Antimicrobial Treatment Guidelines

Antimicrobial Treatment Guidelines1
• Unless otherwise stated, doses are for adults.
• Discuss with patient/carer what they expect as a result of the consultation. Explain risk/benefit of antibiotics.
Consider a delayed antibiotic prescription when appropriate.
Note. Dec. 10 – changes are in blue
• Reinforce importance of self-care to patient/carer.
Infection type
Recommended agent(s)
Antibiotics unlikely to help, symptoms may
take up to 3 weeks to resolve.
Most infections are viral. Give patient advice on
duration of cough. Consider a 7-14 day delayed
antibotic prescription, if appropriate.
Antibiotics have marginal benefits in
otherwise healthy adults.
[Amoxicillin 500 mg TDS, 5 days
or doxycycline 200 mg stat then100 mg OD, 5 days]
First-line - Doxycycline 200mg for 1st day,
100mg od thereafter, 5 day course
Second-line - Amoxicillin 500mg tds (if a
tetracycline not suitable) 5 day course
IF resistance risk factors: Co-amoxiclav
625mg tds, 5 days
IF CRB65=0: suitable for home treatment:
Amoxicillin 500mg tds, 7 days
Or Erythromycin 2 x 250mg qds, 7 days,
Or Doxycycline 200mg for 1 day, 100mg od
thereafter 7 day course
Respiratory infections
Acute bronchitis
Acute exacerbation of
Community Acquired
Pneumonia – start
antibiotics immediately
BTS 2009 Guidelines
IF CRB65=1 & AT HOME (after hospital
Amoxicillin AND Erythromycin 7-10 days
Not indicated in absence of purulent/
mucopurulent sputum.
Treat promptly if purulent sputum and increased
SOB and/or increased sputum volume.
Send sputum for culture if no response to
empirical treatment.
Risk factors for antibiotic resistant organisms
include co-morbid disease, severe COPD,
frequent exacerbations, antibiotics in last 3 months
If no response after 48 hrs consider admission or
add erythromycin if risk of atypical pneumonia.
During a flu pandemic, doxycycline should be the
first line choice (co-amoxiclav for children). This is
to cover S aureus. Detailed guidance will be sent
when this change needs implementing.
For CRB65, score 1 point for each of these:
age ≥ 65 yrs; confusion (AMT<8); respiratory rate
(>30/min); BP systolic <90 or diastolic ≤ 60.
- Score 1-2: hospital assessment or admission
- Score 3-4: urgent hospital admission
Give immediate IM benzylpenicillin or amoxicillin
1G po if delayed admission / life threatening
Or Doxycycline alone 7-10 days
ENT infections
Acute otitis media
If clinically indicated –
60% resolve in 24 hours
without antibiotics.
Consider the delayed
prescription option.
Antibiotics unnecessary in most cases
Amoxicillin – 5 day course
1 month to 1 year – 62.5-125mg tds
1 – 5 years - 125-250mg tds
> 5 years - 250-500mg tds
[Above doses based on 40mg/kg/daily as BNF]
Or Erythromycin – 5 day course
< 2yrs: 125mg qds
2 - 8yrs: 250mg qds
Other: 250-500mg qds
Chronic otitis media
Antibiotics unlikely to help – use analgesia
Sore throat/tonsillitis
If clinically indicated.
Most sore throats are viral.
Penicillin V, 10 day course
Age 1 month - 1 year: 62.5mg qds
Age 1 - 5 years: 125mg qds
Age 6 - 12 years: 250mg qds
Adult dose: 2 x 250mg qds
90% resolve in 7 days
without antibiotics
Consider the delayed
prescription option.
- Antibiotics to prevent Quinsy
NNT >4,000
- Antibiotics to prevent Otitis
Media NNT 200
If penicillin allergic:
Erythromycin 5 day course
Age 1 month - 2 years: 125mg qds
Age 2 - 8 years: 250mg qds
Adult & child >8 years: 250-500mg qds
(or total daily dose split and given BD).
Use analgesia for symptom relief
Poor outcome unlikely if no vomiting or temp
Child is just as likely to have vomiting, diarrhoea
or rashes due to the antibiotic as they are to
benefit from pain relief after 2 days (NNT15)
Antibiotics do not prevent deafness. To
prevent mastoiditis NNT>4000
Depending on clinical assessment of severity,
NICE advises to also consider antibiotics for:
children with otorrhoea; or those <2years with
bilateral acute otitis media
Use analgesia (paracetamol or ibuprofen) for
symptom relief
The probability of preventing one case of
glomerulonephritis or rheumatic fever is the same
as causing a death by penicillin induced
Erythromycin 250mg qds = less side effects than
2 x 250mg bd.
