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Wakefield District

Antimicrobial Guidelines for Primary Care For use in: NHS Calderdale NHS Kirklees NHS Wakefield District

Primary Care Antimicrobial Guidelines – April 2010 Approved by South West Yorkshire Area

Review date: August 2012

Prescribing Committee: August 2010

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Aims • • • •

to provide a simple approach to the treatment of common infections. to promote the safe, effective and economic use of antimicrobials. to minimise the emergence of bacterial resistance in the community. to recommend antimicrobials with consideration to local susceptibility.

Microbiological advice can be obtained from the Consultant Microbiologists at the Calderdale and Huddersfield NHS Foundation Trust (01484) 342000 ext 5364 (Microbiology Registrar) • Microbiology Laboratory on Ext 2507. Mid Yorkshire Hospitals NHS Trust 0844 811 8110, Microbiologists via Secretaries Ext 57028, 57029 and 57032 Microbiology Laboratory - ext 57144 Prepared by a working group consisting of:• Dr Anu Rajgopal - Consultant Microbiologist, Calderdale and Huddersfield NHS Trust • Mrs Sandra Martin/Louise Tweddell - Antibiotic Pharmacist, Calderdale and Huddersfield NHS Trust • Mr John Yorke - Principal Pharmacist - Medicines Information, Calderdale and Huddersfield NHS Trust • Consultant Microbiologists, Mid Yorkshire Hospitals NHS Trust • Ms Paula Gabriel - Antibiotic Pharmacist, Mid Yorkshire Hospitals NHS Trust • NHS Calderdale • NHS Kirklees • NHS Wakefield District

Primary Care Antimicrobial Guidelines – April 2010

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Primary Care Antimicrobial Guidelines – August 2010

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Contents Principles of Treatment.......................

Page 4

Parasitic Infections ..............................

Page 24

Penicillin Allergy ..................................

Page 6

Respiratory Tract Infections - Lower

Page 26

Dental Prophylaxis...............................

Page 8

Respiratory Tract Infections - Upper

Page 31

Eye Infections .......................................

Page 9

Skin/Soft Tissue Infections.................

Page 39

Gastro-Intestinal Tract Infections .....

Page 11

Urinary Tract Infections ......................

Page 47

Genital Tract Infections.......................

Page 16

Viral Infections......................................

Page 51

Meningitis ..............................................

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Advice on doses Unless otherwise stated the doses recommended are for adult patients. Where a range is given the higher dose should only be prescribed for severe infections. The dose may also need to be varied according to age, weight and renal function. Further advice is given in the BNF, or from a Consultant Microbiologist. Presentation by Medicines Information Centre, Calderdale and Huddersfield NHS Trust

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Principles of Treatment 1. General Information a. Always consult the latest BNF or Summary of Product Characteristics for full prescribing details. b. This guidance is based on the best available evidence but its application must be modified by professional judgement. c. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. d. Don’t forget the potential usefulness of delayed prescriptions for certain conditions, e.g. otitis media, acute sinusitis, acute infective conjunctivitis and acute bronchitis. e. Limit prescribing over the telephone to exceptional cases. f. Do not prescribe an antibiotic for viral sore throat, simple coughs and colds.

Primary Care Antimicrobial Guidelines – August 2010

g. High levels of prescribing of quinolones can increase the incidence of MRSA. h. High antibiotic prescribing can select for resistant bacteria, e.g. MRSA and extended spectrum β-lactamase producing bacteria (ESBLs). 2. Where appropriate send samples for microbiological testing. 3. Drug Interactions Remember potential drug interactions between antibiotics and long-term medication, e.g. oral contraceptives, theophylline, statins, warfarin etc further information in the BNF Appendix 1. 4. Which Antibiotics to Prescribe a. Use simple generic antibiotics first whenever possible.

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b. The use of new and more expensive antibiotics (e.g. quinolones and cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective. c. Avoid widespread use of topical antibiotics (especially those agents also available systemically e.g. fusidic acid). d. Clarithromycin is an acceptable alternative in those who are unable to tolerate erythromycin because of side effects. 5. Children a. In children avoid the use of quinolones and tetracyclines. 6. Pregnancy and Lactation a. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole, trimethoprim (theoretical risk in

Primary Care Antimicrobial Guidelines – August 2010

first trimester in patients with poor diet, as folate antagonist) and nitrofurantoin (at term, theoretical risk of neonatal haemolysis). b. Tetracyclines and quinolones should be avoided in breast-feeding. 7. Optimal dosing of antibiotic is encouraged to hasten bacteriological (and clinical) cure, reduce relapses and shorten length of treatment. Inappropriate treatment, e.g. long term or low dose is associated with selection of resistance leading to treatment failure. 8. Course Lengths a. Keep course lengths as short as possible, e.g. 3 days for simple UTIs in women under 65 years of age. 9. This guidance is based on the best available evidence at this time but its application must be modified by professional judgement.

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Penicillin Allergy 1. 2. 3. 4.

