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CLINICAL DIAGNOSIS

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					    ANTIBIOTIC GUIDELINES
                       Adult and Paediatric
  See BNF or Summary of Product Characteristics for full prescribing information




Aim
To produce simple, appropriate and cost-effective guidelines for the treatment of
infections commonly encountered in general practice.
In view of the increasing problems of antibiotic resistance and the cost of
inappropriate prescribing, the PCT Medicines Management Team and the
Consultant Microbiologists, have revised the local Primary Care Antibiotic
Guidelines.




Useful contact numbers: please check correct at time of printing
Manchester Health Protection Unit: 0161 786 6710
Health Protection Agency NW Laboratory – CMMC (MRI) Microbiology: 0161 276 4281
Sexual Health Clinic (GUM) Clinic - Withington Community Hospital: 0161 217 4939
Microbiology – NMGH (Oldham): 0161 627 8360
Microbiology - Wythenshawe: 0161 291 2885 (general enquiries) and 4772 (results)
Infectious Diseases Unit (Consultant on call) - NMGH: contact via switch 0161 795 4567
Medicines Information - CMMC: 0161 276 6270
Medicines Information - NMGH: 0161 720 2152
Medicines Information - UHSM: 0161 291 3331
                                      General Advice
   The Department of Health’s Standing Medical Advisory Committee - SMAC has
    identified 4 things that can make a difference:

                                      KEY MESSAGES:
           NO prescribing of antibiotics for simple coughs and colds
           NO prescribing of antibiotics for viral sore throats
           For uncomplicated cystitis in otherwise fit women limit course to 3 days
           Limit prescribing of antibiotics over the telephone to exceptional cases



   The use of deferred scripts in other indications of doubtful value (e.g. otitis media) is
    one method of managing patient expectation. Retaining the prescription in the surgery
    for future collection is more successful.

   Educating patients about the benefits and disadvantages of antimicrobial agents is
    advocated. Practices can provide leaflets and/or display notices advising patients not
    to expect a prescription for an antibiotic, together with the reasons why. This
    educational material can be obtained from various sources, such as the British Medical
    Association (BMA), Department of Health and PCT Medicines Management Team.

   AVOID:      Using longer courses than are necessary
                Unnecessary use of combinations where a single drug would be equally
            effective
                Broad-spectrum antibiotics where a narrow spectrum agent is indicated
                Prophylactic use of antibiotics unless of proven benefit

   Topical antibiotics should be used very rarely, if at all (eye infections are an exception).
    For wounds, topical antiseptics are generally more effective. Topical antibiotics
    encourage resistance and may lead to hypersensitivity. If antibiotic use is essential, try
    and select an antibiotic that is not used systemically.

   Hypersensitivity to penicillin
    True penicillin-allergic patients will react to all penicillins. Up to 10% of penicillin-
    sensitive patients will also be allergic to cephalosporins. If necessary a microbiologist
    can advise on suitable alternatives. Document clearly in patient notes.

   Pregnancy
    The following are felt to be safe in pregnancy:
    Penicillins, Cephalosporins, Erythromycin and Nitrofurantoin (not after the 8 th month)

   Contraception
    -Some broad-spectrum antibiotics (e.g. amoxicillin, doxycycline) may reduce the
    efficacy of combined oral contraceptives by impairing the bacterial flora responsible
    for recycling of ethinylestradiol from the large bowel. Family Planning Association
    (FPA) advice is that additional contraceptive precautions should be taken whilst taking
    a short course of a broad-spectrum antibiotic and for 7 days after stopping. If these 7
    days run beyond the end of a packet the next packet should be started immediately

                                              -2-
    without a break (in the case of everyday (ED) tablets the inactive ones should be
    omitted). If the antibiotic course exceeds 3 weeks, the bacterial flora develops
    antibiotic resistance and additional precautions become unnecessary; additional
    precautions are also unnecessary if a woman starting a combined oral contraceptive
    has been on a course of antibiotics for 3 weeks or more.
    -It is possible that some antibacterials affect the efficacy of contraceptive patches.
    Additional contraceptive precautions are recommended during concomitant use and
    for 7 days after discontinuation of the antibacterial (except tetracycline). If concomitant
    administration runs beyond the 3 weeks of patch treatment, a new treatment cycle
    should be started immediately without a patch-free break.
    -Anecdotal reports of contraceptive failure have been made with the concomitant use
    of antifungals.

   Interaction with warfarin and other anticoagulants
    Experience in anticoagulant clinics suggests that the INR can be altered by a course of
    most antibiotics. Increased frequency of INR monitoring is necessary during and after
    a course of antibiotics until the INR has stabilized. Cephalosporins, erythromycin,
    ciprofloxacin and trimethoprim seem to cause a particular problem. Contact the
    anticoagulant clinic for any further advice.

   Clostridium difficile infection
    All antibiotics predispose patients to the development of Clostridium difficile gut
    infection. There must be a clear indication for antibiotic use, particularly in the
    vulnerable elderly population. Broad-spectrum agents and prolonged or recurrent
    courses are associated with the greatest risk.
    The antibiotics most commonly associated are the second and third generation
    cephalosporins, co-amoxiclav, antipseudomonal penicillins, clindamycin and
    quinolones.


