RECOMMENDATION FOR THE USE OF ANTIBIOTICS FOR THE TREATMENT OF INFECTION

Transcription

1 RECOMMENDATION FOR THE USE OF ANTIBIOTICS FOR THE TREATMENT OF INFECTION Aims to provide a simple, best guess approach to the treatment of common infections, based on known sensitivity and resistance patterns in Cumbria to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance in the community Principles of Treatment 1. This guidance is based on the best available evidence but its application must be modified by professional judgement in the light of co-existing diseases and other drug therapy. 2. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.. Limit prescribing over the telephone to exceptional cases. 4. Use simple generic antibiotics first whenever possible.. The use of new and me expensive antibiotics (e.g., quinolones and cephalospins) is inappropriate when standard and less expensive antibiotics remain effective. Antibiotics are listed in der of preference. 6. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole. Sht-term use of trimethoprim (theetical risk in first trimester in patients with po diet, as folate antagonist) nitrofurantoin (at term, theetical risk of neonatal haemolysis) is unlikely to cause problems to the foetus. 8. Doses quoted are intended f otherwise fit adults. Doses may need to be changed in children and those with renal impairment. The duration of therapy will vary by individual patient, disease severity and speed of resolution. 9. Where a best guess therapy has failed special circumstances exist, microbiological advice can be obtained from the Consultant Microbiologists at: West Cumberland Hospital Cumberland Infirmary Furness General Hospital This guidance has been produced in consultation with the consultant microbiologists and the Cumbria Medicines Management team. Published: December 2012, Review date: November 20 Condition UPPER RESPIRATORY TRACT/ENT Delayed prescriptions are a useful strategy as most upper respiraty tract infections are viral, self-limiting and improve without antibiotics. Regular use of analgesics such as paracetamol and ibuprofen should be encouraged. Influenza Tonsillitis/pharyngitis/se throat Annual vaccination is essential f all those at risk of influenza. F otherwise healthy adults antivirals not recommended. Treat at risk patients, ONLY within 48 hours of onset and when influenza is circulating in the community in a care home where influenza is likely. At risk: pregnant 6 years over chronic respiraty disease (including COPD and asthma) significant cardiovascular disease (not hypertension) immunocompromised diabetes mellitus chronic neurological renal liver disease AVOID ANTIBIOTICS as 90% resolve in days without and pain only reduced by 16 hours. If Cent sce to 4: lymphadenopathy histy of fever tonsillar exudate no cough consider 2 -day delayed antibiotics immediate antibiotics. OSELTAMIVIR mg BD, if there is resistance to oseltamivir ZANAMIVIR 10mg BD (2 inhalations by diskhaler) F prophylaxis, see NICE. (NICE Influenza). Patients under 1 years see HPA Influenza link. PHENOXYMETHYLPENICILLIN 00mg QDS (severe), CLARITHROMYCIN 20-00mg BD 10 Acute rhinosinusitis Antibiotics to prevent quinsy, NNT >4000 Antibiotics to prevent otitis media, NNT 200 AVOID ANTIBIOTICS as 80% resolve in days without, and they only offer marginal benefit after days (NNT 1) Use adequate analgesia Consider -day delayed immediate antibiotic when purulent nasal discharge (NNT 8) In persistent infection use an agent with anti-anaerobic activity e.g., co-amoxiclav AMOXICILLIN 00mg TDS, 100mg daily, CLARITHROMYCIN 20mg BD 2 nd line CO-AMOXICLAV 62mg TDS

