2014-2016 Management of Infection Guidance for Primary Care

Management of
Infection Guidance for
Primary Care
2014-2016
AIMS
zz to provide a simple, effective, economical and empirical approach to the treatment of common infections
zz to minimise the emergence of bacterial resistance in the community
Adapted from PHE guidelines by: Dr Philippa Moore
Approved by: GHNHSFT Antimicrobial Stewardship Committee
Review date: June 2016
NOTE: Doses are oral and for adults unless otherwise stated.
Please refer to BNF for further information.
CONTENTS.................................................................Page
Principles for use of guidelines............................................... 1
Upper respiratory tract infections ................................. 2-6
Sore Throat/Pharyngitis/Tonsillitis........................................... 2
Acute Otitis Media................................................................. 3
Acute Otitis Externa............................................................... 4
Acute Bacterial Parotitis.......................................................... 5
Acute Rhinosinusitis............................................................... 6
Lower Respiratory Tract Infections...............................7-10
Influenza and Influenza related pneumonia............................ 7
Acute Cough, Bronchitis/Infective Exacerbation COPD ........... 8
Community Acquired Pneumonia .......................................... 9
Hospital Acquired Pneumonia & Aspiration Pneumonia.........10
Meningitis.....................................................................11-12
Urinary Tract Infections .............................................. 13-16
Acute Prostatitis....................................................................14
UTI in Pregnancy...................................................................14
UTI in Children .....................................................................15
Acute Pyelonephritis & Recurrent UTI in Women...................16
Gastrointestinal Infections..........................................17-21
Helicobacter pylori Eradication, Oral Candidiasis............... 17-18
Infectious & Traveller’s Diarrhoea and Threadworm ..............19
Acute Diverticulitis .............................................................. 20
C.difficile Infection (new or relapsing) ..................................21
Genital Tract Infections............................................... 22-25
Vaginal Candidiasis.............................................................. 22
Chlamydia............................................................................ 23
Epididymitis ........................................................................ 23
Bacterial Vaginosis................................................................24
Trichomoniasis......................................................................24
PID ..................................................................................... 25
Skin & Soft Tissue Infections...................................... 26-35
Impetigo, Eczema................................................................ 26
Cellulitis............................................................................... 27
OPAT treatment for Cellulitis .......................................... 28-29
Leg Ulcers............................................................................ 30
Diabetic Ulcers..................................................................... 31
Panton Valentine Leucocidin (PVL) infections....................32-33
Animal & Human Bites ........................................................ 34
Scabies and Herpes Infections (VZV/HSV) ............................ 35
Dermatophyte Infections ................................................ 36-38
Conjunctivitis....................................................................... 38
Acne ................................................................................... 39
Wounds from Deliberate Self Harm ..................................... 40
MRSA Screening, Decolonisation and Treatment..... 41-43
Dental Infections.........................................................44-47
Antibiotic activities............................................................... 48
PRINCIPLES OF TREATMENT
1. This guidance is based on the best available evidence but professional judgement should be used and patients
should be involved in treatment decisions.
2. It is important to initiate antibiotics as soon as possible in severe infection.
3. A dose and duration for treatment of adults is usually suggested but may need modification for age, weight, and
renal function. Children’s doses are provided when appropriate. In severe or recurrent cases consider a larger dose
or longer course. Please refer to the BNF for further dosing and interaction information (e.g. interactions between
macrolides and statins) if needed and please check for hypersensitivity.
4. Lower threshold for antibiotics in immunocompromised or those with multiple comorbidities; consider culture and
seek advice.
5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
6. Consider a no, or delayed, antibiotic strategy for acute self limiting upper respiratory tract infections.
7. Limit prescribing over the telephone to exceptional cases.
8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (eg Co-amoxiclav, Quinolones and
Cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile,
MRSA and resistant UTIs.
9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations e.g.
fucidin).
10.In pregnancy take specimens to inform treatment; avoid Tetracyclines and Quinolones, and avoid where possible
Aminoglycosides, high dose Metronidazole (2g) unless benefit outweighs risk. Short-term use of Nitrofurantoin
is not expected to cause foetal problems (avoid at term, theoretical risk of neonatal haemolysis) . Trimethoprim
is also unlikely to cause problems unless poor dietary folate intake or taking another folate antagonist e.g. an
antiepileptic.
11.Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained via
0300 422 2222. Daytime Ext 5050
12.Check Map of Medicine for diagnostic pathways.
1
UPPER RESPIRATORY TRACT INFECTIONS:
Sore Throat/Pharyngitis/Tonsillitis
zz Avoid antibiotics as 90% resolve in 7 days without antibiotics and pain only reduced by 16 hours.
zz Centor Criteria:
 History of fever
 Absence of cough
 Tender anterior cervical lymphadenopathy
 Tonsillar exudates
 A low Centor score (0-2) has a high negative predictive value (80%) and indicates low chance of
Group A Beta Haemolytic Streptococci (GABHS).
 A Centor score of 3 or 4 suggests the chance of GABHS is 40%.
 If a patient is unwell with a Centor score of 3-or-4 then the chance of developing Quinsy is 1:60.
zz If Centor score 3 of 4: consider 2 or 3 day delayed prescription, or immediate antibiotics.
zz Antibiotics to prevent Quinsy NNT (Number Needed to Treat): more than 4000
zz Antibiotics to prevent Otitis media: NNT200
First line: PHENOXYMETHYLPENICILLIN 500mg QDS, or 1g BD, oral for 10 days
(use QDS when severe)
RCT in <18yr olds shows 10 days had lower relapse.
If allergic to Penicillin: CLARITHROMYCIN 250-500mg BD oral 5 days
2
Acute Otitis Media (child doses)
Optimise analgesia and target antibiotics.
zz OM resolves in 60% in 24 hours without antibiotics
zz Antibiotics only reduce pain at 2 days (NNT 15) and do not prevent deafness.
zz Consider 2 or 3-day delayed prescription, or immediate antibiotics for pain relief if:
 Less than 2 years with bilateral acute otitis media (NNT4) or bulging membrane and 4 or more marked symptoms
 All ages with otorrhoea, NNT3
Antibiotics to prevent mastoiditis: NNT more than 4000
First line:
AMOXICILLIN oral for 5 days
Doses for children:
<7 days: 7-28 days:
1 month to 18 years: 30mg/kg BD (max 62.5mg/dose)
30mg/kg TDS (max 62.5mg/dose)
40mg/kg TDS (Max 500mg per dose)
ERYTHROMYCIN oral for 5 days
Under 1 month
12.5 mg/kg QDS
1 month-2 yrs 125mg QDS
2-8 yrs
250mg QDS
8-18 yrs
250-500mg QDS
If allergic to Penicillin:
3
Acute Otitis Externa
First use aural toilet (if available) and analgesia
zz Cure rates similar at 7 days for topical acetic acid or antibiotic with or without steroid
zz Acute severe otitis externa may be caused by Staphylococcus aureus or Beta-haemolytic Streptococci
zz If cellulitis or disease extending outside ear canal, start oral antibiotics and refer
zz Malignant otitis externa is usually caused by Pseudomonas aeruginosa and presents with unrelenting
pain that interferes with sleep and persists even after swelling of the external ear canal has resolved with
topical antibiotic treatment. Facial nerve palsy may be present. Patients are usually elderly, and may be
diabetics, immunocompromised or healthy individuals. IV antibiotics are required and the patient should
be referred.
First line: ACETIC ACID 2% 1 spray TDS for 7 days
Second line: NEOMYCIN SULPHATE WITH
CORTICOSTEROID (Otomize®) 3 metered sprays TDS for 7-14 days
If there is a stable eardrum perforation:
CIPROFLOXACIN drops: 3 drops TDS for 7-14 days
Use eye drop solution as ear drops: unlicensed indication but BNF recommended.
