Guidelines For Treatment Of Infections In Primary Care In .
Hull and East Riding Prescribing CommitteeGuidelines for Treatment of Infections in Primary Carein Hull and East RidingThis document is based on the Health Protection Agency advice which can be m/uploads/attachment data/file/622637/Managing common infections.pdf (Public Health England Last Update May 2017)The guidelines have been subject to consultation within primary care, public healthand clinicians within the Acute Trust and have been approved by the AdvisoryCommittee on Antimicrobial Therapy (ACAT).Dr Gavin BarlowConsultant in Infectious DiseasesHull and East Yorkshire Hospitals NHS TrustA summary table of main guidance can also be found .htmNote: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 1 of 22
ContentsSectionPageAims of Guidelines and Principles of Treatment3General information on prescribing recommendations4Risk factors for Clostridium difficile associated diarrhoea5Additional guidance on sampling6Upper Respiratory Tract Infections6Lower Respiratory Tract Infections8Meningitis9Urinary Tract Infections10Genito-Urinary Tract Infections13Gastrointestinal Infections15Skin/soft tissue infections17Viral Infections20Oral infections21Miscellaneous21References22Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 2 of 22
Use TARGET toolkit as a resource to optimise antibiotic prescribingwithin primary care settingsAims of Guidelines To provide a simple, evidence based approach to the empirical treatment of common infectionsTo promote the safe, effective and economic use of antibioticsMinimise the risk of toxicity/ adverse effects e.g. Clostridium difficile associated diarrhoea (CDAD)Delay the emergence and reduce the prevalence of bacterial resistance in the communityPrinciples of Treatment This guidance is based on the best available evidence. Professional judgement should be used andpatients should be involved in the decision.Prescribe an antibiotic only when there is likely to be a clear clinical benefit (and where benefitsoutweigh risks).It is important to initiate antibiotics as soon as possible in severe infectionHave a lower threshold for antibiotics in immunocompromised or those with multiple morbidities;consider culture and seek adviceDo not prescribe an antibiotic for viral sore throat, simple coughs and colds.Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.Limit prescribing over the telephone to exceptional cases.Use simple generic antibiotics first whenever possible. Avoid broad spectrum antibiotics (e.g.quinolones, cephalosporins, clindamycin, co-amoxiclav) when narrow spectrum agents remaineffective, as use of broad spectrum agents increase the risk of Clostridium difficile, MRSA andresistant UTIs.Cephalosporins and quinolones should NOT routinely be used as first line antimicrobials exceptwhere indicated in this guidance.Macrolide antibiotics should be only be prescribed in preference to penicillins where the patient istruly hypersensitive (penicillin allergy is presence of rash or anaphylaxis following treatment with apenicillin).The recommended macrolide for general use is clarithromycin (except in pregnancy and breastfeeding) due to improved tolerability, absorption and compliance compared to erythromycin.Avoid widespread use of topical antibiotics (especially those agents also available as systemicpreparations) e.g. fusidic acid (Fucibet , Fucidin , - ophthalmic use ok).In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose ( 400mg)metronidazole. Short term use of trimethoprim after the first trimester (unless low folate status or onother folate antagonists e.g. antiepileptics) is unlikely to cause harm to the foetus.In children AVOID tetracyclines and quinolones.Give antibiotics for the SHORTEST time possible. In most uncomplicated and non-serious/ nonsevere infections 5 days of treatment or less is usually sufficient.When first-line antibiotic sensitivities are provided, further sensitivity results are usually available forspecial situations. Consultant medical microbiologists can be contacted for specialist advice byRegistered Medical Practitioners on 01482 674991 during laboratory hours or out of hours (forurgent advice) via HEY switchboard 01482 875875.Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 3 of 22