   Erythromycin tolerability
    Consider using clarithromycin if patient intolerant to erythromycin.




                                              -3-
      ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

  CLINICAL                COMMENTS                                 DRUG                     DURATION
 DIAGNOSIS                                                                                     of
                                                                                           TREATMENT
UPPER RESPIRATORY TRACT INFECTIONS

Sore throat      The majority of sore throats        Antibiotics are rarely needed.        Treat for 10
                 (viral or bacterial) are self-      1st line: Phenoxymethylpenicillin     days to
                 limiting (lasting up to 7 days) &   500mg bd-qds                          ensure
                 do not respond to antibiotics.      Penicillin allergy: Erythromycin      eradication of
                 Patients with 3 of 4 centor         250-500mg qds or 500mg bd             Group A
                 criteria (history of fever,                                               Streptococci.
                 purulent tonsils, cervical          QDS dosing may be more
                 adenopathy, absence of              appropriate if severe.
                 cough) or history of otitis media
                 may benefit more from
                 antibiotics.
                 Recommend aspirin gargles
                 (adults only) or paracetamol &
                 warm drinks.
Acute otitis     Viral infection common. Not         1st line: Amoxicillin 250-500mg tds   Treat for 5
media            clear whether antibiotics           2nd line: Co-amoxiclav 375mg tds      days.
                 actually affect the outcome or      Penicillin allergy: Erythromycin
                 complications of otitis media.      250-500mg qds or 500mg bd
                 About 80% of cases resolve          2nd line: Doxycycline 200mg stat
                 within 3 days without               then 100mg od (adults only)
                 treatment. Consider waiting 24-
                 48 hours before treating. Use
                 simple analgesics such as
                 paracetamol for pain relief.
Acute otitis     Topical treatment usually           1st line: Flucloxacillin 250-500mg    Treat for 5
externa          effective. Avoid antibiotics        qds                                   days.
                 wherever possible.                  Penicillin allergy: Erythromycin
                 Oral antibiotics only required if   250-500mg qds or 500mg bd
                 severe. Pain relief –
                 paracetamol. Swab severe
                 cases and patients with
                 diabetes.
Chronic otitis   No antibacterials / antifungals     Keep ear(s) clean and dry
externa          needed
Sinusitis        Viral infection common.             1st line: Amoxicillin 500mg tds       Treat for 7
                 Symptomatic benefit of              Alternative 1st line or Penicillin    days.
                 antibiotics is small. Encourage     allergy: Erythromycin 250-500mg
                 drainage with steam                 qds or 500mg bd or doxycycline
                 inhalations.                        200mg stat then 100mg od (adults
                 Reserve for severe or               only)
                 persistent symptoms (lasting at     2nd line: Co-amoxiclav 625mg tds
                 least 7 days).
Chronic                                              1st line: Doxycycline 200mg stat      Treat for 14
sinusitis                                            then 100mg od (adults only)           days.




                                                -4-
      ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

                                                                                              DURATION
  CLINICAL
                           COMMENTS                                  DRUG                        of
 DIAGNOSIS
                                                                                             TREATMENT
LOWER RESPIRATORY TRACT INFECTIONS

Acute           Antibiotics are of no proven           Antibiotics not normally
bronchitis      benefit in otherwise healthy           required.
                adults. Explanation of the likely      Patients > 60yrs old & those
                course of the illness is               with significant co-existing
                recommended. Cough commonly            disease have increased risk of
                persists for 2-3 weeks regardless      bacterial infection & morbidity, so
                of whether an antibiotic has been      early antibiotic use may be
                given.                                 considered. See below - section
                .                                      on acute exacerbation of COPD.
Acute           Antibiotics most valuable if patient   1st line: Amoxicillin 500mg tds       Treat for 5-10
                                                                      st
exacerbation    has increased dyspnoea with            Alternative 1 line or Penicillin      days.
of COPD         increased / purulent sputum.           allergy: Doxycycline 200mg stat
                Higher percentage of                   then 100mg od
                                                        nd
                Haemophilus infections in this         2 line: Co-amoxiclav 625mg
                group. (Erythromycin maybe            tds
                less effective)
                N.B. Quinolones should not be          Recurrent problems: Consult
                prescribed first line. Only use on     local microbiologist.
                the basis of sensitivity results.
                (Poor activity against Strep.
                Pneum.)
Community -     Any patient presenting with new        1st line: Amoxicillin 500mg-1g        Treat for at
acquired        focal chest signs should be            tds Add erythromycin 500mg qds        least 7 days.
pneumonia –     treated for pneumonia and              if atypical infection suspected
treatment in    antibiotic therapy should not be       (especially young adults).
the community   delayed. If no response within 48      If Staph. aureus infection
                hours consider admission or add        suspected (e.g. following viral
                erythromycin to cover                  influenza) add flucloxacillin
                Mycoplasma.                            500mg qds or change amoxicillin
                In severely ill give parenteral        to co-amoxiclav 625mg tds.
                benzylpenicillin before admission.     2nd line or Penicillin allergy:
                Mycoplasma is rare in over 65s.        Erythromycin 500mg qds
                Epidemics occur  every 4 yrs
                when incidence of infection rises
                to 12-15%.




