Antimicrobial treatment guidelines_july_10.sflb

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Antimicrobial treatment guidelines_july_10.sflb

  1. 1. Updated: 31 July 2010 Next update due: 30 September 2010 Cambridgeshire Primary Care Trust Antimicrobial Treatment Guidelines For Prescribing In Primary Care. FORMULARY FIRST AND SECOND LINE CHOICES FOR COMMONLY PRESCRIBED DRUGS (Both sections and individual entries are in alphabetical order)The purpose of this document is to support the appropriate prescribing and use of antibiotics in Primary Care.The top-line principles, in line with evidence based guidelines and PCT priorities, are to: 1) Promote the safe, effective and economic use of antibiotics. Antibiotics should be prescribed at the lowest effective dose and for the minimum effective duration of treatment. 2) Reduce the amount of antibiotics prescribed to minimise the emergence of bacterial resistance in the community. GPs should consider whether a course of antibiotics is necessary to ensure that the numbers of patients exposed to antibiotics falls. 3) Manage the prescribing of antibiotics to reduce levels of superbug infection, e.g. Clostridium difficile associated diarrhea (CDAD) and MRSA infection.Overall Principles and Aims of Treatment • Antibiotic prescribing should only take place where consideration has been given to the origin of infection and where infection of viral origin has been precluded where possible, e.g. viral sore throat, simple coughs and colds, viral conjunctivitis. • Antibiotics should not be prescribed following telephone consultations unless the circumstances are exceptional. • Where possible, antibiotics should be prescribed generically. The use of newer/more expensive antibiotics (e.g.fluoroquinolones and cephalosporins) is inappropriate when well-established and less expensive antibiotics remain effective. • The antibiotic chosen should be the narrowest spectrum for the identified condition. • Topical antibiotic agents should be avoided, if possible.These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 1 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  2. 2. Updated: 31 July 2010 Next update due: 30 September 2010Clostridium difficile Infections 1) Clostridium difficile: current evidence indicates that clindamycin and second or third generation cephalosporins, e.g. cefuroxime, cefixime, cefotaxime, ceftriaxone) are significantly more likely to provoke C. dif associated diarrhoea (CDAD). Anecdotal evidence also incriminates fluoroquinolones, first-generation cephalosporins (e.g. cefalexin) and co-amoxiclav. These antibiotics should be used sparingly especially in the elderly, in patients in institutions with CDAD and in patients previously diagnosed and treated for CDAD. 2) A narrow spectrum antibiotic should be used or the prescriber should be guided by laboratory results. As with all antibiotic prescribing, the minimum effective dose and duration of treatment should be prescribed. 3) There is evidence that the use of Proton Pump Inhibitors (PPIs) increases susceptibility to C dif. and Campylobacter infection. GPs should ensure that all prescribing is within the recommendations of this guideline and that any prescribing is for the shortest appropriate treatment period and at the lowest effective dose.Antibiotics that are associated with C. difficile infection are highlighted in this document with the following symbol:◄ These should beused with caution in those predisposed to infection with C.difficile such as the elderly and those receiving anti-cancer treatment,particularly where there is a history of previous C.difficile infection and when cared for in units (e.g. nursing homes) with C.difficile positivepatients.Dosages: The current guidance for GPs is for the dosage guidance in the BNF to be used. The link is given here and at the bottom of eachpage: BNF Antibiotics DosagesIt is the intention of Cambridgeshire PCT to audit for compliance against the antibiotics formulary to support judicious prescribing of antibiotics andSHA and PCT objectives. This will be carried out by the Medicines Management Team who will be able to give help and support to practices andprescribers in achieving this.Cambridgeshire PCT would like to acknowledge the help of Hugo Ludlam, Consultant Medical Microbiologist and other members of his team at CUHFT, in theproduction of these guidelines.These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 2 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  3. 