Antimicrobial treatment guidelines_july_10.sflb

Updated: 31 July 2010 Next update due: 30 September 2010

These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 1 of 23 Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, [email protected] Those antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribe these 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are based, are updated regularly and while these guidelines are accurate at the date given on Page 1 they may have been superseded.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

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.



Clostridium 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 be used 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 positive patients. 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 each page: BNF Antibiotics Dosages It is the intention of Cambridgeshire PCT to audit for compliance against the antibiotics formulary to support judicious prescribing of antibiotics and SHA and PCT objectives. This will be carried out by the Medicines Management Team who will be able to give help and support to practices and prescribers 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 the production of these guidelines.



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 Formulary Choice

2nd Line Formulary Choice

Duration of Treatment (Days)

Rationale/ Additional Information for Treatment

Dental

Dental infections

Amoxicillin

Metronidazole In penicillin allergy: Erythromycin

5

5 5

Mild – empirical (Strep, anaerobic streps, bacteroides spp (but rarely penicillin resistant)) Moderate/severe/recurrent : (organisms as above but note possibility of penicillin-resistance)

Dental abscess - CKS link – treat for five days

Ear , Nose and Throat

Acute Otitis Media

If antibiotics are indicated: Amoxicillin In penicillin allergy: Erythromycin

Azithromycin

5 3

For acute attacks where there are no systemic features: paracetamol or ibuprofen for pain For acute attacks with systemic features: treat systemically. BNF recommends for children: Acute attacks with no systemic features may be treated systemically after 72 hours if still symptomatic or earlier if there is deterioration or no improvement. Clinical Knowledge Summary

Sore throat (Pharyngitis)

Question necessity for treatment as frequently viral in origin. Treatment with paracetamol or ibuprofen may be appropriate.

Penicillin In penicillin allergy: Erythromycin

10

10

Usually viral and may not require antibiotic treatment. Antibiotics only generally shorten duration of symptoms by approximately 8 hours There may be overlap between viral and streptococcal infections. More severe symptoms (history of fever, purulent tonsils, cervical adenopathy, absence of cough) or patients with a history of otitis media may benefit more from antibiotics. Clinical Knowledge Summary







Acute Sinusitis

Where symptoms have persisted for 7 days or more: or are severe or deteriorating rapidly: Amoxicillin (7 days) In penicillin allergy : Clarithromycin or Doxycycline. Erythromycin

In penicillin allergy : Azithromycin (3 days) Erythromycin for pregnant woemen.

7 7

Many attacks are viral in origin and symptomatic benefit of antibiotics is small (69% resolve without antibiotics, 15% resolve with antibiotics). Initial therapy may include nasal decongestants or intranasal corticosteroids, e.g. beconase Clinical Knowledge Summary

Eye

Ocular Herpes

Refer to secondary care clinicians

- - Herpes simplex – 1,2 virus 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.



Infection 1st Line

Formulary Choice




Gastro-intestinal Diverticulitis Co-amoxiclav ◄ At least 7

days Awaiting comments from gastroenterologist

Eradication of Helicobacter pylori For HP +ve result

Formulary PPI + Amoxicillin + Clarithromycin Or Formulary PPI + Metronidazole + Clarithromycin

(eradication failure) Formulary PPI + Tripotassium dicitratobismuthate + tetracycline + metronidazole

7

14 days treatment for relapse and

maltoma

Where patients are HP negative do not retest unless there is strong clinical need – treat as functional dyspepsia with low dose PPI or H2A for one month then reassess before continuing therapy (reassess dose for maintenance therapy) Do not use the clarithromycin/metronidazole regimen if either drug used for infection in the past year. In the case of treatment failure following TWO treatment regimens consider endoscopy for culture and susceptibility. NICE

Gastro- enteritis

Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1 to 2 days and can lead to antibiotic 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 diarrhoea

Erythromycin (confirmed Campylobacteriosis only)

Ciprofloxacin ◄ 7

Antibiotic treatment for campylobacteriosis is only indicated if the patient has severe symptoms, dysentery or is immunocompromised.