                                               -5-
       ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

   CLINICAL                   COMMENTS                                 DRUG                     DURATION
  DIAGNOSIS                                                                                        of
                                                                                               TREATMENT
URINARY TRACT INFECTIONS

Uncomplicated      UTI can only be proven                1st line: Trimethoprim 200mg         Limit
urinary tract      bacteriologically in 50% of           bd or Nitrofurantoin 50-100mg        treatment to 3
infection in       women, others have                    qds                                  days.
otherwise          inflammation of the urethra.          Reserve cefalexin 500mg bd for
                                                          nd
healthy women      Routine urine culture is              2 line therapy due to risk of C.
                   unnecessary. Use dipstick urine       difficile.
                   tests to reduce antibiotic use        2nd line: Only after MSU culture
                   and unnecessary investigations.       & sensitivity results.

Complicated    Applies to pregnant women,                Treatment depends on MSU             7 days
urinary tract  men, recurrent infection,                 culture & sensitivity results.       treatment
infection      infection ascending to the upper          Amoxicillin & cefalexin may be       usually
               tract.                                    used in pregnancy depending on       required.
               Catheterised patients - Do not            sensitivities.
               give an antibiotic unless the
               patient is symptomatic as
               bacteria are unlikely to clear
               while catheter is in situ.
GENITAL TRACT INFECTIONS

   It is important that patients are REFERRED to GUM clinic for screening for other infections,
                 contact tracing and health promotion BEFORE starting antibiotics.
            The use of antibiotics will affect the screening results of other possible infections.
 In order to prevent re-infection and treatment failure it is important to treat the patient and their sexual
                     partners, plus advice to avoid sexual relations during treatment.
 N.B. Pregnant patients need follow-up to ensure successful eradication of infections. (Ideally by GUM
                                                    clinic.)
Acute                                                     1st line: Ciprofloxacin 500mg bd Treat for 4
Prostatitis                                               2nd line: Trimethoprim 200mg         weeks.
                                                          bd
Bacterial           The commonest infective cause 1st line: Metronidazole 400mg                Treat for 5-7
vaginosis           of vaginal discharge. It is a         bd                                   days.
                    synergistic infection between         Metronidazole 2g as a single         Topical
                    anaerobic bacteria &                  dose may be used, but only if        agents:
                    Gardnerella vaginalis.                compliance is an issue.              metronidazol
                                                          (Avoid 2g dose in pregnancy)         e-
                                                          2nd line: Metronidazole 0.75%        5 nights,
                                                          vaginal gel or clindamycin 2%        clindamycin -
                                                          cream (5g applicatorful)             7 nights.
Urogenital                                                1st line: Metronidazole 400mg        Treat for 5-7
Trichomoniasis                                            bd or                                days.
                                                          2g in a single dose
                                                          (Avoid 2g dose in pregnancy)




                                                  -6-
       ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

   CLINICAL              COMMENTS                                  DRUG                     DURATION
  DIAGNOSIS                                                                                      of
                                                                                           TREATMENT
Gonorrhoea     Cefixime has been                      1st line: Cefixime 400mg stat        Single dose.
               recommended due to increasing          Alternative agent may be used if
               levels of resistance. However, if      possibility of pharyngeal
               isolates are sensitive to agents       infection: IM Ceftriaxone 250mg
               like ciprofloxacin these agents
               could be used.
               Azithromycin may be given to
               cover Chlamydia.
Chlamydia      Azithromycin is more expensive         1st line: Azithromycin 1g stat       Single dose.
               than doxycycline, however,             or Doxycycline 100mg bd (avoid       Treat for 7
               single dose azithromycin may           in pregnancy / breast-feeding)       days.
               be useful if compliance is a
               problem.
Pelvic         It is important to test for STDs       Cefixime 400mg stat +
inflammatory   prior to commencing therapy            metronidazole 400mg bd for 10-
disease        and if positive refer to GUM           14 days
               clinic.                                + ofloxacin 400mg bd or
               Refer pregnant patients.               doxycycline 100mg bd for 14
                                                      days
SKIN

Acne           Oral preparations should be            1st line: Oxytetracycline 500mg      Maximum
               used in moderate-severe cases          bd                                   improvement
               or if topical preparations have        2nd line: Doxycycline 100mg od       usually after
               proved inadequate. Where               or Lymecycline 408mg od              4 to 6
               possible use non-antibiotic            Reserve the following agents         months, but
               antimicrobials (e.g. benzoyl           as 3rd line:                         in severe
               peroxide), Skinoren® (azelaic          Minocycline 100mg od due to SE       cases may
               acid) or a topical retinoid.           profile.                             need 2 years
               Minocycline treatment > 6              Erythromycin 500mg bd due to         or longer.
               months, monitor every 3 months         increasing resistance.
               for hepatoxicity, pigmentation         Change antibiotic if <70%
               and SLE.                               improvement after 3 months.
Cellulitis     Review patient if no                   1st line: Flucloxacillin 500mg-1g    Duration
               improvement within 48 hours.           qds                                  depends on
               Failure to respond may                 Penicillin allergy: Erythromycin     severity and
               necessitate urgent parenteral          500mg qds                            response.
               antibiotics.                           Consider clindamycin 300-450mg       Minimum 7-
               Clindamycin causes increased           qds in severe/extensive infection.   14 days
               risk of colitis in elderly patients.   If facial cellulitis use co-         treatment.
                                                      amoxiclav.
                                                      If sea water injury add
                                                      doxycycline.
                                                      If freshwater injury add
                                                      ciprofloxacin.