Obtain an accurate allergy status from the patient. Ensure that all patients’ allergies and adverse side effects are documented fully. Always check the allergy status of the patient before prescribing, dispensing or administering a medicine. Be alert to the fact that the name of a medicine itself may not indicate 100% of the time that the medicine is a penicillin or related to a penicillin.

Patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration are at risk of immediate hypersensitivity to a penicillin; these individuals should not normally receive a penicillin, a cephalosporin, carbapenem (e.g. imipenem/meropenem), or another β-lactam antibiotic. Signs and symptoms of immediate hypersensitivity include, dyspnoea, swelling, rash, urticaria. Individuals with a history of a minor rash (i.e. non-confluent restricted to a small area of the body), or a rash that occurs more than 72 hours after penicillin administration are probably not allergic and β-lactam antibiotics should not be withheld. Drug intolerance (e.g. gastrointestinal symptoms, feeling faint) is not an indication to avoid β-lactam antibiotics.

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Healthcare associated Infections – MRSA and Clostridium Difficile Cephalosporins and Quinolones The risks of C.difficile associated disease (CDAD) increases with age > 65years and the use of broad spectrum antibiotics. Whilst it is of greatest importance to limit the prescription of all antibiotics, some antibiotics are associated nd rd with a higher risk of CDAD than others. These are 2 and 3 generation cephalosporins (e.g. cefaclor, cefuroxime, cefixime and cefpodoxime), fluoroquinolones (e.g. ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, norfloxacin) and clindamycin. These antibiotics should be restricted especially in the elderly unless prescribed according to antibiotic guidelines or following microbiology approval. Note - Antibiotic prescriptions in patients known to be colonised with MRSA Patients colonised with MRSA may not respond to usual empirical antibiotics treatment (e.g. amoxicillin, flucloxacillin). If your patient is not responding to treatment as expected, please consult microbiology for antibiotic advice.

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Dental Prophylaxis Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Dental prophylaxis for infective endocarditis under local or no anaesthesia

No prophylaxis is required prior to dental treatment. See NICE Clinical Guideline 64 (www.nice.org.uk) or the British National Formulary (www.bnf.org)

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Eye Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Conjunctivitis

Viral infections are common. Conjunctivitis is usually a selflimiting condition. Most people experience remission after 2-5 days - consider offering a delayed prescription. Bacteria may initially present unilaterally with glued eyes, no itch, and no past history of conjunctivitis. Exclude serious causes of red eye.

Chloramphenicol 0.5% drops and 1% ointment at night

2 hourly reducing to QDS

All for 48 hours after resolution

or Chloramphenicol ointment 1%

TDS or QDS

In newborn, consider the possibility of Chlamydia and Neisseria gonorrhoea. Exclusion of single cases from school/nursery is not generally necessary. It may be necessary if an outbreak occurs (http://www.hpa.org.uk/). Primary Care Antimicrobial Guidelines – August 2010

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Primary Care Antimicrobial Guidelines – August 2010

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Gastro-Intestinal Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Note:

Helicobacter test and treatment strategies benefit patients with ulcer disease and 8% of patients with functional dyspepsia. They reduce future risk of ulcer disease and gastric cancer, and reduce the need for long term PPIs.

Eradication of Helicobacter pylori

1. Confirm presence of H. pylori before starting eradication therapy. 2. There is normally no need to continue proton pump inhibitors or H2-receptor antagonists unless the ulcer is complicated by haemorrhage or perforation. 3. Two week triple therapy regimens offer higher eradication rates but poor compliance and adverse effects offset this. 4. There is insufficient evidence to support eradication therapy in patients who continue to take NSAIDs. Eradication rate is around High dose generic PPI 93%. (Omeprazole or (20mg BD or 7 days treatment Lansoprazole) and 30mg BD) and only DO NOT use dual therapy, Clarithromycin and 500mg BD and these are much less effective, Amoxicillin 1g BD and promote resistance. If Penicillin Allergic use Tests for Clearance High dose generic PPI To test for clearance use the (Omeprazole or (20mg BD or 13 C-Urea breath test. This Lansoprazole) and 30 mg BD) and 7 days treatment should NOT be done within 4 Clarithromycin and 500 mg BD and only weeks of treatment with an Metronidazole 400 mg BD antibacterial, or within 2 weeks of treatment with an anti-secretory drug.