4
Acute Bacterial Parotitis
zz Usually unilateral swelling of parotid gland with potential abscess formation.
zz Can be associated with poor dental hygiene, dental caries and dehydration.
zz The most common cause is Staph aureus (including MRSA).
zz Can be associated with trismus and a stone may be palpable in the parotid duct or visible on a plain X-ray.
zz Take a parotid duct pus swab for bacterial culture if pus seen from parotid duct.
zz Typical courses are 5 days but up to 10 days treatment may be needed for severe infection.
FLUCLOXACILLIN 500mg QDS oral for 5 days
If anaerobic infection suspected/poor dentition:
ADD
METRONIDAZOLE 400mg TDS oral for 5 days
If Penicillin allergic:
CLINDAMYCIN 450mg QDS oral for 5 days
If known MRSA carrier: DOXYCYCLINE 200mg OD oral for 5 days
If anaerobic infection suspected/poor dentition:
ADD
METRONIDAZOLE 400mg TDS oral for 5 days
zz If symptoms are slow to resolve further days of antibiotics may be necessary, up to 14 days.
zz Surgical intervention to drain an abscess may be necessary.
5
Acute Rhinosinusitis
Avoid antibiotics as 80% resolve within 14 days without, and they only offer marginal benefit
after 7 days, NNT15
Use adequate analgesia
Consider 7-day delayed prescription or immediate antibiotics when purulent nasal discharge, NNT8.
IF treatment is required:
First line:
OR
OR
If poor response:
AMOXICILLIN 500mg TDS oral for 7 days (1g TDS if severe)
DOXYCYCLINE 200mg STAT/100mg OD oral for 7 days
PHENOXYMETHYLPENICILLIN 500mg QDS oral for 7 days
AZITHROMYCIN 500mg OD for 3 days
In persistent infection use an agent with anti-anaerobic activity (e.g. Co-amoxiclav.)
For persistent symptoms: CO-AMOXICLAV 625mg TDS oral for 7 days
OR
If Penicillin allergic:
CLINDAMYCIN 450mg QDS oral for 7 days
6
Influenza – See PHE influenza website
Annual vaccination is essential for all those at risk of complications of influenza. For
otherwise healthy adults, antivirals are not recommended. Treat ‘at risk’ patients: when influenza is circulating
in the community and within 48 hours of onset or in a care home where influenza is likely. At risk: pregnant
(including up to 2 weeks post partum), 65 years or over, chronic respiratory disease (including COPD and asthma),
significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological,
renal or liver disease.
Use OSELTAMIVIR 75 mg oral capsules BD oral for 5 days
Unless pregnant or suspected resistance to Oseltamivir then use:
ZANAMIVIR 10 mg BD inhaled for 5 days (2 inhalations by diskhaler) and seek advice.
For prophylaxis see NICE influenza website. Patients under 13 years see PHE influenza website.
Influenza Related Pneumonia
DOXYCYCLINE 200mg OD oral for 7 days
OR
CO-AMOXICLAV 625mg TDS oral for 7 days
OR
CLARITHROMYCIN 500mg BD oral for 7 days
If poor response and Penicillin allergic: LEVOFLOXACIN 500mg OD oral for 7 days
Levofloxacin may be used BD initially for more severe cases. Reduce to OD when clearly improving.
7
LOWER RESPIRATORY TRACT INFECTIONS:
Note: Low doses of Penicillins are more likely to select out resistance. Do NOT use quinolones (Ciprofloxacin,
Ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including Levofloxacin) for
proven resistant organisms. Avoid Tetracyclines in pregnancy.
Acute Cough, Bronchitis
Antibiotics have little benefit if no co-morbidity. Consider 7 day delayed antibiotic with symptomatic advice
and patient leaflet. Symptom resolution can take 3 weeks.
Consider immediate antibiotics if over 80yrs and ONE of: hospitalisation in the last year, oral steroids,
diabetic, congestive heart failure. Or over 65yrs and TWO of the above.
AMOXICILLIN 500mg TDS oral for 5 days
OR
DOXYCYCLINE 200mg STAT/100mg OD oral for 5 days
Acute Exacerbation of Copd
Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or
increased sputum volume. 30% are viral, 30-50% bacterial, the rest undetermined. Some patients may need
longer treatment.
Risk factors for resistant organisms include co-morbid disease, severe COPD, frequent exacerbations,
antibiotics in the last 3 months.
AMOXICILLIN
500mg TDS oral for 5-7 days
OR DOXYCYCLINE
200mg OD oral 5-7 days
OR CLARITHROMYCIN 500mg BD oral for 5-7 days
If resistance risk factors:
CO-AMOXICLAV 625mg TDS oral for 5-7 days
8
Community Acquired Pneumonia – Treatment in the community
Use CRB-65 score to help guide and review. Each scores 1:
Confusion (AMT less than 8); Respiratory rate (over 30/min);
BP (systolic less than 90 or diastolic less than 60); Age 65 or over.
Score 0:
suitable for home treatment
Score 1-2: assessment, consider hospital referral/admission
Score 3-4: urgent hospital admission
Give immediate IM Benzylpenicillin or Amoxicillin 1g po if delayed admission or life threatening.
For Influenza-related pneumonia see page 7. Mycoplasma infection is rare in over 65yrs.
If CRB-65 is 0:
AMOXICILLIN
500mg TDS oral for 7 days
OR
CLARITHROMYCIN
500mg BD oral for 7 days
OR
DOXYCYCLINE 200mg OD oral for 7 days
If CRB-65 is 1/2 and at home: AMOXICILLIN 500mg TDS oral AND
CLARITHROMYCIN 500mg BD oral for 7–10 days
If Penicillin allergic:
CLARITHROMYCIN 500mg BD oral for 7–10 days (monotherapy)
DOXYCYCLINE 200mg OD oral for 7-10 days
OR
9
Hospital Acquired Pneumonia
Treatment in the community
zz Patients who have recently been discharged from hospital (within 5 days) may have a hospital acquired
pneumonia that is more likely be resistant to first line antibiotics.
zz If poor response to treatment consult a Microbiologist
If home treatment is appropriate:
CO-AMOXICLAV
625mg TDS oral for 7 days
If Penicillin allergic:
LEVOFLOXACIN
500mg OD oral for 7 days
Levofloxacin may be used BD initially for more severe cases. Reduce to OD when clearly improving.
Aspiration Pneumonia
If home treatment is appropriate:
CO-AMOXICLAV
625mg TDS oral for 7 days
If Penicillin allergic:
LEVOFLOXACIN
500mg OD oral for 7 days
PLUS
METRONIDAZOLE 400mg TDS oral for 7 days
Levofloxacin may be used BD initially for more severe cases. Reduce to OD when clearly improving.
10
MENINGITIS
Suspected Meningococcal Disease
Transfer all patients to hospital immediately.
IF time before admission and non blanching rash, give IV antibiotics unless definite history of hypersensitivity.
Give IM if a vein cannot be found (see local PGD).
Gloucestershire NHS organisations recommend Cefotaxime first line for the following reasons:
 Cefotaxime has better blood brain barrier penetration
 Cefotaxime has a broader spectrum of action and is effective against Penicillin resistant Pneumococci, Penicillin
resistant Meningococci and Haemophilus influenzae (organisms that have all caused meningitis in patients in
Gloucestershire)
 Cefotaxime can be given in Penicillin allergy unless history of Penicillin immediate type or severe hypersensitivity.