                                              -7-
      ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

CLINICAL           COMMENTS                          DRUG                                 DURATION
DIAGNOSIS                                                                                 of
                                                                                          TREATMENT
Erysipelas                                           1st line: Phenoxymethylpenicillin    Treat for 7-14
                                                     500mg qds                            days then
                                                     Add flucloxacillin to cover Staph.   review.
                                                     Aureus if response is poor.
                                                     Penicillin allergy: Erythromycin
                                                     500mg qds
Infected                                             1st line: Flucloxacillin 500mg       Treat for 7-14
eczema                                               qds                                  days.
                                                     Penicillin allergy: Erythromycin
                                                     500mg qds
Impetigo           Remove crusts by soaking          Minor infection: Fusidic acid 2%     Treat for 7
                   before topical treatment.         cream/ointment tds-qds               days.
                                                     Widespread infection:
                                                     Flucloxacillin 500mg qds
                                                     Penicillin allergy: Erythromycin
                                                     500mg qds
Animal/human       Surgical toilet most important. If1st line: Co-amoxiclav 375-          Treat for 7
bites              skin is not broken just clean the 625mg tds                            days.
                   wound.                            Penicillin allergy:
                   ANIMAL BITES:                     ANIMAL: Metronidazole 400mg
                   If not infected and presenting    tds plus doxycycline 100mg bd
                   within 24 hours of injury, give   or oxytetracycline 250-500mg
                   antibiotics ONLY IF high risk of  qds
                   infection, i.e. deep puncture-    HUMAN: Metronidazole 400mg
                   type bite (not easily cleaned),   tds plus doxycycline 100mg bd
                   suspicion of bone or joint        or erythromycin 250-500mg qds
                   involvement, severe bite to       If pregnancy / breast-feeding:
                   hand, foot or face, at risk       Erythromycin only
                   patient e.g. asplenic, diabetic,
                   elderly or immunocompromised.
                   Assess tetanus and rabies risk.
                   HUMAN BITES:
                   Antibiotic prophylaxis
                   recommended for all.
                   Assess tetanus and
                   HIV/hepatitis B & C risk.
MRSA –             Please refer to separate PCT guidance document
treatment and
screening
(before elective
surgery)
Dental             Dental consultation required.     1st line: Amoxicillin 500mg tds      Treat for 5
infections                                           Penicillin allergy: Erythromycin     days whilst
                                                     500mg bd-qds                         awaiting
                                                     For severe abscesses involving       dental
                                                     external facial swelling add         consultation.
                                                     metronidazole 200-400mg tds (3-
                                                     7 days).


                                               -8-
       ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

   CLINICAL                  COMMENTS                                DRUG                    DURATION
  DIAGNOSIS                                                                                     of
                                                                                            TREATMENT
EYES

Bacterial          Most cases of acute                  1st line: Chloramphenicol 0.5%      Eye drops:
conjunctivitis     conjunctivitis are self-limiting.    drops                               Instill 1 drop
                   If recurrent infection, exclude      Alternatively: 1% ointment can      every 2 hours,
                   chlamydia.                           be used at night and the drops      reducing freq.
                   Fusidic acid 1% is in a gel          during the day or use ointment      as infection
                   basis, which liquifies on contact    alone 3-4 times a day.              controlled.
                   with the eye and can be applied      2nd line: Gentamicin 0.3%           Use for 48 hrs
                   twice daily.                         drops or fusidic acid 1% drops      after healing.
                                                        (gel)
GASTRO-INTESTINAL TRACT INFECTIONS

Gastrointestinal   Faeces specimens should be           Antibiotics are NOT usually
infections         sent to the local microbiology       indicated in gastroenteritis. If
                   department. Please state             considering their use please
                   clinical details as special          discuss with a microbiologist or
                   investigations are carried out if:   Infectious Disease Consultant.
                   history of foreign travel, blood
                   in stool or previous antibiotic      Antibiotics are contraindicated
                   treatment.                           if E. coli 0157 is a possibility.
                   Notify Manchester Health
                   Protection Unit if food
                   poisoning suspected.
Diverticulitis     For an infective exacerbation of     1st line: Co-amoxiclav 625mg        Treat for 7-14
                   known diverticulosis which           tds                                 days.
                   does not require hospital            2nd line or Penicillin allergy:
                   admission.                           Ciprofloxacin 500mg bd +
                                                        metronidazole 400mg tds
Giardiasis         It can take 2 to 3 specimens to      1st line: Metronidazole 400mg       Treat for 5
                   confirm.                             tds                                 days
                                                        or
                                                        2g daily (Avoid 2g dose in          Treat for 3
                                                        pregnancy)                          days
Clostridium        No antibiotic is exempt. The         Mild cases: STOP all antibiotics
Difficile          commonest predisposing               if possible. CDAD may resolve. If
Associated         antibiotics associated with          clinically impossible to stop
Diarrhoea          CDAD are cephalosporins,             antibiotic, switch to an
(CDAD)             clindamycin and quinolones. If       alternative antibiotic preferably
                   suspected, send faeces               narrow-spectrum that is not
                   specimen(s) to test for              known to be associated with
                   Clostridium Difficile Toxin          CDAD.
                   (CDT).                               Moderate - severe cases: as         Treat for 10
                   If in doubt or for persistent        above and treat as follows:         days
                                                          st
                   unresponsive cases, seek             1 line: Metronidazole 400mg
                   advice from Microbiologist.          tds
                   In severe cases – urgent             For relapse cases: Vancomycin
                   surgery may be required.             125mg qds