Infective diarrhoea (cont’d)

Metronidazole (antibiotic related inc. C.difficile assoc. diarrhoea, amoebic dysentery and giardiasis) Ciprofloxacin ◄ (Traveller’s diarrhoea)

C.diff assoc diarrhoea 10-

14 days

Giardiasis 5 days

Amoebic

dysentery 5 – 10 days

Stat dose or

3 days

Ciprofloxacin ◄ may occasionally be required for those who are at high risk (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 positive patients), or who present with dysentery. CKS - Infective diarrhoea

Threadworm Mebendazole (for adults and children over 6m) Only retreat after 14 days if infestation persists

Piperazine

Stat Dose of Piperazine, where used, should be repeated after 2 weeks

Piperazine can be given second line and for children aged 3 to 6 months. Household contacts should be treated. Advise on morning shower/baths and on hand hygiene. If an anthelmintic is contraindicated (e.g. first trimester of pregnancy, children aged less than 3 months) or if the individual does not wish to take an anthelmintic, advise physical removal of eggs, combined with hygiene measures for 6 weeks Threadworm -CKS link







Genital Tract - BASHH Vaginal

candidiasis

Clotrimazole 10% OR Clotrimazole

Oral fluconazole Miconazole

Stat. All topical and oral azoles give 80-95% cure.

In pregnancy avoid oral azole.

Bacterial

vaginosis Metronidazole

OR Metronidazole 0.75% vaginal gel

- - Clindamycin 2% cream

Stat or 7 days 5 7

A 7 day course of oral metronidazole is slightly more effective than 2g stat. Avoid 2g stat dose in pregnancy.

Topical treatment gives similar cure rates but is more expensive.

Candidal Balanitis Gardnerella associated balanitis

Topical clotrimazole 1% Oral metronidazole

Oral fluconazole (adults and children over 16 only), if candidal balanitis has not cleared after 7 days or is severe.

Until 2-3 days after clinical

cure

Single dose 7

An irritant balanitis is more common than infective

Diagnosis of candidal balanitis is probably more common than bacterial (e.g strep, anaerobes) and should be made on clinical grounds whilst awaiting culture results.

Advise to avoid contact with any potential skin irritants (e.g. soap). Keeping area clean by bathing twice daily with a weak saline solution while symptoms persist.

Children should be treated using topical anti-fungals.

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 balanitis







Acute streptococcal balanitis

Oral amoxicillin In penicillin sensitivity: Erythromycin/ clarithromycin

7 An infective complication of an underlying dermatosis should also be considered. Balanitis - CKS link

Chlamydia trachomatis

Azithromycin

- Doxycycline OR Erythromycin (for

pregnancy)

Stat 7

14

Tetracyclines are contra-indicated in pregnancy. Erythromycin is less efficacious than doxycycline. Treat partners and refer contacts of positive patients to CPCT Chlamydia screening service, Tel 01480 398787 [email protected]

Trichomo- niasis

Metronidazole

Topical clotrimazole

Tinidazole Or Second course of Metronidazole

7 Refer to GUM. Treat partners simultaneously In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief but no cure. Clinical Knowledge Summary

Pelvic Inflammatory Disease (PID)

Ceftriaxone I/M ◄ (single dose) + Metronidazole +Doxycycline

Metronidazole + Ofloxacin ◄

14 Test for N. gonorrhoea (as increasing antibiotic resistance) and chlamydia. Microbiological and clinical cure are greater with ofloxacin than with doxycycline. Refer contacts to GUM clinic Clinical Knowledge Summary







Meningitis Suspected

meningio- coccal disease

Benzyl penicillin In penicillin allergy: Cefotaxime ◄

Chloramphenicol if history of anaphylaxis with penicillin or cephs

Administer antibiotic prior to hospital admission.

Respiratory NNoottee:: 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 Exacerbation of COPD

Doxycycline

(only where tetracyclines contraindicated) Co-amoxiclav (If penicillin intolerant, consult microbiologist for advice)

7 30% of cases are viral in origin, 30-50% bacterial, remainder undetermined. Antibiotics are not indicated in the absence of purulent/mucopurulent sputum. In the event of treatment failure the second line drug should be considered, and a sputum specimen sent for analysis. Co-amoxiclav is only recommended where doxycycline is inappropriate or ineffective, as it may predispose patient to c difficile infection. Other antibiotics should only be used on microbiological advice due to resistance of some organisms locally. Thorax, CKS, NICE

Acute Bronchitis

Amoxicillin In Penicillin allergy: Erythromycin or Clarithromycin

Doxycycline Clarithromycin

5 Antibiotics are not indicated in people who are otherwise well. Explain why antibiotics are not necessary, giving written information if necessary. Clinical Knowledge Summary







Acute Community Acquired Pneumonia

Amoxicillin In Penicillin allergy: Erythromycin or Clarithromycin

Doxycycline In Penicillin allergy: Clarithromycin

7 If no response at 48 hours consider addition of erythromycin, oxytetracycline or doxycycline. BTS pdf, BTS, IDSA -http://www.thoracic.org/sections/publications/statements/pages/mtpi/idsaats-cap.html

Seasonal Influenza

Annual vaccination for at risk patients When flu circulating, antivirals may be prescribed as per local advice

- Yearly In otherwise healthy adults, antivirals are not recommended - only when influenza is circulating in the community, within 48 hours of onset. At risk: 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic renal disease and chronic liver disease.