2 Otitis externa (acute) Otitis media (acute) child doses First use aural toilet and analgesia. Cure rates similar f topical acetic acid antibiotic steroid Antibiotics do not reduce pain in first 24 hours, subsequent attacks deafness. Use paracetamol NSAID. Otitis media resolves in 60% of patients in 24 hours without antibiotics. Antibiotics reduce pain at 2 days (NNT 1) Consider antibiotics (2 to days) if: <2 years AND bilateral otitis media (NNT 4) marked otoscopic signs and symptoms All ages with otrhea (NNT ) Immediate prescribing may be appropriate f the following groups: otrhoea <2 years with bilateral acute otitis media ACETIC ACID spray (EarCalm ) 1 spray TDS, PREDNISOLONE + NEOMYCIN ear drops drops TDS AMOXICILLIN 40-90mg/kg/day in divided doses up to 1 gram TDS, CLARITHROMYCIN <8kg -.mg/kg BD 8-11kg 62.mg BD 12-19kg 12mg BD 20-29kg 18.mg BD 0-40kg 20mg BD 2 nd line - CO-AMOXICLAV 1-6yrs - 16mg TDS 6-12yrs - 12mg TDS LOWER RESPIRATORY TRACT Lower respiraty tract infection (including acute bronchitis) in otherwise healthy individuals Exacerbations of COPD Community acquired pneumonia Bronchiectasis EYES Bacterial conjunctivitis Ocular Herpes simplex infection Haemophilus is an extracellular pathogen so macrolides (e.g., erythromycin), which concentrate intracellularly, are less effective therapy. Antibiotics are not routinely indicated. Consider prescribing an antibiotic if the person has a significantly impaired ability to fight infection (e.g., immunocompromised status, cancer, physical frailty) if acute bronchitis is likely to significantly wsen a pre-existing condition (e.g. heart failure, angina, diabetes). Alternative antibiotics may be used on the basis of sputum results. Treat exacerbations promptly with antibiotics if: purulent sputum and increased shtness of breath and/ increased sputum volume Risk facts f antibiotic resistant ganisms include co-mbid disease, severe COPD, frequent exacerbations, antibiotics in last months Assess the person's need f admission by determining CRB6 sce: Confusion (AMT<8) Respiraty rate > 0/minute Age >6 years BP systolic <90 diastolic 60 Sce 0, suitable f home treatment Sce 1-2, hospital assessment admission Sce -4, urgent hospital admission Give immediate Benzylpenicillin 1.2 grams IM Amoxicillin 1 gram al if delayed admission life-threatening Antibiotics should be given f exacerbations that present with an acute deteriation with wsening symptoms (cough, increased sputum volume change in viscosity, increased sputum purulence with without increasing wheeze, breathlessness, haemoptysis) and/ systemic upset. Sputum samples should be taken to guide therapy. Need long course of 10 to days. Treat if severe, as most are viral self-limiting. Bacterial conjunctivitis is unilateral and also selflimiting. It is characterised by red eye with mucopurulent, not watery discharge. 6% resolve on placebo by day. STD: unilateral inclusion conjunctivitis usually with urethritis (causative agent: C. trachomatis). Urgent ophthalmic referral necessary. In recurrent infection treatment may be initiated but this must be done in consultation with ophthalmologist. Avoid topical steroids and remove contacts lenses. If antibiotics are required, AMOXICILLIN 00mg TDS, 100mg daily AMOXICILLIN 00mg TDS, 100mg daily, CLARITHROMYCIN 00mg BD If CRB6=0 AMOXICILLIN 00mg TDS, 100mg daily, CLARITHROMYCIN 00mg BD If CRB6=1 & AT HOME AMOXICILLIN 00mg TDS AND CLARITHROMYCIN 00mg BD, 100mg daily Antibiotic choice should be based on previous culture results. Consider need f anti-pseudomonal cover if not responding, Pseudomonas growth from the sputum. If culture negative send sample f Aspergillus CHLORAMPHENICOL eye drops 1 drop every 2 hours f 2 days, then 4 hourly (whilst awake) f up to 1 week; eye ointment at night If pregnant histy of blood dyscrasia use FUSIDIC ACID BD Chlamydial: DOXYCYCLINE 100mg BD, AZITHROMYCIN 1 gram stat (treat the sex partner as well) Commence ACICLOVIR eye ointment, applied times a day