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Gastro-Intestinal Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

Gastroenteritis

Giardiasis

If eradication has failed with this treatment. 1. Check that the original treatment indications were valid. 13 2. Check that failure of eradication has been confirmed with C urea breath test. 3. Check that patient is strongly motivated (treatment failure is often due to poor compliance). 4. If treatment failure has occurred despite the above – seek further advice from Gastroenterologists. Most infections are self-limiting. Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days, can cause resistance, and may be associated with side effects. Initiate treatment if the patient is systemically unwell following advice from the microbiologist. Notification and advice on exclusion from environmental health (Calderdale – (01422) 392329; Kirklees – (01484) 226456; Wakefield (0845) 8506506). General holding advice is to exclude until 48 hours after cessation of symptoms where the patient may be in a position to pass on infection. For more difficult cases contact HPA (0113) 2840606, to speak to the duty professional. Metronidazole 3 days Adults: 2g OD Children: < 1 yr - 40mg/kg/day 1-3 yrs - 500mg OD 3-7 yr - 600-800mg OD 7-10 yr - 1g OD

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Gastro-Intestinal Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

Cryptosporidium This coccoidal protozoa causes No effective specific treatment. Symptomatic treatment only. diarrhoea in animals and man. Symptoms may last for 1-3 weeks in healthy individuals, and Infection is common in children resolves slowly and spontaneously. and young adults. Clostridium Clostridium difficile is implicated in 20% -30% of patients with antibiotic-associated diarrhoea, in difficile 50% to 75% of those with antibiotic- associated colitis and in >90% of those with antibioticassociated pseudomembranous colitis. Risk factors for C.difficile associated disease (CDAD) include treatment with antibiotics (commonly broad-spectrum penicillins, cephalosporins, clindamycin), advanced age, hospitalisation, exposure to other cases, Proton pump inhibitors (PPIs), recent chemotherapy. Clinical diagnosis Diarrhoea in patients (profuse +/- blood), particularly if >65years of age who are currently on antibiotic(s) or received antibiotic(s) over preceding 4 weeks should have stools sent for C.difficile toxin (CDT). CDT should be looked for routinely in patients with an exacerbation of inflammatory bowel disease. It is less frequent in a community setting but should be considered in those patients who have received antibiotics. Infection Control measures (if Patient in Nursing or Residential Home etc) - Isolate the patient and start contact isolation precautions as per the infection control manual. - Maximise hand hygiene after contact with cases; hand washing in addition to alcohol gel decontamination is required as alcohol gel alone is not adequate for the inactivation of C.difficile spores. - Inform the PCT infection control team. Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

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Gastro-Intestinal Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

Investigations FBC, Stool for C. difficile toxin For severe cases, refer to hospital.

Stop/review antibiotics (switch to narrow spectrum antibiotics) if possible. Consider other causes of diarrhoea e.g. antacids, tube feeds. Do not prescribe antimotility agents, or laxatives, and consider stopping or reducing the dose of proton pump inhibitors.

Definition of severe C.difficile. Any patient with CDAD and fever, raised WCC, abdominal pain/tenderness, acute rise in serum creatinine (more than 50% of baseline) may have severe disease, and the case should be discussed with microbiology and referred urgently to the hospital.

Mild disease - (< 4 stools/day, patient not unwell). Supportive therapy initially. Treat as below if toxin positive and diarrhoea persists. Moderate disease (>4 stools/day, pt well) Metronidazole 400 mg TDS

10 â&#x20AC;&#x201C; 14 days

Severe disease - refer to hospital

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Gastro-Intestinal Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

Recurrence of symptoms Recurrence of following initial improvement after symptoms a 10-14 day course is likely to be Metronidazole due to re-infection by another If > 1 recurrence or C.difficile strain, further severe disease, antibacterial treatment or relapse contact due to germination of residual Microbiology C.difficile spores within the colon. Send repeat investigations as above and treat. Review - If no improvement within 3 days or clinical deterioration, contact Microbiology. NB Clearance stools are not required for C.difficile infection. Repeat stool specimens for C.difficile toxin on previous positive patients should only be sent if; - Symptoms persist despite treatment when a further test may be undertaken after 4 weeks. - Symptoms resolve and then recur, which may be due to re-infection or relapse. Salmonella

Most cases are mild and self-limiting. Seek Microbiological advice if treatment considered.

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details Vaginal Candidiasis

Bacterial vaginosis

All topical and oral azoles give 80-95% cure. In pregnancy avoid oral azole. If treatment failure send swab for culture. A 7 day course of oral metronidazole is slightly more effective than 2 g stat. Avoid 2g stat dose in pregnancy.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Fluconazole or Clotrimazole 10% vaginal cream or Clotrimazole pessary

150mg orally

stat

5g

stat

500mg

stat

Metronidazole or if unable to tolerate oral treatment, or if woman prefers topical therapy: Metronidazole 0.75% vaginal gel or Clindamycin 2% cream

400mg BD 7 days or 2g (if compliance is an stat issue) 5g applicatorful at night

5 days

5g applicatorful at night

7 days

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details Chlamydia trachomatis

Genital chlamydia most common in sexually active population women aged 16-19yr and men aged 20-24yr. 70% of infection is asymptomatic in women. Pending the introduction of a funded screening programme testing should be done on Women and Men with signs and symptoms attributable to chlamydia; Women (especially those <25yr): vaginal discharge, post coital/intermenstrual bleeding, inflamed/friable cervix, urethritis, PID, and lower abdominal pain or reactive arthritis in the sexually active. Men: Urethral discharge, dysuria, urethritis, and epididymo-orchitis or reactive arthritis in the sexually active. In addition testing should be offered to all women with risk factors undergoing uterine instrumentation; all patients with another sexually transmitted infection, sexual partners of those with C. trachomatis infection and mothers of infants with chlamydial conjunctivitis. Treat partners

First Line Azithromycin

1g stat

Note: Refer patients and contacts Second Line with STDs (including Seek advice from trichomoniasis) to GUM for GUM Clinic. contact tracing and follow up. If pregnant or breast feeding. Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Refer to GUM Clinic for treatment

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details Trichomoniasis

Treat partners simultaneously Avoid high dose metronidazole in pregnancy or use clotrimazole for SYMPTOMATIC relief and treat post-natally.