                                                 -9-
      ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

  CLINICAL                 COMMENTS                                 DRUG                  DURATION
 DIAGNOSIS                                                                                   of
                                                                                         TREATMENT
MENINGITIS

Meningitis      Rapid admission to hospital is          Give: Benzylpenicillin 1.2g stat  Immediately
                highest priority when                   Penicillin allergy:
                meningococcal disease is                GPs do not need to carry an
                suspected. All GPs should               alternative antibiotic.
                carry benzylpenicillin and give         However, if other antibiotics
                whilst arranging hospital               are available, a 3rd generation
                transfer (unless there is a             cephalosporin may be used:
                history of immediate allergic           Ceftriaxone 2g or cefotaxime 2g
                reactions after previous                stat
                penicillin administration).             IV administration recommended
                The Manchester Health                   unless a vein cannot be found, in
                Protection Unit will be notified of     which case IM administration
                any cases of systemic                   may be used.
                meningococcal or haemophilus            If there is history of immediate
                meningitis infections and they will     allergic reactions to penicillin
                advise on prophylaxis for               or cephalosporins,
                contacts.                               chloramphenicol may be
                                                        used: Chloramphenicol 25mg/kg
                                                        IV
VIRAL INFECTIONS

Varicella       Seek advice from Microbiologist     Aciclovir 800mg 5xdaily              Treat for 7
zoster          or Infectious Diseases Consultant                                        days.
(chickenpox)    if patient is pregnant or
Herpes zoster   immunocompromised.
(shingles)      Chicken pox: Clinical value
                minimal unless
                immunocompromised, severe
                pain, adult on steroids, secondary
                household case and started within
                24 hours of onset of rash.
                Shingles: Always treat
                ophthalmic.
                Non-opthalmic: Treat >60 yrs if
                <72h of onset of rash, as post
                herpetic neuralgia rare in <50 yrs
                but occurs in 20% >60y. HPA
Herpes          Severe cases only.                  Aciclovir 200mg 5xdaily              Treat for 5
simplex         Treatment should begin as early                                          days.
                as possible after the start of an
                infection.                          Aciclovir 5% cream 5xdaily
                For Cold Sores topical treatment
                is only effective if started at the
                onset of symptoms.
Genital herpes refer to GUM clinic



                                               - 10 -
          ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

PARASITES

Refer to Scabies & Head Lice Guidance produced by the Infection Control Team on the
Manchester PCT website.

   CLINICAL              COMMENTS                               DRUG                      DURATION
  DIAGNOSIS                                                                                  of
                                                                                         TREATMENT
FUNGAL INFECTIONS

Oral                                               1st line: Nystatin 1ml suspension    Usually treat for
candidiasis                                        (100,000 units) qds                  7 days.
                                                   2nd line: Amphotericin 1 lozenge     (Amphotericin
                                                   qds                                  10-15 days)
                                                   or miconazole oral gel 5-10ml qds    Continue for
                                                                                        48hrs after
                                                                                        lesions
                                                                                        resolved.
Vaginal          Oral fluconazole should be        1st line: Clotrimazole pessary       Pessary =
candidiasis      avoided in pregnancy /            500mg for internal use 1 single      single dose
                 breast-feeding.                   dose at night +/- clotrimazole 2%
                 Repeated relapses, consider       cream for external application 2-3   Cream - usually
                 treatment of sexual partners.     times daily. (If require both        treat for 14
                                                   prescribe as Combi pack.)            days.
                                                   2nd line: Fluconazole cap 150mg
                                                                                        Single dose
Candidal skin                                      Clotrimazole 1% cream applied 2-     Continue for 7
infections                                         3 times daily                        days after
                                                                                        lesions
                                                                                        resolved.
Dermatophyte     Drug treatment only if            Scalp                                Treat for 4-6
infections       infection is confirmed by         1st line: Terbinafine 250mg daily    weeks. Review
Tinea capitis    microscopy / culture.             2nd line: Itraconazole 100mg         after 2 weeks.
                 Selenium or Ketoconazole          daily                                Continue for at
                 shampoo used twice weekly         (Above treatments are not            least 2 weeks
                 for 2 weeks may reduce the        licensed for tinea capitis.)         after all signs of
                 spread of infective spores.                                            infection have
                                                                                        disappeared.
Tinea corporis   Patients should be reassured      Body/groin/feet                      Treat for 1-2
/cruris/pedis    that infections may still         1st line: Terbinafine 1% cream       weeks in tinea
                 respond even after treatment      apply twice daily                    pedis and 2-4
                 course has finished.              Consider oral therapy if poor        weeks in tinea
                                                   response.                            corporis/cruris.