 Cephalosporins are given to patients with meningitis in hospital and therefore Cefotaxime is consistent with
hospital treatment.
 Patients with meningitis usually come from community settings at lower risk of C. difficile.
 Cefotaxime, like Benzylpenicillin, can be given IV or IM, and has a reasonably long shelf-life for storage.
First line: CEFOTAXIME Ideally give IV but IV or IM
Adults and children 12 years and over:
CEFOTAXIME 1g
Children, including neonates, under 12 years and under 50kg:
CEFOTAXIME 50mg/kg to a maximum of 1g
11
MENINGITIS
Suspected Meningococcal Disease continued
OR BENZYLPENICILLIN Ideally give IV but IV or IM
Children under 1 yr: 300mg
Children 1 - 9 yrs: 600mg
Age 10 years or over: 1200mg
Prevention of Secondary Case of Meningitis:
Only prescribe prophylaxis following advice from Public Health Doctor: 9am–5pm: 0845 504 8668
Out of hours: Contact on-call Public Health Doctor 0844 257 8195 or via switchboard 0300 422 2222
First line (PHE Meningococcal Guidelines Feb 2011):
CIPROFLOXACIN 500mg STAT oral (adult)
Children 1 month - 4 yrs: 125mg STAT oral
Children 5 - 12 yrs:
250mg STAT oral
Age 12 years or over:
500mg STAT oral
Second line:
RIFAMPICIN 600mg BD oral for 2 days
Children under 1 yr:
Children 1-12 yrs:
Age 12 years and over:
5mg/kg BD oral for 2 days
10mg/kg BD oral for 2 days
600mg BD oral for 2 days
12
URINARY TRACT INFECTIONS – (See PHE UTI quick reference guide)
zz In the elderly (over 65 years), do not treat asymptomatic bacteriuria; it is common but is not
associated with increased morbidity.
zz Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria: only treat if
symptomatically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless
history of catheter-change-associated UTI or trauma.
Uncomplicated UTI in Men and Women
(no fever or flank pain)
Women with severe / 3 or more symptoms: treat
Women with mild / 2 or fewer symptoms: use urine dipstick and presence of cloudy urine to guide treatment. With
2 symptoms, nitrite and blood/leucocytes has 92% positive predictive value; Negative nitrite, leucs and blood: 76%
negative predictive value.
Men: Consider prostatitis and send pre-treatment MSU OR if symptoms mild/non-specific, use negative dipstick to
exclude UTI.
TRIMETHOPRIM 200mg BD oral Avoid in established renal failure (GFR less than 15 ml/min) OR
NITROFURANTOIN 100mg m/r BD oral
Contraindicated in renal failure. Not recommended if GFR less than 60 ml/min or creatinine over 150 umol/l.
Use 3 days in women, 7 days in men
Second line: Perform culture in all treatment failures
Amoxicillin resistance is common, only use if susceptible.
Community multi-resistant Extended-Spectrum-Beta-Lactamase (ESBL) E. coli are increasing: consider Nitrofurantoin if
susceptible or Fosfomycin 3g stat in women, plus second 3g dose in men 3 days later. Give 2-3 hours before food.
Fosfomycin is only available on a named patient basis: community pharmacists can order via IDIS, Specials Lab or Quantum.
13
Acute Prostatitis
zz Send MSU for culture and start antibiotics.
zz 4 week course may prevent chronic prostatitis.
zz Quinolones achieve higher prostate levels.
CIPROFLOXACIN 500mg BD oral for 28 days OR
OFLOXACIN 200mg BD oral for 28 days
Second line: TRIMETHOPRIM 200mg BD oral for 28 days
Uti in Pregnancy
zz Send MSU for culture & sensitivity and start empirical antibiotics.
zz Short-term use of Nitrofurantoin in pregnancy is unlikely to cause problems to the foetus, although avoid
at term (may produce neonatal haemolysis).
zz Avoid Trimethoprim if low folate status or on folate antagonist (e.g. antiepileptic or proguanil)
First line:
NITROFURANTOIN 100mg m/r BD oral for 7 days
Nitrofurantoin is contraindicated in renal failure (GFR less than 60 ml/min or creatinine over 150 umol/l).
OR if susceptible......................... AMOXICILLIN 500mg TDS oral for 7 days
Second line: TRIMETHOPRIM 200mg BD oral for 7 days (off label). Give folic acid if first trimester.
Or:
CEFALEXIN 500mg BD oral for 7 days
14
Uti in Children
zz Children under 3 months: refer urgently for assessment.
zz Children 3 or more months old: use positive nitrite to start antibiotics. Send pre-treatment MSU for all.
zz Imaging: only refer if child is under 6 months, recurrent or atypical UTI (see NICE guidelines)
TRIMETHOPRIM OR NITROFURANTOIN
Lower UTI:
Nitrofurantoin is contraindicated in renal failure (GFR less than 60 ml/min or creatinine over 150 umol/l).
If susceptible AMOXICILLIN
CEFALEXIN
See BNF for oral dosage
Second line:
Treat lower UTI for 3 days.
Upper UTI:
CO-AMOXICLAV
CEFIXIME
See BNF for oral dosage
Second line:
Treat upper UTI for 7-10 days.
15
Acute Pyelonephritis
If admission not needed, send MSU for culture and sensitivities and start empirical antibiotics. If no
response within 24 hours admit.
CIPROFLOXACIN 500mg BD oral 7 days
OR
CO-AMOXICLAV 625mg TDS oral 14 days
Recurrent UTI in non-pregnant women
(at least 3 UTIs per year)
Cranberry products or post coital or standby antibiotics are options. Standby antibiotics may be
more suitable for less frequent recurrences.
Nightly antibiotics: reduces UTIs but adverse effects
Prophylactic:
NITROFURANTOIN 50mg-100mg oral
Nitrofurantoin is contraindicated in renal failure (GFR less than 60 ml/min or creatinine over 150 umol/l).
OR TRIMETHOPRIM 100mg oral
Post coital: STAT (off label)
Prophylactic: OD at night
16
GASTRO-INTESTINAL TRACT INFECTIONS
Eradication of Helicobacter pylori –
Also see PHE HP quick reference guide
zz Eradication is beneficial in known Duodenal Ulcer (DU), Gastric Ulcer (GU) or low grade MALToma.
zz In Non Ulcer Dyspepsia (NUD), the NNT is 14 for symptom relief.
zz Consider test and treat in persistent uninvestigated dyspepsia
zz Do not offer eradication for Gastro-Oesophageal Reflux Disease (GORD).
zz Do not use Clarithromycin or Metronidazole if used in the past year for any infection.
First line: PPI (use cheapest) BD oral
PLUS
CLARITHROMYCIN 250mg BD oral
PLUS
METRONIDAZOLE 400mg BD oral
OR
PPI (use cheapest) BD oral
PLUS
CLARITHROMYCIN 500mg BD oral
PLUS
AMOXICILLIN 1g BD oral
(Note higher dose Clarithromycin when used with Amoxicillin rather than Metronidazole)
All oral for 7 days
For MALToma use 14 days
17
GASTRO-INTESTINAL TRACT INFECTIONS
Eradication of Helicobacter pylori – CONTINUED
Managing symptom relapse
zz DU/GU relapse: retest for H. pylori using breath test or faecal antigen test (if available) OR consider
endoscopy for biopsy culture and sensitivity.
zz NUD: do not retest, offer PPI or H2RA
Second line:
PLUS
PLUS 2 unused antibiotics out of:
PPI BD oral
BISMUTHATE (DE-NOL tabs) 240mg BD oral
AMOXICILLIN 1g BD oral
METRONIDAZOLE 400mg TDS oral
TETRACYCLINE 500mg QDS oral
CLARITHROMYCIN 500mg BD oral
For relapse or MALToma use 14 days – If further advice is required please contact a Microbiologist
and see PHE Helicobacter pylori quick reference guide.
