GUIDELINE FOR ANTIBIOTIC (INCLUDING ANTIVIRAL AND PATIENTS IN COMMUNITY HOSPITALS/UNITS AND

GUIDELINE FOR ANTIBIOTIC (INCLUDING ANTIVIRAL AND
ANTIFUNGAL) TREATMENT OF INFECTIONS IN ADULT
PATIENTS IN COMMUNITY HOSPITALS/UNITS AND
COMMUNITY SERVICES
Status and Version
Final version
Category
Clinical:
Clinical Guideline (CG) 01 0413
Reference
CP01 0413
Lead Director
Dr Hemal Desai, Medical Director
Lead Author
Jo Jenkins, HCT Pharmacist
Approved by: (Designated Subcommittee & date of approval)
HCT Medicines Management Group
Ratified by: (Designated
Committee & date of ratification)
Clinical Effectiveness Sub-committee (CES)
Application:
All Staff
Date of Issue
April 2013
Operational Date(If different from
Date of Issue)
As above
Review Date
To be reviewed 6 months after the
operational date; every 2 years thereafter or
earlier at the discretion of the Lead Director
Signature of Authorising Director
& Date:
Dr H Desai, HCT Medical Director
12th March 2013
2nd April 2013
8th April 2013
Hertfordshire Community NHS Trust is committed to being an organisation within which
diversity, equality and human rights are valued. We will not discriminate either directly or
indirectly and will not tolerate harassment or victimisation in relation to gender, marital status
(including civil partnerships), gender reassignment, disability, race, age, sexual orientation,
religion or belief, trade union membership, status as a fixed-term or part-time worker, socioeconomic status and pregnancy or maternity leave status.
Equality Impact Assessment (Level 1)
completed by author
Date: March 2013
This document is available electronically, in a larger font, or alternative format on request.
Please refer to latest BNF for further prescribing information.
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Document History and version control:
Progress
V1 First Draft
V2 Second draft
(consultation draft)
Final copy
Circulation List
Lead Person & Contact Number
Jo Jenkins (based on current version)
01279 827230
Jo Jenkins (based on current version)
01279 827230
Jo Jenkins (based on current version)
01279 827230
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Dr Hemal Desai – Medical Director HCT
Carolyn Haselden – Lead Pharmacist
HCT
Dr Fiona Sinclair – PBC Chair, Primary
Care Medicines Management Group
(PMMG)
Sarah Mantle - Lead Infection Control
Nurse
Caroline Holmes – Infection Control Nurse
Shiona Robb – Infection Control Nurse
HCT Medicines Management Group
members
HCT Locality Managers
HCT Bed Based Unit Ward
Managers/Team Leaders
Dr Tammy Angel – St Albans City Hospital
and Langley House
Dr Clifford Lisk - Potters Bar Hospital
Dr Alice Dain – Princess Alexandra
Hospital
Dr Bridget Andu – Gossoms End Rehab
Unit
Dr Joanna Gleasure – St Alban’s
Community Hospital
Dr Eleanor Mair – HCT
Dr Yasmin Latief – Potters Bar
Community Hospital
Elizabeth Gregory - Diabetes Nurse
Consultant, SUDS
Dr Anjali Agrawal – Lead clinician for
family planning
Lynne Cross - Services Manager Podiatry,
Skin Health, Leg Ulcer and Bowel and
Bladder Services
Dr Robin Wiggins - Consultant
Microbiologist, West Hertfordshire NHS
Trust
Dr F M Awad-El-Kariem - Consultant
Microbiologist, East and North
Hertfordshire NHS Trust
Mr David Ladenheim - Antimicrobial
Pharmacist, East and North Hertfordshire
NHS Trust
Dr Sanjiv Agrawal - Skin Health Service
Lee O’Hara - Adult bladder & Bowel care
service
Jacqui Carrett - Respiratory Specialist
Nurses
Helen Tilbe – Leg Ulcer Nurse Specialist
HCT
Louise Connolly - HCT Specialist
Palliative Care and Lymphoedema service
Dr Carol Scholes - Palliative Care
Anne Barnett, Antibiotic pharmacist,
Princess Alexandra Hospital
Please refer to latest BNF for further prescribing information.
Date
January 2013
25th February 2013
6th March 2013
January –March
2013
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Peter Leslie, Pharmacist, Princess
Alexandra Hospital
Rochelle Bye, Pharmacist, Barnet and
Chase Farm Hospital
Kirta Patel, Antibiotic Pharmacist, Barnet
and Chase Farm Hospital
Gina Woodhead, Pharmacist, East and
North Hertfordshire NHS Trust
Sue Schechter, West Hertfordshire
Hospitals NHS Trust
Gill Salsbury, HCT Prison Services
Manager
Lynne Rotchell, HCT Service Manager,
Skin Health Service
Caroline Leith, HCT Podiatry Service
Abby Cox, HCT Podiatry Service
Dr F Sundram, Consultant Microbiologist,
Barnet and Chase Farm NHS Trust
Contents
Page
Introduction, purpose and scope of guidance
Disclaimer
Aims
Principles of treatment
Gentamicin prescribing
IV therapy and step down to oral therapy
Clostridium difficile infection
Specific drug warnings
Reference sources used
Acknowledgements
Comments
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Prescribing guidance:
Upper Respiratory Infections
Lower Respiratory Tract Infections
Meningitis
Septicaemia
Urinary Tract Infection
Gastro-intestinal Tract Infections
Genital Tract Infections
Skin and Bone Infections
Viral Infections
Appendix 1: Gentamicin – once daily dosage guidance
Glossary
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29
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Please refer to latest BNF for further prescribing information.
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GUIDANCE FOR THE MANAGEMENT OF INFECTION
Introduction, Purpose & Scope of the Guidance
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To support the appropriate prescribing of antibiotics by prescribers, including those who are employed directly and those contracted via
other organisations to work for Hertfordshire Community NHS Trust.
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This guidance applies to treatment of adults only. Generally the advice contained within this guideline is applicable to the
management of infection in children but for all children’s doses please refer to the most recent edition of the BNF for children.
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This policy is based on the NHS Hertfordshire Primary Care Guidance and also that of the Acute Trusts in Hertfordshire where HCT
have an SLA in place for Medical/ Pharmacy services.
Monitoring and audit
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Adherence and monitoring of antibiotic usage will be demonstrated through regular and timely audits of antibiotic prescribing within our
Community Hospitals/Units and by our Community Services. The audits will also provide information on the prescribing of antibiotics
which have been identified as ‘high risk’ to endeavour to reduce antibiotic associated infection like Clostridium difficile associated
diarrhoea and MRSA.
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Antibiotic prescribing data will be regularly collated and sent to our services and non-medical prescribers who prescribe on FP10’s.
Disclaimer
Whilst every effort has been made to ensure the accuracy of this guideline, Hertfordshire Community NHS Trust (HCT) cannot accept any
responsibility for any errors or omissions. The prescriber should be aware of any side effects, drug interactions or patient specific contraindications as detailed in the current British National Formulary or the Summary of Product Characteristics.
