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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...
27.14  Expand sub section  Dental infections
 note 

 

Suspected dental infections in primary care (outside dental settings)

Non-dental primary care prescribers are not licensed and are not indemnified to treat suspected dental infections

Patients presenting to non-dental primary care services with dental problems should be directed to their regular dentist or, if this is not possible, to the NHS 111 service (in England) who will be able to provide details of how to access emergency dental care. In Cheshire and Merseyside there is also an emergency dental helpline (0161 476 9651) which operates from 9.00 am to 9.30 pm every day including weekends and Bank Holidays.

Note: antibiotics do not cure toothache. First line treatment is with paracetamol or ibuprofen, or both. Codeine has no proven efficacy for toothache.

PHE (2019). Patient information leaflet: antibiotics don’t cure toothache.

 

Abscess, dental

Antibiotics are not appropriate in cases where the infection is localised to the peri‑radicular tissues as this indicates that the infection is being adequately managed by the immune system. In these cases, the abscess is mostly isolated from the circulation, resulting in very little antibiotic penetration.

Regular analgesia dosed appropriately should be advised until a dentist can be seen for urgent drainage.

Antibiotics are only required if immediate drainage is not achieved using local measures or in cases of spreading infection (swelling, cellulitis, lymph node involvement) or systemic involvement (fever, malaise) or a high risk of complications.

Patients with severe odontogenic infections (cellulitis, plus signs of sepsis; difficulty in swallowing; impending airway obstruction) should be referred urgently for hospital admission to protect airway, for surgical drainage and for IV antibiotics.

If antibiotics are indicated: amoxicillin 500 mg TDS for up to 5 days. Review at 3 days. Doses can be doubled in severe infection.

Penicillin allergy: clarithromycin 500 mg BD for up to 5 days. Review at 3 days.

If spreading infection (lymph node involvement or systemic signs, that is, fever or malaise): add metronidazole 400 mg TDS for up to 5 days, review at 3 days.

Last updated: Dec 2019

 
   
Mucosal ulceration and inflammation
(simple gingivitis)

There are no indications for the prescribing of systemic antimicrobials for the management of gingivitis.

The primary cause for mucosal ulceration or inflammation (aphthous ulcers; oral lichen planus; herpes simplex infection; oral cancer) needs to be evaluated and treated.

Superficial infections of the mouth are often helped by warm mouthwashes which have a mechanical cleansing effect and cause some local hyperaemia. However, to be effective, they must be used frequently and vigorously.

First line: simple saline mouthwash PRN (half a teaspoon of salt dissolved in a glass of warm water) or

chlorhexidine gluconate 0.2% mouthwash, rinse or gargle with 10ml BD for 1 minute (do not use within 30 minutes of toothpaste) or

hydrogen peroxide 6% solution, dilute 15 ml in half a glass of warm water and rinse or gargle 2-3 times a day for 2-3 minutes.

Always spit out mouthwashes after use. Use until lesions resolve or less pain allows for oral hygiene. Reversible discoloration of teeth and tongue may occur with chlorhexidine mouthwash.

Last updated: Dec 2019

 
   
Necrotising ulcerative gingivitis, acute

Refer to dentist for scaling and hygiene advice.

Prescribe a mouthwash for plaque control.

Only commence metronidazole if there are systemic signs and symptoms.

First line: chlorhexidine gluconate 0.2% mouthwash, rinse or gargle with 10 ml BD for 1 minute (do not use within 30 minutes of toothpaste) or

hydrogen peroxide 6% solution, dilute 15ml in half a glass of warm water and rinse or gargle 2-3 times a day for 2-3 minutes.

Always spit out mouthwashes after use. Use until pain allows for oral hygiene. Reversible discoloration of teeth and tongue may occur with chlorhexidine mouthwash.

If antibiotics are indicated: metronidazole 400 mg TDS for 3 days.

Last updated: Dec 2019

 
   
Pericoronitis
(soft tissues surrounding the crown of a partially erupted tooth)

Refer to dentist for irrigation and debridement.

Use antiseptic mouthwash if pain and trismus limit oral hygiene.

If severe local swelling, systemic symptoms or trismus, prescribe antibiotics.

First line: chlorhexidine gluconate 0.2% mouthwash, rinse or gargle with 10 ml BD for 1 minute (do not use within 30 minutes of toothpaste) or

hydrogen peroxide 6% solution, dilute 15 ml in half a glass of warm water and rinse or gargle 2-3 times a day for 2-3 minutes.

Always spit mouthwashes out after use. Use until pain allows for oral hygiene.

If antibiotics are indicated: metronidazole 400 mg TDS for 3 days or
if metronidazole can’t be used, amoxicillin 500 mg TDS for 3 days.

Last updated: Dec 2019

 
   
Prophylaxis against endocarditis

Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. (NICE CG64, SDCEP, FGDP).

Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures.

Any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing. [NICE CG64]

SDCEP (2018). Antibiotic Prophylaxis Against Infective Endocarditis.

The vast majority of patients at increased risk of infective endocarditis will not be prescribed prophylaxis as per NICE CG64. However, for a very small number of patients, it may be prudent to consider antibiotic prophylaxis (non-routine management), in consultation with the patient and their cardiologist or cardiac surgeon.

Note: GPs would not routinely be involved in this decision or asked to prescribe. This responsibility lies with the dental practitioner.

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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