Metronidazole

400mg BD or 2g

7 days stat

100mg OD

6 days

or Clotrimazole pessary

Note: Refer patients with STDs (including trichomoniasis) to GUM for contact tracing and follow up.

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details Pelvic Inflammatory Disease (PID)

PID is almost always a sexually transmitted disease and the commonest organisms are C trachomatis and N gonorrhoeae. • Tubal infertility, ectopic pregnancy, and chronic pelvic pain are the main complications of PID • A diagnosis of pelvic inflammatory disease (PID) should be made on clinical grounds. • Take endocervical swabs for gonorrhoea and chlamydia and a high vaginal swab. (NB: Negative swab results do not rule out a diagnosis of PID). A referral to the hospital should be considered in the following situations • a surgical emergency cannot be excluded • lack of response to oral therapy • clinically severe disease • presence of a tubo-ovarian abscess • intolerance to oral therapy • pregnancy •

Start empirical antibiotics as soon as a presumptive diagnosis of PID is made clinically. Note: Refer patients with STDs (including trichomoniasis) to GUM for contact tracing and follow up

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details If the risk of gonococcal infection is low: . Ofloxacin plus 400mg BD plus 14 days Metronidazole 400 mg BD 14 days OR Ceftriaxone 250 mg as a single Stat plus intramuscular dose Doxycycline plus 100 mg BD 14 days Metronidazole 400mg BD 14 days If the risk of gonococcal infection is high: (the woman's partner has gonorrhoea, her symptoms and signs are clinically severe, has had sexual contact whilst abroad) Ceftriaxone 250 mg as a single Stat plus intramuscular dose Doxycycline plus 100 mg BD 14 days 400mg BD 14 days Metronidazole

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details Epididymoorchitis

Diagnostic Criteria: $ Severe scrotal pain, usually unilateral +/- inguinal pain. Scrotum of affected side may be erythematous and oedematous and a urethral discharge may be present. Epididymis swollen and tender on palpation. $ Take urethral swab for culture and Chlamydia nucleic acid amplification; urine for culture. Aetiology $ <35 years of age: Neisseria gonorrhoea and Chlamydia trachomatis $ >35 years of age: Coliforms and Ps. aeruginosa also Neisseria gonorrhoea and Chlamydia trachomatis Gram -ve enteric organisms are more likely if recent instrumentation or catheterisation has occurred. Notes $ Mumps orchitis develops in 20-30% of post-pubertal patients with mumps. $ Also consider testicular torsion, abscess, hydrocele, spermatocele, hernia, trauma, testicular cancer.

$ Refer to hospital if severely unwell or testicular torsion (especially in adolescents or males under 30yrs) Most probably due to Chlamydia Ceftriaxone trachomatis or N. gonorrhoea: And Refer patients to GUM for contact Doxycycline tracing and follow up.

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250mg IM

stat

100mg BD

10-14 days

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Genital Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. NOTE: Certain vaginal preparations may affect latex condoms and diaphragms - see BNF for details Most probably due to enteric gram negatives:

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Ciprofloxacin Or Co-amoxiclav

500mg BD

10 days

625mg TDS

10 days

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Meningitis Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Suspected meningococcal disease

Prevention of secondary case of meningitis

Transfer all patients to hospital IV or IM Adults and children immediately. Administer Benzylpenicillin 10 years and over: benzylpenicillin prior to 1200 mg admission, unless history of Children 1 - 9 year: 600 anaphylaxis, NOT allergy. Ideally mg IV but IM if a vein cannot be Children <1 year: 300 found. mg (Chloramphenicol is an alternative in patients with immediate hypersensitivity reactions to beta-lactam antibiotics - it would not be expected that routinelyofcarry Prophylaxis forGPs prevention secondary infection should only be prescribed in line with local policy chloramphenicol). as recommended by the HPA. This will involve close family contacts, and will usually be managed from the admitting ward. If in doubt seek advice from the Health Protection Agency duty professional (0113) 284 0606. Out of hours discuss with Public Health doctor on call, available through the switch boards at: â&#x20AC;˘ Huddersfield Royal Infirmary (01484) 342000 or Pinderfields General Hospital (0844) 8118110.

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Parasitic Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Threadworm

Treat household contacts.