Oral Candidiasis
Antifungal agents absorbed from the gastrointestinal tract prevent oral candidiasis in patients receiving
treatment for cancer.
Drugs fully absorbed (Fluconazole, Ketaconazole, Itraconazole) and partially absorbed (Miconazole,
Clotrimazole) are effective compared with placebo or no treatment.
See BNF for licensed dosage.
18
Infectious Diarrhoea
Also see PHE Infectious Diarrhoea quick reference guide
Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection:
refer to PHE guidelines. Antibiotics should NOT be prescribed.
Antibiotic therapy is not indicated unless the patient is systemically unwell.
If patient systemically unwell and Campylobacter suspected (e.g. undercooked meat and abdominal pain),
consider: CLARITHROMYCIN 250-500mg BD oral for 5-7 days if treated early.
Traveller’s Diarrhoea
Only consider standby antibiotics for remote areas or people at high-risk of severe illness with
traveller’s diarrhoea.
If standby treatment appropriate give: CIPROFLOXACIN 500mg BD oral for 3 days (private Rx).
If Quinolone resistance high (e.g. South Asia): consider: BISMUTH SUBSALICYLATE (Pepto-Bismol) 2 tablets
QDS oral as prophylaxis or for 2 days treatment.
Threadworms
Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene,
pants at night, morning shower, PLUS wash sleepwear, bed linen, dust, and vacuum on day one.
Over 6 months: MEBENDAZOLE 100mg STAT oral (off label if under 2 years old)
3-6 months: PIPERAZINE/SENNA sachet 2.5ml spoon STAT oral, repeat after 2 weeks
Under 3 months: 6 weeks hygiene measures
19
Acute Diverticulitis
Diverticulosis should be managed with a high fibre diet. Pain may occur in diverticular disease (without
infection) that can be managed with oral Paracetamol.
People with mild, uncomplicated acute diverticulitis can be managed at home with Paracetamol, clear fluids,
and oral antibiotics (see CKS guidelines).
IF treatment required:
First Line:
CO-AMOXICLAV 625mg TDS oral for 7 days
If Penicillin allergic: CIPROFLOXACIN 500mg BD oral for 7 days
PLUS
METRONIDAZOLE 400mg TDS oral for 7 days
Bristol Stool Chart
NB: Cephalosporins are NOT recommended (e.g. see CKS guidelines)
Type 1
Separate hard lumps, like nuts (hard to pass)
Type 2
Sausage-shaped but lumpy
Type 3
Like a sausage but with cracks on the surface
Type 4
Like a sausage or snake, smooth and soft
Type 5
Soft blobs with clear-cut edges
Type 6
Fluffy pieces with ragged edges, a mushy stool
Type 7
Watery, no solid pieces. Entirely liquid.
20
Clostridium difficile INFECTION
zzStop unnecessary antibiotics and/or PPIs and H2RAs.
zzAvoid antimotility agents e.g. Loperamide or Opiates.
zzHistorically 70% respond to Metronidazole in 5 days, 92% in 14 days; use longer courses if slow response.
zzNew strains e.g. 027 may not respond well to Metronidazole, change to Vancomycin if poor response by 5-7
days.
zzSevere if Temp over 38.5oC; WCC over 15/L, rising creatinine or signs/symptoms of severe colitis, or known ribotype
027 (may cause more severe disease): use Vancomycin. Review progress closely and/or consider hospital referral.
zzNote in very severe disease, diarrhoea may be absent.
1st/2nd episodes:
METRONIDAZOLE 400mg oral TDS 10-14 days
3rd episode/severe: VANCOMYCIN 125mg oral QDS 10-14 days
Relapsing disease:
VANCOMYCIN 125mg oral QDS 14 days (until settled),
then 125mg oral BD 7 days,
then 125mg oral OD 7 days,
then 125mg oral alternate days 7 days,
then 125mg oral every 3rd day for 14 days
For those at high risk of C. difficile consider primary prophylactic probiotics. Advise probiotics for relapsing
disease (most evidence for Actimel).
Fidaxomicin may also be considered for those with relapsing disease. This should only be prescribed after
discussion with a Microbiologist.
21
GENITAL TRACT INFECTIONS – UK NATIONAL GUIDELINES
Contact UKTIS for information on foetal risks if the patient is pregnant.
See PHE Vaginal Discharge and Chlamydia quick reference guide or BASHH website
zz People with risk factors should be screened for Chlamydia, Gonorrhoea, HIV, Syphilis.
zz Refer individuals and partners to GUM service.
zz Risk factors for STIs: under 25y, no condom use, recent (less than 12mths) or frequent change of sexual
partner, previous STI, symptomatic partner.
Vaginal Candidiasis
All topical and oral azoles give 75% cure.
CLOTRIMAZOLE 500mg pessary or 10% cream STAT
OR FLUCONAZOLE 150mg STAT oral
In pregnancy: avoid oral azoles and use intravaginal treatment: see below.
CLOTRIMAZOLE 100mg pessary at night for 6 nights
OR MICONAZOLE 2% cream 5g intravaginally BD for 7 days
22
Chlamydia trachomatis Infection/Urethritis
See PHE Chlamydia quick reference guide
zz Opportunistically screen all aged 15-25 years.
zz Treat partners and refer to GUM service.
AZITHROMYCIN 1g STAT oral OR DOXYCYCLINE 100mg BD oral for 7 days
(Doxycycline can also be used at 200mg OD)
In pregnancy or breastfeeding: AZITHROMYCIN 1g STAT oral (off label)
OR
OR ERYTHROMYCIN 500mg QDS oral for 7 days
AMOXICILLIN 500mg TDS oral for 7 days
zz For pregnancy or breastfeeding Azithromycin is the most effective option.
zz Due to the lower cure rate in pregnancy, test for cure 6 weeks after treatment.
Suspected Epididymitis in men
OFLOXACIN 200mg BD oral for 14 days
OR DOXYCYCLINE 100mg BD oral for 14 days (Doxycycline can also be used at 200mg OD)
If high risk of Gonorrhoea:
ADD CEFTRIAXONE 500mg STAT im
Note: oral/other Cephalosporins are NOT considered an appropriate substitute due to low tissue levels leading
to resistance (BASHH 2011 guidelines).
For Acute Prostatitis see page 14
23
Bacterial Vaginosis
zz Oral Metronidazole is as effective as topical treatment but is cheaper.
zz There is less relapse at 4 weeks with a 7 day course than 2g stat.
zz In pregnancy and breast feeding avoid the 2g stat dose.
zz Treating partners does not reduce relapse.
METRONIDAZOLE 400mg BD oral for 7 days
OR METRONIDAZOLE 2g STAT oral (avoid in pregnancy and breast feeding)
OR METRONIDAZOLE 0.75% vaginal gel 5g applicatorful at night for 5 nights
OR CLINDAMYCIN 2% cream 5g applicatorful at night for 7 nights
Trichomoniasis
Treat partners simultaneously and refer to GUM service.
In pregnancy or breastfeeding: avoid 2g single dose Metronidazole. Consider topical
Clotrimazole for symptom relief (not cure) if Metronidazole declined.
METRONIDAZOLE 400mg BD oral for 5-7 days
OR METRONIDAZOLE 2g STAT oral (avoid in pregnancy and breast feeding)
Symptom relief in pregnancy (if Metronidazole declined):
CLOTRIMAZOLE 100mg pessary at night for 6 nights
24
Pelvic Inflammatory Disease (PID)
zz Refer woman and contacts to GUM service
zz Always culture for Gonorrhoea and test for Chlamydia
zz 28% of Gonorrhoea isolates are now resistant to Quinolones. If Gonorrhoea likely (partner has it, severe
symptoms, sex abroad), consider GUM referral as IM Ceftriaxone required.
