Antib Primary Care

Influenza Influenza		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 (notification by Public Health email), 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. Patients over 12 years use oseltamivir 75 mg oral capsule BD (for OD prophylaxis see Influenza ) or zanamivir 10 mg (2 inhalations by diskhaler) BD for 5 days.
Pharyngitis / sore throat / tonsillitis Prodigy 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+ NNT = 30 (child) or 145 (adult) 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 TDS for 7 days is more effective than 3 days.^B+ Twice daily higher dose can also be used.^A- QDS may be more appropriate if severe.^D		phenoxymethylpenicillin first line		500 mg BD-QDS		7-10 days
				erythromycin if allergic to penicillin		500 mg BD or 250 mg QDS (QDS less side-effects)		5-10 days
Otitis media (child doses)		Many are viral. Resolves in 80% without antibiotics.^A+ Poor outcome unlikely if no vomiting or temp <38.5^oC.^A- Use NSAID or paracetamol.^A- Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.^A+ NNT = 20 (>2y) and NNT = 7 (6-24m old) to get pain relief in one at 2-7 days.^A+B+		amoxicillin first line		<2 yrs 125 mg TDS 2-10 yrs 250 mg TDS >10 yrs 500 mg TDS		3-7 days* 3-7 days* 3-7 days*
Prodigy				erythromycin if allergic to penicillin Azithromycin 2^nd line if allergic to penicillins co-amoxiclav 2^nd line		<2 yrs 125 mg QDS 2-8 yrs 250 mg QDS Other: 250-500 mg QDS 15-25kg 200 mg OD 26-35kg 300 mg OD 36-45kg 400 mg OD 1-6 yrs 156 mg TDS 6-12 yrs 312 mg TDS		3-7 days* 3-7 days* 3-7 days* 3 days 3 days 3 days 3-7 days* 3-7 days*
Rhinosinusitis acute or chronic Prodigy		Many are viral. Symptomatic benefit of antibiotics is small - 69% resolve without antibiotics; and 84% resolve with antibiotics.^A+ Reserve for severe^B+ or symptoms (>10 days). Cochrane review concludes that amoxicillin ^A+ and phenoxymethylpenicillin^A+ have similar efficacy to the other recommended antibiotics.		phenoxymethylpenicillin or amoxicillin or oxytetracycline or erythromycin or doxycycline		500 mg TDS 500 mg TDS 250 mg QDS 250 mg QDS/500mg BD 200 mg stat/100 mg OD		7-10 days 7-10 days 7-10 days 7-10 days 7-10 days
		If failure to respond to first line antibiotics		co-amoxiclav		625 mg TDS		7-10 days
Laryngitis/ laryngtracheo bronchitis		Caused by respiratory virus		No antibiotic treatment
* 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 Prodigy	Systematic reviews indicate antibiotics have marginal benefits in otherwise healthy adults.^A+ onsider antibiotics in > 60 yrs or if underlying chest disease. Patient leaflets can reduce antibiotic use.^B+		amoxicillin or oxytetracycline or doxycycline		500 mg TDS 250–500 mg QDS 200 mg stat/100 mg OD		5 days 5 days 5 days
Acute exacerbation of COPD NICE	30% viral, 30-50% bacterial 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		amoxicillin or oxytetracycline or doxycycline erythromycin co-amoxiclav		500 mg TDS 250 mg QDS 200 mg stat/100 mg OD 250 – 500 mg QDS 625 mg TDS		5-10 days 5-10 days 5-10 days 5-10 days 5-10 days
Community-acquired pneumonia - treatment in the community BTS BTS pdf	Start antibiotics immediately.^B- If no response in 48 hours consider admission or add erythromycin first line or a tetracycline^C to cover Mycoplasma infection (rare in over 65s) In severely ill give parenteral benzylpenicillin before admission^C and seek risk factors for Legionella and Staph. aureus infection.^D Sputum examination is not recommended after starting antibiotics If post influenzal, consider adding flucloxacillin (500mg qds) or co-amoxiclav		amoxicillin and / or erythromycin		500 mg - 1g TDS 500 mg QDS		Up to 10 days Up to 10 days
			oxytetracycline or doxycycline		250-500 mg QDS 200 mg stat/100 mg OD		Up to 10 days Up to 10 days
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.		IV or IM benzylpenicillin If allergic to penicillin Chloramphenicol Ceftriaxone IV		Adults and children 10 yr and over: 1200 mg Children 1 - 9 yr: 600 mg Children <1 yr: 300 mg Adults: 50 to 100 mg / kg Children > 1yr: 12.5 to 25mg / kg Children 2 wks to 1 yr: 12.5 mg / kg Infants < 2 wks: 6mg / kg Adult: 2g Neonate: 20-50mg/kg Infant & child under 50kg: 20-50mg/kg Over 50kg: adult dose
Prevention of secondary case of meningitis: Only prescribe following advice from Public Health Doctor: 9 am – 5 pm: Birmingham and Solihull Health Protection Unit 0121 224 4670 Out of hours: Contact on-call Public Health doctor via Heartlands switchboard 0121 424 2000
URINARY TRACT INFECTIONS UTI quick reference guide ESBL Prodigy
Note:. Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic bacteriuria. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely.