3 Cneal abrasions ORAL Mucosal ulceration and inflammation Dental abscess Oral thrush If cneal ulcer - Urgent ophthalmic referral is necessary. Tempary pain and swelling relief can be attained with saline mouthwash(½tsp in glass of warm water) Advise urgent dental consultation, as repeated courses of antibiotics f abscess are not appropriate. Antibiotics are only recommended if there are: signs of severe infection systemic symptoms high risk of complications Otherwise, regular analgesia should be first option until a dentist can be seen. CHLORAMPHENICOL eye ointment BD CHLORHEXIDINE 0.2% mouthwash, rinse mouth f 1 minute BD with ml diluted with equal volume of water, HYDROGEN PEROXIDE 6%, 1mls in ½ glass of warm water TDS AMOXICILLIN 00mg TDS, PHENOXYMETHYLPENICILLIN 00mg-1 gram QDS If penicillin allergic, in severe infection METRONIDAZOLE 200mg TDS NYSTATIN 100,000 units QDS, MICONAZOLE gel, ml QDS (miconazole interacts with statins and anticoagulants) Until lesion resolves of less pain allows al hygiene Acute necrotising ulcerative Refer to dentist f scaling and al hygiene advice, gingivitis after starting antibiotic Periconitis Refer to dentist f irrigation and debridement. If persistent swelling systemic symptoms, use metronidazole GASTRO-INTESTINAL INFECTIONS H.pyli infection Tetracycline 00mg four times a day may be used instead of amoxicillin in penicillin-allergic patients. Resistance to clarithromycin to metronidazole is much me common than to amoxicillin and can develop during treatment. Do not use clarithromycin metronidazole if used f any infection in the past year. Giardiasis Recurrence is high even with optimal treatment, therefe follow-up with a stool sample is advised. Threadwms Acute gastroenteritis Travellers diarrhoea C.difficile infection Treat all household contacts at the same time PLUS advise hygiene measures f 2 weeks (hand hygiene, pants at night, mning shower) PLUS wash sleepwear, bed linen, dust and vacuum on day one. Antibiotics not usually indicated. Discuss any intended treatment with microbiologist. Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 00mg single dose, unlicensed indication) to people travelling to remote areas in whom an episode of infective diarrhoea could be dangerous. Stop unnecessary antibiotics and/ PPIs. 0% respond to metronidazole in days, 92% in days. Admit if severe: Temperature >8. C WCC >1 Rising creatinine Signs/symptoms of severe colitis If immunosuppressed, consider fluconazole 0-100mg OD f to days METRONIDAZOLE 200mg TDS METRONIDAZOLE 200mg TDS Triple-therapy: LANSOPRAZOLE 0mg BD plus AMOXICILLIN 1 gram BD plus either CLARITHROMYCIN 00mg BD, METRONIDAZOLE 400mg BD METRONIDAZOLE 200mg TDS f days is the most tolerable and effective doses; 400mg TDS f days 2 grams daily f days MEBENDAZOLE 100mg (mebendazole is not licensed f children under 2 years, use piperazine instead) Antibiotic treatment not routinely recommended Fluid replacement essential METRONIDAZOLE 400mg TDS f 1 st and 2 nd episodes VANCOMYCIN 12mg QDS f rd episode/severe type 02 - depending on the doses One dose repeat in two weeks URINARY TRACT Amoxicillin resistance is common, therefe ONLY use if culture confirms susceptibility. In the elderly (>6 years), do not treat asymptomatic bacteriuria: it occurs in 2% of women and 10% of men and is not associated with increased mbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell pyelonephritis likely. Co-amoxiclav is alternative in patients with low GFR. Nitrofurantoin should not be used if GFR is <60mL/min/1.m 2 trimethoprim if GFR is <1mL/min/1.m 2. Cystitis in women UTI in men Routine urine culture unnecessary f simple cystitis in adult women. Further diagnosis should be made on basis of symptoms and dipstick analysis (see HPA guidance). TRIMETHOPRIM 200mg BD, NITROFURANTOIN MR 100mg BD (Note that trimethoprim may cause a rise in serum creatinine especially in pre-existing renal impairment due to competition f renal excretion) Co-amoxiclav is alternative in patients with low GFR (see above) TRIMETHOPRIM 200mg BD, NITROFURANTOIN MR 100mg BD Co-amoxiclav is alternative in patients with low GFR (see above)