AZITHROMYCIN 1g oral STAT
PLUS OFLOXACIN 400mg BD oral 14 days
PLUS METRONIDAZOLE 400mg BD oral 14 days
If high risk of Gonorrhoea: CEFTRIAXONE 500mg STAT im
Note: oral/other Cephalosporins are NOT considered an appropriate substitute due to low tissue levels leading
to resistance (BASHH 2011 guidelines).
PLUS DOXYCYCLINE100mg BD oral 14 days (Doxycycline can also be used at 200mg OD)
PLUS METRONIDAZOLE 400mg BD oral 14 days
For pregnancy or breastfeeding: CEFTRIAXONE 500mg STAT im
Note: oral/other Cephalosporins are NOT considered an appropriate substitute as noted above.
PLUS METRONIDAZOLE 400mg BD oral 14 days
(Warn women about taste of Metronidazole in breast milk)
PLUS ERYTHROMYCIN 500mg BD oral for 14 days (OR AZITHROMYCIN 1g STAT then
500mg OD oral for 4 days)
25
Skin/Soft Tissue Infections
For MRSA screening and suppression see PHE MRSA quick reference guide.
For abbreviated version on MRSA screening and suppression see pages 31-33
Impetigo
zz For extensive, severe or bullous impetigo use oral antibiotics.
zz Reserve topical antibiotics for very localised lesions to reduce the risk of resistance.
zz Reserve Mupirocin for MRSA.
For localised lesions only:
FUSIDIC ACID TDS topically for 5 days
For MRSA localised lesions only:
MUPIROCIN TDS topically for 5 days
For more severe/non-localised lesions: FLUCLOXACILLIN 500mg QDS oral for 7 days
If Penicillin allergic:
CLARITHROMYCIN 250-500mg BD oral for 7 days
Eczema
If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and
does not improve healing. In eczema with visible signs of infection, use treatment as in impetigo.
26
Cellulitis
If patient is afebrile and healthy other than cellulitis, use oral Flucloxacillin alone.
zz If river or sea water exposure, discuss with Microbiologist.
zz If febrile and ill, admit for IV treatment.
zz Clarithromycin is more likely to be successful in limited area cellulitis; for extensive cellulitis with or without
lymphangitis use Clindamycin.
zz Stop Clindamycin if diarrhoea occurs.
FLUCLOXACILLIN 500mg QDS oral for 7 days, up to 1g QDS for 14 days if slow response.
OR
CLARITHROMYCIN alone 500mg BD for 7 days
CLINDAMYCIN 300mg-450mg QDS for 7 days
Increase both to 14 days if slow response.
If known MRSA carrier:
DOXYCYCLINE 200mg OD oral for 7-14 days
For more severe cases: ADD
RIFAMPICIN 450mg BD oral for 7-14 days
If facial cellulitis:
CO-AMOXICLAV 500/125mg TDS for 7-14 days,
If Penicillin allergic:
CLINDAMYCIN 300mg-450mg QDS for 7-14 days
If Penicillin allergic: For MRSA localised lesions only: DOXYCYCLINE 200mg OD oral for 7-14 days
ADD
RIFAMPICIN 450mg BD oral for 7-14 days
See over for pages on OPAT.
27
Outpatient Home (IV) Antibiotic Therapy (OPAT) for Cellulitis (class 2)
zz Home IV antibiotics may prevent hospital admissions for treatable conditions such as cellulitis class 2.
zz OPAT Home IV team contact Pager: 07659 113695
Assessment of grade of cellulitis (Eron/Dall criteria):
Class
1
Class
2
Class
3
Class
4
Healthy patients with cellulitis, up to 15 cm diameter, with or without fever
Healthy patients or patient with peripheral vascular disease, diabetes or obesity with cellulitis more
than 15 cm with or without fever. Patient in whom oral antibiotics have failed
Patients with fever and mental status change, physical findings of gangrene, crepitus bullae or open
draining wounds (requires hospital admission)
Patients with systemic complication of severe infection which includes hypotension, renal failure and
acute respiratory distress syndrome (requires hospital admission)
First line:
CEFTRIAXONE 2g OD iv until oral switch
Second line or if severely Penicillin allergic, or Cephalosporin allergic, or high risk of C. difficile infection or
MRSA carrier:DAPTOMYCIN 4mg/kg OD iv until oral switch
Since Daptomycin is expensive and can be used at higher doses, round up the dose to the nearest whole vial
(350mg or 500mg).
Less than 60kg: 4mg/kg iv od; 60-80kg: 350mg iv od 80-125kg: 500mg iv od; Greater than 125kg: 850mg iv od
Creatine (Phospho) Kinase (CK/CPK), should be measured before/as treatment starts and monitored weekly
thereafter whilst Daptomycin continues. Discontinue if unexplained muscular symptoms develop or CK
markedly elevated (5x normal before treatment) or marked elevation occurs on treatment.
28
OutPatient Home (IV) Antibiotic Therapy (OPAT) For Cellulitis (class 2)
Antibiotics will be switched to oral once clear clinical response. Oral switch as per page 27.
Inclusion criteria
zzPatient is over 18 years of age and registered with a Gloucestershire GP (or 16 – 18 discuss with IV team)
zzIV therapy is needed to treat a patient who has been diagnosed with class II cellulitis (see classification
above) as alternative routes of drug delivery are not feasible or appropriate. Healthcare staff are able to
gain suitable IV access
zzThe medical and psychological condition of the patient is suitable and stable and hospitalisation is not
needed and complex nursing/medical intervention is not required. Consider increased package of care for
individual patients if necessary.
zzThe patient must have received a comprehensive assessment by the clinician responsible for their care and/
or a member of the District Nursing team.
zzA satisfactory home condition exists i.e. running water, telephone and the patient and carer understand
the implications, risks and benefits of the treatment plan and have given informed consent.
Exclusion criteria
zz The patient does not meet criteria for inclusion
zz Patient has facial, orbital or palmar cellulitis, received IV antibiotics for cellulitis of the same site within the
preceding month, peripheral IV access not obtainable/reliable, current substance misuse, pregnancy or
signs of rapid extensions/necrosis suggestive of necrotising fasciitis
zz Co-morbidities such as: Immunosuppression, Unstable diabetes, Peripheral Vascular disease, Alcoholism.
29
Leg Ulcers – See PHE Leg Ulcer quick reference guide
zz Ulcers are always colonised with bacteria.
zz Antibiotics do not improve healing unless there is active infection (e.g. cellulitis, increased pain; enlarging
ulcer, purulent exudate, new odour or pyrexia).
zz If there is active infection, send pre-treatment swab.
zz Review antibiotics after culture results.
If signs of active infection: FLUCLOXACILLIN 500mg QDS oral 7 days,
If Penicillin allergic:
increased to 14 days if slow response.