Depending on clinical assessment of severity,
NICE advises to also consider antibiotics for
patients when 3 or more Centor criteria are
present. [Centor criteria are : history of fever;
tonsillar exudates; tender anterior cervical
lymphadenopathy; and an absence of cough]
ENT infections (continued)
Updated from the Health Protection Agency Antibiotic Guidance 05/08/10.
Updated 22.11.10. Dr Diane Harris & Temi Omorinoye, Antimicrobial Pharmacists.
Sinusitis – if clinically
Usually viral do not treat with antibiotics.
Secondary infection or symptoms >10 days:
First-line - Doxycycline 200mg for 1st day,
100mg od thereafter, 7 day course
(or Erythromycin 2 x 250mg qds for 7 days)
For persistent infection with symptoms:
co-amoxiclav 625mg tds for 7days
Trimethoprim 200mg bd for 3 days or
Nitrofurantoin 50mg-100mg qds for 3 days
Women (non- pregnant) with severe/≥ 3
symptoms: treat or 48hr delayed prescription
Women (non- pregnant) with mild/ ≤ 2 symptoms:
use dipstick to guide treatment. Nitrite & blood or
leucocytes has 92% +ve predictive value; but
negative nitrite, leucocytes & blood has 76% NPV
Perform culture & susceptibility only in treatment
failure, pregnant, children, men, renal impairment
In the elderly (>65 years) do not treat
asymptomatic bacteriuria.
Symptomatic benefit of antibiotics is small
80% of cases resolve in 14 days without
antibiotics (thus reserve for severe / symptoms >
10 days).
Consider pain relief and steam inhalation.
Consider 7-day delayed or immediate antibiotic
when purulent nasal discharge (NNT8).
Use analgesia for symptom relief
Urinary/Genital Tract
UTI uncomplicated in men
& non-pregnant women
i.e. no fever or flank pain
Recurrent UTI symptoms
in non-pregnant women:
Note: Treat UTIs for 7 days in men
Acute episode - review diagnosis & culture urine
Recurrent UTIs ≥ 3 UTIs/year:
- Consider stand by antibiotic or
- nightly prophylaxis of Nitrofurantoin / Trimethoprim
Obtain specialist advice before giving prophylaxis
UTI in pregnancy:
Nitrofurantoin 50-100mg qds for 7 days (but
(Important- see HPA & CKS)
See - PCT Update on UTI
diagnosis & management:
not to be used at term)
or Trimethoprim 200mg bd for 7 days (Avoid in
first trimester of pregnancy)
Acute Pyelonephritis
Loin pain and/or Pyrexia
Ofloxacin 400mg bd for 7 days
Acute prostatitis
Ofloxacin 200mg bd for 28 days
Uncomplicated Genital
Chlamydia Infection
Doxycycline 100mg bd for 7 days
or Azithromycin 1g as a single dose
Pregnancy or breastfeeding –
Erythromycin 2 x 250mg qds 7days (or bd 14
High risk of gonorrhoea
Cefixime 400 mg as a single dose PLUS
metronidazole 400 mg BD for 14 days PLUS
doxycycline 100 mg BD for 14 days
OR (if gonorrhoea low risk) Ofloxacin 400mg bd PLUS
Metronidazole 400mg bd for 14 days
Trichomoniasis vaginalis
Trimethoprim: - in renal impairment use BNF for
dosages; and avoid in renal transplant patients
Avoid nitrofurantoin if eGFR is less than 60ml /
minute /1.73m (see BNF).
Nitrofurantoin – contra-indications include: G6PD
deficiency; acute porphyria; infants <3months old
or Cefalexin 500mg bd for 7 days
Or Co-amoxiclav 625mg tds for 14 days
Pelvic Inflammatory
Metronidazole 400mg bd for 5 - 7 days
Dipstick test the urine for evidence of UTI.
Take MSU for culture and sensitivity testing and
then start empirical antibiotics
If no response within 24 hours, admit to hospital
Send MSU for culture and then start antibiotics
Treat partners & refer to GUM for follow-up and
contact tracing
Tetracyclines contraindicated in pregnancy.
Testing should be targeted to 15- 25s (over 25s
are at much lower risk).
If erythromycin is used, retest after 6 weeks, as
less effective (HPA).
Always culture for gonorrhoea & chlamydia.
28% of gonorrhoea isolates now resistant to
If high risk of gonorrhoea (defined as patient
having severe symptoms or has had sexual
contact abroad or partner has gonorrhoea) avoid
ofloxacin regimen.
