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7 days

SKIN / SOFT TISSUE INFECTIONS

Herpes zoster/ Chicken pox Clinical Knowledge Summaries: Practical, reliable, evidence-based Varicella zoster/ shingles Chicken pox: Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND treatment started <24h of onset of rash.AShingles: Treatment indicated if: ophthalmic or predictors of post-herpetic neuralgia: >60 yA+, severe pain,A+ severe skin rash, prolonged prodomal painB+ AND <72h of onset of rash. Child doses see BNF If pregnant seek advice re treatment and prophylaxis aciclovir 800 mg 5x/day

This guidance was initially developed by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users, and information from systematic reviews as they have been published and further amended in consultation with local microbiologists and GPs. Grading of guidance recommendations. The strength of each recommendation is qualified by a letter in parenthesis. Study design Good recent systematic review of studies One or more rigorous studies, not combined One or more prospective studies One or more retrospective studies Formal combination of expert opinion Informal opinion, other information Recommendation grade A+ AB+ BC D

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ILLNESS COMMENTS DRUG DOSE DURATION OF Tx

SKIN / SOFT TISSUE INFECTIONS/ OTHER

Conjunctivitis Clinical Knowledge Summaries: Practical, reliable, evidence-based Most bacterial infections are self-limiting (64% resolve on placeboA+). They are usually unilateral with yellow-white mucopurulent discharge. chloramphenicol 0.5% drops + 1% ointment fusidic acid eyedrops (Fucithalmic) at night twice daily All for 48 hours after resolution 2 hrly reducing to 6hrly

If the patient has ever been MRSA positive or is in a high risk group Scabies Clinical Knowledge Summaries: Practical, reliable, evidence-based Dermatophyte infection of the proximal fingernail or toenail Treat whole body including scalp, face, neck, ears, under nails. Treat all household contacts.

permethrinA+

5% cream

2 applications one week apart

Only consider treatment if symptomatic. Take nail clippings: Start therapy only if infection is confirmed by laboratory. Idiosyncratic liver reactions occur rarely with terbinafine.

5% amorolfine nail lacquer now available to purchase OTC

1-2x/weekly fingers toes 6 months 12 months

For children seek advice

terbinafine A+

250 mg OD fingers toes 200 mg 12hrly fingers toes 6 12 weeks 3 6 months 7 days monthly 2 courses 3 courses

Pulsed itraconazole monthly is recommended for infections with yeasts and nondermatophyte moulds.C

itraconazole

Dermatophyte infection of the skin Clinical Knowledge Summaries: Practical, reliable, evidence-based

Take skin scrapings for culture. Treatment: 1 week terbinafine is as effective as 4 weeks azole. A-If intractable consider oral itraconazole. Discuss scalp infections with specialist.

Topical 1% terbinafine A+

OD - 12hrly

1 weekA+

Topical undecenoic acid or 1% azoleA+

1-2x/daily

4 6 weeksA+

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Flucloxacillin is an appropriate first-line antibiotic [CREST, 2005]. We recommend using flucloxacillin alone, without the addition of phenoxymethylpenicillin (as advocated by some authorities). In sufficient dosage, flucloxacillin covers both beta-haemolytic streptococci and penicillinase-resistant staphylococci [Jones, 2002; CREST, 2005 Note: up to 20% of Staphylococcus aureus and Streptococcus pyogenes organisms are resistant to erythromycin and there may be cross-class resistance with other macrolides. Make sure that the person is reviewed within 48 hours to check that the infection is responding to treatment and that they are aware of the need for earlier review if their symptoms worsen significantly. Clindamycin is recommended as an alternative by some experts. Clindamycin has good soft-tissue penetration, and suppresses streptococcal toxin production. Use clindamycin + / - rifampicin, as per microbiologist advice. If there has been exposure to salt water at the site of the skin break, add doxycycline to the antibiotic regimen to cover the possibility of infection with Vibrio vulnificus [Swartz, 2004]. If a tetracycline cannot be used (e.g. in children under 12 years, pregnant women, or breastfeeding women), seek advice from the local microbiologist. If the patient has ever been MRSA positive or is in the high risk group, use doxycycline + /- rifampicin In facial cellulitis, co-amoxiclav is recommended to cover organisms from the mouth and sinuses [HPA, 2003]. If facial cellulitis is secondary to a superficial abrasion on the face distal to the mouth, flucloxacillin should be sufficient. If the person is allergic to penicillin, discuss a suitable alternative with the local microbiologist. Intravenous drug users (IVDUs): if the cellulitis is mild and the person is systemically well, treat with oral flucloxacillin.