CLARITHROMYCIN 500mg BD oral 7-14 days
Leg Ulcers: MRSA
See PHE MRSA quick reference guide
zz Most leg ulcers that grow MRSA on culture are only colonised and do not require antibiotic treatment,
(see also section on decolonisation, pages 41-42).
zz For active MRSA infection use antibiotic sensitivities to guide treatment. If severe infection or no response
to monotherapy after 24-48 hours, seek advice from Microbiologist on combination therapy.
zz If active infection, MRSA confirmed or suspected from previous culture results, infection not severe, and
admission not required:
DOXYCYCLINE 200mg OD oral for 7-14 days
OR IF susceptible:
CLINDAMYCIN 450mg QDS oral for 7-14 days
Stop Clindamycin if diarrhoea occurs
30
Diabetic Ulcers without Osteomyelitis
zz Ulcers are always colonised with bacteria and treatment should only be given if there are signs of active
infection.
zz Longer courses may be needed for infections that are slow to respond
If signs of active infection: CO-AMOXICLAV 625mg TDS oral for 7-14 days
If Penicillin allergic: CLINDAMYCIN 450mg QDS oral for 7-14 days
If suspected MRSA: DOXYCYCLINE 200mg OD oral for 7-14 days
Diabetic Ulcers With Osteomyelitis
zz Ulcers that probe to bone are likely to have associated osteomyeltitis.
zz Tissue samples may help direct therapy; superficial swabs are of less predictive value for underlying
causative organisms. Deep swabs taken after clearance of superficial debris may be useful.
zz Patients should be referred for specialist assessment. IV antibiotics are often needed at least initially.
zz Duration of treatment depends on resolution of the osteomyelitis and 12 or more weeks of treatment may
be needed.
zz If MRSA is suspected treatment must be discussed with a Microbiologist.
CIPROFLOXACIN 750mg BD oral
PLUS CLINDAMYCIN 450mg QDS oral
Typical course would be for at least 6 weeks.
31
Panton-Valentine Leucocidin (PVL)
See PHE PVL quick reference guide
zzPanton-Valentine Leucocidin (PVL) is a toxin produced by approximately 2% of Staphylococcus aureus.
These can be MSSA or MRSA strains.
zzPVL can cause, albeit rarely, severe invasive infections in healthy people.
zzPVL is also associated with persistent recurrent pustules, carbuncles, boils or abscesses.
Send swabs for culture in these clinical scenarios.
zzRisk factors for PVL include: nursing homes, close contact communities or sports, sharing equipment,
poor hygiene.
zzPVL abscesses should be incised and drained.
zzMinor furunculosis, folliculitis, and small abscesses without cellulitis do not need antibiotic treatment
(may need incision and drainage).
zzTopical antibiotics are not usually appropriate.
If treatment of skin and soft tissue infection is required:
For MSSA use:
FLUCLOXACILLIN 500mg QDS oral 5-7 days
For penicillin allergy:
CLINDAMYCIN 450mg QDS oral for 5-7 days
For MRSA use (after checking susceptibility): DOXYCYCLINE 200mg OD oral for 5-7 days
OR (if susceptible)
Stop Clindamycin if diarrhoea occurs
CLINDAMYCIN 450mg QDS oral for 5-7 days
For more severe infection but not requiring hospital admission:
ADD
RIFAMPICIN 300mg BD oral for 5-7 days
32
Panton-Valentine Leucocidin (PVL) decolonisation (suppression) therapy
After successful treatment of PVL infections, decolonisation is recommended:
Use: NASAL 2% MUPIROCIN 3 times a day for 5 days
Apply matchstick-head sized amount of ointment to inner surface of each nostril. Patients should be able to
taste Mupirocin at back of the throat.
PLUS SKIN 4% Chlorhexidine Gluconate DAILY topically as body-wash for 5 days
TWICE DURING 5 DAYS as shampoo
Second line for skin (e.g. if patient has irritant dermatitis): OCTENISAN DAILY topically as body-
wash for 5 days
TWICE DURING 5 DAYS as shampoo
Moisten skin and apply undiluted antiseptic then rinse. Particularly apply to known carriage sites (axilla, groin
and perineum).
Wash hair using antiseptic body-wash/shampoo at least twice during the 5 days.
After washing, use clean towels, sheets and clothing DAILY. Launder items separately from other family
members, using as high a temperature as fabric allows.
Consider also spring cleaning of house including soft furnishings.
Family/close contacts should also be screened and offered decolonisation if found to be
carriers. Contact PHE Health Protection Unit for further advice
(Telephone office hours: 0845 504 8668)
33
Animal and Human Bites
Thorough irrigation is important.
Human:
zz Assess risk of tetanus, HIV, hepatitis B and C and discuss with Microbiologist if appropriate.
zz Antibiotic prophylaxis is advised.
Animal:
zz Assess risk of tetanus and rabies.
zz Antibiotic prophylaxis advised for cat bite/puncture wound; bite involving hand, foot, face, joint,
tendon, ligament; immunocompromised, diabetic, asplenic or cirrhotic.
First line animal & human prophylaxis and treatment:
CO-AMOXICLAV 375-625mg TDS oral for 7 days
If Penicillin allergic: METRONIDAZOLE 200-400mg TDS oral for 7 days
PLUS DOXYCYCLINE (cat/dog/human) 100mg BD oral for 7 days
OR PLUS METRONIDAZOLE 200-400mg TDS oral for 7 days
CLARITHROMYCIN (human only) 250-500mg BD oral for 7 days
Review at 24 & 48 hours
34
Scabies
zz Treat all home and sexual contacts within 24 hours.
zz Treat whole body from ear/chin downwards and under nails.
zz If under 2 years or elderly, also treat the face and scalp.
PERMETHRIN 5% CREAM 2 applications topically one week apart
If allergy: MALATHION 0.5% AQUEOUS LIQUID 2 applications topically one week apart
Varicella Zoster/Chickenpox
zz If pregnant / immunocompromised / neonate: seek urgent specialist advice.
zz Chicken pox: Consider Aciclovir IF within 24 hrs of rash onset and over 14 yrs old, or severe pain or
dense/oral rash, or secondary household case, or on steroids, or smoker.
Shingles: Treat if over 50 yrs old, and within 72 hrs of rash onset (post herpetic neuralgia is rare in under
50’s), or if active ophthalmic disease, or Ramsey Hunt, or eczema.
If indicated: ACICLOVIR 800mg 5 times day oral for 7 days
Second line if compliance a problem, as ten times cost VALACICLOVIR 1g TDS oral for 7 days
OR
FAMCICLOVIR 250mg TDS oral for 7 days
Cold Sores
Cold sores resolve after 7-10 days without treatment. Topical antivirals applied prodromally reduce duration
by 12-24 hrs only.
35
Dermatophyte Infection of the Proximal Fingernail or Toenail
See PHE Fungal Skin and Nail infections quick reference guide
zz Take nail clippings
zz Start therapy only if infection is confirmed by laboratory.
zz Terbinafine is more effective than azoles.
zz Liver reactions occur rarely with oral antifungals.
zz If Candida or non-dermatophyte infection confirmed, use oral Itraconazole.
zz For children seek specialist advice.
Superficial infection on the top surface of nail plate only:
5% AMOROLFINE NAIL LACQUER 1-2 times weekly
fingers 6 months
First line:
TERBINAFINE 250mg OD oral
fingers 6-12 weeks
toes 3-6 months
toes 12 months
Second line (infections with Candida spp or non-dermatophyte moulds):
ITRACONAZOLE 200mg BD oral for 7 days monthly
fingers 2 courses
toes 3 courses
36
Dermatophyte Infection Of The Skin
zz Terbinafine is fungicidal so treatment time is shorter than with fungistatic imidazoles.
zz If Candida is possible, use imidazole.
zz If intractable send skin scrapings. If infection confirmed, use oral Terbinafine/Itraconazole.
zz Discuss scalp infections with specialist.