Refer woman and contacts to GUM
Treat partners simultaneously & refer to GUM
Transfer all patients to hospital immediately
If time before admission, give IV/IM antibiotic asap
Benzyl penicillin should be given unless there is a
clear history of ANAPHYLAXIS following previous
penicillin administration (i.e history of difficulty
breathing, collapse, loss of consciousness etc)
A stat dose of cefotaxime is a suitable alternative in
cases of penicillin allergy. [Note. 0.5 - 6.5% of
penicillin sensitive patients will also be allergic to
Emergency treatment of
suspected meningococcal
Benzylpenicillin IV or IM
Child 1 - 9 years
Adult (10 years and over) 1200mg
If penicillin allergic:
Cefotaxime IV or IM
Child 12 yrs & under
Adult (over 12 yrs)
Skin and Soft Tissue
Mild – benzoyl peroxide topical 5% 1-2 times
OD after washing
Moderate – first-line Doxycycline 100mg od
(or oxytetracycline 2 x 250mg bd)
2 line: Lymecycline 408mg od
3 line: Erythromycin 2 x 250mg bd
Severe Add topical peroxide prn to oral choice
Skin and Soft Tissue (continued)
Reserve topical antibiotics for those who cannot
tolerate oral.
Use oral antibiotics for 3 months and review
Increasing widespread erythromycin resistance of
propionibacteria may mean poor response
Photosensitivity reported with doxycyline, advice
adequate sun protection in patients regularly
exposed to sunlight.
Impetigo – if localised try
Polyfax ointment
If widespread Flucloxacillin 500mg qds - 7 days
If penicillin allergic – Erythromycin 2 x
250mg qds
Flucloxacillin 500mg qds for 7 days & review
If Penicillin allergic Erythromycin 2 x 250mg
qds 7days
Facial cellulitis
Co-amoxiclav 625mg tds 7days
Dermatophyte infection of
finger/toe nails
Terbinafine 250mg od
• Fingernails 6 – 12 weeks
• Toenails 3 – 6 months
First-line - Permethrin 5 % cream
Second-line – Malathion 0.5% aqueous
Antivirals not needed: see exceptions
Aciclovir Tabs or Dispersible 800mg five
times a day for 7 days
Reduce dose in renal impairment (BNF)
Co-amoxiclav 375 - 625 mg tds for 7 days
If penicillin allergic:
Metronidazole 200-400mg tds, 7 days PLUS
either Erythromycin 2 x 250mg qds 7 days
(human bites only).
or Doxycycline 100mg bd 7 days
(cat/dog/human bites)
Mild infection: Flucloxacillin 500mg-1g qds
for 7-14 days
Moderate: Co-amoxiclav 625 mg tds for 7- 14
All treatments usually for 7-14 days, then review
Mild cellulitis – flucloxacillin may be used as
single drug treatment.
Severe cellulitis may require parenteral antibiotics
If slow response continue for a further 7 days
Take nail clippings
Consider therapy only if infection is confirmed by
Discuss risk/benefit of drug treatment with patient
for a self-limiting cosmetic problem
Treat whole body, and wash off: after 8 - 12 hours
for permethrin; and after 24 hours for malathion.
Use two applications 7 days apart
Treat all household & sexual contacts
> 50 years and within 72 hours of rash
Young patients with severe acute pain and within
72 hours of rash
Immunocompromised patients (specialist advice)
Active ophthalmic/facial
Shingles with eczema
Ramsay Hunt Syndrome
Infected diabetic foot ulcer
If penicillin allergic: Clindamycin 300mg qds
for 7-14 days
Avoid topical products to minimise antibiotic
resistance – if localised try Polyfax ointment.
Do not use mupirocin (reserved for MRSA)
Thorough irrigation is important
Human: Assess risk of tetanus, HIV, hepatitis
Cat/Dog: Assess risk of tetanus and rabies
Review at 24-48 hours
Refer to foot care multidisciplinary clinic
Antibiotics should be reserved for when
surrounding cellulitis is present
Take swabs & start empirical antibiotic treatment
Review patient within 48 hours
Advise patient to seek urgent medical attention if
symptoms or general condition deteriorates
Clindamycin, co-amoxiclav and prolonged
courses of amoxicillin may cause C.diff diarrhoea,
warn patient to stop antibiotic and contact GP
immediately if diarrhoea develops
Dental infection (acute
dento-alveolar infection)
Amoxicillin 250mg tds for 5 days or
Metronidazole (anaerobes) 200mg tds for 3
Refer to dentist.