ILLNESS

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SKIN / SOFT TISSUE INFECTIONS

Leg ulcers Clinical Knowledge Summaries: Practical, reliable, evidence-based Animal bite Clinical Knowledge Summaries: Practical, reliable, evidence-based Bacteria will always be present. Antibiotics do not improve healing.A+ Routine wound swabs are not recommended, as there is no evidence for their use [SIGN, 1998]. Antibiotics have little effect on wound healing generally [O'Meara et al, 2000], so there is no value in using them to treat organisms that have colonized a wound but are not causing clinical signs or symptoms of infection. Antibiotics should be used only if there is evidence of cellulitis or active infection (e.g. pyrexia, increasing pain, enlarging ulcer, or cellulitis). Sampling for culture requires cleaning then vigorous curettage and aspiration. Await microbiology sensitivities and guidance. Surgical toilet most important. First line animal & human Assess tetanus and rabies risk. Antibiotic prophylaxis advised for puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic prophylaxis and treatment co-amoxiclavBIf penicillin allergic: metronidazole PLUS doxycycline or oxytetracycline (animal) Do not use macrolides or clindamycin in animal bites as pastuerella intrinsically resistant .Assess HIV/hepatitis B & C risk and review at 24 & 48 hrs 375-625 mg 8hrly 200-400 mg 8hrly 100 mg 12hrly 250-500 mg 6hrly 7 days 7 days 7 days 7 days

Human bite

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ILLNESS COMMENTS DRUG DOSE DURATION OF Tx

SKIN / SOFT TISSUE INFECTIONS

Impetigo See below Prodigy flucloxacillin or erythromycin betadine ointment Fusidic acid First line Oral 500 mg 6hrly Oral 500 mg 6hrly Once or twice a day Topically 6 hrly 7 days 7 days 14 days 5 days

Remove the crusting areas by soaking in soapy water before applying topical antibiotics as this will increase the efficacy of treatment. Topical treatment avoids possible adverse effects from taking oral antibiotics, although more likely to lead to antibiotic resistance, and their use should be restricted to treating small, localized lesions [HPA, 2005]. First-line choice is fusidic acid for 7 days, with mupirocin as an alternative. There is no significant difference in their effectiveness at treating impetigo and are similar in effectiveness to oral antibiotics for the treatment of localized impetigo. The Health Protection Agency recommends that, where possible, mupirocin should be reserved for the treatment of MRSA (methicillin-resistant Staphylococcus aureus) [HPA, 2005]. Other topical antibiotic preparations are not recommended as the evidence best supports the use of fusidic acid or mupirocin. Prescribe oral antibiotics if lesions are extensive, refractory to topical treatment or there is associated systemic illness. All individuals must be put on the staphylococcal decontamination regimen (10 days nasal mupiricin three times daily and daily baths and hair wash using Octenisan or chlorhexidine 4%). All clothes, towels and bedding should be changed at the start of treatment. Consider other members of the family and the need for decontamination of them as well. Children should not attend school or nursery until there is no further crusting of lesions or until 48 hours after antibiotic treatment has been started. Treat pre-existing skin disorders to reduce the risk of recurrence. Referral may be necessary in severe cases or in impetigo unresponsive to systemic treatment. Eczema Clinical Knowledge Summaries: Practical, reliable, evidence-based Cellulitis Using antibiotics, or adding them to steroids, in eczema does not improve healing unless there are visible signs of infection.

