Aims



|Aims |

|to provide a simple, empirical approach to the treatment of common infections |

|to promote the safe, effective and economic use of antibiotics |

|to minimise the emergence of bacterial resistance in the community |

|Principles of Treatment |

|This guidance is based on the best available evidence but professional judgement should be used and patients should be involved in the decision. |

|A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and renal function. In severe or recurrent |

|cases consider a larger dose or longer course. |

|Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice. |

|Prescribe an antibiotic only when there is likely to be a clear clinical benefit. |

|Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1A+ |

|Limit prescribing over the telephone to exceptional cases. |

|Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (eg co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics |

|remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs. |

|Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g. fusidic acid). |

|In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole (2 g). Short-term use of nitrofurantoin (at term, theoretical risk of |

|neonatal haemolysis) is unlikely to cause problems to the foetus. Trimethoprim also unlikely to cause problems unless poor dietary folate intake or taking another |

|folate antagonist such as antiepileptic. |

|We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic tablets are similar |

|cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost. |

|Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from ** ( ** |

|ILLNESS |COMMENTS |DRUG |DOSE |DURATION OF TX |

|UPPER RESPIRATORY TRACT INFECTIONS1 |

|Influenza1-3 |Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not recommended. Treat ‘at risk’|

|HPA Influenza |patients, ONLY within 48 hours of onset & when influenza is circulating in the community or in a care home where influenza is likely. At |

| |risk: 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), |

| |immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Use 5 days treatment with oseltamivir 75 mg bd or if |

| |there is resistance to oseltamivir use 5 days zanamivir 10 mg BD (2 inhalations by diskhaler). For prophylaxis, see NICE. (NICE Influenza). |

| |Patients under 13 years see HPA Influenza link. |

|Acute Sore Throat |Avoid antibiotics as 90% resolve in 7 days without, |phenoxymethylpenicillin 5B- |500 mg QDS |10 days 8A- |

|CKS |and pain only reduced by 16 hours 2A+ | |1G BD 6A+ | |

| |If Centor score 3 or 4: (Lymphadenopathy; No Cough; | |(QDS when severe 7D) | |

| |Fever; Tonsillar Exudate) 3A- consider 2 or 3-day |Penicillin Allergy: | |5 days 9A+ |

| |delayed or immediate antibiotics 1,A+ |clarithromycin |250-500mg BD | |

| |Antibiotics to prevent Quinsy NNT >4000 4B- | | | |

| |Antibiotics to prevent Otitis media NNT 2002A+ | | | |

|Acute Otitis Media |Optimise analgesia 2,3B- | |Child doses | |

|(child doses) |Avoid antibiotics as 60% are better in 24 hours |amoxicillin 8A+ |40mg/kg/day in 3 doses (max. |5 days 11A+ |

|CKS |without: they only reduce pain at 2 days (NNT15) and | |3g daily) 10B- | |

| |do not prevent deafness 4A+ | | | |

| |Consider 2 or 3-day delayed 1A+ or immediate |Penicillin Allergy: | | |

| |antibiotics for pain relief if: |erythromycin 9D |< 2yrs 125mg QDS |5 days 11A+ |

| |< 2yrs with bilateral AOM NNT45A+ | |2-8yrs 250mg QDS | |

| |All ages with otorrhoea NNT3 6A+ | |8-18yrs 250-500mg QDS | |

| |Abx to prevent Mastoiditis NNT >4000 7B- | | | |

|Acute Otitis Externa|First use aural toilet (if available) & analgesia |First Line: | |7 days |

| |Cure rates similar at 7 days for topical acetic acid |acetic acid 2% |1 spray TDS | |

|CKS |or antibiotic +/- steroid 1A+ | | |7 days min to 14 days|

| |If cellulitis or disease extending outside ear canal, |Second Line: | |max 1A+ |

| |start oral antibiotics and refer 2A+ |neomycin sulphate with |3 drops TDS | |

| | |corticosteroid 3A-,4D | | |

|Acute Rhinosinusitis|Avoid antibiotics as 80% resolve in 14 days without, |amoxicillin 4A+,7A |500mg TDS |7 days 9A+ |

|5C |and they only offer marginal benefit after 7 days | |1g if severe 11D | |

|CKS |NNT15 2,3A+ |or doxycycline |200mg stat/100mg OD |7 days |

| |Use adequate analgesia 4B+ |or phenoxymethylpenicillin8B+ |500mg QDS | |

| |Consider 7-day delayed or immediate antibiotic when | | |7 days |

| |purulent nasal discharge NNT8 1,2A+ |For persistent symptoms: | | |

| |In persistent infection use an agent with |co-amoxiclav 6B+ |625mg TDS |7 days |

| |anti-anaerobic activity eg. co-amoxiclav 6B+ | | | |

|ILLNESS |COMMENTS |DRUG |DOSE |DURATION OF TX |

|LOWER RESPIRATORY TRACT INFECTIONS |

|Note: Low doses of penicillins are more likely to select out resistance1, Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal |

|activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms. |

|Acute cough, |Antibiotic little benefit if no co-morbidity1-4A+ |amoxicillin |500 mg TDS |5 days |

|bronchitis | |or doxycycline |200 mg stat/100 mg OD |5 days |

|CKS6 NICE 69 |Symptom resolution can take 3 weeks. | | | |

| |Consider 7-14 day delayed antibiotic with symptomatic | | | |

| |advice/leaflet 1,5A- | | | |

|Acute |Treat exacerbations promptly with antibiotics if |amoxicillin |500 mg TDS |5 days |

|exacerbation of COPD|purulent sputum and increased shortness of breath |or doxycycline |200 mg stat/100 mg OD |5 days |

|NICE 12 GOLD |and/or increased sputum volume 1-3B+. |clarithromycin |500 mg BD |5 days |

| |Risk factors for antibiotic resistant organisms |If resistance risk factors: | | |

| |include co-morbid disease, severe COPD, frequent |co-amoxiclav |625 mg TDS |5 days |

| |exacerbations, antibiotics in last 3 m 2 | | | |

|Community-acquired |Use CRB65 score to help guide and review:1 Each scores|IF CRB65=0: amoxicillinA+ or |500 mg TDS |7 days |

|pneumonia - |1: Confusion (AMT30/min; |or doxycycline D |200 mg stat/100 mg OD |7 days |

|community2,3 |BP systolic 6 months: mebendazole (off-label|100 mg 1C |stat |

| |advise hygiene measures for 2 weeks (hand hygiene, |if ................
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