1% TERBINAFINE BD TOPICAL for 1-2 weeks
OR IMIDAZOLE BD TOPICAL for 1-2 weeks after healing (i.e. for 4-6 weeks)
For athletes’ foot only: UNDECANOATES (Mycota®) BD TOPICAL for
1-2 weeks after healing (i.e. for 4-6 weeks)
Candida Infection of the Skin
zz Confirm by laboratory
zz Treat with 1% azole cream but use lotion if treating paronychia
zz Seek advice for nail infection
1% AZOLE CREAM BD TOPICAL for 1-2 weeks
(In case of paronychia treat until swelling goes)
37
Pityriasis Veriscolor
zz Scratching the surface of the lesion should demonstrate mild scaling
1% AZOLE CREAM OD- BD TOPICAL
OR 1% TERBINAFINE OD –BD TOPICAL
OR SHAMPOO CONTAINING KETOCONAZOLE OD-BD TOPICAL
All usually for 1 week
Conjunctivitis
zz Treat if severe as most infections are viral or self-limiting.
zz Bacterial conjunctivitis is usually unilateral and also self-limiting (65% resolve on placebo by day 5). It is
characterised by red eye with mucopurulent, not watery, discharge.
zz Fusidic acid has less Gram-negative activity
If severe:
CHLORAMPHENICOL 0.5% DROPS PLUS 1% OINTMENT 4 HRLY (whilst awake) AT NIGHT
OR CHLORAMPHENICOL 1% OINTMENT 3-4 times DAILY
OR FUSIDIC ACID 1% GEL BD topically
Continue for 48 hrs after symptom resolution
38
Acne
For all grades of acne dispel myths and give general advice, improvement may not be seen for 2+ months
with any treatment. See Clinical Knowledge Summaries for more information.
zz Mild acne: mainly non-inflammatory comedones, usually limited in its extent.
zz Moderate acne: a mixture of non-inflammatory comedones and inflammatory papules and pustules, may
extend to the shoulders and back.
zz Severe acne: nodules and cysts (nodulocystic acne), as well as a preponderance of inflammatory papules
and pustules, may be extensive.
Mild/Moderate Acne:
First line: BENZOYL PEROXIDE: use lowest strength first, see BNF. Useful especially if papules and
pustules are present.
OR TOPICAL RETINOID (tretinoin, isotretinoin or adapalene) use lowest strength first, see BNF.
Consider prescribing a standard combined oral contraceptive in women who require contraception,
particularly if the acne is having a negative psychosocial impact. Topical antibiotics are of limited benefit and
resistance is increasing.
Moderate/Severe Acne:
Use a topical agent (above) with a Tetracycline (little difference in efficacy between most, but Minocycline
NOT recommended):
OXYTETRACYCLINE 500mg BD oral OR DOXYCYCLINE 100mg OD oral OR
LIMECYCLINE 408mg OD oral
Review efficacy at 3 months, usually given for 6+ months up to 2 years. Second line options are available:
see CKS, BNF or discuss with a Dermatologist or Microbiologist.
39
Wounds from Deliberate Self Harm
zz Wounds resulting from deliberate self harm should be assessed for need for empirical treatment antibiotics.
zz There is no evidence for antibiotic prophylaxis being of benefit.
zz Repeated courses of antibiotics in patients who repeatedly deliberately self harm may precipitate C. difficile
infection.
zz Consider whether tetanus vaccination/booster is required.
zz Superficial wounds: lacerations, burns
 The majority of superficial wounds will NOT need antibiotic therapy if there is no sign of local infection.
 Antibiotics should not be given prophylactically.
 Local wound toilet is appropriate especially following foreign body removal or if contamination with dirt.
 If evidence of local infection, take a wound swab for MC&S. Treatment should be adjusted according to results.
zz Deep wounds (penetrating the fascial layer), insertion of foreign bodies per vagina, per rectum, etc with
penetration of mucosal surface,
 Antibiotics should not routinely be prescribed. The wound should be regularly assessed for evidence of
infection.
 Foreign bodies should be removed and local wound toileting should be performed.
First Line IF REQUIRED: FLUCLOXACILLIN 500mg QDS oral for 5 days
If Penicillin allergic:
CLARITHROMYCIN 500mg BD oral for 5 days
Second Line: or if likely anaerobic wound infection: CO-AMOXICLAV 375-625mg TDS oral 5 days
OR If Penicillin allergic: CLINDAMYCIN 300-450mg QDS oral for 5 days
40
Skin/Soft Tissue – MRSA Screening, Decolonisation and Treatment
Adapted from PHE MRSA quick reference guide and also see BSAC guidelines
How do I screen a patient for MRSA?
In most cases, patients should be swabbed as close to elective admission as possible.
Swab anterior nares (nose): Wipe a swab around inside rim of patient’s nose for 5 seconds (both nares with the
same swab). Also swab skin lesions or wounds: includes skin lesions or wounds, sites of catheters, catheter urine,
groin/perineum, tracheostomy and other skin breaks and sputum from patients with a productive cough.
Label the bacteriology form “MRSA screen”.
Interpreting the L aboratory Result
Only MRSA will be looked for when swabs are labelled “MRSA screen”. Positive cultures are reported as “MRSA
isolated”. Negative cultures are reported as “MRSA not isolated”. After the first swab, laboratories do not usually
report antibiotic susceptibilities.
Decolonisation (Suppression) of MRSA
Regimens aim to reduce MRSA below detection level at time of risk, to decrease chance of infection and spread.
Decolonisation/Suppression should usually take place in the 5 days prior to operation, as it may not be successful
in the long term. Nasal and skin treatments may only suppress MRSA, therefore always advise admitting ward of
patient’s MRSA status, to allow appropriate pre-operative preparation and prophylaxis.
Systemic treatment should only be prescribed in line with local policy for established infection.
How do I suppress MRSA?
To reduce persistent MRSA carriage, treat underlying skin conditions (e.g. eczema, dermatitis), remove and/or replace
invasive devices and treat skin breaks.
Choice of skin regimen for patients with underlying skin conditions should consider the potential for skin irritation.
Where necessary, seek advice from Dermatologist or Microbiologist.
41
Decolonisation (Suppression) of MRSA
Always use both nasal and skin regimens
NASAL 2% MUPIROCIN in paraffin base 3 times a day for 5 days
Apply matchstick-head sized amount of ointment to inner surface of each nostril.
Patients should be able to taste Mupirocin at back of the throat.
PLUS SKIN 4% CHLORHEXIDINE GLUCONATE body-wash/ shampoo. DAILY for 5 days.
OR
Second line e.g. if patient has irritant dermatitis): OCTENISAN body-wash/ shampoo. DAILY for
5 days.
Moisten skin and apply undiluted antiseptic then rinse. Particularly apply to known carriage sites (axilla, groin
& perineum).
Wash hair using antiseptic body-wash/shampoo at least twice during the 5 days.
After washing, use clean towels, sheets and clothing. Launder items separately from other family members,
using as high a temperature as fabric allows.
42
MRSA TREATMENT
What do I use to treat a patient with MRSA Infection?
MRSA can cause infection at any site. Deep seated infection e.g. osteomyelitis may not respond to antibiotics
alone and may need surgical intervention.
Skin and Soft Tissue Infection and UTI or RTI
zz Total daily dose dependant on severity of infection.
zz Severe soft tissue infection may require up to three weeks antibiotics.
zz For osteomyelitis or septic arthritis please consult a Micro-biologist.
First line if sensitive: DOXYCYCLINE 200mg OD oral for 7-10 days
Second line if sensitive: RIFAMPICIN 600mg OD or BD oral 7-10 days
PLUS OR
FUSIDIC ACID 500mg TDS oral 7-10 days
If sensitive: CLINDAMYCIN 450mg QDS oral for 7-10 days
Stop Clindamycin if diarrhoea occurs
Patients with severe or deep seated infection may be discharged from hospital to complete a course of:
LINEZOLID 600mg BD oral
Note that this drug has a maximum 28 day license, and requires monitoring of FBC weekly, and assessment
of the risk of peripheral neuropathy including optic neuropathy: see BNF or seek specialist advice if not
previously prescribed.
