if high prevalence area and the longer tick is attached to the skin. Only give prophylaxis within 72 hours of tick removal. Give safety netting advice about erythema migrans and other possible symptoms that may occur within one month of tick removal.
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BMJ (2018) Infographic
NICE (2018) NG95
BNFC Amoxicillin
BNFC Doxycycline
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Mastitis
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Formulary
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Flucloxacillin 500 mg QDS for 14 days if clinical evidence of infection.
In penicillin allergy: Erythromycin 500 mg QDS for 14 days
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The most common cause of mastitis is an ineffective attachment at the breast. It is essential that this is corrected otherwise the problem will persist and secondary problems may result despite antibiotic treatment
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CKS Mastitis and breast abscess
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Post-operative wound infections
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Formulary
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Flucloxacillin 500 mg QDS for 7 days
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
* Avoid in pregnancy
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Infection within 30 days of surgery should be referred back to the responsible Trust.
Swab wound for culture and sensitivity. Consider nature of the operation and likely pathogens including MRSA status.
Consider hospital admission and discuss with a medical microbiologist.
Post-operative infections involving a prosthetic implant avoid prescribing antibiotics and refer urgently back to the surgeon.
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BNFC Flucloxacillin
BNFC Clarithromycin
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Scabies
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Formulary
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Permethrin 5% dermal cream applied for 12 hours.
Apply to the whole body from ear and chin downwards and under nails. Do not apply after a hot bath.
It is important that ALL household and sexual contacts (previous 2 months) should also be treated at the same time (within 24hrs).
Apply 2 treatments 1 week apart
If allergic to permethrin, Malathion 0.5% aqueous solution, 2 applications 1 week apart
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Infants aged less than 2 years and the elderly aged over 65 years require head and face application (avoiding eyes) initially. Unlicensed use in less than 2 months of age, refer to paediatric dermatologist.
Itch may persist for 4-6 weeks following effective treatment; crotamiton or aqueous cream may be beneficial. Sedative antihistamines may help with nocturnal itch.
Hot wash (50°C) all clothes and bedding or dry clean following first treatment.
If patient institutionalised refer to Community Infection Prevention and Control Team
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NHS Scabies
BNFC Malathion
BNFC Permethrin
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Scabies, crusted (Norwegian)
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Formulary
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Rare. Treat as for scabies but include head and neck.
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Refer to Dermatology for specialist advice including prescribing oral ivermectin (unlicensed).
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Shingles (Varicella zoster)
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Formulary
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Antiviral treatment not recommended if < 50 years
Treat if ≥ 50 years (PHN rare if < 50 years) or one or more of the following: active ophthalmic lesions, Ramsey Hunt, eczema, non-truncal involvement (e.g. meningitis), moderate or severe pain, moderate or severe rash if within 72 hours of rash.
First line: Valaciclovir 1 g TDS for 7 days
Alternative (expensive): Famciclovir 500 mg TDS for 7 days OR Famciclovir 750 mg BD for 7 days
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Refer to ophthalmologist urgently if ocular involvement.
Antiviral treatment if not within 72 hours of rash: consider up to one week after rash onset if high risk of severe shingles or complications (continued vesicle formation, older age, immunocompromised, severe pain).
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PCDS Herpes zoster
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Superficial skin and soft tissue infections, Paronychia
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Formulary
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Flucloxacillin 500 mg QDS for 7 days
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
If infection due to MRSA, use Doxycycline* 100 mg BD for 7 days Use sensitivity results to guide therapy.
In children (mild)
< 1 month: Cefalexin
> 1 month and older: Flucloxacillin capsules (depending on age and ability to swallow) OR Cefalexin.
* Avoid in pregnancy
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Wound debridement if suspected foreign body and swab.
Empirical antibiotic treatment
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BNFC Clarithromycin
BNFC Cefalexin
BNFC Flucloxacillin
BNFC Doxycycline
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Ulcer, diabetic foot (grade 0 or 1)
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Formulary
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Mild infection in patients previously untreated with antibiotics: Flucloxacillin 1 g QDS for 7 days
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
If MRSA-positive: Doxycycline* 100 mg BD
Consider adding Metronidazole 400 mg TDS if anaerobic infection is suspected.
If treatment failure or chronic infection
Consider referral to secondary care (see decision triggers)
Co-amoxiclav 520/125 mg TDS
In penicillin allergy or MRSA carriage: seek advice from a Medical Microbiologist
* Avoid in pregnancy
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Refer all patients immediately to the community podiatry team as per local guidance stating clearly that the patient has diabetes and a new ulcer.
Decision triggers for referral
- New foot ulceration
- Recurrent foot ulceration
- Unexplained foot pain, swelling and deformity
- Cellulitis of the foot
- Suspected osteomyelitis of the toes
- Suspected Charcot neuroarthropathy
- Severe neuropathic pain
- Deteriorating foot ulcer, despite earlier assessment by MDT
Clinical emergency
- Critical limb ischaemia
- Acute Charcot suspected
- Spreading cellulitis
- Gangrene
- Significantly deteriorating foot ulceration
This list is not exhaustive, use clinical judgement
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NWCSCN Foot care
BNFC Clarithromycin
BNFC Co-amoxiclav
BNFC Doxycycline
BNFC Flucloxacillin
BNFC Metronidazole
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Ulcer, leg
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Formulary
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Flucloxacillin 500 mg QDS for 7 days
Severe infection: Flucloxacillin 1 g QDS for 7 days (unlicensed)
In penicillin allergy: Clarithromycin* 500 mg BD for 7 days
If slow response, continue for a further 7 days
* Avoid in pregnancy
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Ulcers are always colonised. Check MRSA status. Antibiotics do not improve healing unless active infection. If active infection, send pre treatment swab. Review antibiotics after culture results.
Signs of active infection: cellulitis, increased pain, pyrexia, purulent exudate, odour
Refer to local district nurse team as per local guidance.
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PHE Venous leg ulcer
BNFC Clarithromycin
BNFC Flucloxacillin
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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
Status |
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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