General information on prescribing recommendationsThe information contained within this document is for guidance to assist in the prescribing of antimicrobials. The doses specified are recommended for use in those with normal pharmacokinetic handlingof the drug. Dose adjustments may be necessary in children or those of advanced age or with comorbidities that could affect the pharmacokinetics of the drug (e.g. liver or renal impairment, pregnancy).Certain drug interactions may also have an impact on anti-microbial drug dosing.Before prescribing, the information contained within these guidelines should be read in conjunction with themost recent British National Formulary (www.bnf.org or www.bnfc.org) or the electronic medicinescompendium www.medicines.org.uk for contraindications, cautions, use in pregnancy/ breast feeding andother disease states (e.g. renal or hepatic impairment) and drug interactions.Unless otherwise stated the doses are for ADULT patients.Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 4 of 22
Main risk factors for Clostridium difficile infection (CDI)Risk factors for CDI are given below. The more of these risk factors a patient has, the higher the risk islikely to be. Age 65 years (especially 75 years)* Previous CDAD* Recent exposure to cephalosporins*, quinolones* or clindamycin* or other broad-spectrumantibiotics such as co-amoxiclav (Augmentin ) – see graph below Recent prolonged*/multiple* or IV antibiotic exposure (especially if antibiotics above) Nursing/residential home resident NG or PEG tube in-situ Recent hospital stay Extensive co-morbidity Gastrointestinal surgery Severe underlying/inter-current illness Low albumin/poor nutritional status H2 antagonist or proton pump inhibitor therapy (Ask, does the patient really need this?Consider stopping)ImmunosuppressionThese are probably the most important, particularly in combination.RISK OF COMMUNITY-ASSOCIATED CDI FOR DIFFERENT ANTIBIOTICSLinear association between a 4-point antibiotic risk index and community-associated CDIrisks.Brown K A et al. Antimicrob. Agents Chemother.2013;57:2326-2332Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 5 of 22
Additional guidance on samplingCatheter Urine SpecimensBy 14 days post-catheterisation, almost all urine samples from catheterised patients will yield bacterialgrowth. There is no evidence that giving antibiotics to asymptomatic catheterised patients will produce anyclinical benefit whilst they are asymptomatic, and antibiotics do not cure catheter blockage, by-passing ofcatheters, peri-urethral discharge, and are not an appropriate solution to malodorous urine.Repetitious use of antibiotics produces selection of highly-resistant strains of bacteria and culminates incolonisation with yeasts. Subsequent manipulation of the catheter may result in bacteraemia bloodstream infection with these resistant bacteria and fungi. It is therefore inappropriate to test for the currentbacteria present in the urinary system where the patient has no symptoms, except when manipulation ofthe urinary tract is planned i.e. a urological procedure. In those cases it is appropriate to send a preprocedure sample, allowing sufficient time (72 hours) for the sample to arrive and for sensitivity tests to beperformed.Routine catheter replacement does not require antibiotic prophylaxis. If a patient is treated forcatheter associated UTI, the catheter must be changed whilst patients is on antibiotics.Wound Swabs, Ulcers of the Skin, Pressure sores, Surface Abrasions and Drain sitesBreaches in the skin result in fluid exudate in a considerable proportion of wounds. The fluid is highlynutritious for bacteria and the growth of a number of organisms to a high level is to be expected. Swabs ofsuch wounds will therefore yield growth. The use of antibiotics in such circumstances will be futile inimproving the patient’s condition where no clinical evidence of infection is present.Specimens from wound swabs should therefore state that redness, swelling, pain, pus or systemic infectionis evident (CRP is a useful test to demonstrate systemic infection) and should state the intended antibioticswhich should be started after the swab has been obtained. A swab is always a poor substitute for obtainingpus and if pus is available, this should be placed in a sterile container and sent instead of a swab. Thesame considerations apply to ulcers of the skin, pressure sores, surface abrasions and drain sites.Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 6 of 22