                                               - 11 -
        ADULT GUIDELINES - RECOMMENDED DOSES ARE FOR ADULTS ONLY

  CLINICAL              COMMENTS                               DRUG                     DURATION
 DIAGNOSIS                                                                                 of
                                                                                       TREATMENT
Onychomycosis   Nail clippings should be          Finger nails
                sent for mycological              1st line: Terbinafine 250mg od      Treat for 6-12
                examination prior to              2nd line: Itraconazole ‘pulse       wks.
                commencing treatment.             therapy’ 200mg bd for 7 days        Treat for 7 days
                Re-assure patients that their     then 3 weeks treatment-free.        monthly. Give 2
                nail infection will continue to   (Useful for yeasts, other non-      cycles of
                respond, after the course has     dermatophyte mould infections &     treatment.
                finished.                         mixed infections.)
                Topical agents should only        Alternatives: Amorolfine 5% nail
                be used                           paint applied 1-2 times weekly      Treat for 6
                in infections confined to the                                         months.
                distal nail ends (such            Toe nails
                infections may not require        1st line: Terbinafine 250mg od
                treatment at all).                2nd line: Itraconazole ‘pulse
                Monitoring:                       therapy’ 200mg bd for 7 days        Treat for 3-6
                Idiosyncratic liver reactions     then 3 weeks treatment-free.        months
                occur rarely with terbinafine.    Alternatives: Amorolfine 5% nail    Treat for 7 days
                                                  paint applied 1-2 times weekly      monthly. Give 3
                Itraconazole can also be                                              cycles of
                prescribed continuously as a      N.B. Adding Amorolfine nail paint   treatment.
                once daily dose (see BNF).        to oral treatment increases         Treat for 6-12
                LFTs are necessary for            response rate.                      months.
                continuous treatment longer
                than 1 month.                                                         It may take 3-6
                The pulsed regimen may                                                months for
                reduce the risk of liver                                              finger nails and
                problems.                                                             6-12 months for
                The continuous regimen may                                            toe nails before
                be better tolerated – lower                                           the nail returns
                daily dose.                                                           to normal.




                                             - 12 -
                                    PAEDIATRIC GUIDELINES

  CLINICAL                COMMENTS                                DRUG                      DURATION
 DIAGNOSIS                                                                                     of
                                                                                           TREATMENT
RESPIRATORY TRACT INFECTIONS

Sore throat      The majority of sore throats        Antibiotics are rarely needed        Treat for 10
                 (viral or bacterial) are self-      1st line: Phenoxymethylpenicillin    days to ensure
                 limiting (lasting up to 7 days) &   Penicillin allergy: Erythromycin     eradication of
                 do not respond to antibiotics.                                           Group A
                 See Centor criteria in adult                                             streptococci
                 section. Recommend
                 paracetamol & warm drinks.
Acute otitis     Viral infection common. Not         1st line: Amoxicillin                Treat for 5 days
media            clear whether antibiotics           2nd line: Co-amoxiclav
                 actually affect the outcome or      Penicillin allergy: Erythromycin
                 complications of otitis media.
                 About 80% of cases resolve
                 within 3 days without treatment.
                 Consider waiting 24-48 hours
                 before treating. Use
                 paracetamol for pain relief.
Acute otitis     Topical treatment usually           1st line: Flucloxacillin             Treat for 5 days
externa          effective. Avoid antibiotics        Penicillin allergy: Erythromycin
                 wherever possible. Oral
                 antibiotics only required if
                 severe. Pain relief –
                 paracetamol.
                 Swab severe cases and
                 patients with diabetes.
Chronic otitis   No antibacterials / antifungals     Keep ear(s) clean and dry
externa          needed
Sinusitis        Viral infection common.             1st line: Amoxicillin                Treat for 7 days
                 Symptomatic benefit of              Alternative 1st line or Penicillin
                 antibiotics is small. Encourage     allergy: Erythromycin
                 drainage with steam                 2nd line: Co-amoxiclav
                 inhalations.
                 Reserve for severe or
                 persistent symptoms (lasting at
                 least 7 days).
Community -      Between 1 month and 4 years,        1st line: Amoxicillin                Treat for 7 days
acquired         most respiratory infections are     Alternative 1st line or Penicillin
pneumonia –      viral. After 4 years of age,        allergy: Erythromycin
treatment in     bacterial infections become         (particularly if Mycoplasma is
the community    more common.                        suspected)
                 Mycoplasma is more common
                 in older school-aged children &
                 adolescents.