3. Updated: 31 July 2010 Next update due: 30 September 2010 ANTIMICROBIAL TREATMENT GUIDELINES FOR PRESCRIBING IN PRIMARY CARE. FORMULARY FIRST AND SECOND LINE CHOICES FOR COMMONLY PRESCRIBED DRUGS (Both sections and individual entries are in alphabetical order) 5. Infections Infection 1st Line 2nd Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days)Dental Dental Amoxicillin 5 Mild – empirical (Strep, anaerobic streps, bacteroides spp (but infections rarely penicillin resistant)) Metronidazole 5 Moderate/severe/recurrent : (organisms as above but note possibility of penicillin-resistance) In penicillin allergy: 5 Erythromycin Dental abscess - CKS link – treat for five daysEar , Nose and Throat Acute Otitis If antibiotics are For acute attacks where there are no systemic features: Media indicated: paracetamol or ibuprofen for pain Amoxicillin 5 For acute attacks with systemic features: treat systemically. BNF recommends for children: Acute attacks with no systemic In penicillin allergy: features may be treated systemically after 72 hours if still Erythromycin symptomatic or earlier if there is deterioration or no improvement. Azithromycin 3 Clinical Knowledge Summary Sore throat Question necessity Penicillin 10 Usually viral and may not require antibiotic treatment. (Pharyngitis) for treatment as Antibiotics only generally shorten duration of symptoms by frequently viral in In penicillin allergy: 10 approximately 8 hours origin. Treatment Erythromycin There may be overlap between viral and streptococcal with paracetamol or infections. ibuprofen may be More severe symptoms (history of fever, purulent tonsils, appropriate. cervical adenopathy, absence of cough) or patients with a history of otitis media may benefit more from antibiotics. Clinical Knowledge SummaryThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 3 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  4. 4. Updated: 31 July 2010 Next update due: 30 September 2010 Infection 1st Line 2nd Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Acute Where symptoms 7 Many attacks are viral in origin and symptomatic benefit of Sinusitis have persisted for 7 antibiotics is small (69% resolve without antibiotics, 15% resolve days or more: or with antibiotics). are severe or deteriorating Initial therapy may include nasal decongestants or intranasal rapidly: corticosteroids, e.g. beconase Amoxicillin (7 days) In penicillin allergy : Azithromycin (3 days) In penicillin allergy : Clarithromycin or 7 Doxycycline. Erythromycin for Clinical Knowledge Summary Erythromycin pregnant woemen.Eye Ocular Refer to secondary - - Herpes simplex – 1,2 virus Herpes care clinicians On suspicion - refer immediately to eye casualty – corticosteroids should not be used in undiagnosed red eye. Acanthamoeba spp is a cause of corneal ulcer primarily in contact lens wearers - refer urgently. For contact lens wearers with keratitis, the contact lens should be sent for culture in a sample of contact lens fluid.These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 4 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  5. 5. Updated: 31 July 2010 Next update due: 30 September 2010 Infection 1st Line 2nd Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days)Gastro-intestinal Diverticulitis Co-amoxiclav ◄ At least 7 Awaiting comments from gastroenterologist days Eradication of Formulary PPI + 7 Where patients are HP negative do not retest unless there is Helicobacter Amoxicillin + strong clinical need – treat as functional dyspepsia with low pylori Clarithromycin dose PPI or H2A for one month then reassess before continuing Or therapy (reassess dose for maintenance therapy) For HP +ve Formulary PPI + result Metronidazole + Do not use the clarithromycin/metronidazole regimen if either Clarithromycin (eradication failure) drug used for infection in the past year. Formulary PPI + 14 days Tripotassium treatment for In the case of treatment failure following TWO treatment dicitratobismuthate relapse and regimens consider endoscopy for culture and susceptibility. + tetracycline + maltoma NICE metronidazole Gastro- Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1 to 2 days and can lead to antibiotic enteritis resistance. Check travel, food, hospitalisation and antibiotic history (C. difficile is increasing). Initiate treatment if the patient is systemically unwell. Fluid replacement is essential. Please send stool specimens from suspected cases of food poisoning and post antibiotic use and notify the Health Protection Unit (via the statutory ‘Notification of Infectious Disease or Food Poisoning’ form faxed to 01480 398684) on clinical suspicion or after seeking advice from a Public Health Doctor. Infective Erythromycin Ciprofloxacin ◄ 7 Antibiotic treatment for campylobacteriosis is only indicated if diarrhoea (confirmed the patient has severe symptoms, dysentery or is Campylobacteriosis immunocompromised. only)These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 5 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  6. 6. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Infective Metronidazole C.diff assoc Ciprofloxacin ◄ may occasionally be required for those who are diarrhoea (antibiotic related diarrhoea 10- at high risk (such as the elderly and those receiving anti-cancer (cont’d) inc. C.difficile 14 days treatment), particularly where there is a history of previous assoc. diarrhoea, C.difficile infection and when cared for in units (e.g. nursing amoebic dysentery Giardiasis 5 homes with C.difficile positive patients), or who present with and giardiasis) days dysentery. Amoebic dysentery 5 – CKS - Infective diarrhoea 10 days Ciprofloxacin ◄ Stat dose or (Traveller’s 3 days diarrhoea) Threadworm Mebendazole Piperazine Stat Piperazine can be given second line and for children aged 3 to 6 (for adults and months. children over 6m) Household contacts should be treated. Only retreat after 14 days if Advise on morning shower/baths and on hand hygiene. infestation persists Dose of If an anthelmintic is contraindicated (e.g. first trimester of Piperazine, pregnancy, children aged less than 3 months) or if the individual where used, does not wish to take an anthelmintic, advise physical removal should be of eggs, combined with hygiene measures for 6 weeks repeated after 2 weeks Threadworm -CKS linkThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 6 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  7. 7. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days)Genital Tract - BASHH Clotrimazole 10% Oral fluconazole Stat. Vaginal All topical and oral azoles give 80-95% cure. OR Miconazole candidiasis Clotrimazole In pregnancy avoid oral azole. Bacterial Metronidazole - Stat or 7 days A 7 day course of oral metronidazole is slightly more effective vaginosis OR than 2g stat. Metronidazole - 5 0.75% vaginal gel Avoid 2g stat dose in pregnancy. Clindamycin 2% 7 Topical treatment gives similar cure rates but is more cream expensive. Candidal Topical Until 2-3 days An irritant balanitis is more common than infective Balanitis clotrimazole 1% after clinical cure Diagnosis of candidal balanitis is probably more common than bacterial (e.g strep, anaerobes) and should be made on clinical Oral fluconazole Single dose grounds whilst awaiting culture results. (adults and children over 16 only), if Advise to avoid contact with any potential skin irritants (e.g. candidal balanitis has not cleared soap). Keeping area clean by bathing twice daily with a weak after 7 days or is saline solution while symptoms persist. severe. Gardnerella Oral metronidazole 7 Children should be treated using topical anti-fungals. associated balanitis If symptoms not improving by 7 days, a sub-preputial swab should be taken for culture, (to exclude or confirm infection type) A mild topical steroid cream may settle inflammation for irritant balanitisThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 7 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  8. 8. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Acute Oral amoxicillin 7 An infective complication of an underlying dermatosis should streptococcal In penicillin also be considered. balanitis sensitivity: Erythromycin/ Balanitis - CKS link clarithromycin Chlamydia Azithromycin - Stat Tetracyclines are contra-indicated in pregnancy. trachomatis 7 Doxycycline Erythromycin is less efficacious than doxycycline. OR Erythromycin (for 14 Treat partners and refer contacts of positive patients to CPCT pregnancy) Chlamydia screening service, Tel 01480 398787 cambridgeshirecso@nhs.net Trichomo- Tinidazole 7 Refer to GUM. Treat partners simultaneously Metronidazole niasis Or Second course of In pregnancy avoid 2g single dose metronidazole. Topical Metronidazole clotrimazole Topical clotrimazole gives symptomatic relief but no cure. Clinical Knowledge Summary Pelvic Ceftriaxone I/M ◄ Metronidazole + 14 Test for N. gonorrhoea (as increasing antibiotic resistance) and Inflammatory (single dose) Ofloxacin ◄ chlamydia. Disease + Metronidazole Microbiological and clinical cure are greater with ofloxacin than (PID) +Doxycycline with doxycycline. Refer contacts to GUM clinic Clinical Knowledge SummaryThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 8 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  9. 9. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days)Meningitis Suspected Benzyl penicillin Chloramphenicol if Administer antibiotic prior to hospital admission. meningio- history of coccal In penicillin allergy: anaphylaxis with disease Cefotaxime ◄ penicillin or cephsRespiratory 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 Acute Doxycycline (only where 7 30% of cases are viral in origin, 30-50% bacterial, remainder Exacerbation tetracyclines undetermined. Antibiotics are not indicated in the absence of of COPD contraindicated) purulent/mucopurulent sputum. Co-amoxiclav In the event of treatment failure the second line drug should be considered, and a sputum specimen sent for analysis. (If penicillin intolerant, consult Co-amoxiclav is only recommended where doxycycline is microbiologist for inappropriate or ineffective, as it may predispose patient to c advice) difficile infection. Other antibiotics should only be used on microbiological advice due to resistance of some organisms locally. Thorax, CKS, NICE Acute Amoxicillin Doxycycline 5 Antibiotics are not indicated in people who are otherwise well. Bronchitis Explain why antibiotics are not necessary, giving written In Penicillin allergy: Clarithromycin information if necessary. Erythromycin or Clarithromycin Clinical Knowledge SummaryThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 9 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  10. 10. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Acute Amoxicillin Doxycycline 7 If no response at 48 hours consider addition of erythromycin, Community oxytetracycline or doxycycline. Acquired In Penicillin allergy: In Penicillin allergy: Pneumonia Erythromycin or Clarithromycin BTS pdf, BTS, Clarithromycin IDSA - http://www.thoracic.org/sections/publications/statements/pages/ mtpi/idsaats-cap.html Seasonal Annual vaccination - Yearly In otherwise healthy adults, antivirals are not recommended - Influenza for at risk patients only when influenza is circulating in the community, within 48 hours of onset. At risk: 65 years or over, chronic respiratory When flu disease (including COPD and asthma) significant cardiovascular circulating, disease (not hypertension), immunocompromised, diabetes antivirals may be mellitus, chronic renal disease and chronic liver disease. prescribed as per local advice For swine flu (H1N1) please follow the latest Department of Health/ Health Protection Agency adviceSkin and Soft Tssue Acne Oxytetracycline / Erythromycin if At least 3 Propionibacterium acnes Moderate to Tetracycline tetracyclines not months The tetracyclines should not be used in pregnancy, during severe 500mg bd tolerated breastfeeding, or in children under 12 years of age, as they are 500mg bd deposited in the teeth and bones of the unborn or developing child. Lymecycline 408mg od Women of childbearing age should use effective contraception (note that tetracyclines may cause oral contraceptives to fail during the first few weeks of treatment). Acne vulgaris - CKS linkThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 10 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  11. 11. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Balanitis – see under Genital Tract Bites Doxycycline + In penicillin allergy: 7 Antibiotic prophylaxis (antibiotics and duration as for treatment (Cat, Dog, Metronidazole Metronidazole + (CKS)) advised for puncture wounds; bites involving hand, foot, Human) (Animal) doxycycline face, joint, tendon, ligament in immunocompromised, diabetic, (animal) elderly and asplenic patients Erythromycin And Antibiotic prophylaxis (antibiotics and duration as for treatment Metronidazole Metronidazole + (CKS)) advised for all human bites. (Human) Erythromycin (human) Human bites should be reviewed after 24 and 48 hours. Co-amoxiclav ◄ Assess HIV/hepatitis B & C risk, tetanus and rabies. (Human/animal) Clinical Knowledge Summary Breast Flucloxacillin - 7 Abscess Erythromycin Cellulitis – Flucloxacillin 7 If the patient is afebrile and healthy other than cellulitis, treat as minimal or indicated. minor trauma Co-amoxiclav ◄ in facial cellulitis For diabetic patients or patients where the infected area has been exposed to fresh water – ciprofloxacin◄ should be added In penicillin allergy: to the primary treatment. Erythromycin Where the infected area has been exposed to salt water – doxycycline shoud be added. Clinical Knowledge Summary (See also Appendix B).These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 11 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  12. 12. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Chicken Pox Aciclovir - 7 days If pregnant seek advice (see link). 800mg 5x/day Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND Child doses – see treatment started less than 24 hours from onset of rash. BNF / RCPCH Medicines for If patients develop life-threatening complications (encephalitis, Children pneumonia or CNS deterioration) send them immediately to hospital for IV aciclovir treatment. Immunocompromised patients with severe chickenpox must always be given IV aciclovir. It is recommended that immunocompromised patients who come into contact with chicken pox should be given Varicella- Zoster immunoglobulin (VZIG) Chickenpox - CKS link Cold sores Aciclovir topical 5 days Herpes simplex virus Topical aciclovir must be started, five times a day, as soon as symptoms begin to be of any benefit, otherwise paracetamol or ibuprofen can be used for pain and pyrexia. Herpes Simplex (oral) - CKS link Conjunctivitis Chloramphenicol Fusidic acid Until 48 hours Many infections are viral in origin 0.5% drops after Most bacterial infections are self-limiting (64% resolve on OR resolution placebo). They are usually unilateral with yellow-white Chloramphenicol mucopurulent discharge. 