Aims
The aim of these guidelines, in line with evidence based national guidelines and HCT priorities are to:
Please refer to latest BNF for further prescribing information.
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Promote the safe, effective and economic use of antibiotics.
Manage the prescribing of antibiotics thus reducing the incidence of antibiotic associated infections such as Clostridium difficile
associated diarrhoea (CDAD) and MRSA infection.
Minimise the emergence of bacterial resistance to antibiotics within the community and community hospital settings.
Assist prescribers in selecting an appropriate antibiotic for commonly encountered infections.
Changes from October 2012
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Addition of choice of antibiotic for the following indication:
o Epididymo-orchitis
Removal of section on management of dental infections. This information will be incorporated into a new stand alone guideline
incorporating adult and paediatric management to reflect the dental services offered within HCT.
Revised or new drug choices for:
o Pharyngitis / sore throat / tonsillitis
o Otitis media
o Acute sinusitis
o Community acquired pneumonia
o UTI in pregnancy
o Clostridium difficile associated diarrhoea
o Helicobacter pylori
o Pelvic inflammatory disease
o Bites
o Cellulitis
o Impetigo
o Insect bites
o Leg ulcers
o Herpes simplex
Revised dosage or frequency of treatment for:
o Pharyngitis / sore throat / tonsillitis
o Clostridium difficile associated diarrhoea relapse
o Vaginal candidiasis in pregnancy
Please refer to latest BNF for further prescribing information.
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o Trichomoniasis
o Conjunctivitis
o Dermatophyte infection of the skin
Revision / addition of comments or advice:
o Link to prescribing PPIs in dyspepsia
o Principles of treatment
o Position of clarithromycin and erythromycin in guidelines
o Otitis media
o Acute sinusitis
o Lower respiratory tract infections
o Acute bronchitis
o Acute exacerbation of COPD
o Community acquired pneumonia
o Meningitis
o UTI in men
o UTI - complicated
o UTI recurrent
o Acute prostatitis
o Clostridium difficile associated diarrhoea
o Helicobacter pylori
o Threadworm
o Vaginal candidiasis
o Chlamydia trachomatis
o Bites
o Cellulitis
o Infected eczema
o Leg ulcers
o Scabies
o Chicken pox
o Shingles
Please refer to latest BNF for further prescribing information.
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Dental infections – please refer to separate guideline - HCT Guideline For Antibiotic (Including Antiviral And Antifungal) Treatment Of Dental
Infections In Adult And Paediatric Patients In Community Settings (CG 02 04 13)
Principles of treatment
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This guidance is based on the best available evidence but professional judgement should always be used and patients should be
involved in the decision making process.
Antibiotics should be initiated as soon as possible in severe infection.
Prescribing of antibiotics should only occur where consideration has been given to the origin of infection, there is a clinical need and the
presence of viral infection such as sore throat, coughs and colds, viral conjunctivitis has been excluded.
Antibiotics should never be prescribed during a telephone consultation apart from in exceptional circumstances.
Consider the use of a delayed prescription for infections such as simple urinary tract infections, acute sore throat, acute cough, acute
sinusitis, common cold.
Where an antibiotic is indicated, the agent chosen should be the narrowest spectrum for the identified condition i.e. avoid broad
spectrum antibiotics such as co-amoxiclav♣, cephalosporins♣ and quinolones♣.
Always prescribe for the shortest duration (using broad spectrum antibiotics for long periods can promote resistance).
Always prescribe generically.
Avoid topical antibiotics unless indicated as they can promote resistance.
Always check for allergy before prescribing an antibiotic.
In pregnancy AVOID prescribing tetracyclines, quinolones♣, high dose metronidazole and trimethoprim (in the first trimester). Short term
use of nitrofurantoin (at term there is a theoretical risk of neonatal haemolysis) is not expected to cause foetal problems.
For recurrent or resistant infection, please contact your local microbiologist for advice.
Gentamicin prescribing
For gentamicin guidance (once daily regime only recommended in this guideline) please see appendix 1.
IV therapy and step down to oral therapy
IV therapy should only be initiated where clinically indicated and a switch to oral therapy should be made at the earliest opportunity to reduce
the risk of further infection.
Please refer to latest BNF for further prescribing information.
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Considerations for IV to oral switch
COMS
C Clinical improvement
O Oral route not compromised
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Vomiting
NBM
Unconscious
Mechanical
Swallowing disorder
Malabsorptive disorder
NB: if NG/PEG feeding then please consult your pharmacist
Suitable oral antibiotic option available
M Markers showing a trend towards normal
O
o Apyrexial: Temp>36 and <38 C
o Plus not more than one of
o HR >90 beats/min
o Resp rate >20 breaths/min
o BP unstable
o WCC <4 OR >12 (if abnormal, a trend towards the normal range
and without neutropenia is acceptable)
S Specific indication/deep seated infection (e.g. meningitis/encephalitis,
endocarditis, mediastinitis, deep seated abscess/empyema, bone/joint infection,
Staph.aureus bacteraemia) when a switch to oral therapy would not be appropriate.
Many antibiotics are highly bioavailable in the oral form and as such IV may not be required, even in severe infection.
Clostridium difficile infection (CDAD)
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All antibiotic prescribing should be within the recommendations of this guideline for the shortest period.
Antibiotics that are associated with Clostridium difficile infection are highlighted in this guideline by the following symbol: ♣ and should
be avoided in ‘at risk’ groups such as the elderly and those in institutions.
Please refer to latest BNF for further prescribing information.
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Current evidence has shown that clindamycin♣ and second/third generation cephalosporins♣ such as cefuroxime♣, cefixime♣,
cefotaxime♣ and ceftriaxone♣ are significantly more likely to cause C. difficile associated diarrhoea (CDAD). Anecdotal evidence has
also implicated agents such as quinolones♣, first generation cephalosporins♣ and co-amoxiclav♣. These agents should therefore be
used sparingly, especially in the elderly and for patients who live in institutions where CDAD is present. They should also be avoided in
patients who have previously been treated for CDAD.
There is evidence that proton pump inhibitors (PPIs) increase the susceptibility to Clostridium difficile infection and the prescribing of
PPIs should therefore be considered carefully in at risk groups of patients and only be prescribed where there is a clear clinical
indication (see guideline available at
http://www.hertschs.nhs.uk/Library/staffarea/Polices_and_Guidance/Clinical_Policies/PPI%20prescribing%20guideline%20final.pdf).
Where possible, the prescriber should be guided by laboratory results. Where this is not possible a narrow spectrum antibiotic should be
selected.
Cephalosporin Prescribing
Analysis of electronic data has shown that NHS Hertfordshire are above average prescribers of cephalosporins♣ although this gap is starting to
narrow. Prescribers are reminded that recommendations to prescribe cephalosporins♣ appear in the following areas only:
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2nd line in meningitis
3rd line in UTI in pregnancy
2nd line in Pelvic inflammatory disease (PID) – high risk of gonorrhoea
1st line in epididymo-orchitis
Specific Drug Warnings
• Erythromycin
Erythromycin interacts with many other medications, the majority of which are classified by the BNF as ‘potentially hazardous’. Please see
appendix 1: interactions (macrolides) of the current BNF for further information. Interaction with statins – simvastatin should be temporarily
stopped during therapy with erythromycin.