                                                - 13 -
                                 PAEDIATRIC GUIDELINES

  CLINICAL                COMMENTS                                   DRUG                    DURATION
 DIAGNOSIS                                                                                      of
                                                                                            TREATMENT
URINARY TRACT INFECTIONS

Urinary tract   Refer infants <3 months of age           1st line: Trimethoprim             Treat for 5-7
infection       immediately to specialist care.          2nd line: Nitrofurantoin           days
                Refer for further investigation          (>3months old)
                following 1st proven UTI.                Reserve cefalexin therapy as
                Consider low-dose antibiotic             risk of C.difficile.
                prophylaxis after recurrent UTI          Can use Amoxicillin if organism
                until paediatric out-patient             known to be sensitive.
                appointment.
                Collection of one or more urine
                samples for C&S testing prior to
                drug treatment is essential.
SKIN

Cellulitis      Failure to respond may                   1st line: Flucloxacillin           Duration
                necessitate urgent parenteral            Penicillin allergy: Erythromycin   depends on
                antibiotics.                                                                severity and
                                                                                            response.
                                                                                            Minimum 7-14
                                                                                            days
                                                                                            treatment.
Erysipelas                                               1st line:                          Treat for 7-14
                                                         Phenoxymethylpenicillin            days then
                                                         Add flucloxacillin to cover        review.
                                                         Staph. Aureus if reponse is
                                                         poor.
                                                         Penicillin allergy: Erythromycin
Infected                                                 1st line: Flucloxacillin           Treat for 7-14
eczema                                                   Penicillin allergy: Erythromycin   days.
Impetigo        Remove crusts by soaking before          Minor infection: Fusidic acid      Treat for 7
                topical treatment.                       2% cream/ointment tds-qds          days.
                                                         Widespread infection:              Restrict topical
                                                         Oral flucloxacillin.               treatment to
                                                         Penicillin allergy: Erythromycin   max. 10 days
                                                                                            to avoid
                                                                                            reistance.




                                                - 14 -
                                   PAEDIATRIC GUIDELINES

  CLINICAL                 COMMENTS                                 DRUG                     DURATION
 DIAGNOSIS                                                                                        of
                                                                                            TREATMENT
Animal/          Surgical toilet most important. If     1st line: Co-amoxiclav for 7       Treat for 7
human bites      skin is not broken just clean the      days                               days.
                 wound.                                 Penicillin allergy: Erythromycin
                 ANIMAL BITES:                          (less effective)
                 If not infected and presenting
                 within 24 hours of injury, give
                 antibiotics ONLY IF high risk of
                 infection, i.e. deep puncture-type
                 bite (not easily cleaned),
                 suspicion of bone or joint
                 involvement, severe bite to hand,
                 foot or face, at risk patient e.g.
                 asplenic, diabetic and
                 immunocompromised.
                 Assess tetanus and rabies risk.
                 HUMAN BITES:
                 Antibiotic prophylaxis
                 recommended for all.
                 Assess tetanus and HIV/hepatitis
                 B & C risk.
Dental           Dental consultation required.          1st line: Amoxicillin              Treat for 5
infections                                              Penicillin allergy: Erythromycin   days whilst
                                                        For severe abscesses involving     awaiting dental
                                                        external facial swelling add       consultation.
                                                        metronidazole.
EYES

Bacterial        Most cases of acute conjunctivitis     1st line: Chloramphenicol 0.5%     Eye drops:
conjunctivitis   are self-limiting.                     eye drops                          Instill 1 drop
                 If recurrent infection, exclude        Alternatively: 1% ointment can     every 2 hours,
                 chlamydia.                             be used at night and the drops     reducing freq.
                 Fusidic acid 1% is in a gel basis,     during the day or use ointment     as infection
                 which liquifies on contact with the    alone 3-4 times a day.             controlled.
                 eye and can be applied twice           2nd line: Gentamicin 0.3%          Use for 48 hrs
                 daily.                                 drops or fusidic acid 1% drops     after healing.
                                                        (gel)




                                               - 15 -
                                  PAEDIATRIC GUIDELINES

  CLINICAL                COMMENTS                                  DRUG                   DURATION
 DIAGNOSIS                                                                                    of
                                                                                          TREATMENT
MENINGITIS

Meningitis      Rapid admission to hospital is         Give: Benzylpenicillin 300mg       Immediately
                highest priority when                  for infants aged under 1 year,
                meningococcal disease is               600mg for 1-9 year olds, 1.2g if
                suspected. All GPs should              10 years or over
                carry benzylpenicillin and give        Penicillin allergy:
                whilst arranging hospital              GPs do not need to carry an
                transfer (unless there is a            alternative antibiotic.
                history of immediate allergic          However, if other antibiotics
                reactions after previous               are available, a 3rd generation
                penicillin administration).            cephalosporin may be used:
                The Manchester Health                  Ceftriaxone or cefotaxime
                Protection Unit will be notified of    (50mg/kg/dose – max dose 4g)
                any cases of systemic                  IV administration recommended
                meningococcal or haemophilus           unless a vein cannot be found,
                meningitis infections and they will    in which case IM administration
                advise on prophylaxis for              may be used.
                contacts.                              If there is history of
                                                       immediate allergic reactions
                                                       to penicillin or
                                                       cephalosporins,
                                                       chloramphenicol may be
                                                       used:
                                                       Chloramphenicol 25mg/kg IV
                                                       (12.5mg/kg if < 14 days old)
FUNGAL INFECTIONS