For most people with cellulitis, the chosen antibiotic should cover beta-haemolytic streptococci and Staphylococcus aureus.

flucloxacillin clindamycin (see following notes)

500 mg 6hrly 450 mgms 6 hrly

5 days 5 days

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ILLNESS COMMENTS DRUG DOSE DURATION OF Tx
BASHH

GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES Vaginal discharge quick reference guide

Note: Refer patients with risk factors for STIs (<25y, no condom use, recent (<12mth) or frequent change of sexual partner, previous STI, symptomatic partner) to GUM clinic or general practices with level 2 or 3 expertise in GUM.
Vaginal candidiasis Bacterial vaginosis All topical and oral azoles give 80-95% cure.AIn pregnancy avoid oral azole.B A 7 day course of oral metronidazole is slightly more effective than 2 g stat.A+ Avoid 2g stat dose in pregnancy. Topical treatment gives similar cure ratesA+ but is more expensive. Tetracyclines are contra-indicated in pregnancy. Erythromycin and ciprofloxacin are less efficacious than doxycycline. Treat partners Refer contacts to GUM clinic Consider treating patients who are fitted with a coil for emergency contraception. Refer to GUM. Treat partners simultaneously In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure). Pelvic Inflammatory Disease (PID) Acute prostatitis Essential to test for N. gonorrhoea (as increasing antibiotic resistance) and chlamydia. Refer contacts to GUM clinic 4 weeks treatment may prevent chronic infection. clotrimazole 10% or clotrimazole or fluconazole metronidazoleA+ or metronidazole 0.75% vag gelA+ or clindamycin 2% creamA+ doxycyclineA+ or oxytetracyclineAerythromycin AazithromycinA+ metronidazoleA5 g vaginal cream 500 mg pessary 150 mg orally 400 mg 12hrly 5 g applicatorful at night 5 g applicatorful at night 100 mg 12hrly 500 mg 6hrly 500 mg 12hrly or 500 mg 6hrly 1 g stat 400 mg 12hrly or 2 g in single dose 100 mg pessary stat stat stat 7 days 5 days 7 days 7 days 7 days 14 days 7 days 1 hr before or 2 hrs after food 5-7 days

Chlamydia trachomatis Chlamydia quick reference guide Trichomoniasis

clotrimazole

6 days 14 days

The recommended treatment regimen is: Ceftriaxone 250 mg as a single intramuscular dose, followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily, both for 14 days. 500 mg 12hrly ciprofloxacin 200 mg 12hrly or trimethoprimC

28 days 28 days

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ILLNESS COMMENTS DRUG DOSE DURATION OF Tx

GASTRO-INTESTINAL TRACT INFECTIONS

Eradication of Helicobacter pylori NICE Helicobacter quick reference guide Managing symptomatic relapse Eradication is beneficial in DU, GU and low grade MALTOMA, but NOT in GORD.A In NUD (Non-Ulcer Dyspepsia), 8% of patients benefit. First lineA+ cheapest option Omeprazole capsules OR Lansoprazole capsules PLUS metronidazole AND clarithromycin Alternative regimens A+ PPI OR ranitidine bismuth citrate PLUS 2 antibiotics: amoxicillin clarithromycinA+ metronidazole oxytetracycline 20 mg 12hrly 30mg 12 hrly 400 mg 12hrly 250 mg 12hrly

All for 7 daysA 14 days in relapse or maltoma

Triple treatment attains >85% eradication.A+ Do not use clarithromycin or metronidazole if used in the past year for any infection