• Clarithromycin
Interaction with statins: simvastatin should be temporarily stopped during therapy with clarithromycin; atorvastatin should be temporarily
stopped during therapy with clarithromycin but if continued dose of atorvastatin should not exceed 20mg daily.
Please refer to latest BNF for further prescribing information.
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• Flucloxacillin
The Committee on the Safety of Medicines (CSM) has advised that very rarely cholestatic jaundice and hepatitis may occur up to 2 months
after treatment with flucloxacillin has been stopped. Administration for greater than 2 weeks and increasing age are risk factors. Flucloxacillin
should not be used in patients with a history of hepatic dysfunction associated with flucloxacillin and should be used with caution in patients
with hepatic impairment.
• Quinolones♣
The CSM has warned that quinolones may induce convulsions in patients with or without a history of convulsions. Tendon damage (including
rupture) has been reported rarely in patients receiving quinolones. Tendon rupture may occur within 48 hours of starting treatment up to several
months after stopping a quinolone. Quinolones are contra-indicated in patients with a history of tendon disorders. Patients over 60 years or
those concomitantly taking corticosteroids are at increased risk of tendon damage.
• Co-amoxiclav♣
The CSM has advised that cholestatic jaundice can occur either during or shortly after treatment. An epidemiological study has shown that the
risk of acute liver toxicity was about 6 times greater than with amoxicillin. Cholestatic jaundice is more common in patients over 65 and in men
and rarely occurs in children. Jaundice is usually self-limiting and very rarely fatal. Duration of treatment should not usually exceed 14 days.
• Itraconazole
Following rare reports of heart failure, the CSM has advised caution when prescribing itraconazole to patients at high risk of heart failure. This
includes patients who are receiving high doses and longer treatment courses, older patients, those with cardiac disease and patients receiving
treatment with negative inotropic drugs such as calcium channel blockers. Itraconazole should be avoided in patients with ventricular
dysfunction or a history of heart failure unless the infection is serious.
Reference Sources Used
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NHS Clinical Knowledge Summaries. Current evidence references for individual infections – commissioned by NHS Evidence, a service
provided by the National Institute for Health and Clinical Excellence. Accessed January 2013.
Health Protection Agency. Meningococcal Disease – updated April 2011Accessed January 2013.
Health Protection Agency. General information on extended spectrum beta lactamases – January 2009. Accessed January 2013.
Please refer to latest BNF for further prescribing information.
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Health Protection Agency. Clostridium difficile infection – updated December 2012. Accessed January 2013.
Health Protection Agency. Helicobacter pylori – updated May 2009. Accessed January 2013.
National Institute for Health and Clinical Excellence. CG101 Management of Chronic Obstructive Pulmonary Disease in adults in
Primary and Secondary Care – June 2010. Accessed January 2013.
British National Formulary No 64 – September 2012. Accessed January 2013.
British Association for Sexual Health and HIV. Current guidelines for individual genital tract infections. Accessed January 2013.
British Thoracic Society. Guidelines for the management for community acquired pneumonia in adults – updated 2009. Accessed
January 2013.
National Electronic Library for Medicines. Clostridium difficile infection – which antimicrobials are implicated? Q&A 28.10.08. Accessed
January 2013.
Health Protection Agency. Management of Infection Guidance for Primary Care – for Consultation and Local Adaptation – November
2012. Accessed January 2013.
Acknowledgements
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The authors would like to thank the many health care professionals whose insightful and valuable comments helped to shape this
document. Particular thanks to Alison Dossetter, Prescribing Advisor with NHS Hertfordshire who produced the original NHS
Hertfordshire Guidance on the management of infection in Primary Care on which this document is based.
Other NHS organisations.
Comments
Comments are welcome and should be directed to Carolyn Haselden (Lead Pharmacist HCT) at [email protected]
Contacts
For further advice please contact one of the HCT Medicines Management Team:
Carolyn Haselden, Lead Pharmacist ([email protected]) 01279 827229
Jo Jenkins, Pharmacist ([email protected] k) 01279 827230
Ranjit Nagra, Pharmacist ([email protected] ) 01707 369664
Please refer to latest BNF for further prescribing information.
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Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
UPPER RESPIRATORY TRACT INFECTIONS NICE - Respiratory Tract Infections CG69
Pharyngitis / sore throat /
tonsillitis
Otitis media
Do not routinely prescribe
antibiotics or consider a
delayed prescribing
strategy. Majority of
infections are viral and
resolve within 1 week.
Do not routinely prescribe
antibiotics. For acute
attacks with no systemic
features advise
paracetamol or ibuprofen
for pain.
Phenoxymethylpenicillin
500mg QDS
10 days
The majority of sore throats are viral but there is
clinical overlap between viral and streptococcal
infections. Consider delayed script as antibiotics
generally shorten duration of symptoms by 8 hours.
Patients with 3 or 4 Centor criteria (history of fever,
purulent or enlarged tonsils, cervical adenopathy,
absence of cough) or history of otitis media may
benefit from antibiotics.
Clarithromycin
500mg BD
5 days
CKS - Sore Throat
Amoxicillin or
clarithromycin (penicillin
allergy). Azithromycin for
treatment failure (3 days).
Consult current BNF for
Children for doses.
5 days
60% of attacks resolve within 24 hours without
antibiotics. They only reduce pain at 2 days and do
not prevent deafness. Consider 2 or 3 day delayed
or immediate antibiotics for pain relief if:
• < 2 years with bilateral AOM or bulging
membrane and ≥ 4 marked symptoms
• All ages with otorrhoea
CKS - Otitis media
Acute sinusitis
Do not routinely prescribe
antibiotics and advise use
of adequate analgesia.
Amoxicillin 500mg TDS
Clarithromycin 500mg BD
or doxycycline 200mg stat
then 100mg OD. Consider
erythromycin for pregnant
women and coamoxiclav♣ for persistent
symptoms.
Please refer to latest BNF for further prescribing information.
7 days
Many attacks are viral and symptomatic benefit of
antibiotics is small – 80% resolve within 14 days
without antibiotics. Consider an immediate script if
patient is systemically unwell, has co-morbidities or
when purulent nasal discharge is present.
CKS - Sinusitis
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Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
LOWER RESPIRATORY TRACT INFECTIONS Low doses of penicillins are more likely to select out resistance. Do NOT use quinolones first line
due to poor pneumococcal activity. Reserve all quinolones for proven resistant organisms.
The benefits of antibiotics are marginal in otherwise
healthy adults. The use of leaflets explaining the
nature of the illness and why antibiotics are not
necessary may be helpful. Consider immediate
Amoxicillin 500mg TDS or
antibiotics if > 80 years and ONE of: hospitalisation
Acute Bronchitis
Doxycycline 200mg stat
5 days
in last year, oral steroids, diabetic, congestive heart
then 100mg OD
failure OR > 65 years with 2 of above.