For swine flu (H1N1) please follow the latest Department of Health/ Health Protection Agency advice

Skin and Soft Tssue Acne

Moderate to severe

Oxytetracycline / Tetracycline 500mg bd 500mg bd Lymecycline 408mg od

Erythromycin if tetracyclines not tolerated

At least 3 months

Propionibacterium acnes The tetracyclines should not be used in pregnancy, during breastfeeding, or in children under 12 years of age, as they are deposited in the teeth and bones of the unborn or developing child. 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 link







Balanitis – see under Genital Tract

Bites (Cat, Dog, Human)

Doxycycline + Metronidazole (Animal) Erythromycin Metronidazole (Human) Co-amoxiclav ◄ (Human/animal)

In penicillin allergy: Metronidazole + doxycycline (animal) And Metronidazole + Erythromycin (human)

7 Antibiotic prophylaxis (antibiotics and duration as for treatment (CKS)) advised for puncture wounds; bites involving hand, foot, face, joint, tendon, ligament in immunocompromised, diabetic, elderly and asplenic patients

Antibiotic prophylaxis (antibiotics and duration as for treatment (CKS)) advised for all human bites.

Human bites should be reviewed after 24 and 48 hours. Assess HIV/hepatitis B & C risk, tetanus and rabies. Clinical Knowledge Summary

Breast Abscess

Flucloxacillin Erythromycin

- 7

Cellulitis – minimal or minor trauma

Flucloxacillin Co-amoxiclav ◄ in facial cellulitis In penicillin allergy: Erythromycin

7 If the patient is afebrile and healthy other than cellulitis, treat as indicated. For diabetic patients or patients where the infected area has been exposed to fresh water – ciprofloxacin◄ should be added to the primary treatment. Where the infected area has been exposed to salt water – doxycycline shoud be added. Clinical Knowledge Summary (See also Appendix B).







Chicken Pox

Aciclovir 800mg 5x/day Child doses – see BNF / RCPCH Medicines for Children

- 7 days

If pregnant seek advice (see link). Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND treatment started less than 24 hours from onset of rash. If patients develop life-threatening complications (encephalitis, 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 0.5% drops OR Chloramphenicol 1% ointment

Fusidic acid Until 48 hours after

resolution

Many infections are viral in origin Most bacterial infections are self-limiting (64% resolve on placebo). They are usually unilateral with yellow-white mucopurulent discharge. Fusidic acid has less Gram-negative activity. Clinical Knowledge Summary







Dermatophyte infection of the proximal fingernail or toenail

Amorolfine nail lacquer 5% (for superficial infections)

-

Oral Terbinafine

(generic only) Oral Itraconazole (pulsed)

Once or twice a week: Fingers, 6m Toes, 12m Fingers: 6 – 12 weeks Toes: 3 – 6 months Fingers: 7 days monthly – 2 courses Toes 7 days monthly – 3 courses

Treatment should only be considered if the patient has poor or diminished circulation (diabetes, imunocompromised or peripheral vascular disease) and can/will comply with a long course of treatment. Take nail clippings: Start therapy only if infection is confirmed by mycological examination. Idiosyncratic liver reactions occur rarely with terbinafine. For infections with yeasts and non-dermatophyte moulds use itraconazole. Itraconazole can also be used for dermatophytes. For children seek advice Clinical Knowledge Summary

Dermatophyte infection of the skin

Topical 1% terbinafine

- Topical 1% azole

7

4 - 6 weeks treatment

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

Eczema

Not usually required

Oral flucloxacillin Or in penicillin allergy: Erythromycin

7 7

Using antibiotics, or adding them to steroids, in eczema does not improve healing unless there are visible signs of infection. Where there are visible signs of infection treat orally. Topical antimicrobial/corticosteroid combinations have been shown to be no more effective than topical corticosteroid alone in treating either visibly infected or uninfected flare-ups. Clinical Knowledge Summary







Erysipelas Penicillin V Erythromycin 7 - 10 days Only if diagnosis certain (beta-haem Strep A,B,C,G) Genital

herpes

Aciclovir (for first episode & acute recurrence)

Famciclovir or Valaciclovir

5 days

5 days

Herpes simplex virus Oral antiviral treatment should be given to people presenting within 5 days of the start of the episode, or while new lesions 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 malathion. Repeat after 7 days. Where phenothrin or malathion needed, choose a product with the longest contact time (i.e. not mousses or shampoos).