1% ointment Fusidic acid has less Gram-negative activity. Clinical Knowledge SummaryThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 12 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  13. 13. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Dermatophyte Amorolfine nail Once or twice Treatment should only be considered if the patient has poor or - infection of lacquer 5% (for a week: diminished circulation (diabetes, imunocompromised or the proximal superficial Fingers, 6m peripheral vascular disease) and can/will comply with a long fingernail or infections) Toes, 12m course of treatment. toenail Fingers: 6 – 12 weeks Take nail clippings: Start therapy only if infection is confirmed by Oral Terbinafine mycological examination. Toes: (generic only) 3 – 6 months Idiosyncratic liver reactions occur rarely with terbinafine. Fingers: 7 For infections with yeasts and non-dermatophyte moulds use days monthly itraconazole. Itraconazole can also be used for dermatophytes. Oral Itraconazole – 2 courses (pulsed) For children seek advice Toes 7 days monthly – 3 courses Clinical Knowledge Summary Dermatophyte Topical 1% - 7 Take skin scrapings for culture. infection of terbinafine the skin Topical 1% azole 4 - 6 weeks Treatment: 1 week terbinafine is as effective as 4 weeks of an treatment azole. -If intractable consider oral itraconazole. Discuss scalp infections with specialist. Clinical Knowledge Summary Eczema Not usually Oral flucloxacillin 7 Using antibiotics, or adding them to steroids, in eczema does required not improve healing unless there are visible signs of infection. Or in penicillin 7 Where there are visible signs of infection treat orally. allergy: Topical antimicrobial/corticosteroid combinations have been Erythromycin shown to be no more effective than topical corticosteroid alone in treating either visibly infected or uninfected flare-ups. Clinical Knowledge SummaryThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 13 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  14. 14. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Erysipelas Penicillin V Erythromycin 7 - 10 days Only if diagnosis certain (beta-haem Strep A,B,C,G) Genital Aciclovir Famciclovir 5 days Herpes simplex virus herpes (for first episode & acute recurrence) or Oral antiviral treatment should be given to people presenting 5 days within 5 days of the start of the episode, or while new lesions Valaciclovir are still forming. If new lesions are still appearing after 5 days treatment – continue treatment. Recurrent episodes of genital herpes are often mild and may be managed by supportive measures alone. Second line drug choices should only be considered where there is recurrence and compliance may be an issue. Genital Herpes - CKS link Head Lice Hedrin Phenothrin or As recommended by the local Health Protection Unit (based on malathion. Stafford Report and CKS). Repeat after 7 Hedrin (dimeticone) unlikely to provoke resistance in head lice. days. Where Permethrin not recommended for head lice in BNF or CKS. phenothrin or malathion needed, choose a product with the longest contact time (i.e. not mousses or shampoos). Impetigo Minor – topical Topical Mupirocin 7 Topical antibiotics should only be used for very localised lesions fusidic acid (should be to prevent resistance developing. reserved for MRSA Severe or or if fusidic acid has extensive disease – been ineffective or 7 Oral Flucloxacillin not tolerated). Erythromycin Clinical Knowledge SummaryThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 14 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  15. 15. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Insect bites or Oral Flucloxacillin Try alternative first 7 As recommended by CKS stings (If allergic to line treatment penicillin – Erythromycin/ Clarithromycin 7 days) Lacerations Co-amoxiclav◄ Erythromycin + 5 Only treat if at high risk of infection, i.e. where laceration may Metronidazole be contaminated with soil, faeces, bodily fluids, or purulent exudates. 5 In penicillin allergy Clarithromycin For clean lacerations flucloxacillin may be used or erythromycin Erythromycin + +Metronidazole where there is penicillin allergy. Metronidazole Clinical Knowledge Summary Leg ulcers Flucloxacillin In penicillin allergy: 7 Antibiotics do not improve healing. Culture swabs and Clarithromycin or antibiotics are only indicated if there is evidence of clinical Erythromycin infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid deterioration of ulcer or pyrexia. Clinical Knowledge Summary (See also Appendix B). As above As above 7 Refer for specialist opinion if severe infection. Diabetic leg Co-amoxiclav ◄ or Cefradine ◄ may be considered by ulcer specialist (See also Appendix B).These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 15 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  16. 16. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Paronychia Flucloxacillin 7 Empirical therapy (Staph. Aureus, beta-haem Strep A, B, C, G) In penicillin allergy: If there is no response to initial antibiotic, swab to confirm In penicillin allergy: 7 infecting organism and treat according to sensitivities. Arrange Erythromycin Erythromycin + for incise and drain if fluctuant. (or clarithromycin if metronidazole If no pus and incision not possible, change to second line erythromycin not (or clarithromycin if antibiotic. In the event of treatment failure consider candidal tolerated) erythromycin not paronychia. tolerated) Co-amoxiclav ◄ only for treatment failures and where patients show no sensitivities. Paronychia – CKS link Swab or scrape for mycological culture and treat only if positive Until healed for candida albicans +/- mixed coliforms. Candidal Topical (Treatment Paroncychia Systemic treatment is only indicated in patients unresponsive to clotrimazole lasting 3-6 topical treatment or where immunocompromised. months may Candidal paronychia – CKS link be required)These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 16 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  17. 17. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Otitis externa: Topical In resistant cases: 7 days NB: cleaning essential Mild betamethasone Otosporin Topical treatment is recommended unless systemically unwell, +neomycin drops perforated eardrum or infection is spreading Colistin/Polymixin (Otosporin) required if resistant to neomycin, but this still contains neomycin – i.e. not suitable in neomycin allergy Empirical therapy and Staph. aureus Beta-haem Strep A, C, G If severe or Flucloxacillin In penicillin allergy: 7 days N.B. Pseudomonas aeruginosa not covered by flucloxacillin. cellulitis or Erythromycin Seek specialist advice if spreading cellulitis outside ear canal, or boil where Pseudomonas infection suspected (immunocompromised, diabetic). Refer urgently if suspected malignant otitis externa If fungal Topical For 4 weeks Infection clotrimazole Fungi (dermatophytes, yeasts, moulds Otitis externa – CKS link Pubic lice Malathion aqueous As recommended by CKS lotion or Permethrin cream. Repeat application after 7 days. Permethrin only suitable in over- 18’s, and not for those who are pregnant or breast feeding.These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 17 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  18. 18. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) 2 applications Treat whole body including scalp, face, neck, ears, under nails. Scabies Permethrin Malathion 0.5% 1 week apart (BNF guidance). Treat all household contacts. NICE Guideline CG 54 Varicella Aciclovir [Valaciclovir] / 7 days Because of the higher risk of complications, it would seem zoster / 800mg 5x/day [Famciclovir] sensible to give a course of antiviral treatment to a person shingles [1g tds] presenting for the first time after 72 hours of the onset of the [750mg 1x/day] rash if they have: ophthalmic or predicators of post-herpetic neuralgia, are >60yrA+, severe painA+, severe skin rash, prolonged prodromal painB+, or are immunosuppressed. In pregnant women Valaciclovir can be given, because the active ingredient aciclovir has been shown to be safe in pregnancy Shingles - CKS linkThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 18 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  19. 19. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days)Urinary Tract 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. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely. Uncompli- Trimethoprim Try an alternative 3 For patients with clinical signs of UTI treat empirically.There cated lower Nitrofurantoin 1st line agent should be no fever or flank pain. UTI/Cystitis in To confirm presence of infection in patients with few clinical women. signs of UTI – use dipstick test for nitrite and leucocyte esterase [LE] – only treat if both are positive. Community multi-resistant E. coli with ESBLs (Extended Spectrum Beta-Lactamases) are increasing so perform culture in all treatment failures. ESBLs are multi-resistant but remain sensitive to nitrofurantoin. [There is less relapse with trimethoprim than cephalosporins.] Complicated Trimethoprim Nitrofurantoin 5 - 10 Send MSU for culture. lower (if susceptible) Cefalexin ◄, Co-amoxiclav ◄ can be used following prior UTI treatment failure (See Appendix A for further treatment options) http://www.cks.nhs.uk/uti_lower_women#191454001 Lower UTI in Trimethoprim Nitrofurantoin 7 Send MSU for culture. menThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 19 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  20. 