CKS - Acute bronchitis
Acute exacerbation of
COPD
Amoxicillin 500mg TDS or
Doxycycline 200mg stat
then 100mg OD
Co-amoxiclav♣ 625mg
TDS (if resistance)
5 days
NICE - CG69
Treat exacerbations promptly with antibiotics if
purulent sputum and increased shortness of breath
and/or increased sputum volume. Risk factors for
antibiotic resistant organisms include co-morbidities,
severe COPD, frequent exacerbations or antibiotic
treatment within last 3 months. Oral steroids may be
considered in conjunction with antibiotics where
inflammation is a factor or considered alone if cause
viral or environmental.
CKS - COPD
NICE - COPD
Community acquired
pneumonia - treatment in
the community
If CRB*65 score = 0
Amoxicillin 500mg TDS or
Clarithromycin 500mg BD
or Doxycycline 200mg stat
then 100mg OD
Please refer to latest BNF for further prescribing information.
7 days
Start antibiotics immediately. Use CRB65 score to
help guide and review.
0 = suitable for home treatment.
1-2 = hospital assessment or admission.
3-4 = Urgent admission.
*Each scores 1: Confusion (AMT<8); Respiratory
rate > 30/minute; Age > 65; Bp systolic <90 or
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Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
diastolic ≤60.
Give immediate IM Benzylpenicillin or oral
amoxicillin (1G) if delayed admission or life
threatening.
If CRB65 score = 1 and
patient at home
Amoxicillin 500mg TDS
plus Clarithromycin 500mg
BD or doxycycline 200mg
stat then 100mg OD
Community Acquired
Pneumonia: Hospital
Treated Non-Severe
Pneumonia
Community Acquired
Pneumonia: Hospital
Treated Severe
Pneumonia
Amoxicillin 500mg – 1g tds
plus clarithromycin 500mg
bd PO
If penicillin allergic:
clarithromycin 500mg bd
PO
Amoxicillin 1g tds IV plus
clarithromycin 500mg bd IV
Switch to oral
amoxicillin/clarithromycin
when clinically appropriate
CKS - Pneumonia
10 days
BTS - 2009 Guideline
Alternative if intravenous
treatment needed
because patient cannot
7-10 days
take by mouth:
Amoxicillin 500mg – 1g tds
IV plus clarithromycin
500mg bd IV
If penicillin allergic:
clarithromycin 500mg bd
IV
If penicillin allergic:
teicoplanin 400mg once
daily (after
3 loading doses of 400mg
12 hourly) plus
clarithromycin 500mg bd
IV
Please refer to latest BNF for further prescribing information.
7-10 days
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Infection
1st Line Choice
2nd Line Choice
Duration
Hospital acquired
pneumonia
Piperacillin/tazobactam
2.25g IV TDS
If penicillin allergic:
Consult Consultant
Microbiologist
7-10 days
Aspiration pneumonia
Co-amoxiclav IV 1.2g 8
hourly
If allergic to penicillin:
clarithromycin IV/oral
500mg 12 hourly
plus metronidazole IV
500mg or oral 400mg 8
hourly
Rationale/Comments
7-10 days
If severe and hospital
acquired
add ciprofloxacin as
above
MENINGITIS
Suspected meningococcal
disease
Adults and children aged
10 years and over
Benzylpenicillin IV
(preferable) or IM 1200mg,
children aged 1 to 9 years
600mg, children aged
under 1 year 300mg
Cefotaxime♣ 1G IV
(preferable) or IM (minor
penicillin allergy)
Please refer to latest BNF for further prescribing information.
Transfer all patients to hospital immediately.
NICE recommends that children and young people
with suspected bacterial meningitis without nonblanching rash should be transferred directly to
secondary care and not given parenteral antibiotics.
If urgent transfer is not possible then antibiotics
should be administered.
For suspected meningococcal disease (meningitis
with non-blanching rash or meningococcal
septicaemia), parenteral antibiotics should be given
at the earliest opportunity but transfer to secondary
care should not be delayed in order to give the 15
parenteral antibiotics.
Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
Secondary prevention should only be prescribed
after consulting a public health doctor.
HPA - Guidelines
NICE - Meningococcal disease
SEPTECAEMIA (not meningitis – see separate entry)
Septicaemia
Continue to follow the care
plan as provided by the acute
setting
URINARY TRACT INFECTIONS Nitrofurantoin is usually first line but should be avoided if eGFR is < 60ml/minute/1.73m
Uncomplicated UTI i.e. no
fever or flank pain
(women)
Nitrofurantoin 50mg QDS
or 100mg BD (MR) or
trimethoprim 200mg BD
3 days
2
Consider delayed script for 2 days. Extended
spectrum beta lactamases (ESBLs) are increasing
so perform cultures in all treatment failures. ESBLs
remain sensitive to nitrofurantoin and there is less
failure with trimethoprim than with cephalosporins. If
clinical signs present treat empirically. If few clinical
signs present then do dipstick tests for both
leukocyte esterase (LE) and nitrite - only treat if both
are positive.
CKS - UTI
HPA - ESBLs
NICE - UTI 3 day course
Complicated UTI
(including UTI with
underlying pathology)
Nitrofurantoin 50mg QDS
or 100mg BD (MR) or
trimethoprim 200mg BD
Please refer to latest BNF for further prescribing information.
7 days
16
Infection
UTI in pregnancy
1st Line Choice
Nitrofurantoin 50mg QDS
(risk of foetal/neonatal
haemolysis if used near to
term)
2nd Line Choice
Trimethoprim 200mg BD
(not in first trimester) or
Cefalexin♣ 250mg QDS
rd
(3 line)
Duration
7 days
Rationale/Comments
Mid-stream urine (MSU) should always be taken
to confirm sensitivity. Do not use trimethoprim in
women who are in the first trimester. Do not use
nitrofurantoin in women who are G6PD deficient or
are near to term.
CKS - UTI in pregnancy
UTI in men
UTI - recurrent (≥ 3 per
year) in non-pregnant
adult women
Nitrofurantoin 50mg QDS
or 100mg BD (MR) or
trimethoprim 200mg BD
Trimethoprim 100mg nocte
or nitrofurantoin 50mg
nocte
7 days
MSU should always be taken to confirm
sensitivity. Consider prostatitis.
CKS - UTI in men
6 month trial
Offer a script for stand by treatment before
considering prophylactic antibiotics. Use a STAT
dose of trimethoprim 100mg post coital if recurrent
infection is associated with sexual intercourse
(unlicensed and within 2 hours of sexual
intercourse). Use a nightly prophylactic dose for
recurrent infection NOT associated with sexual
intercourse.
Caution - prolonged use of nitrofurantoin can cause
pulmonary fibrosis
CKS - UTI recurrent
Pyelonephritis - acute
Ciprofloxacin♣ 500mg BD
OR
7 days
Co-amoxiclav♣ 625mg
TDS
14 days
Please refer to latest BNF for further prescribing information.
MSU should always be taken to confirm
sensitivity. If no response within 24 hours or there
is clinical deterioration arrange for admission.