As recommended by the local Health Protection Unit (based on Stafford Report and CKS). Hedrin (dimeticone) unlikely to provoke resistance in head lice. Permethrin not recommended for head lice in BNF or CKS.

Impetigo Minor – topical fusidic acid Severe or extensive disease – Oral Flucloxacillin Erythromycin

Topical Mupirocin (should be reserved for MRSA or if fusidic acid has been ineffective or not tolerated).

7 7

Topical antibiotics should only be used for very localised lesions to prevent resistance developing. Clinical Knowledge Summary







Insect bites or stings

Oral Flucloxacillin (If allergic to penicillin – Erythromycin/ Clarithromycin 7 days)

Try alternative first line treatment

7 As recommended by CKS

Lacerations Co-amoxiclav◄ In penicillin allergy Erythromycin + Metronidazole

Erythromycin + Metronidazole Clarithromycin +Metronidazole

5 5

Only treat if at high risk of infection, i.e. where laceration may be contaminated with soil, faeces, bodily fluids, or purulent exudates. For clean lacerations flucloxacillin may be used or erythromycin where there is penicillin allergy. Clinical Knowledge Summary

Flucloxacillin

In penicillin allergy: Clarithromycin or Erythromycin

7 Antibiotics do not improve healing. Culture swabs and antibiotics are only indicated if there is evidence of clinical infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid deterioration of ulcer or pyrexia. Clinical Knowledge Summary (See also Appendix B).

Leg ulcers Diabetic leg ulcer

As above As above 7 Refer for specialist opinion if severe infection. Co-amoxiclav ◄ or Cefradine ◄ may be considered by specialist (See also Appendix B).







Paronychia Candidal Paroncychia

Flucloxacillin In penicillin allergy: Erythromycin (or clarithromycin if erythromycin not tolerated) Topical clotrimazole

In penicillin allergy: Erythromycin + metronidazole (or clarithromycin if erythromycin not tolerated)

7 7

Until healed (Treatment lasting 3-6 months may be required)

Empirical therapy (Staph. Aureus, beta-haem Strep A, B, C, G) If there is no response to initial antibiotic, swab to confirm infecting organism and treat according to sensitivities. Arrange for incise and drain if fluctuant. If no pus and incision not possible, change to second line antibiotic. In the event of treatment failure consider candidal paronychia. 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 for candida albicans +/- mixed coliforms. Systemic treatment is only indicated in patients unresponsive to topical treatment or where immunocompromised. Candidal paronychia – CKS link







Otitis externa: Mild If severe or cellulitis or boil If fungal Infection

Topical betamethasone +neomycin drops Flucloxacillin Topical clotrimazole

In resistant cases: Otosporin In penicillin allergy: Erythromycin

7 days 7 days For 4 weeks

NB: cleaning essential Topical treatment is recommended unless systemically unwell, 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 N.B. Pseudomonas aeruginosa not covered by flucloxacillin. Seek specialist advice if spreading cellulitis outside ear canal, or where Pseudomonas infection suspected (immunocompromised, diabetic). Refer urgently if suspected malignant otitis externa Fungi (dermatophytes, yeasts, moulds Otitis externa – CKS link

Pubic lice Malathion aqueous 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.

As recommended by CKS







Scabies

Permethrin Malathion 0.5% 2 applications 1 week apart

Treat whole body including scalp, face, neck, ears, under nails. (BNF guidance). Treat all household contacts. NICE Guideline CG 54

Varicella zoster / shingles

Aciclovir 800mg 5x/day

[Valaciclovir] / [Famciclovir] [1g tds] [750mg 1x/day]

7 days Because of the higher risk of complications, it would seem sensible to give a course of antiviral treatment to a person presenting for the first time after 72 hours of the onset of the 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 link







Urinary Tract

NNoottee::. 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-cated lower UTI/Cystitis in women.

Trimethoprim Nitrofurantoin

Try an alternative 1st line agent

3 For patients with clinical signs of UTI treat empirically.There should be no fever or flank pain.

To confirm presence of infection in patients with few clinical 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 lower UTI

Trimethoprim (if susceptible)

Nitrofurantoin 5 - 10 Send MSU for culture. Cefalexin ◄, Co-amoxiclav ◄ can be used following prior treatment failure (See Appendix A for further treatment options) http://www.cks.nhs.uk/uti_lower_women#191454001

Lower UTI in men

Trimethoprim Nitrofurantoin 7 Send MSU for culture.