4 UTI confirmed asymptomatic bacteriuria in pregnant women UTI in children Screening requires a urine sample to be sent to microbiology f microscopy and culture, dip stick testing alone is not adequate < months, immediate paediatric referral > months with acute pyelonephritis/upper UTI, consider referral to paediatric specialist, treat with antibiotics > months with cystitis/lower UTI, treat. If still unwell after 24 to 48 hours, child should be reassessed AMOXICILLIN 00mg TDS, NITROFURANTOIN MR 100mg BD, CEFALEXIN 00mg TDS f days, TRIMETHOPRIM 200mg BD f days (unless folate deficient taking folate antagonist [e.g. antiepileptic proguanil]) TRIMETHOPRIM 4mg/kg BD (max 200mg), CEFALEXIN 1 month-1 year - 12mg BD 1 years - 12mg TDS - 12years - 20mg TDS Pyelonephritis Culture required. CO-AMOXICLAV 62mg TDS, CIPROFLOXACIN 00mg BD Epididymo-chitis Screen f chlamydia. DOXYCYCLINE 100mg BD (lower) -10 if upper UTI GENITAL SYSTEM Vaginal candidiasis Bacterial vaginosis Chlamydia Clotrimazole and fluconazole are available over-thecounter. day course recommended during pregnancy. Fluconazole is contra-indicated in pregnancy. Usually associated with anaerobes, recurrence is frequent, but is not a sexually transmissible infection (STI). Do not retest if symptoms resolve. In pregnancy days of clindamycin gel recommended. In pregnancy testing should be repeated after 1 month to ensure cure achieved. Advise sexual abstinence until the infected woman and her partner(s) have both completed the course of treatment. If treatment with single-dose azithromycin is given, then sexual abstinence f the following days is advised. (Azithromycin has been used f 20 years, during which time a number of studies have shown that there is no increased risk of adverse effects associated with using the drug during pregnancy. It is significantly me effective and better tolerated than the alternative agents (erythromycin and amoxicillin), but its use is me limited). Pregnant woman must be retested after weeks after completing therapy (6 weeks if azithromycin used). Refer to GUM clinic f contact tracing. Add IM CEFTRIAXONE 00mg stat if there likelihood of sexually transmitted pathogen CLOTRIMAZOLE pessaries 00mg, 200mg FLUCONAZOLE 10mg METRONIDAZOLE 400mg BD, 2 grams stat, METRONIDAZOLE vaginal gel, 0.% daily apply at night CLINDAMYCIN vaginal gel, 2% daily apply at night DOXYCYCLINE 100mg BD, AZITHROMYCIN 1 gram (not licensed f use in pregnancy, see comments) Trichomoniasis Refer to GUM may be associated with other STDs. METRONIDAZOLE 400mg BD Gonrhoea - uncomplicated Increasing resistance Refer to GUM clinic f contact CEFTRIAXONE IM 00mg stat and stat tracing and screening f other sexually transmitted diseases. AZITHROMYCIN 1 gram stat Pelvic inflammaty disease Refer to GUM. Tests essential f gonococcus and chlamydia. CEFTRIAXONE IM 00mg stat followed by DOXYCYCLINE 100mg BD and METRONIDAZOLE 400mg BD OFLOXACIN 400mg BD and METRONIDAZOLE 400mg BD Acute prostatitis Send MSU f culture and start antibiotics. 2 week course may prevent chronic prostatitis. CIPROFLOXACIN 00mg BD, TRIMETHOPRIM 200mg BD Genital herpes Screening f low risk patients may be done in practice. ACICLOVIR 200mg five times a day Higher risk should be referred to GUM. Bartholins gland infection May be associated with STD consider screening. Antibiotics not indicated f uncomplicated disease Genital warts Screening f co-existent STD indicated. Podophyllotoxin is contra-indicated in pregnancy. PODOPHYLLOTOXIN applied twice daily f three consecutive days, repeated at weekly intervals if necessary f a total of 4 to courses Liquid nitrogen if small number of low volume warts keratinized WOUND AND SKIN INFECTION Cellulitis - limb If afebrile and well other than cellulitis al therapy is adequate. If febrile and unwell admit arrange f IV antibiotics (flucloxacillin clarithromycin, as approved under PCT Cellulitis pathway). FLUCLOXACILLIN 00mg QDS, CLARITHROMYCIN 00mg BD If river seawater exposure discuss with microbiologist. - facial Early referral necessary if not responding to treatment. CO-AMOXICLAV 62mg TDS 1 Stat dose stat