Mebendazole (for all over 2 years of age)

Use Pripsen in children under 2.

or

Pripsen

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

100mg

stat (if reinfection occurs, second dose may be needed after 2 weeks)

3 months -1 yr: 1 level 2.5ml spoonful

Repeat after 14 days

1 - 2yrs: 1 level 5ml spoonful

Repeat after 14 days

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Lower Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Acute exacerbation of COPD

Many cases are viral. Antibiotics are not indicated in absence of purulent/ mucopurulent sputum. Recommended if any two of the following: - increased sputum secretion - increased sputum purulence - increased dyspnoea *Avoid tetracyclines in pregnancy and when breast feeding

Acute Bronchitis

Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults. Offer a delayed

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

First line Amoxicillin or Erythromycin or Doxycycline*

Antibiotics should be given until 250mg - 500mg QDS clinical improvement 200mg stat then 100mg - review after 5 days â&#x20AC;&#x201C; up OD to 10 days If there is no clinical benefit after the first antibiotic consider using an alternative first line treatment may be option and review culture and sensitivity required reports. 500mg TDS

If patient fails to respond - discuss the case with a Microbiologist. First Line No antibiotics needed in otherwise healthy adults with no underlying lung disease. Consider use in the elderly, comorbidity (e.g. heart failure, diabetes) or deteriorating clinically.

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Lower Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. prescription.

Community acquired pneumonia (CAP) Severity assessment chart (BTS guidelines)

Second Line Amoxicillin Or Doxycycline

500mg TDS

5 days

200mg stat then 100mg OD

1. Start antibiotics immediately. 2. Microbiological investigations not recommended routinely for those managed in the community consider if no response to empirical therapy after 48 hours. 3. Examination for Mycobacterium tuberculosis should be considered for patients with a persistent productive cough, especially if malaise, weight loss, or night sweats, or if other risk factors exist. 4. Serological investigations should be considered during outbreaks (e.g. legionella, mycoplasma) or when there are particular or epidemiological reasons. 5. BTS guidelines include oral co-amoxiclav. Local advice is for amoxicillin to be used instead, resistance is not problematic. Co-amoxiclav may cause cholestatic jaundice (CSM 1993, 1997). 6.Amoxicillin 250mg TDS is insufficient to treat, prescribe 500mg to 1g TDS

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Lower Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Amoxicillin

500mg - 1g TDS

or if immediate type penicillin allergy Erythromycin 500mg QDS or Clarithromycin (if gastrointestinal intolerance to erythromycin)

500mg BD

7 days

7 days 7 days

Review of patients * Review of patients recommended after 48 hours or earlier if clinically indicated. Core and additional adverse prognostic features should be assessed as part of the clinical review. * If no response after 48 hours antibiotics consider adding erythromycin if only on amoxicillin to cover Legionella or Mycoplasma (rare in those >65yr). Additionally, consider for hospital admission, chest radiography, microbiological and serological investigations.

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Lower Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Patients to be transferred to hospital Consider starting antibiotic therapy in those severely ill if there is likely to be a delay in admission to hospital of over 2 hours.

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Lower Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Severity assessment chart for Community Acquired Pneumonia (CAP)

Severity assessment used to determine the management of CAP in patients in the community. The social circumstances and wishes of the patient should also be considered.

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Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Influenzae

Annual vaccination is essential for all those at high risk of influenza. For otherwise healthy adults the use of antivirals is not recommended. Treat symptomatic at risk patients only when influenza is circulating in the community, within 48 hours of the start of symptoms, i.e. those aged 65years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus and chronic renal disease. Patients over 12 years use oseltamivir 75mg oral capsule BD. N.B. See current guidance on the management of influenza (especially in pandemic situations) via the HPA website.

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Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

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Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Pharyngitis / sore throat / tonsillitis

The majority of sore throats are viral; most patients do not benefit from antibiotics. There is clinical overlap between viral and streptococcal infections. Patients with more severe symptoms (3 of 4 of history of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from antibiotics. Antibiotics only shorten duration of symptoms by 8 hours. Antibiotics can prevent non-suppurative complications of beta-haemolytic streptococcal pharyngitis but, in developed societies, such complications are rare. You need to treat 30 children or 145 adults to prevent one case of otitis media. Recent evidence indicates that penicillin for 7 days is more effective than 3 days. 10 days treatment required to eliminate carriage

First line: No antibiotics NB: Antibiotics recommended if one or more of the following: history of rheumatic fever, scarlet fever, pronounced systemic infection, immunosuppression. Second line: Phenoxymethylpenicilli n

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Adult: 500mg QDS < 1 year: 62.5mg QDS 1-5 years:125mg QDS 6-12 years: 250mg QDS

10 days

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Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. If allergic to penicillin Erythromycin

Otitis media (child doses)

Many are viral. Resolves in 80% without antibiotics. Poor outcome unlikely if no o vomiting or temp <38.5 C. Use ibuprofen or paracetamol. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or

Adult: 500mg BD or 250mg – 500mg QDS (less side-effects) < 2 years:125mg QDS 2-8 years:250mg QDS

10 days

First line No antibiotics – “Wait and see” recommended for 72 hours Offer a delayed prescription. Second line Amoxicillin or

Primary Care Antimicrobial Guidelines – August 2010

<2 yrs: 125 mg TDS 2-10 yrs: 250mg TDS >10 yrs: 500mg TDS

5-7 days

34


Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. deafness. Need to treat 20 children >2yr and seven 624 month old to get pain relief in one at 2-7 days.

if allergic to penicillin Erythromycin

Systematic reviews indicate benefits of antibiotics are marginal in otherwise healthy adults.