20. Updated: 31 July 2010 Next update due: 30 September 2010 st nd Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Lower UTI in Trimethoprim 7 Send MSU for culture. pregnancy (First trimester: teratogenic risk – In women with a low folate status (i.e. women with established manufacturer folic acid deficiency or low dietary intake, or in those already advises avoid) taking known folate antagonists), trimethoprim should be avoided unless the woman is also taking a folate supplement Nitrofurantoin In women with normal folate status, short-term use of (Third trimester – trimethoprim is unlikely to induce folate deficiency. Note: women may induce neo- who are pregnant, or at risk of pregnancy, should be taking folic natal haemolysis if acid until week 12 of their pregnancy in order to prevent neural used at term) tube defects in the foetus. However, the BNF cautions against the use of trimethoprim in Cefalexin ◄ the first trimester of pregnancy because the manufacturers recommend that it not be used then. The manufacturers information leaflet also advises against the use of trimethoprim for women who are pregnant or planning to become pregnant. Nitrofurantoin should not be prescribed if the mother is glucose- 6-phosphate dehydrogenase (G6PD)-deficient. It can otherwise be used during pregnancy, but should not be taken near term as it can cause haemolysis in the foetus During pregnancy, cefalexin◄ has not been shown to cause harm to the foetus. http://www.cks.library.nhs.uk/uti_lower_women/view_whole_topicThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 20 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  21. 21. Updated: 31 July 2010 Next update due: 30 September 2010 Infection 1st Line 2nd Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Lower UTI in Trimethoprim Nitrofurantoin 3 For children ≥ 3m and under 3 with signs and symptoms of UTI, Children send MSU for culture and susceptibility. Treat with antibiotics. The child should be taken for reassessment if they remain unwell after 24 – 48 hours. For chldren ≥ 3 years, use dipstick test – if both leukocyte/nitrite +ve, treat with antibiotics otherwise send MSU for culture and susceptibility and treat with antibiotics if appropriate. Cefalexin ◄ can be considered for patients with prior treatment failure. For children < 3m, possible UTI should be referred to the care of a paediatric specialist for treatment with parenteral antibiotics. Clinical Knowledge Summary, NICE Guidance CG54 Recurrent UTI Trimethoprim Nitrofurantoin Post coital prophylaxis is as effective as prophylaxis taken lower women nightly. Prophylactic doses ≥ 3/yr Cephalexin ◄ can be considered for patients with prior treatment failure May be needed for up to 6 months.These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 21 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages
  22. 22. Updated: 31 July 2010 Next update due: 30 September 2010 Infection 1st Line 2nd Line Duration of Rationale/ Additional Information for Treatment Formulary Formulary Treatment Choice Choice (Days) Prostatitis Acute – Trimethoprim 4 weeks 4 weeks treatment may prevent chronic infection. (acute and Ciprofloxacin ◄ chronic) Ofloxacin ◄ Quinolones are more effective. Aged <35 years - 4 weeks Ciproflaxacin◄ + Azithromycin Chronic – Ofloxacin◄ 4 weeks Trimethoprim Clinical Knowledge Summary Ciprofloxacin◄ plus microbiology advice Acute Ciprofloxacin◄ - 7 Send MSU for culture. pyelonephritis OR If no response within 24 hours admit Co-amoxiclav ◄ 14 CKS - pyelonephritis acuteCKS = Clinical Knowledge Summaries, previously known as ‘Prodigy’Appendix A - Recurrent Urinary Tract InfectionsFor recurrent infection where treatment failure has occurred despite optimal treatment with appropriate formulary antibiotics and where patientcompliance has been assessed, the following process should be followed to ensure a reduction in referrals to hospital: 1) For lower urinary tract infection resistant to all other oral antibiotics, consider fosfomycin trometamol (Monuril) sachets: For uncomplicated infection, 1 x 3g sachet at night after emptying the bladder may be given (BNF 34). For complicated infections, 1 x 3g sachet every other night, 3 times may be given (Pullukcu H et al. International Journal of Antimicrobial Agents 2007; 29: 62-65). Complicated infections occur in the presence of a structural abnormality of the urinary tract, and may be suspected in recurrent UTI. Note local procedure for procurement: FP10 to be taken to Peterborough, Addenbrooke’s or Hinchingbrooke Hospital pharmacyThese CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 22 of 23Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.ukThose antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribethese drugs before doing so.It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given onPage 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.Dosages are obtainable from the following link: BNF Antibiotics Dosages

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