12hrly 400 mg 12hrly 1 g 12hrly 500 mg 12hrly 400 mg 12hrly 500 mg 6hrly

H pylori eradication reduces duodenal ulcer recurrence in H pylori positive people. A Cochrane review found that after 312 months, 39% of people receiving short-term acid suppression therapy are without an ulcer. Eradication increases this by a further 52%, a number needed to treat of 2 [Delaney et al, 2003b; NICE, 2004]. H pylori eradication also reduces gastric ulcer recurrence in H pylori positive people. A Cochrane review found that after 312 months, 45% of people receiving short-term acid suppression therapy are without an ulcer. Eradication increases this by a further 32%, a number needed to treat of 3. First-line H pylori eradication regimens One-week triple therapy regimens (a proton pump inhibitor [PPI] plus two antibiotics) are recommended. Two-week regimens are no more effective than one-week regimens. Dual therapy is not as effective as triple therapy. Quadruple therapy (a PPI, bismuth, tetracycline, and metronidazole) is as effective as triple therapy, but taking 17 tablets per day does not make it a practical first-line option [Delaney et al, 2003a]. The recommended PAC regimen (a PPI plus amoxicillin 1 g and clarithromycin 500 mg, all given twice a day) and PCM regimen (a PPI plus metronidazole 400 mg and clarithromycin 250 mg, all given twice a day) are the optimum regimens on current evidence. Data pooled by NICE show that [NICE, 2004]: Double-dose PPIs are more effective than single-dose PPIs in PAC regimens (eradication rate of 85.4% for double-dose PPIs and 78.5% for single-dose PPIs). The data were less clear for PCM regimens (due to much smaller patient numbers). Double-dose PPIs are therefore also recommended in PCM regimens as there is not enough data to clearly support single dose PPIs. The dose of clarithromycin differs between the two regimens. Pooled data for PAC regimens show eradication rates of 79.8% with clarithromycin 250 mg compared with 89.6% with clarithromycin 500 mg. In PCM regimens, doubling the dose of clarithromycin had no statistically significant effect: eradication rates were 87.4% for clarithromycin 250 mg and 88.9% for clarithromycin 500 mg. Pooled data for the recommended PAC and PCM regimens show no statistically significant difference in eradication rates: 82% for PAC, and 82.6% for PCM. Although triple therapy using a PPI plus amoxicillin and metronidazole has previously been recommended as a first-line therapy, pooled data from four randomized, controlled trials have shown that it is less effective than either of the two triple therapies that contain clarithromycin [NICE, 2004]. Second-line H pylori eradication regimens Two randomized, controlled trials comparing one-week quadruple therapy to one-week triple therapy found that both types of eradication therapy seemed equally effective [Delaney et al, 2004]. Quadruple therapy is therefore preferred as second-line therapy since it is likely to be more effective than a PAM regimen. It can also be used by people who are penicillin-hypersensitive. The recommendation to use an alternative triple therapy regimen if quadruple therapy is not tolerated is based on consensus [Malfertheiner et al, 2002]. It would seem sensible to use a regimen with a different combination of antibiotics as second-line eradication therapy. The inclusion of oxytetracycline as one of these antibiotics is a pragmatic recommendation since there is no evidence to guide which second-line triple-therapy regimens should be offered to people with penicillin hypersensitivity. However, the efficacy of the suggested combinations of a PPI, metronidazole, and tetracycline, or a PPI, clarithromycin, and tetracycline, is unknown; they have not been studied in randomized, controlled trials. DU/GU: Retest for helicobacter if symptomatic NUD: Do not retest, treat as functional dyspepsia In treatment failure substitute oxytetracycline for clarithromycin or metronidazole and add bismuth salt.AGastroenteritis Clinical Knowledge Summaries: Practical, reliable, evidence-based Travellers diarrhoea Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 daysB+ and destroys important normal bowel flora and causes resistance.B+ It may prolong carrier status. Initiate treatment, on advice of microbiologist, if the patient is systemically unwell. Please send stool specimens from suspected cases of food poisoning. Notify and seek advice on exclusion of patients from Public Health Doctor  0845 1550069

Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 500 mg single dose) to people travelling to remote areas and for people in whom an episode of infective diarrhoea could be dangerous.