Lower UTI in pregnancy

Trimethoprim (First trimester: teratogenic risk – manufacturer advises avoid) Nitrofurantoin (Third trimester – may induce neo-natal haemolysis if used at term) Cefalexin ◄

7 Send MSU for culture. In women with a low folate status (i.e. women with established folic acid deficiency or low dietary intake, or in those already taking known folate antagonists), trimethoprim should be avoided unless the woman is also taking a folate supplement In women with normal folate status, short-term use of trimethoprim is unlikely to induce folate deficiency. Note: women who are pregnant, or at risk of pregnancy, should be taking folic acid until week 12 of their pregnancy in order to prevent neural tube defects in the foetus. However, the BNF cautions against the use of trimethoprim in the first trimester of pregnancy because the manufacturers recommend that it not be used then. The manufacturer's 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_topic



Infection 1st Line

Formulary Choice




Lower UTI in Children

Trimethoprim

Nitrofurantoin

3 For children ≥ 3m and under 3 with signs and symptoms of UTI, 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 lower women ≥ 3/yr

Trimethoprim Nitrofurantoin Post coital prophylaxis is as effective as prophylaxis taken nightly. Prophylactic doses Cephalexin ◄ can be considered for patients with prior treatment failure May be needed for up to 6 months.



Infection 1st Line

Formulary Choice




Acute – Ciprofloxacin ◄ Ofloxacin ◄

Trimethoprim 4 weeks

Aged <35 years Ciproflaxacin◄ + Azithromycin

- 4 weeks

Prostatitis (acute and chronic)

Chronic – Trimethoprim Ciprofloxacin◄ plus microbiology advice

Ofloxacin◄

4 weeks

4 weeks treatment may prevent chronic infection. Quinolones are more effective. Clinical Knowledge Summary

Acute pyelonephritis

Ciprofloxacin◄

OR Co-amoxiclav ◄

- 7

14

Send MSU for culture. If no response within 24 hours admit CKS - pyelonephritis acute

CKS = Clinical Knowledge Summaries, previously known as ‘Prodigy’ Appendix A - Recurrent Urinary Tract Infections For recurrent infection where treatment failure has occurred despite optimal treatment with appropriate formulary antibiotics and where patient compliance 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 pharmacy



2) For multiple relapsing complicated or severe urinary tract infections or upper urinary tract infection where microbiological assessment

has shown resistance to all oral antibiotics, then intravenous or intramuscular ertapenem may be given daily for the treatment of susceptible extended spectrum beta-lactamase (ESBL) organisms, duration according to the tables given above for each condition, or according to microbiological advice.

NB. Ertapenem can be administered I/V (licensed) or I/M (unlicensed). Primary care clinicians administering the drug by the I/M route should ensure patients are aware of this unlicensed use of a licensed medicine in line with the Cambridgeshire PCT policy on the use of Unlicensed medicines and Unlicensed Uses of Licensed Medicines. It is advised that a risk assessment be carried out for its use. Other Recurrent Infections For other infections shown on microbiological examination to be resistant to all oral antibiotics, then for susceptible organisms, I/M ertapenem may be administered once-daily for a treatment duration consistent with the condition, as per the guideline above. Appendix B - *NOTES ON Methicillin Resistant Staphylococcus aureus (MRSA) MRSA are resistant to all beta-lactam antibiotics (e.g. flucloxacillin, co-amoxiclav, cephalosporins) and many other first-line antibiotics. All local strains remain susceptible to the parenteral antibiotics vancomycin and teicoplanin, most are also susceptible to tetracyclines. Most (87%) community Staph. aureus infections remain sensitive to b-lactam antibiotics. Almost all of the infections caused by MRSA are acquired in hospital or residential care (a study is planned to address this problem) and virtually all the MRSA infections seen in General Practice occur in patients with the following risk factors:

• Recently discharged from hospital • Nursed in residential home with MRSA-positive residents • Infection in a known carrier of MRSA

Skin and soft tissue Infections in these patients, which may be caused by MRSA, should be managed as follows:

• Take a specimen for microbiological investigation in all cases • Empirical treatment: mild infections - as shown in the table • Moderately severe infections and mild infections at site of known carriage of MRSA (eg. leg ulcer): doxycycline may be added to

the above regimens (doxycycline monotherapy is problematic: 20-40% of streptococci are resistant) • Severe infections - consider referral to hospital for parenteral vancomycin/teicoplanin therapy

Review empirical therapy when results of microbiological investigation are available.

Health & Medicine

Antimicrobial treatment guidelines_july_10.sflb