Uncomplicated UTI ie no fever or flank pain	Use urine dipstick to exclude UTI -ve nitrite and leucocyte 95% negative predictive value. Multi-resistant E. coli with ESBLs are increasing so perform culture in all treatment failures. There is less relapse with trimethoprim than cephalosporins or quinolones^A-		trimethoprim^B+ or nitrofurantoin^A-		200 mg BD 50-100 mg QDS		3 days^B+ 7 days^C in elderly^C
UTI quick reference guide			2^nd line - depends on susceptibility of organism isolated eg nitrofurantoin amoxicillin, cefalexin, co-amoxiclav, quinolone ESBLs are multi-resistant but some remain sensitive to nitrofurantoin
UTI in pregnancy and men	Send MSU for culture. Short-term use of trimethoprim (avoid 1^st trimester) or nitrofurantoin (avoid third trimester, at term) in pregnancy is unlikely to cause problems to the foetus.^B+		nitrofurantoin or trimethoprim 2^nd line cefalexin or co-amoxyclav		50 mg – 100 mg QDS 200 mg BD 500 mg BD 375 mg TDS		7 days 7 days 7 days 7 days
Catheter UTI	Only treat if systemic signs or symptoms of infection Bacterial eradication is not a realistic goal Consider whether catheter is clinically essential		Co-amoxiclav 1^st line 2^nd line depends on sensitivity		375mg TDS		5 days
Children	Send MSU for culture and susceptibility. Waiting 24 hours for results is not detrimental to outcome.^A-		trimethoprim or nitrofurantoin or cefalexin If susceptible, amoxicillin		See BNF for dosage		7 days^A+
Acute pyelonephritis	Send MSU for culture. A recent RCT showed 7 days ciprofloxacin was as good as 14 days co-trimoxazole.^A- If no response within 24 hours admit.		ciprofloxacin^A- or co-amoxiclav If susceptible, trimethoprim		500 mg BD 500/125 mg TDS 200 mg BD		7 days^A- 14 days 14 days
Recurrent UTI women ≥ 3/yr	Post coital prophylaxis is as effective as prophylaxis taken nightly. Prophylactic doses		nitrofurantoin or trimethoprim		50 mg 100 mg		Stat post coital or od at night
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, 8% of patients benefit. Triple treatment attains >85% eradication.^A+ Avoid clarithromycin or metronidazole if used in the past year for any infection.^C DU/GU: Retest for helicobacter if symptomatic NUD: Do not retest, treat as functional dyspepsia In treatment failure consider endoscopy for culture & susceptibility.^C Substitute oxytetracycline for clarithromycin or metronidazole and add bismuth salt.^A-		First line^A+ cheapest option lansoprazole PLUS metronidazole AND clarithromycin Alternative regimens A⁺ PPI OR ranitidine bismuth citrate PLUS 2 antibiotics: amoxicillin clarithromycin^A+ metronidazole oxytetracycline		30 mg BD 400 mg BD 250 mg BD BD 400 mg BD 1 g BD 500 mg BD 400 mg BD 500 mg QDS		All for 7 days^A 14 days in relapse or maltoma
Gastroenteritis Prodigy	Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days^B+ and can cause antibiotic resistance.^B+ 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 ( as above
Traveller’s diarrhoea	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.
GASTRO-INTESTINAL TRACT INFECTIONS (Continued)
Threadworms Prodigy	Treat household contacts. Advise morning shower/baths and hand hygiene. Use piperazine in children under 2. Do not withhold from school		mebendazole or piperazine		100 mg 1-6 yrs 5ml spoon 3-12 mths 2.5ml spoon		stat stat, repeat after 2 weeks
Antibiotic associated diarrhoea	Send stool sample for Clostridium difficile toxin testing		metronidazole		400mg TDS		10 days
Dysentry	Send stool sample for testing. If history of recent travel, add in metronidazole		ciprofloxacin		500mg BD		5 days
GENITAL TRACT INFECTIONS – UK NATIONAL GUIDELINES Vaginal discharge quick reference guide BASHH
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	All topical and oral azoles give 80-95% cure.^A- In pregnancy avoid oral azole^.B In complicated cases (diabetes, recurrence or severe cases) send sample for culture and treat 7-14 days		clotrimazole 10% or clotrimazole or fluconazole		5 g vaginal cream 500 mg pessary 150 mg orally		stat stat stat
Bacterial vaginosis	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 rates^A+ but is more expensive.		metronidazole^A+ or metronidazole 0.75% vag gel^A+ or clindamycin 2% cream^A+		400 mg BD 5 g applicatorful at night 5 g applicatorful at night		7 days 5 days 7 days
Chlamydia trachomatis Chlamydia quick reference guide	Tetracyclines are contra-indicated in pregnancy. Erythromycin and ciprofloxacin are less efficacious than doxycycline. Treat partners Refer contacts to GUM clinic		doxycycline^A+ or oxytetracycline^A- erythromycin ^A- azithromycin^A+		100 mg BD 500 mg QDS 500 mg BD or 500 mg QDS 1 g stat		7 days 7 days 14 days 7 days 1 hr before or 2 hrs after food
Trichomoniasis	Refer to GUM. Treat partners simultaneously In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure).		metronidazole^A- clotrimazole		400 mg BD or 2 g in single dose 100 mg pessary		5-7 days 6 days