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MENINGITIS
Suspected meningococcal disease HPA HPA pdf Transfer all patients to hospital immediately. Administer benzylpenicillin prior to admission, unless history of anaphylaxis,B- NOT allergy. Ideally IV but IM if a vein cannot be found. Chloramphenicol if history of anaphylaxis IV or IM benzylpenicillin Adults and children 10 years and over: 1200 mg Children 1 - 9 year: 600 mg Children <1 year: 300 mg See package insert.

IV or IM chloramphenicol

Prevention of secondary cases of meningitis: Mid-Essex area: Only prescribe following advice from Public Health Infection Control Nurse or Public Health on-call 9 am 5 pm: Mon-Fri Out of hours: Contact Public Health on-call via Essams paging Or Fax. Number North East Essex Only prescribe following advice from Public Health Infection Control Team 9 am 5 pm: Out of hours: Contact Public Health on-call via CGH switchboard or Essams paging  0845 1550069  01245 444417  01376 302278

 01206 286863  01245 444417

ILLNESS

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DURATION OF Tx

URINARY TRACT INFECTIONS UTI quick reference guide Prodigy Note:. Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not
treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with increased morbidity.B+ In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely.
Use urine dipstick to exclude UTI -ve nitrite and leucocyte 95% negative predictive value. MRSA and Multi-resistant E. coli with ESBLs are increasing so perform culture in all treatment failures. There is less relapse with trimethoprim than cephalosporins NB Never do urine dipsticks in catheterised patients. Send MSU for culture. Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus, unless at term when nitrofurantoin should be avoidedB+ Send MSU for culture; treat according to sensitivities and consider referral to urology specialist. Send MSU for culture and sensitivity. Waiting 24 hours for results is not detrimental to outcome.ASend MSU for culture. A recent RCT showed 7 days ciprofloxacin was as good as 14 days cotrimoxazole.AIf no response within 24 hours admit. Post coital prophylaxis is as effective as prophylaxis taken nightly. Prophylactic doses trimethoprimB+ or nitrofurantoinA200 mg 12hrly 50-100 mg 6hrly

Uncomplicated UTI i.e. no fever or flank pain UTI quick reference guide

3 daysB+

2nd line - depends on susceptibility of organism isolated eg nitrofurantoin, amoxicillin, cefalexin, co-amoxiclav, quinolone, Extended Spectrum Bacterial Lactamases (ESBLs) are multi-resistant, but usually remain sensitive to nitrofurantoin nitrofurantoin or trimethoprim 2nd line cefalexin Prescribe according to sensitivities trimethoprim or nitrofurantoin or cefalexin If susceptible, amoxicillin co-amoxiclav or ciprofloxacinAnitrofurantoin or trimethoprim 50 mg 100 mg 6hrly 200 mg 12hrly 500 mg 12hrly 7 days 7 days 7 days 7 days

UTI in pregnancy

UTI in men

Children

See BNF for dosage

7 daysA+

Acute pyelonephritis

500/125 mg 8hrly 500 mg 12hrly 50 mg 100 mg

7 daysA14 days Stat post coital or od at night

Recurrent UTI women 3/yr

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ILLNESS COMMENTS DRUG DOSE DURATION OF Tx

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.ARhinosinusitis acute or chronic Clinical Knowledge Summaries: Practical, reliable, evidence-based Many are viral. Symptomatic benefit of antibiotics is small - 69% resolve without antibiotics; and 84% resolve with antibiotics.A+ Reserve for severeB+ or symptoms (>10 days). Cochrane review concludes that amoxicillin and phenoxymethylpenicillin have similar efficacy to the other recommended antibiotics. If failure to respond to first line antibiotics phenoxymethylpenicillin or amoxicillin or oxytetracycline or erythromycin or doxycycline co-amoxiclav or azithromycin 500 mg 6hrly 500 mg 8hrly 250 mg 6hrly 250 mg 6hrly/500mg 12hrly 200 mg stat/100 mg OD 625 mg 8hrly 500 mg OD 7-10 days 7-10 days 7-10 days 7-10 days 7-10 days 7-10 days 3 days

* Standing Medical Advisory Committee guidelines suggest 3 days. In otitis media, relapse rate is slightly higher at 10 days with a 3 day course but long-term outcomes are similar.A+.