Flucloxacillin 500 mg qds for 14 days
Use analgesia for symptom relief.
Advise women to continue to
breastfeed or express milk by
hand/ pump from the affected
breast to ensure effective milk
(NICE CG37, WHO 2000,
NCCPC 2006)
If no improvement after 48 hours, change to:
Co-amoxiclav 375-625 mg tds for 14 days
Or as per culture results
If penicillin allergic:
Erythromycin 2 x 250mg qds 10-14 days - but
if no improvement after 72 hours, add
Metronidazole 400mg tds
Antibiotic treatment is only indicated in the following
cell and bacterial colony counts and culture are
available and indicate infection, or
symptoms are severe from the beginning, or
a nipple fissure is visible, or
symptoms do not improve after 12 hours of
improved milk removal
Send a sample of the milk for culture if no
improvement after 48 hours of antibiotic
Advise ALL women to seek further information &
continued breastfeeding support from their health
visiting team or specialist infant feeding team
1. Updated from Health Protection Agency, 2010. Management of infection guidance for primary care.
Note. Several Quick reference guides e.g. for Chlamydia testing and UTI testing are available from this website.
Care pathway for respiratory tract infections (NICE Clinical Guideline 69 – Respiratory tract infections – antibiotic prescribing, July 2008).
- for self-limiting RTIs in adults & children over 3 months, in primary care
At the first face-to-face contact in primary care, including walk-in centres and emergency departments, offer a clinical assessment, including:
History (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant risk factors, relevant comorbidities)
Examination as needed to establish diagnosis.
Address patients’ or parents’/carers’ concerns and expectations when agreeing the use of the three antibiotic strategies (no prescribing, delayed prescribing and immediate prescribing)
Agree a no antibiotic or delayed antibiotic prescribing strategy for patients
with acute otitis media, acute sore throat/pharyngitis/acute tonsillitis, common
cold, acute rhinosinusitis or acute cough/acute bronchitis.
No antibiotic prescribing
Offer patients:
• Reassurance that antibiotics
are not needed immediately
because they will make little
difference to symptoms and
may have side effects, for
example, diarrhoea, vomiting
and rash.
• A clinical review if the RTI
worsens or becomes
However, also consider an immediate prescribing strategy for the
following subgroups, depending on the severity of the RTI.
Delayed antibiotic prescribing
Offer patients:
• Reassurance that antibiotics are
not needed immediately because
they will make little difference to
symptoms and may have side
effects, for example, diarrhoea,
vomiting and rash.
• Advice about using the delayed
prescription if symptoms do not
settle or get significantly worse.
• Advice about re-consulting if
symptoms get significantly worse
despite using the delayed
The delayed prescription with
instructions can either be given to
the patient or collected at a later
No antibiotic, delayed antibiotic or
immediate antibiotic prescribing
Depending on clinical assessment of
severity, also consider an immediate
prescribing strategy for:
• Children younger than 2 years with
bilateral acute otitis media
• Children with otorrhoea who have
acute otitis media
• Patients with acute sore throat/acute
tonsillitis when three or more Centor
criteria are present.
Centor criteria are: presence of
tonsillar exudate, tender anterior
cervical lymphadenopathy or
lymphadenitis, history of fever and an
absence of cough.
The patient is at risk of developing complications.
Immediate antibiotic prescribing or further
investigation and/or management
Offer immediate antibiotics or further
investigation/management for patients who:
• Are systemically very unwell
• Have symptoms and signs suggestive of serious
illness and/or complications (particularly pneumonia,
mastoiditis, peritonsillar abscess, peritonsillar
cellulitis, intraorbital or intracranial complications)
• Are at high risk of serious complications because of
pre-existing comorbidity. This includes patients with
significant heart, lung, renal, liver or neuromuscular
disease, immunosuppression, cystic fibrosis, and
young children who were born prematurely
• Are older than 65 years with acute cough and two or
more of the following, or older than 80 years with
acute cough and one or more of the following:
- hospitalisation in previous year
- type 1 or type 2 diabetes
- history of congestive heart failure
- current use of oral glucocorticoids
Offer all patients:
• Advice about the usual natural history of the illness and average total illness length:
acute otitis media: 4 days
acute sore throat/acute pharyngitis/acute tonsillitis: 1 week
common cold: 1½ weeks
acute rhinosinusitis: 2½ weeks
acute cough/acute bronchitis: 3 weeks
• advice about managing symptoms including fever (particularly analgesics and antipyretics), For information about fever in children younger than 5 years, refer to ‘Feverish illness in
children’ (NICE clinical guideline 47)