UPPER RESPIRATORY TRACT INFECTIONSILLNESSCOMMENTSDRUGDOSEDURATION OFTxInfluenzaLatest guidance on vaccination and treatment of influenza can be found at PHE m/uploads/attachment data/file/580509/PHE guidance antivirals influenza 2016 2017.pdfAcute sorethroatAvoid antibiotics as 90%Acute otitismediaresolve in 7 days without, andA pain only reduced by 16 hours .Use FeverPAIN Score: Fever inlast 24h, Purulence, Attend rapidlyunder 3d, severely Inflamedtonsils, No cough or coryza).Score 0-1: 13-18% streptococci,use NO antibiotic strategy; 2-3:34-40% streptococci, use 3 dayback-up antibiotic; 4 or more: 6265% streptococci, use immediateantibiotic if severe, or 48hr short5Aback-up prescription.Optimise analgesiaBAvoid antibiotics as 60% are10 daysA-Child: see BNF for childrenSecond line / penicillinallergic (where indicated)ClarithromycinAdults: 500mg BD5 daysA Child: see BNF for childrenFirst line (where indicated)A See BNF for children5 daysA ADULT & CHILD over 12years:Doxycycline200 mg stat/100 mg OD5 daysA Use analgesia and topicalApreparations first line .First line (12 years and over)Acetic acid 2%.1 spray TDS7 days Consider oral antibiotics ifspreading cellulitis, extendingoutside of ear canal orsystemically unwell (see treatmentguidelines for cellulitis).Second line (2 years &over)Otomize ear spray ORConsider 2 or 3-day delayed orimmediate antibiotics if: 2yrs with bilateral AOM orbulging membrane and 3 orA more marked symptomsA all ages with otorrhoeaRhinosinusitisAdult: 500 mg QDS5 daysbetter in 24 hours without: theyonly reduce pain at 2 days and doA not prevent deafness .Otitis externaFirst line (where indicated)BPhenoxymethylpenicillinAvoid antibiotics as 80%resolve in 14 days without, andthey only offer marginal benefit,A after 7 daysOnly use for persistent symptomsand purulent discharge lasting atleast 7 days or if severesymptoms, or high risk of seriouscomplications (e.g.immunocompromised, cysticA fibrosis) .AmoxicillinA Adult: 500mg TDSChild: see BNF for childrenSecond line/penicillinallergic (where indicated)CHILD:Clarithromycin7-14 daysA A 1 spray TDSSecond line (any age)Hydrocortisone 1% gentamicin 0.3% ear drops2-4 drops, 3-4 times daily,and at night7-14 daysFirst line (where indicated)A AmoxicillinAdult:7 days500mg TDSChild: see BNF for childrenSecond line/penicllin allergic(where indicated)CHILD: ClarithromycinSee BNF for children7 daysADULT & CHILD over 12years:Doxycycline200 mg stat/100 mg OD7 daysBUse adequate analgesia .Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 7 of 22
LOWER RESPIRATORY TRACT INFECTIONSNote: Low doses of penicillins are more likely to select out resistance. Do NOT use quinolones (ciprofloxacin andofloxacin) first line due to poor activity against pneumococci. However, they do have use in PROVEN pseudomonalinfections. Reserve ALL quinolones for proven resistant infections.ILLNESSCOMMENTSAcute cough,BronchitisAntibiotic little benefit if no comorbidity A Patient leaflets can reduce antibioticAuse.DRUGFirst line(where indicated)AmoxicillinDOSEAdult:500mg TDSDURATIONOF Tx5 daysChild: see BNF for childrenConsider immediate antibiotics if 80yr and ONE of: hospitalisation inlast year, oral steroids, diabetic, CCFOR 65 years with 2 of aboveSecond line /penicillinallergic (where indicated)Second line /penicillinallergicCHILD:See BNF for children5 days200mg stat /100mg OD5 daysFirst line:Amoxicillin500 mg TDS5 daysSecond line/ penicillinallergicDoxycycline200mg stat /100mg OD5 days500 mg TDS5 days100mg BD5-7 daysClarithromycinADULT & CHILD over 12years:DoxycyclineAcuteexacerbationof COPDConsider whether antibioticsare needed. 30% is viral, 30-50% isbacterial (rest undetermined). BTSCOPD guidelines – only prescribe ifA two out of three are present : DyspnoeaIncreased sputum Purulent sputumConsider a sputum sample in nonrespondersCommunity acquiredpneumonia treatment inthecommunity(simplifiedfrom NICEguideline)Manage using clinicaljudgement and CRB-65 scorewith review:CRB scoring: each scores 1:Confusion (AMT 8);Respiratoryrate 30/min;BP systolic 90 ordiastolic 60;Age 65 years.First line for CRB65 0:AmoxicillinA Second line orCRB65 1or2/ allergic to penicillinDoxycyclineScore 0 suitable for home treatment;1-2 consider hospital referral andassessment3-4 urgent hospital admission.For guidance for assessment inchildren see BTS GuidelinesNote: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 8 of 22