<2 yrs: 125mg QDS 2-8 yrs: 250mg QDS > 8yrs: 250-500mg QDS

5-7 days *

Consider antibiotics in those at risk of poor outcome e.g. under 2 years of age, bilateral acute otitis media, vomiting and high fever. Otitis externa

Otitis externa can be localised or diffuse; acute or chronic and can be caused by infection, allergy, irritants or inflammatory conditions. Of the infectious causes localized otitis externa (furunculosis) is normally caused by S. aureus. Acute diffuse otitis externa by Pseudomonas aeruginosa or S. aureus. Fungal infection is less common but may result from Candida and dermatophyte infection. N.B. Caution in those with symptoms >7 days with diabetes or immuno-compromised due to the risk of necrotising otitis externa. Consider referral to emergency ENT services for ear dressing in severe cases.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

35


Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Acute Symptomatic treatment with localized otitis analgesia and application of local externa heat (e.g. warm flannel) often adequate. Use oral antibiotics only if severe infection or if person at risk of severe infection (poorly controlled diabetes mellitus or immunocompromised).

When necessary Flucloxacillin or if allergic to penicillin Erythromycin

Acute diffuse otitis externa (Bacterial)

Gentamicin/Neomycin According to and steroid drops manufacturers (several preparations instructions. available).

Exclude the possibility of underlying otitis media. Effective ear toilet is most important. Clean canal of debris and discharge. Topical treatment usually effective. Contact sensitivity may occur with topically applied ear drops usually due to the antibiotic if present.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Preparations formulated with aminoglycosides should not be used if there is tympanic perforation.

500mg QDS

5-7 days

250mg - 500mg QDS

5-7 days

7 days. If symptoms persist >7days patients should continue drops until pain free for a further 7 days maximum, with referral to ENT thereafter.

36


Upper Respiratory Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Acute Sinusitis

Many are viral. Symptomatic benefit of antibiotics is small. 69% resolve without & 84% with antibiotics. Reserve for severe profuse purulent nasal discharge, facial pain, systemic symptoms) or persistent (>10 days) symptoms.

First Line No antibiotic - offer a delayed prescription Second line Amoxicillin or Erythromycin

500mg TDS

5-7 days *

250mg - 500mg QDS

5-7 days *

* Standing Medical Advisory Committee guidelines suggest 3 days but longer courses of 5-7 days may be needed to prevent relapse. Relapse at 10 days is higher with a 3 day course in otitis media, but long-term outcome is similar.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

37


Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

38


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Impetigo

Topical use should be minimised to reduce development of resistance. Caution with the topical use of fusidic acid as there may be local resistance. Multiple courses of topical antibiotics may lead to increased resistance.

Cellulitis

Flucloxacillin or Erythromycin For minor infections only: Hydrogen Peroxide Cream 1% Second line Mupirocin or Fusidic acid

500mg QDS 500mg QDS

7 days 7 days

2-3 times daily

up to 3 weeks

topically TDS

5 days

Class 1:patients have no signs or symptoms of systemic toxicity and have no uncontrolled comorbidities and are managed on an outpatient basis with oral antibiotics. Class 2:patients are either systemically ill, without any unstable co-morbidities, or are systemically well, but have one or more co-morbidities. Require initial parenteral antibiotic therapy which may be delivered from home if home parenteral antibiotic services available Class 3:patients may appear toxic, or have at least one unstable co-morbidity, or a limbthreatening infection. Require admission to hospital for parenteral antibiotic therapy. Class 4:refer to hospital immediately.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

39


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Manage underlying pre-disposing conditions if any (e.g. tinea pedis, ulcers, lymphoedema). Consider urgent hospital admission for intravenous antibiotic treatment in severe, or rapidly worsening infection; suspected orbital, or periorbital cellulitis; facial cellulitis in a child - maintain a low threshold for hospital admission; immunocompromised; diabetes mellitus - admission may not be necessary if diabetes is stable, but maintain a low threshold for hospital admission; significant co-morbidity (e.g. heart failure, renal failure); neonate or child under 1 year. Recurrent cellulitis - treat underlying pre-disposing conditions if any (e.g. tinea pedis, ulcers, lymphoedema). For more than 2 episodes of cellulitis at the same site, long term prophylaxis may be appropriate - seek specialist advice from Dermatology. If no significant improvement occurs in 5 days - IV therapy may be necessary. Serious infections - refer to hospital.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Flucloxacillin or Erythromycin Facial cellulitis: consider coamoxiclav or add metronidazole.