LOWER RESPIRATORY TRACT INFECTIONS Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones
ciprofloxacin and ofloxacin have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections. Levofloxacin has some anti-Gram-positive activity but should not be needed as first line treatment.
Acute bronchitis Clinical Knowledge Summaries: Practical, reliable, evidence-based Acute exacerbation of COPD NICE Systematic reviews indicate antibiotics have marginal benefits in otherwise healthy adults.A+ Patient leaflets can reduce antibiotic use.B+ 30% viral, 30-50% bacterial, rest undetermined Antibiotics not indicated in absence of purulent/mucopurulent sputum.B+ Most valuable if increased dyspnoea and increased purulent sputum.B+ In penicillin allergy use erythromycin if tetracycline contraindicated If clinical failure to first line antibiotics Start antibiotics immediately.B- If no response in 48 hours consider admission or add azihromycin first line or a doxycyclineC to cover Mycoplasma infection (rare in over 65s) In severely ill give parenteral benzylpenicillin before admissionC and seek risk factors for Legionella and Staph. aureus infection.D amoxicillin or doxycycline 500 mg 8hrly 200 mg stat/100 mg OD 5 days 5 days

amoxicillin or doxycycline erythromycin (avoid if Haemophilus influenzae likely) co-amoxiclav Amoxicillin or azithromycin doxycycline

500 mg 8hrly 200 mg stat/100 mg OD 250 500 mg 6hrly

5-10 days 5-10 days 5-10 days

625 mg 8hrly 500 mg - 1g 8hrly 500mg OD 200 mg stat/100 mg OD

5-10 days Up to 10 days 3 days Up to 10 days

Community-acquired pneumonia treatment in the community BTS BTS pdf

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Treatment Tables
Aims
to provide a simple, best guess approach to the treatment of common infections to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance in the community to avoid destroying bowel flora (a vital defence mechanism)

Principles of Treatment
1. 2. 3. 4. 5. 6. This guidance is based on the best available evidence but its application must be modified by professional judgement Prescribe an antibiotic only when there is likely to be a clear clinical benefit. The benefit must be documented in the patients notes Do not prescribe an antibiotic for viral sore throat, simple coughs and colds Limit prescribing over the telephone to exceptional cases Use simple generic antibiotics first whenever possible for as short a time as possible The use of new and broad spectrum antibiotics (e.g. quinolones and cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective 7. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations such as Fucidin) 8. In pregnancy AVOID tetracyclines, quinolones, and high dose metronidazole. Short-term use of trimethoprim (theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus 9. Clarithromycin is an acceptable alternative in those who are unable to tolerate erythromycin because of side effects 10. Where a best guess therapy has failed or special circumstances exist, microbiological advice can be obtained from North East Essex  01206 747474 or Mid-Essex Switchboard on 0844 822 0002 and ask for the duty Microbiologist or Dr. Teare  07770736427

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UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.AInfluenza Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals are not recommended. Treat at risk patients, only when influenza is circulating in the community, within 48 hours of onset. At risk: 65 years or over, chronic respiratory disease (including COPD and asthma), significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic renal disease, poultry workers. Use oseltamivir 75 mg oral capsule 12hrly (patients over 13 years), (for OD prophylaxis see Influenza ) or zanamivir 10 mg (2 inhalations by diskhaler) 12hrly for 5 days.(see BNF for childrens doses)

Influenza

Pharyngitis / sore throat / tonsillitis Clinical Knowledge Summaries: Practical, reliable, evidence-based SIGN