l-disease-clinical-and-public-health-managementIn children: OMMENTSDRUGDOSESuspectedmeningococcal diseaseTransfer all patients to hospitalimmediately.IF time before admission, andnon blanching rash, administerbenzylpenicillin (or cefotaxime)prior to admission, unlesshypersensitive i.e. history ofbreathing difficulties, collapse,loss of consciousness or urticariaor rash within 1 hour ofadministration of beta lactamFirst line:Benzylpenicillin IV or IMIf allergic to penicillin(and available):Cefotaxime IV or IMDURATIONOF TxAdults and children10 years and over:1200 mgChildren 1 - 9 year:600 mgChildren 1 year:300 mgSTATAdult and children12 years and over: 1gChildren 12 yrs:50mg/kg (max 1g)STATIdeally IV but IM if a vein cannotbe found.Preventionof secondarycase ofmeningitisOnly prescribe following advice from Public Health Doctor9 am –Out of hours: Contact on-call doctor via TENYAS switchboard63863601904 666030Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.A systematic review, A- rigorous RCT, B RCT or cohort study, B- case-control studyC formal combination of expert opinion.HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017Review Date: September 2020Page 9 of 22
URINARY TRACT INFECTIONSNote: Amoxicillin resistance is common therefore only use if culture confirms susceptibility.Do not treat asymptomatic bacteriuria in adults except in pregnancy; it is common (especially in 65 years) but isB not associated with increased morbidity. In this population urine cultures are useful only to exclude UTI not to make adiagnosis.In the presence of a catheter, antibiotics will not eradicate bacteriuria and will select out more resistant organismsmaking subsequent treatment more difficult; only treat if systemically unwell or evidence of pyelonephritis. Do not useprophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or traumaguidance).3B(NICE & SIGNHPA guidance: -tract-infection-diagnosisSexual Health: omplicatedUTI(no fever orflank pain)NOTPREGNANTNOTE: Performcultures in alltreatmentfailures ORwhen risk ofresistance isconsidered high(e.g. recentprior antibiotictherapy,recurrent UTI,previousresistantorganism)Women: severe or 31, 2A 3Csymptoms: TreatWomen: mild or 2symptoms: use dipstick andpresence of cloudy urine toguide treatment. Nitrite &blood/ leucocytes has 92%positive predictive value; -venitrite, leucocytes, and blood4Ahas a 76% NPV . Clear urinehas 97% NPV for no UTI.Dipsticks likely to be lessuseful in older patients inwhom asymptomaticbacteruria is common.Men: Consider prostatitis &1,5Csend pre-treatment MSUORif symptoms mild/non-specific,use -ve dipstick to exclude UTI.6CNOTE 2: In mildto moderate,uncomplicatedUTI in nonpregnantfemales aged18-65 years, arecent trialshowed twothirds of womenrecoveredwithoutantibioticsfollowing a 3day course ofibuprofen400mg/8hrs –Consider asRefer male patients with 1 UTIepisode to urologyMacrocrystalline nitrofurantoin (i.e.capsules or m/r capsules) preferredBdue to reduced side effects .)DRUGDOSEDURATION OFTxDO NOT TREATASYMPTOMATICBACTERURIA ORASYMPTOMATICPOSITIVE DIPSTICKFirst line:B Nitrofurantoin capsMay be used with caution ifeGFR 30–44 ml/minute totreat uncomplicated lowerUTI caused by suspected orproven multidrug resistantbacteria and only if potentialbenefit outweighs risk100mg MR BDOr50mg QDSWomen: 3 daysCMen: 7 daysA 400mg stat then 200mgTDSWomen: 3 daysA 500mg TDSMen: 7 days(Otherwise If eGFR 245ml/min/1.73m usetrimethoprim as abovendOR one of the 2 lineoptions below)OtherwiseIf risk of resistance lowor organism known tobe sensitive use:B TrimethoprimSecond line(perform culture in alltreatment failures)200 mg BDSecond line(Perform culture in alltreatment fail
Routine catheter replacement does not require antibiotic prophylaxis. If a patient is treated for catheter associated UTI, the catheter must be changed whilst patients is on antibiotics. Wound Swabs, Ulcers of the Skin, Pressure sores, Surface Abrasions and Drain sites
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