500mg QDS

7-14 days

500mg QDS

(Durations depend on response.)

625mg TDS 400mg TDS

40


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Leg ulcers

Bacteria will always be present. Antibiotics do not improve healing. Culture swabs and antibiotics are only indicated when there is evidence of clinical infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid deterioration of ulcer or pyrexia. Ideally, sampling for culture should be done by vigorous curettage and aspiration to get an accurate result, however, cleaning of the wound followed by thorough swabbing of the wound bed is deemed practicable in the community.

Acne Vulgaris (severe)

Tetracyclines are considered first line choice if oral antibiotics are required. Avoid tetracyclines in pregnancy and when breast feeding. Minocycline is not recommended.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Doxycycline or Erythromycin (if tetracyclines contraindicated).

100mg OD 500mg BD

Durations depend on response.

41


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Diabetic foot ulcer infections

Comments: Samples should not Non-limb be taken routinely. Repeat threatening samples are not required unless Flucloxacillin 500mg QDS 1-2 weeks worsening infection. +/Bone/joint involvement has to be Amoxicillin 500mg TDS excluded clinically and (if penicillin allergic: radiologically. Clindamycin) 300mg QDS Investigations - CRP, Swabs C&S. Sampling for culture should Deep infections be deep, ideally tissue including biopsies/pus aspirates to get an osteomyelitis accurate result, however, Clindamycin 450mg QDS 2-4 weeks cleaning of the wound followed by and (4-6 weeks if thorough swabbing of the wound Ciprofloxacin 500mg BD Osteomyelitis) bed is deemed practicable in the community. Modify antibiotic treatment on the basis of sensitivities and/or clinical response.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

42


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Human bite

Animal bite

Antibiotic prophylaxis advised for all wounds < 72 hours old. Consider tetanus prophylaxis. Assess risk of HIV/ Hepatitis B and C. Post exposure prophylaxis should be offered if bite is from someone known or strongly suspected to be HIV positive (attend A&E).

First line (for both animal and human bites) Co-amoxiclav

Prescribe antibiotic prophylaxis for wounds < 48hrs old and risk of infection is high (e.g. bites on face/hands/feet). Consider tetanus prophylaxis and risk of Rabies.

* Avoid in pregnancy, breast-feeding and children.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

625mg TDS

if allergic to penicillin: Metronidazole 400mg TDS and Doxycycline* 100mg BD

7 days 7 days 7 days

43


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Dermatophyte infection of the proximal fingernail or toenail (Adults) For children seek advice

Fungal nail infections are common affecting 4.7% of those >55y. Many patients do not seek medical advice and the only symptoms are frequently cosmetic changes in the appearance of the nail. Therapy should be considered ONLY if all of the following apply and not for cosmetic reasons alone: 1. The patient has poor or diminished circulation (diabetes or peripheral vascular disease). 2. The results of mycological examination confirm the diagnosis (Nail clippings required). 3. The patient can and will comply with the long courses of treatment necessary. Take nail clippings; start therapy only if infection is confirmed by microbiology. N.B. Terbinafine is not active Terbinafine 250mg OD fingers 6 - 12 weeks against candida Idiosyncratic liver 3 - 6 months toes reactions occur rarely with Children < 12 years, terbinafine. obtain advice from Nail infections may still respond Dermatologist. after a treatment course is complete.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

44


Skin/Soft Tissue Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Candida

Pulsed itraconazole monthly is recommended for infections with yeasts and non-dermatophyte moulds.

Take nail clippings; start therapy only if infection is confirmed by microbiology. Dermatophyte Administer for 14 days after infection of symptomatic resolution. If intractable, consider oral the skin itraconazole following microbiological report.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Itraconazole (caution when prescribing in patients at high risk of heart failure)

200mg BD

toes Children < 12 years obtain advice from Dermatologist.

7 days/ month 3 courses

Clotrimazole 1% Cream

BD

4 - 6 weeks

BD

1 week

If failure: Terbinafine 1% Cream following results of skin scrapings.

fingers

7 days/month 2 courses

45


Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

46


Urinary Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Note: 1. In adult women with uncomplicated UTI (i.e. no fever or loin pain) it is reasonable to start empirical treatment with no culture if dipstick positive for nitrite or leucocyte esterase. Negative nitrite and leucocyte esterase have a 95% negative predictive value. 2. Urine culture is always indicated in men, children, pregnant women, those with complicated infection or where empirical treatment has failed 3. In sexually active young men and women with urinary symptoms consider Chlamydia trachomatis. 4. Asymptomatic bacteriuria occurs in 25% of women and 10% of men >65 years and is not associated with increased morbidity and does not require antibiotic therapy. Catheterised patients with asymptomatic bacteriuria should not receive antibiotic therapy. 5. Tests of cure in uncomplicated resolved UTIs are unnecessary. 6. Patients with long-term catheters usually have bacteriuria. Urine samples should only be sent if clinically indicated and not because of the appearance or smell suggest bacteriuria. Raised urinary WCC may result solely from the presence of the catheter. Uncomplicated UTI +ve nitrites or leucocyte esterase Trimethoprim 200mg BD 3 days (i.e. no fever, flank on morning urine increases or pain in adult females likelihood of UTI. Nitrofurantoin 50mg QDS 3 days <65 yr old without nd 2 line - depends on sensitivity of organism isolated underlying disease) Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

47


Urinary Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. UTI in men, women >65yr, recurrent infections in both sexes, and failure of therapy.