5 Surgical wounds, abscesses, mastitis, wound infection Leg ulcers and pressure ses Herpes zoster Animal and human bites Tick bite Abscesses should be drained. If wound could be contaminated with soil, faeces bodily fluids if infection area has po vascular supply. FLUCLOXACILLIN 00mg QDS, CLARITHROMYCIN 00mg BD CO-AMOXICLAV 62mg TDS, CLARITHROMYCIN 00mg BD and METRONIDAZOLE 400mg TDS, CLINDAMYCIN 00mg QDS Bacteria will always be present. Antibiotics do not improve healing, unless active infection. Culture swabs and antibiotics are only indicated if diabetic there is evidence of clinical infection such as inflammation/redness/cellulitis, increased pain, purulent exudate, rapid deteriation of ulcer pyrexia. ACICLOVIR 800mg five times a day, started within 2 hours of onset of rash Human bites should generally be treated with antibiotics if the skin is broken, and consideration given to tetanus, hepatitis B and HIV prophylaxis. If the skin is broken following an animal bite, consider antibiotics if puncture wound, bite to hand, foot, face, joint, tendon, ligament immunocompromised, diabetic, asplenic cirrhotic. Cat bites carry a high risk of infection and should be treated. Consider tetanus, and, if the bite occurred abroad, rabies. Lyme disease prophylaxis is indicated if tick is likely to have been attached f >24 hours, it is obviously engged. Prophylaxis not indicated if the bite occurred me than 2 hours ago, if the patient is continually exposed to ticks. CO-AMOXICLAV 62mg TDS 2 nd line Cat, dog and human bites - DOXYCYCLINE 100mg BD and METRONIDAZOLE 400mg TDS Human bites - CLARITHROMYCIN 20-00mg BD and METRONIDAZOLE 400mg TDS DOXYCYCLINE 200mg single dose Impetigo Fungal nail infections Treatment of localised erythema migrans: Treatment of later stages of Lyme disease - discuss with Microbiologist. F extensive, severe bullous impetigo, use al antibiotics DOXYCYCLINE 100mg BD, AMOXICILLIN 00mg TDS; children <8 years Amoxicillin 0mg/kg/day in divided doses f 2 weeks Erythromycin FLUCLOXACILLIN 00mg QDS, CLARITHROMYCIN 20mg to 00mg BD Reserve topical antibiotics f very localised lesions to FUSIDIC ACID, topical TDS reduce the risk of resistance. Reserve mupirocin (local) f MRSA infections. MUPIROCIN, topical TDS Take nail clippings. TERBINAFINE 20mg daily; Treatment must only be commenced after mycological fingernails, confirmation of infection. Topical amolfine should only be used where infection is confined to the distal edge of the nail in the very early stages of distal and lateral subungual onychomycosis in superficial white onychomycosis. toenails, ITRACONAZOLE 200mg BD fingernails, (2 courses) 6 to 12 weeks; to 6 months days monthly toenails, ( courses) Fungal skin infections Terbinafine not licensed in children but listed in BNFc. - dermatophyte (ringwm) Clotrimazole is an alternative. TERBINAFINE cream twice a day candida CLOTRIMAZOLE cream BD/TDS, Continue 1-2 weeks after affected area has healed Varicella zoster/chickenpox Pregnant/immunocompromised/neonate, seek urgent specialist advice Chicken pox: If started < 24 hours of rash and > ACICLOVIR 800mg five times day years severe pain dense/al rash 2 household case smoker Shingles: treat if > 0 years and within 2 hours of rash if active ophthalmic Ramsey Hunt eczema. CENTRAL NERVOUS SYSTEM Meningitis stat Urgent hospital transfer is primary consideration. Only contra-indication to benzylpenicillin if true penicillin anaphylaxis; use of alternate antibiotics is not recommended. BENZYLPENICILLIN, preferably IV, but IM if access difficult Over 10 years, 1.2 grams 1 to 9 years, 600mg Under 1 year, 00mg