43
DENTAL INFECTIONS
Derived from the 2011 SDCEP Guidelines (Scottish Dental Clinical Effectiveness Programme)
This guidance is not designed to be a definitive guide to oral conditions. It is for GPs for the management
of acute oral conditions pending being seen by a dentist or dental specialist. GPs should not routinely be
involved in dental treatment and, if possible, advice should be sought from the patient’s dentist, who should
have an answer-phone message with details of how to access treatment out-of-hours, or NHS 111.
Mucosal Ulceration and Inflammation (simple gingivitis)
zz Temporary pain and swelling relief can be attained with saline mouthwash
SIMPLE SALINE MOUTHWASH – (Half a teaspoon of salt dissolved in a glass of warm water)
zz Use antiseptic mouthwash if more severe and pain limits oral hygiene to treat or prevent secondary
infection
CHLORHEXIDINE 0.12%-0.2%
Rinse mouth for 1 minute BD with 5ml diluted in 5-10mls of water.
Do not use within 30 minutes of toothpaste.
zz The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes
simplex, oral cancer) needs to be evaluated and treated
HYDROGEN PEROXIDE 6%
Rinse mouth for 2 mins TDS with 15mls diluted in half a glass of warm water.
For each always spit out after use.
Use until lesions resolve or less pain allows oral hygiene.
44
Acute Necrotising Ulcerative Gingivitis
zz Commence Metronidazole and refer to Dentist for scaling and oral hygiene advice
METRONIDAZOLE 400mg TDS oral for 3 days
zz Use Metronidazole in combination with antiseptic mouthwash if pain limits oral hygiene
CHLORHEXIDINE 0.12%-0.2%
Rinse mouth for 1 minute BD with 5ml diluted in 5-10mls of water.
Do not use within 30 minutes of toothpaste.
zz The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes
simplex, oral cancer) needs to be evaluated and treated
HYDROGEN PEROXIDE 6%
Rinse mouth for 2 mins TDS with 15mls diluted in half a glass of warm water.
For each always spit out after use.
Use until less pain allows oral hygiene.
45
Pericoronitis
zz Pericoronitis is the inflammation and infection of perimolar soft tissue, often provoked by emerging molar
teeth.
zz Refer to Dentist for irrigation and debridement
zz If persistent swelling or systemic symptoms use Metronidazole
zz For severe infections ADD Amoxicillin to Metronidazole
METRONIDAZOLE 400mg TDS oral for 3 days
Second line or additional for severe infections (see above):
AMOXICILLIN 500mg tds oral for 3 days
zz Use antiseptic mouthwash if pain and trismus limit oral hygiene
CHLORHEXIDINE 0.12%-0.2%
Rinse mouth for 1 minute BD with 5ml diluted in 5-10mls of water.
Do not use within 30 minutes of toothpaste.
OR
HYDROGEN PEROXIDE 6%
Rinse mouth for 2 mins TDS with 15mls diluted in half a glass of warm water.
For each always spit out after use.
Use until lesions resolve or less pain allows oral hygiene.
46
Dental Abscess
zz Regular analgesia should be first option until a dentist can be seen for urgent drainage; repeated courses
of antibiotics for abscess are inappropriate. Repeated antibiotics alone, without drainage are ineffective in
preventing spread of infection.
zz Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of
complications
zz Use higher dose antibiotics for more severe infections
zz Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending
airway obstruction, Ludwigs angina. Refer urgently for admission to protect airway, achieve surgical
drainage and IV antibiotics.
zz The empirical use of Cephalosporins, Co-amoxiclav, Clarithromycin, and Clindamycin do not offer any
advantage for most dental patients and should only be used if no response to first line drugs when
referral is the preferred option
If pus: Drain by local incision, tooth extraction or via root canal. Send pus for microbiology.
AMOXICILLIN 500mg-1g TDS oral for 5 days (Review at 3 days)
OR PHENOXYMETHYLPENICILLIN 500mg-1g QDS oral for 5 days (Review at 3 days)
If penicillin allergy: CLARITHROMYCIN 500mg BD oral for 5 days (Review at 3 days)
For severe or spreading infection (lymph node involvement, systemic signs, fever, malaise) ADD:
METRONIDAZOLE 400mg TDS oral for 5 days
For Metronidazole allergy use: CLINDAMYCIN 300mg QDS oral for 5 days
47
Antibiotic Activities (based on local data)
Greater than 90% 80-90% sensitive 70-80% sensitive
sensitive
50-70% sensitive
Classes of antibiotics for Gram positive bacteria:
Penicillins
ACG Streps Strep pneumo
Penicillin V
99%
93%
Amoxicillin
99%
Not tested
Flucloxacillin
Co-amoxiclav
99%
No data
Macrolides
Erythromycin
Not tested
Not tested
Clarithromycin
90%
89%
Tetracyclines
80%
92%
Cephalosporins
Cefalexin
No data
No data
Cefotaxime
No data
98%
Cefixime
Others
Trimethoprim
Quinolones (e.g. Ciprofloxacin)
Levofloxacin 99%
Clindamycin
No data
No data
Linezolid
No data
No data
Teicoplanin (iv)
No data
No data
Dapytomycin (iv)
No data
No data
Gentamicin (iv)
Enterococci
Not tested
99%
Not tested
99%
Less than 50%
sensitive
Staph aureus
18%
MRSA
0% by
definition
100%
Not tested
Not tested
Not tested
Not tested
Not tested
84%
95%
Not tested
40%
94%
Not tested
Not tested
Not tested
No data
No data
No data
Not tested
Not tested
Not tested
93%
86% (do not use alone)
No data
100%
100%
No data
99%
62%
24%
No data
99%
100%
No data
96%
No data
No data
No data
Antibiotics for Anaerobic bacteria:
Metronidazole, Co-amoxiclav and Clindamycin all have activity against anaerobes.
48
Not tested/ not
appropriate)
Antibiotic Activities (based on local data)
Classes of antibiotics for Gram negative bacteria
Penicillins
Haem influenza Moraxella catarrhalis Other Coliforms Pseudomonas aeruginosa
Amoxicillin
74%
Not tested
40%
Not tested
Co-amoxiclav
93%
99%
69%
Not tested
Macrolides
Erythromycin
28%
96%
Not tested
Not tested
Clarithromycin
35%
96%
Not tested
Not tested
Tetracyclines
99%
99%
Not tested
Not tested
Cephalosporins
Cefalexin
No data
No data
No data
Not tested
Cefotaxime
99%
No data
Not tested
Not tested
Cefixime
99%
No data
95%
No tested
Others
Trimethoprim
No data
No data
Not tested
Not tested
Quinolones (eg Ciprofloxacin)
99%
99%
91%
No data
Gentamicin (iv)
No data
No data
96%
No data
Penicillin V, Clindamycin, Linezolid, Teicoplanin and Daptomycin have no anti-Gram negative activity.
GP urine sensitivities: all causes UTI (based on local data)
Amoxicillin
51%
Nitrofurantoin
91%
Trimethoprim
71%
Ciprofloxacin
96%
Others
Co-amoxiclav
86%
Cefalexin
No data
Fluconazole has activity against Candida albicans but limited activity against non-albicans Candida. For these consider
Itraconazole if an oral agent is required, or consult a Microbiologist.
All data collected or extrapolated from local primary care specimen sensitivities only, hence data not available for all
drug/bug combinations.
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