Pelvic Inflammatory Disease (PID)	Essential to test for N. gonorrhoea (as increasing antibiotic resistance) and chlamydia. Microbiological and clinical cure are greater with ofloxacin than with doxycycline.^A+ Refer contacts to GUM clinic		metronidazole + ofloxacin^B or metronidazole + doxycycline^B		400 mg BD 400 mg BD 400 mg BD 100 mg BD		14 days 14 days 14 days 14 days
Acute prostatitis	4 weeks treatment may prevent chronic infection. Quinolones are more effective.		ciprofloxacin or trimethoprim^C		500 mg BD 200 mg BD		28 days 28 days
Urethritis	Refer with partners to GUM		Doxycycline First line Ciprofloxacin + Azithromycin		100mg BD 500mg 1g		7 days stat stat
Epididymitis	A) Younger patient (< 35 years). Exclude sexually transmitted epididymitis (Chlamydia / Gonorrhoea) even in the absence of urethral discharge. Diagnosis and treatment (also partners) should be best managed by GUM referral. B) Older Patient (> 35 years). Underlying urological pathology common. Non-specific bacterial infections with coliforms, Pseudomonas,eneterococcus. May develop after urinary tract surgery or catheterisation. Treat with ciprofloxacin (*500mg BD, 5 days*) initially. If failure to respond (or develops increasing pain or swelling), infarction,abscess or pyocoele should be suspected warranting urgent referral to urology.
SKIN / SOFT TISSUE INFECTIONS
Impetigo Prodigy	Systematic review indicates topical and oral treatment produces similar results^A+ As resistance is increasing reserve topical antibiotics for very localised lesions^{C or D}Reserve Mupirocin for MRSA.		flucloxacillin First or erythromycin line fusidic acid mupirocin		Oral 500 mg QDS Oral 500 mg QDS Topically QDS Topically QDS		7 days 7 days 5 days 5 days
Eczema Prodigy	Using antibiotics, or adding them to steroids, in eczema does not improve healing unless there are visible signs of infection.
Cellulitis	In mild cellulitis flucloxacillin maybe used as single drug treatment.^C Refer severe cases to consultant microbiologist In facial cellulitis use co-amoxiclav^C In sacral or chronic wound associated cellulitis, add metronidazole		flucloxacillin OR erythromycin alone co-amoxiclav		500 mg QDS 500 mg QDS 500/125 mg TDS		7 – 14 days 7 – 14 days 7 - 14 days
Leg ulcers Prodigy	Bacteria will always be present. Antibiotics do not improve healing.^A+ Culture swabs and antibiotics are only indicated if diabetic or there is evidence of clinical infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid deterioration of ulcer or pyrexia. Sampling for culture requires cleaning then vigorous curettage and/or aspiration.
	Diabetic leg ulcer Refer for specialist opinion if severe infection.		co-amoxiclav		625 mg TDS		7-10 days and review
Animal bite Prodigy Human bite	Surgical toilet most important. Assess tetanus and rabies risk. Antibiotic prophylaxis advised for – puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic Antibiotic prophylaxis advised. Assess HIV/hepatitis B & C risk		First line animal & human prophylaxis and treatment co-amoxiclav^B- If penicillin allergic: metronidazole PLUS doxycycline or oxytetracycline (animal) or erythromycin (human) and review at 24 & 48 hrs		375-625 mg TDS 200-400 mg TDS 100 mg BD 250-500 mg QDS 250-500 mg QDS		7 days 7 days 7 days 7 days
Conjunctivitis Prodigy	Most bacterial infections are self-limiting (64% resolve on placebo^A+). They are usually unilateral with yellow-white mucopurulent discharge. Refer if secondary to trauma or contact lens use		chloramphenicol 0.5% drops + 1% ointment fusidic acid		2 hrly reducing to QDS at night 1% gel BD		All for 48 hours after resolution
Scabies Prodigy	Treat whole body including scalp, face, neck, ears, under nails. Treat all household contacts.		permethrin^A+		5% cream		2 applications one week apart
Dermatophyte infection of the proximal fingernail or toenail For children seek advice	Take nail clippings Idiosyncratic liver reactions occur rarely with terbinafine.		5% amorolfine nail lacquer^B- terbinafine^A-		1-2x/weekly fingers toes 250 mg OD fingers toes		6 months 12 months 6 – 12 weeks 3 – 6 months
	Pulsed itraconazole monthly is recommended for infections with yeasts and non-dermatophyte moulds.^C		itraconazole		200 mg BD fingers toes		7 days monthly 2 courses 7 days monthly 3 courses
Dermatophyte infection of the skin Prodigy	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+ Topical undecenoic acid or 1% azole^A+		OD - BD 1-2x/daily		1 week^A+ 4 – 6 weeks^A+
Herpes zoster/ Chicken pox Prodigy & Varicella zoster/ shingles	If pregnant seek advice re treatment and prophylaxis Chicken pox: Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND treatment started <24h of onset of rash.^A- Shingles: Treatment indicated if: ophthalmic or predictors of post-herpetic neuralgia: >60 y^A+, severe pain,^A+severe skin rash, prolonged prodomal pain^B+ AND <72h of onset of rash.		aciclovir or valaciclovir		800 mg 5x/day 1 g TDS Child doses – see BNF		7 days 7 days

Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care. Clinical Guideline 12 February 2004. www.nice.org.uk/CG012NICEguideline

PHLS Meningococcus Forum, endorsed by the PHLS, Public Health Medicine Environment Group and Scottish Centre for Infection and Environmental Health. Guidelines for public health management of meningococcal disease in the UK. Commun Dis Public Health 2002;5:187-204. http://www.hpa.org.uk/cdph/issues/CDPHVol5/no3/Meningococcal_Guidelines.pdf

NICE dyspepsia guidance. August 2004. Evidence indicates once daily PPI plus metronidazole 400mg BD + clarithromycin 250mg BD is as effective as using BD PPI or 500mg clarithromycin. This regimen is cheaper than using BD PPI or higher dose clarithromycin. http://www.nice.org.uk/pdf/CG017fullguideline.pdf

Sexually Transmitted Infections 1999;75:Suppl 1. UK National Guidelines on Sexually Transmitted Infections and Closely Related Conditions. These guidelines are fully comprehensive and extensively referenced. Also available on the web. http://www.bashh.org/guidelines/ceguidelines.htm

Smith J. Bacterial conjunctivitis. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2004;11:156.Scabies

Prodigy Guidance – Shingles & postherpetic neuralgia. April 2002. At www.prodigy.nhs.uk and go to guidance list.

Study design	Recommendation grade
Good recent systematic review of studies	A+
One or more rigorous studies, not combined	A-
One or more prospective studies	B+
One or more retrospective studies	B-
Formal combination of expert opinion	C
Informal opinion, other information	D