CKS - Pyelonephritis
17
Infection
1st Line Choice
Prostatitis - acute
Ciprofloxacin♣ 500mg BD
Urinary catheter insertion
or change
No treatment
recommended unless:
o History of bacteremia on
previous insertion/change
o Prosthetic material in situ
o Neutropenia (pt not
already on antibiotics)
o Patients undergoing
peritoneal dialysis
Patients with indwelling
urinary catheters
Usually antibiotic treatment
is not required unless
patient
is
systemically
unwell, when treatment
should follow antibiotic
sensitivity test result with
changing /removal of the
catheter. If symptoms are
moderate/severe
and
cannot wait for sensitivity
test
result
before
commencing
antibiotics
treat as for UTI and review
once results available.
2nd Line Choice
Trimethoprim 200mg BD
Duration
4 weeks
Rationale/Comments
4 weeks treatment may prevent chronic infection.
Quinolones♣ are more effective as they achieve
higher prostate levels. If patient is sexually active,
chlamydia needs to be excluded. Infection should be
confirmed with a urine culture which will guide
treatment if it is positive.
CKS - Prostatitis
BASHH - Prostatitis
Please refer to latest BNF for further prescribing information.
For empirical management: Discuss with Consultant
Microbiologist
CKS-Prevention of UTI in women during catheter
change
CKS-Prevention of UTI in men during catheter
change
Do not treat asymptomatic bacteriuria. Considerable
clinical judgement is required to diagnose urinary tract
infection (UTI) in men with an indwelling urinary
catheter. If symptoms are severe (for example severe
nausea and vomiting, confusion, tachypnoea,
tachycardia, hypotension, reduced urine output), admit
the person to hospital; intravenous antibiotics may be
required. Check that the catheter is correctly positioned
and is not blocked. If the catheter has been in place for
more than a week, consider changing it before starting
antibiotic treatment. If there is fever or loin pain (or
both), manage as acute pyleonephritis. Otherwise, treat
as for UTI but before starting antibiotic treatment, obtain
a urine sample for culture/microscopy.
CKS-Indwelling catheter related UTI men
CKS-Indwelling catheter related UTI women
18
Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
GASTRO-INTESTINAL TRACT INFECTIONS
Gastro-enteritis
Clostridium difficile
Associated Diarrhoea
(CDAD)
Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and can cause resistance. Fluid
replacement is essential and only initiate antibiotic treatment if the patient is systemically unwell. Check travel, food, hospital and
antibiotic history as C. difficile is increasing.
In community setting please send stool specimens from suspected cases of food poisoning and post antibiotic use and notify the
Health Protection Unit after seeking advice from a public health doctor. In HCT Bed Based Units please inform the infection
control team who will notify the HPA as necessary.
Stop all antibiotics unless it is absolutely essential
that they are continued (consider hospital admission
in these circumstances) and review need for PPI
and laxative therapy (see HCT guidance for
prescribing of PPIs and laxatives at
http://www.hertschs.nhs.uk/staffarea/Polices_and_Guidance/Clinical_Policies.aspx).
Send a stool sample. 70% respond to metronidazole
Vancomycin 125mg QDS
in 5 days; 92% in 14 days. Recurrent disease occurs
Metronidazole 400mg TDS
rd
10 - 14 days in about 20% of patients treated initially with either
(3 episode or if severe or
st nd
(1 /2 episodes)
if type 027 confirmed)
metronidazole or vancomycin. The same antibiotic
that was used initially can be used to treat the first
recurrence because the majority of recurrences are
reinfections as opposed to relapses.
CKS - CDAD
HPA - Clostridium difficile
CDAD relapse (second
and subsequent
recurrences)
Vancomycin 125mg QDS
Please refer to latest BNF for further prescribing information.
14 days
Send stool sample for confirmation. Withhold
antibiotic treatment if symptoms mild. Discuss
management with a consultant microbiologist.
HPA - C Diff guidelines
19
Infection
Helicobacter Pylori
eradication (positive test)
Diverticulitis (acute)
1st Line Choice
2nd Line Choice
PPI (use cheapest) plus
clarithromycin 250mg BD
plus metronidazole 400mg
BD OR PPI (use cheapest)
plus clarithromycin 500mg
BD plus amoxicillin 1G BD
7 days
PPI plus tripotassium
dicitratobismuthate 120mg
QDS plus 2 unused
antibiotics: amoxicillin 1G
BD, metronidazole 400mg
TDS, tetracycline 500mg
QDS
Co-amoxiclav♣ 625mg
TDS
Duration
Metronidazole 400mg
TDS plus ciprofloxacin♣
500mg BD in penicillin
allergy
Rationale/Comments
Do not use either metronidazole or clarithromycin if
used in the past year for any infection. SEE
CURRENT BNF FOR INFORMATION. It is not
usually necessary to continue PPI therapy but if the
ulcer is large, haemorrhaging or perforated then PPI
treatment can be continued for 3 weeks. Discuss
treatment with local gastroenterologists to ensure
compliance with local guidelines.
14 days
HPA - Helicobacter pylori
7 days
Broad spectrum antibiotics should be prescribed to
cover both anaerobes and Gram-negative rods.
Paracetamol should be prescribed for pain and the
patient should be advised to consume clear liquids
only. Solid food can be gradually introduced as
symptoms improve over 2 to 3 days. Review within
48 hours or sooner if symptoms deteriorate.
CKS - Acute Diverticulitis
GENITAL TRACT INFECTIONS - BASHH (British Association of Sexual Health and HIV) GUIDELINES. Refer all patients and contacts with suspected
STIs to GUM clinic.
Guidelines - BASHH
Vaginal Candidiasis
Clotrimazole cream 10%
PV or clotrimazole 500mg
pessary
Fluconazole 150mg oral
Please refer to latest BNF for further prescribing information.
STAT dose
All topical and oral azoles give 75% cure. Avoid oral
azoles in pregnancy. There are many other options
for treatment including a 3 day course of
clotrimazole 200mg pessary and a 6 day course of
clotrimazole 100mg pessary.
20
Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
CKS - Candidiasis
Vaginal Candidiasis in
pregnancy
Clotrimazole 100mg
pessary
6 Nights
HPA - Vaginal candidiasis
Counsel patient that applicators may be used but
care must be taken to avoid damage to the cervix.
Pessaries may be inserted by hand.
CKS - Candida - female genital
Metronidazole 400mg BD
or 2g stat
Bacterial Vaginosis
Clindamycin 2% vaginal
cream 5g at night
Metronidazole 0.75%
vaginal gel 5g at night
7 days
A 7 day course of oral metronidazole is slightly more
effective than 2g stat. Avoid 2g stat dose in
pregnancy. Topical treatment gives similar cure
rates but is more expensive.
5 days
CKS - Bacterial vaginosis
HPA - Bacterial vaginosis
Azithromycin 1g
STAT dose
Chlamydia Trachomatis
Doxycycline 100mg BD
7 days
Treat partners and refer all patients and contacts to
GUM clinic. Use azithromycin (unlicensed) in
pregnancy or breastfeeding as doxycycline is
contraindicated and test for cure 6 weeks after
treatment due to lower cure rate in pregnancy.