The majority of sore throats are viral; most patients do not benefit from antibiotics. Patients with 3 of 4 centor criteria (history of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from antibiotics.A- Antibiotics only shorten duration of symptoms by 8 hours.A+ You need to treat 30 children or 145 adults to prevent one case of otitis media.A+ Seven days treatment gives less relapse than three days.B+ Recent evidence indicates that penicillin 500 mg 8hrly for 7 days is more effective than 3 days.B+ Twice daily higher dose can also be used.A- 6hrly may be more appropriate if severe.D Many are viral. Resolves in 80% without antibiotics.A+ Poor outcome unlikely if no vomiting or temp <38.5oC.A- Use NSAID or paracetamol.A- Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.A+ Need to treat 20 children >2y and seven 6-24m old to get pain relief in one at 2-7 days.A+B+ Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, have poor activity, erythromycin being ineffective. first line phenoxymethylpenicillin erythromycin if allergic to penicillin amoxicillin first line erythromycin if allergic to penicillin Azithromycin 2nd line if allergic to penicillins co-amoxiclav 2nd line 500 mg 12hrly-6hrly 500 mg 12hrly or 250 mg 6hrly (6hrly less side-effects) <2 yrs 125 mg 8hrly 2-10 yrs 250 mg 8hrly >10 yrs 500 mg 8hrly <2 yrs 125 mg 6hrly 2-8 yrs 250 mg 6hrly Other: 250-500 mg 6hrly 15-25kg 200 mg OD 26-35kg 300 mg OD 36-45kg 400 mg OD 1-6 yrs 156 mg 8hrly 6-12 yrs 312 mg 8hrly 7-10 days 5-10 days

Otitis media (child doses) Clinical Knowledge Summaries: Practical, reliable, evidence-based

3-7 days* 3-7 days* 3-7 days* 3-7 days* 3-7 days* 3-7 days* 3 days 3 days 3 days 3-7 days* 3-7 days*

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Macrolides
There is no convincing evidence to support any differences in the tolerability of different formulations of erythromycin. There is evidence that in some patients clarithromycin is better tolerated than erythromycin. Note that Haemophilus influenzae is intrinsically resistant to erythromycin. Clarithromycin and azithromycin are therefore preferable for treating COPD, pneumonia and some otitis media. There is no reason to use the more expensive modified release form of clarithromycin.

Trimethoprim & co-trimoxazole interaction with methotrexate

Co-trimoxazole is now rarely used as it is associated with a number of rare but serious side effects. Trimethoprim, a constituent, is still used, mainly for urinary tract infections. The use of methotrexate tablets for a number of medical conditions has increased over recent years. All patients are given a supplement of folic acid to help the body withstand the effects of the methotrexate and reduce some of the side effects. The National Patient Safety Authority (NPSA) has issued a Patient Safety Alert which states that a patient should not take co-trimoxazole or trimethoprim whilst taking methotrexate as the medications can interact.

Mid-Essex PCT would like to thank Suffolk PCT who allowed us to use their guidelines as a basis for our guidelines.

Mid-Essex Antibiotic Guidelines June 2008 Revision date June 2010

Common Prescribing Dilemmas

Cephalosporins There is confusion over the place of the cephalosporins in modern antibiotic therapy and concern over the development of resistance to the newer agents. Their widespread use is unnecessary and may lead to the development of antibiotic resistance and few are recommended within this formulary. Antibiotic associated diarrhoea and the more serious pseudomembranous colitis are particularly associated with these broad spectrum agents.

Fluoroquinolones These are the most associated antibiotics with Clostridium difficile. Resistance to quinolones is also increasing. All MRSA strains locally are resistant. They should be avoided. The long term adverse effects of quinolones are less well established compared to other agents such as penicillins and these drugs are all involved in drug interactions. Of particular concern are tendonitis and tendon rupture with ofloxacin and ciprofloxacin. The interaction of ciprofloxacin and theophyllines is potentially life threatening. The MHRA has warned that quinolones may induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them. They should be used with caution in patients with a history of epilepsy or conditions that predispose to seizures.

Mid-Essex Antibiotic Guidelines June 2008 Revision date June 2010