Oral            Localised lesions - apply a small      1st line: Nystatin 1ml             Usually treat
candidiasis     amount of miconazole gel to the        suspension (100,000 units) qds     for 7 days.
                affected area with a clean finger      2nd line: Miconazole oral gel (1   Continue for
                2-4 times daily.                       month - 2 years 2.5ml bd, 2-6      48hrs after
                                                       years 5ml bd, 6-12 years 5ml       lesions
                                                       qds, 12-18 years 5-10ml qds)       resolved.
Candidal skin                                          Clotrimazole 1% cream applied      Continue for 7
infections                                             2-3 times daily.                   days after
                                                                                          lesions
                                                                                          resolved.




                                              - 16 -
                                     PAEDIATRIC GUIDELINES

  CLINICAL                    COMMENTS                                    DRUG                      DURATION
 DIAGNOSIS                                                                                               of
                                                                                                  TREATMENT
Dermatophyte       Drug treatment only if infection is       Scalp                               Terbinafine or
infections         confirmed by microscopy /                 1st line: Terbinafine tablets       itraconazole -
Tinea capitis      culture.                                  Over 1 year, body weight 10-        treat for 4-6
                                                             20kg = 62.5mg daily, 20-40kg =      weeks.
                   Selenium or Ketoconazole                  125mg daily, >40kg = 250mg          Griseofulvin -
                   shampoo used twice weekly for 2           daily (unlicensed)                  treat for 8-10
                   weeks may reduce the spread of            2nd line: Itraconazole 3-           weeks.
                   infective spores.                         5mg/kg/day (unlcensed)              Review after 2
                                                             3rd line: Griseofulvin 1month -     weeks.
                                                             12 years 15-20mg/kg once daily      Continue for at
                                                             or in divided doses (max 1g         least 2 weeks
                                                             daily).                             after all signs
                                                             (‘Specials’ liquid available from   of infection
                                                             Novo Laboratories)                  have
                                                                                                 disappeared.

Tinea              Reassure that infections still            Body/groin/feet                     Treat for 1-2
corporis/cruris/   respond even after treatment              1st line: Terbinafine cream 1%      weeks in tinea
pedis              course has finished.                      apply bd                            pedis and 2-4
                                                                                                 weeks tinea
                                                                                                 cruris /
                                                                                                 corporis,
                                                                                                 review after
                                                                                                 2wks.




                                                    - 17 -
                                USUAL PAEDIATRIC DOSAGES

See appropriate paediatric formulary/text for neonatal dosages.

Amoxicillin                         1 month-1 year                62.5mg tds
                                    1-5 years                     125mg tds
                                    5-18 years                    250mg tds

Co-amoxiclav                        1 month-1 year                0.25ml/kg of 125/31 suspension
tds                                 1-6 years                     5ml of 125/31 suspension tds
                                    6-12 years                    5ml of 250/62 suspension tds
                                    12-18 years                   1 (250/125) tablet tds

Erythromycin*                       1 month-2 years               125mg qds
                                    2-8 years                     250mg qds
                                    8-18 years                    250-500mg qds

Flucloxacillin                      1 month-2 years               62.5-125mg qds
                                    2-10 years                    125-250mg qds
                                    10-18 years                   250-500mg qds

Nitrofurantoin                      3 months-12 years             750micrograms/kg qds
                                    12-18 years                   50mg qds

Phenoxymethylpenicillin             1 month-1 year                62.5mg qds
                                    1-6 years                     125mg qds
                                    6-12 years                    250mg qds
                                    12-18 years                   500mg qds

Trimethoprim > 1 month              4mg/kg bd (max. single dose = 200mg)


Dosage information from BNF for Children (BNFC) and Central Manchester and Manchester
Children’s University Hospital Antibiotic Guidelines.
Doses may need to be doubled in severe infections.
Refer to BNFC or Summary of Product Characteristics for further prescribing information.
* Consider Clarithromycin if intolerant to Erythromycin.




                                              - 18 -
Developed by the Medicines Management Team, Manchester Primary Care Trust in
consultation with the local Manchester Hospital Trusts.


Jennifer Bartlett - Medicines Management Pharmacist, Manchester PCT
Dr. B. Isalska - Consultant Microbiologist, UHSM
Dr. A. Qamruddin - Consultant Microbiologist, CMMC
Dr H. Panigrahi – Consultant Microbiologist, NMGH
Dr J. Ferguson - Consultant Dermatologist, UHSM
Dr S. Ahmad - Consultant Genitourinary Medicine, UHSM
Kelly Alexander - Antibiotic Pharmacist, CMMC
Fiona Gilchrist – Antibiotic Pharmacist, UHSM
Cathy Chow – Antibiotic Pharmacist, NMGH
Robert Hallworth - Prescribing Support Pharmacist, Tameside and Glossop PCT / Oldham PCT



Further information is available on request from the Medicines Management Team,
Manchester PCT.



PRODUCED: APRIL 2008                                REVIEW DATE: APRIL 2010




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