CKS - Chlamydia
HPA - Chlamydia
Epididymo-orchitis
Due to any sexually
transmitted pathogen
Ceftriaxone♣ 500mg IM
(stat) PLUS doxycycline
100mg BD
Under 35 years and/or
high risk of sexually
transmitted infection
Doxycycline 100mg BD or
ofloxacin♣ 200mg BD
Over 35 years and/or low
risk of sexually transmitted
infection
Please refer to latest BNF for further prescribing information.
14 days
Use ofloxacin for all cases where patient is allergic
to cephalosporins and/or doxycycline.
10 days
CKS - Epididymo-orchitis
21
Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
Co-amoxiclav♣ 625mg
TDS or ciprofloxacin♣
500mg BD
Trichomoniasis
Pelvic Inflammatory
Disease (PID)
Metronidazole 400mg BD
or 2g stat
Metronidazole 400mg BD
plus ofloxacin♣ 400mg BD
Tinidazole 2g stat
Ceftriaxone♣ 500mg IM
(single dose) plus
metronidazole 400mg BD
plus doxycycline 100mg
BD if gonorrhoea likely
5 – 7 days
14 days
Refer to GUM clinic and treat partners
simultaneously. Avoid 2g stat dose in pregnancy.
There is some evidence to suggest that a 2g stat
dose of metronidazole is less effective than 400mg
BD.
CKS - Trichomoniasis
HPA - Trichomoniasis
Refer patients and contacts to GUM clinic. Test for
N. Gonorrhoeae and Chlamydia. Microbiological and
clinical cure are greater with ofloxacin than with
doxycycline however there is emerging clinical
resistance to quinolones and they therefore
shouldn't be used for patients at high risk of
gonococcal infection.
CKS - PID
RCOG - PID
SKIN AND BONE INFECTIONS
Acne (moderate or severe)
Bites (animal and human)
Oxytetracycline 500mg BD
or Lymecycline 408mg OD
Co-amoxiclav♣ 375mg 625mg TDS (animal and
human)
Erythromycin 500mg
(2x250mg) BD (in
pregnancy or if
tetracyclines not tolerated)
Animal Bites (penicillin
allergy) metronidazole
400mg TDS plus
doxycycline 100mg BD
Please refer to latest BNF for further prescribing information.
4 to 6 months
Tetracyclines should not be used in pregnancy,
breastfeeding or in children under the age of 12 as
they are deposited in teeth and bones.
CKS - Acne
7 days
Antibiotic prophylaxis (antibiotics and duration as for
treatment - CKS) advised for all cat bites, animal
bites to the hand, foot or face; puncture wounds;
wounds requiring surgical debridement; wounds
22
Infection
1st Line Choice
2nd Line Choice
Human Bites (penicillin
allergy) metronidazole
400mg TDS plus
clarithromycin 250mg to
500mg BD
Duration
7 days
Rationale/Comments
involving joints, tendons, ligaments or suspected
fractures. Also patients at risk of serious wound
infection e.g. diabetics, cirrhotics, asplenic or
immunocompromised patients and the elderly.
Antibiotic prophylaxis advised for all human bites
and review after 24 and 48 hours. Assess for HIV,
tetanus, hepatitis B&C in human bites and tetanus
and rabies risk in animal bites.
CKS - Bites
Bites (insect)
Boils
Cellulitis
Systemic antibiotics only if
clinical evidence of
infection or patient is
systemically unwell or
purulent discharge present
Flucloxacillin 250mg 500mg QDS
Flucloxacillin 250mg –
500mg
Clarithromycin 250mg –
500mg BD (penicillin
allergy)
Clarithromycin 250mg –
500mg BD (penicillin
allergy) or erythromycin
250mg – 500mg
(2x250mg) QDS (in
pregnancy)
7 days
7 days
CKS - Insect bites
Antibiotics are not always necessary but can be
considered if the lesion is large or there is
associated fever or cellulitis, there are co-morbidities
e.g. diabetes or complications are more likely
because of the site affected e.g. face. Self care
advice should also be given
CKS - Boils
Non severe:
Flucloxacillin oral 500mg
qds
Moderate/ Severe:
Benzylpenicillin IV 1.2g
QDS plus
Flucloxacillin IV1g QDS
Treat as for cellulitis if infected. Fever/lymphangitis
are indicators for treatment. Hot/sore bites may be
due to local histamine release.
If MRSA suspected then add teicoplanin 400mg bd
every 12 hours for 3 doses then 400mg od for 10
days
If allergic to penicillin:
Contact microbiologist
If changing from IV, change
Please refer to latest BNF for further prescribing information.
7 days
For advice on the management of cellulitis in
patients with lymphoedema see Consensus
Document on the management of cellulitis in
lymphoedema
23
Infection
1st Line Choice
2nd Line Choice
Duration
Rationale/Comments
to oral amoxicillin AND oral
flucloxacillin
a) Mild infections:
Flucloxacillin 500mg qds
Patients with diabetes
(Diabetic Foot)
b) Cellulitis:
As cellulitis management
above
14 days
Note patients with peripheral neuropathy and or
peripheral vascular disease do not always display
the normal inflammatory signs of redness, heat and
swelling for example
For penicillin allergy
contact Consultant
Microbiologist.
Contact Consultant
Microbiologist
c) Severe infections:
Discuss with
local
microbiology
team
Start oral flucloxacillin
500mg qds and refer to the
acute medical/diabetes
team for further advice
Severe/limb threatening diabetic/Hot Foot is a
medical emergency that requires co-ordinated
input from the Diabetes Podiatrist, Consultant
Diabetologist and Consultant Microbiologist in
addition to surgical input
Cellulitis related to leg
ulcer(s) CREST guidance
Class I
Class I - Patients have no
signs of systemic toxicity,
have no uncontrolled comorbidities and can
usually be managed with oral
anti-microbials on an
outpatient basis
Flucloxacillin 500mg QDS
Clarithromycin 500mg BD
Please refer to latest BNF for further prescribing information.
7 days
CKS - Leg Ulcers/CREST (Clinical Resource
Efficiency Support Team) Management of Cellulitis
in Adults guidance 2005
http://www.acutemed.co.uk/docs/Cellulitis%20guideli
nes,%20CREST,%2005.pdf
24
Infection
1st Line Choice
2nd Line Choice
Cellulitis related to leg
ulcer(s) Class II/III
Class II -Patients are either
systemically ill or systemically
well but with a co-morbidity
such as peripheral vascular
disease, chronic venous
insufficiency or morbid
obesity which may complicate
or delay resolution of their
infection.
Flucloxacillin 2g QDS IV
Clarithromycin 500mg BD
IV
Class III -patients may have
a significant systemic upset
such as acute confusion,
tachycardia, tachypnoea,
hypotension or may have
unstable co-morbidities that
may interfere with a response
to therapy or have a limb
threatening infection due to
vascular compromise.