MSU required to confirm the diagnosis and susceptibility testing.

UTI in pregnancy

MSU required to confirm Cefalexin 500mg BD diagnosis and susceptibility or testing.(Avoid trimethoprim in the Amoxicillin 500mg TDS first trimester and nitrofurantoin at term.) Prophylactic antibiotics Should be considered to cover the period whilst waiting for imaging or specialist assessment. In those <1yr of age, or where other complications exist. Send MSU for culture and Trimethoprim see BNF for childrens susceptibility. Waiting 24 hrs for or doses results is not detrimental to Nitrofurantoin or outcome. Cefalexin

UTI in children

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Trimethoprim or Nitrofurantoin

200mg BD

7 days

50mg QDS

7 days

7 days

48


Urinary Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Patients with a urinary catheter

Aetiology Varies with duration of catheterisation and antibiotic use. Notes: 1.Routine CSU for cultures and sensitivities are not indicated. 2.Laboratory microscopy and dipstick testing should not be used to diagnose UTI in catheterised patients. 3.Symptoms that may suggest UTI include fever, flank pain, or supra-pubic discomfort, change in voiding patterns, nausea, vomiting, malaise or confusion. Patients should be referred to hospital if systemic symptoms such as fever, chills, rigors or confusion appear. 4.A clearly marked CSU with relevant clinical details should be sent for C&S prior to starting antibiotic treatment. 5. Patients with a long term indwelling catheter should be changed before starting treatment for symptomatic UTI. 6. Antibiotics should be chosen on the basis of susceptibility tests whenever possible 7. If there is fever and flank, loin, back pain or tenderness - treat as for upper UTI. 8. If immediate treatment for lower UTI is required, treat empirically with trimethoprim 200mg BD or nitrofurantoin 50mg QDS for 7 days. â&#x20AC;˘ 9. Take into account previous treatments and culture results when choosing an

antibiotic for empirical treatment.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

49


Urinary Tract Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.

Acute pyelonephritis

Acute prostatitis

Chronic prostatitis

10. Review choice of antibiotic with progress and culture results. 11. Antibiotic prophylaxis is not recommended for the prevention of symptomatic UTI in catheterised patients. MSU is required to confirm Co-amoxiclav (not in 625mg TDS 14 days diagnosis and susceptibility pregnancy) testing. Ciprofloxacin 500mg BD or Cefalexin (if If no response within 48 hours 500mg TDS pregnant) consider referral. 4 weeks treatment may prevent chronic infection. Exclude infections with Chlamydia trachomatis and Neisseria gonorrhoea. *Quinolones are more effective. Seek expert advice.

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

Ciprofloxacin* or Trimethoprim

500mg BD

28 days

200mg BD

50


Viral Infections Illness

Comments

Drug

Dose

Duration of Tx

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. Chicken pox & shingles (Varicella zoster)

Chicken pox: Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND treatment started <24h of onset of rash.

Aciclovir

800mg 5x/day

7 days

Child: see BNF

Shingles: Treatment indicated if: ophthalmic or predictors of postherpetic neuralgia: >50 yr, severe pain, severe skin rash, prolonged prodromal pain AND <72h of onset of rash. If pregnant - VZIG (varicella zoster immunoglobulin) should be offered to all non-immune pregnant patients following serological confirmation. Determine the date and nature of contact, and discuss with Microbiologist

Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

51


Viral Infections Illness

Comments

Drug

Dose

Duration of Tx

Shingles Antivirals are recommended for adults aged 50 years and over. Antiviral drugs are recommended in adults of any age who: • present with severe acute pain or extensive rash. • have ophthalmic involvement. • are immunocompromised. • have Ramsey Hunt Syndrome. • have atopic eczema. • have contact with very young infants, immunocompromised individuals, or pregnant women. Adults under the age of 50 years: expert opinion is divided as to whether antivirals should routinely be offered to people under the age of 50 years who are not in the category above. The incidence of post-herpetic neuralgia is low in people under the age of 50 years, so antivirals will only have minimal impact on reducing the risk of the progression to post-herpetic neuralgia in this age group. However, the rash may not have fully developed at the time of presentation. Antivirals may therefore provide benefit for those people who would otherwise have gone on to develop a severe rash or extensive rash until more evidence becomes available, CKS recommends offering antivirals to all adults under the age of 50 years, after discussing these issues with each individual.

Primary Care Antimicrobial Guidelines – August 2010

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Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

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Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

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Primary Care Antimicrobial Guidelines â&#x20AC;&#x201C; August 2010

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