Duration
Rationale/Comments
Total course
length
dependent of
clinical
presentation
but typically
up to 14 days
– step down
to oral
therapy as
soon as
clinically
appropriate
(usually
within 3-4
days) - see
Class I for
dosages
Cellulitis related to leg
ulcer(s) Class IV
Class IV - patients have
sepsis syndrome or severe
life threatening infection such
as necrotizing
fasciitis.
Recurrent cellulitis related
to leg ulcer(s) - 2 or more
episodes at the same site
Seek Consultant Microbiologist advice
Penicillin V 250mg bd
Erythromycin 250mg bd
Please refer to latest BNF for further prescribing information.
Up to 2 years
depending on
clinical
situation
CREST (Clinical Resource Efficiency Support Team)
Management of Cellulitis in Adults guidance 2005
25
Infection
1st Line Choice
2nd Line Choice
Conjunctivitis
Local cleansing of affected
eye(s) using boiled, cooled
water can be
recommended before use
of topical antibiotics.
Chloramphenicol 0.5%
drops 2 hourly for 2 days
then 4 hourly whilst awake
or chloramphenicol 1%
eye ointment at night or
fusidic acid eye drops 1%
BD
Terbinafine 250mg OD
Amorolfine 5% topical
paint (mild or superficial
infections only) once or
twice a week
Dermatophyte infection of
the finger or toe nail
Itraconazole pulsed
therapy 200mg BD
Dermatophyte infection of
the skin
Clotrimazole 1% cream
BD-TDS
Terbinafine 1% cream BD
Eczema - infected
Impetigo
Duration
For 48 hours
after
resolution
Rationale/Comments
Most infections are viral, self-limiting and will clear
within 1-2 weeks without treatment (even if they are
bacterial). Chloramphenicol is available to buy over
the counter for patients over the age of 2 years.
CKS - Conjunctivitis
Fingers - 6 to
12 weeks and
toes - 3 to 6
months
Fingers - 6
months and
toes - 12
months
1 week with
subsequent
courses
repeated
after 21 days
For 1-2
weeks after
the infected
area has
healed
7-14 days
Take nail clippings. Treatment should only be
started if infection is confirmed. If symptoms are not
troublesome or patients are not at increased risk of
developing side effects, then self care measures
should be considered. NHS Hertfordshire has stated
that the treatment of dermatophyte infections is a
LOW priority.
Hertfordshire decision
Fingers require 2 pulsed courses and toes require at
least 3 courses
CKS - Fungal nail infection
Take skin scrapings for culture. Consider oral
itraconazole if intractable. Topical terbinafine is as
effective as clotrimazole.
CKS - Fungal skin infection
If there are no visible signs of infection, the use of antibiotics either alone or in combination with corticosteroids, encourages
resistance and does not improve healing. In infected eczema, treat as per impetigo below.
Fusidic acid 2%
Topical treatments should be reserved for
cream/ointment TDS (non
5 days
localised/minor infection to prevent resistance
bullous)
developing.
Please refer to latest BNF for further prescribing information.
26
Infection
1st Line Choice
2nd Line Choice
Flucloxacillin 500mg QDS
(bullous and non bullous)
Duration
Rationale/Comments
7 days
Clarithromycin 250500mg BD (penicillin
allergy – bullous and non
bullous)
7 days
CKS - Impetigo
CKS - Insect bites
Surgical wound infections
(post surgery)
Flucloxacillin 500mg-1g qds
(oral or IV)
In contaminated sites such
as groin co-amoxiclav
625mg tds or 1.2g IV tds if
severe
Dirty/penetrating wound
Co-amoxiclav 625mg tds
PO (or 1.2g tds IV for
severe infection)
Penicillin allergy –
Contact Consultant
Microbiologist
7 days
If allergic to penicillin:
Contact Consultant
Microbiologist
Consider tetanus prophylaxis
7 days**
Leg Ulcers
Flucloxacillin 500mg QDS
Clarithromycin 500mg BD
Please refer to latest BNF for further prescribing information.
Penicillin allergy consult local microbiology team for
advice. In severe infections, discuss with the
Consultant Microbiologist.
Ulcers always colonized. Antibiotics do not
improve healing unless there is active infection.
Swabs and antibiotics are only indicated if there is
either cellulitis or evidence of clinical infection e.g.
inflammation, redness, pyrexia, increased pain or
enlarging ulcer. Send pre-treatment swab in active
infection and review antibiotics after culture results.
Refer for specialist opinion in severe infection e.g.
diabetics.
**If the infection is sensitive to the empirical
antibiotic but only slowly responding and not
27
Infection
Mastitis
1st Line Choice
Flucloxacillin 500mg QDS
2nd Line Choice
Erythromycin 250mg –
500mg QDS
Duration
14 days
Rationale/Comments
deteriorating, review after 7 days and consider
continuing the antibiotic for a further 7 days
Antibiotic treatment is recommended if the woman
has an infected nipple fissure, symptoms do not
improve or are worsening after 12-24 hours despite
effective milk removal or bacterial culture is positive.
Antibiotics indicated are only excreted in very small
amounts and the infant should not be affected but
occasionally stools may be looser or more frequent
or the infant may be more irritable. The woman
should continue to breastfeed and paracetamol can
be used to relieve discomfort in addition to warm
compresses on the breast or a warm bath/shower.
CKS - Mastitis
PVL
Scabies
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of S.aureus. Can rarely cause severe invasive infections in
healthy people. Send swabs if recurrent boils/abscesses. Risks: close contact in communities or sports, poor hygiene, eczema.
HPA - PVL
Permethrin 5% dermal
cream
Malathion 0.5% aqueous
liquid – in permethrin
allergy
Repeat after
7 days
Treat whole body from ear/chin downwards including
under the nails. The very young, elderly and
immunocompromised should also apply treatment to
the face and scalp. Treat ALL household and sexual
contacts within 24 hours.
CKS - Scabies
Acute osteomyelitis
Flucloxacillin 1 – 2g qds IV
plus sodium fusidate 500mg
tds orally (NOT IV))
Change to oral antibiotics
after 10 – 14 days.
Penicillin allergy –
Contact Consultant
Microbiologist
Please refer to latest BNF for further prescribing information.
4 – 6 weeks
Blood cultures are essential. Review therapy when
culture results are available and the pathogen has
been identified.
28
Infection
Septic arthritis
1st Line Choice
Flucloxacillin 1 – 2g qds IV
plus
sodium fusidate 500mg tds
orally (NOT IV))
Consider oral switch when
clinically appropriate
2nd Line Choice
Penicillin allergy –
Contact Consultant
Microbiologist
Duration
Treat for 3 –
4 weeks
Rationale/Comments
Blood cultures essential. Aspirate pus for Gram
film and culture before initiating treatment with
antibiotics. Review therapy when culture results
available and pathogen known.
Initial high dose parenteral therapy is essential.
VIRAL INFECTIONS
Chicken Pox
Aciclovir 800mg five times
a day
7 days
If pregnant, immunocompromised or neonatal seek
urgent specialist advice. Consider aciclovir if onset
of rash is < 24 hours and over 14 years or severe
pain or dense/oral rash or secondary household
case or smoker. If patients develop life-threatening
complications such as encephalitis, pneumonia or
CNS deterioration they should be sent immediately
to hospital. It is recommended that non-immune
immunocompromised patients or pregnant women
who come into contact with chicken pox are given
Varicella-Zoster immunoglobulin (VZIG) if they meet
the criteria according to the current 'green' book.
Supplies can be obtained from the HPA Colindale on
020 8327 7471.
CKS - Chickenpox
Herpes Simplex (Oral)
Cold sores resolve after 710 days without treatment.
Topical antivirals applied
prodromally reduce
duration by 12-24 hours.
Aciclovir 5% topical cream
five times a day
Please refer to latest BNF for further prescribing information.
5 days
Counsel patient that treatment needs to be initiated
at the onset of symptoms before vesicles appear
and that topical antivirals only affect the course of
the current episode - they do not cure the individual
or prevent further recurrence.
CKS - Herpes
29
Infection
Shingles
1st Line Choice
Aciclovir 800mg five times
a day
2nd Line Choice
Use ONLY if compliance
is a problem because cost
is ten times greater than
aciclovir
Valaciclovir 1g TDS or
famciclovir 250mg TDS or
famciclovir 750mg OD
Please refer to latest BNF for further prescribing information.
Duration
7 days
Rationale/Comments
If pregnant or immunocompromised, seek urgent
specialist advice. Treat if over 50 years and within
72 hours of the rash or if there is active ophthalmic
infection or Ramsey Hunt or eczema.
CKS - Shingles
30
Appendix 1
Gentamicin – once daily dosage guidance (all gentamicin prescribing referred to in this guidance follows this once daily regime)
Despite the availability of newer, broad-spectrum antimicrobial agents, gentamicin has retained its major place in the treatment of severe infection due to
aerobic Gram negative bacilli for the following reasons:
o Potent broad spectrum bactericidal activity
o Minimal initial resistance and minimal development of resistance on therapy
o Cost
Gentamicin carries a risk of ototoxicity and nephrotoxicity. This can be minimised by:
o Not using gentamicin in patients with renal impairment
o Employing short courses (avoid more than 5 days therapy)
o Monitoring serum concentrations every 2 – 3 days (more often if renal function is changing)
o Employing a regimen with extended dosing interval (once-daily dose) instead of the standard 8 or 12 hourly regimens
Rationale for using once-daily doses:
o Gentamicin exhibits concentration-dependent killing of Gram negative organisms and prolonged post-antibiotic effects.
o Nephrotoxicity from gentamicin is saturable. With the same total dose a bolus dose carries a significantly lower risk of renal impairment than the same dose
as a constant infusion.
o The important factors for nephrotoxicity, whether a bolus or same dose in several administrations, are a) – high trough levels and b) – prolonged duration of
therapy.
o Uptake of gentamicin into the inner ear is also saturable (i.e. accumulation is not the cause of ototoxicity). For ototoxicity the important risk factors are
duration and concomitant renal impairment
o Therefore, if given correctly, once-daily bolus gentamicin results in improved bactericidal activity and reduced toxicity.
o Once-daily dosing, in addition to being convenient for staff, also results in reduced costs of drug administration and omission of measurements of peak
antibiotic levels should result in substantial cost savings.
Exclusions to using once-daily gentamicin dosing include:
o Creatinine Clearance (CrCl) < 40 ml/min or dialysis dependent
o Endocarditis (once-daily doses less satisfactory than multiples in experimental models)
Please refer to latest BNF for further prescribing information.
31
o
o
o
o
o
Major burns
Blindness (ototoxicity would be disastrous)
Neonates
Pregnancy (lack of data on teratogenicity)
Prophylaxis
Before initiating treatment:
1. Measure serum creatinine
2. Record the patient’s weight and serum creatinine in the medical notes
3. Record the actual infusion start time on the drug chart for each dose
Dosage and administration:
o 5mg/kg gentamicin IV as a once-daily dose rounded to the nearest 20mg
o Use Corrected Body Weight (CBW) if the patient is >15% obese (see below)
o If in doubt re calculation of dose, consult a Pharmacist
o 400mg is the maximum once-daily dose
o Administer as an intravenous infusion in 100ml sodium chloride 0.9% over 30 minutes at 14:00 hrs if possible to allow levels to be reported before
subsequent doses.
o Prescribe and sign for the first dose only on the ‘once only’ section of the drug chart.
o If further doses are required, continue to prescribe and sign on the ‘once only’ section of the drug chart on a daily basis
Monitoring of once-daily gentamicin dosing:
1. Monitor the gentamicin level and serum creatinine just before second dose.
2. For gentamicin monitoring, only a trough level (taken within one hour prior to the second dose) is required. Ensure the sample request form is labelled as a
‘pre-dose sample’ and that the time of the specimen is clearly recorded on it.
3. Sample Details:
o 5ml blood in the appropriate vacuette
o Label sample with Patient name, Hospital Number, Ward, Date
o Mark form with “Once-daily gentamicin dosing”
o Record date and actual time of sample
o Record date and actual time of last dose (use the time the dose is completed)
o Record the dose, clinical diagnosis and start date of gentamicin
o Send to Microbiology Laboratory with fully completed Assay Request Form.
Please refer to latest BNF for further prescribing information.
32
Level interpretation:
o If there is no evidence of renal impairment and the calculated CrCl is >60ml/min the second dose should be given before the level is reported
o The trough level should be <1mg/L (The actual level reported should be recorded in the medical notes)
o If recorded trough level is <1 mg/L, and gentamicin therapy is still indicated, the third dose may be prescribed and given when due. A further trough level
must be taken before the fourth dose if therapy is to continue
o If recorded trough level is >1 mg/L seek advice from Consultant or Pharmacy
o If the calculated CrCl is <60ml/min do not give the second dose until the result of the trough level is known
o If recorded trough level is <1 mg/L and gentamicin therapy is still indicated the second dose may be prescribed and given when due. A trough level must
be taken and the result known before each subsequent dose if therapy is to continue
o If recorded trough level for any subsequent dose is >1 mg/L seek advice from Consultant or Pharmacy before further administration.
Useful Equations
1) Creatinine clearance:
CrCl = F x (140 – age) x weight (kg)
Serum creatinine (micromol/L)
where F = 1.23 for males F = 1.04 for females
Use patient’s actual weight unless s/he is >15% obese when the ‘corrected’ body weight should be used
2) Corrected Body Weight (CBW) (To be used if patient >15% obese*)
CBW (kg) = Ideal Body Weight + (0.4 x Excess Body Weight)
3) Ideal Body Weight (IBW)
IBW (male) (kg) = 50kg + (2.3 x every inch over 5ft)
IBW (female) (kg) = 45.5kg + (2.3 x every inch over 5ft)
4) Excess Body Weight (EBW)
EBW (kg) = ABW – IBW
5) Percentage Obesity = ABW – IBW x 100
Glossary
Please refer to latest BNF for further prescribing information.
33
•
Bioavailability - The percent of dose entering the systemic circulation after administration of a given dosage form and so is able to have an active
effect.
Please refer to latest BNF for further prescribing information.
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