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					Antimicrobial Guidelines for Donegal
Primary, Community and Continuing
Care (PCCC) Settings, HSE West.
October 2009
For review by October 2010




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This document was developed by Dr. Michael Mulhern, Consultant
Microbiologist, letterkenny General Hospital.
Adapted from “NI Antimicrobial Guidelines for Primary Care” with
permission from the Department of Health, Social Services and Public
Safety, Northern Ireland.


Collaborators:
Dr. John Sweeney, General Practitioner.
Dr. Diarmuid Mee, General Practitioner.
Ms. Mags Moran, Community Infection Control Nurse Manager.


Approved by:
Primary, Community & Continuing Care- Local Health Office- Infection
Control Committee (PCCC- LHO- ICC).
Chairperson: Mr. Kieran Doherty, General Manager, Donegal
Community Services.




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CONTENTS



AIMS                                                                                              4
PRINCIPLES OF TREATMENT                                                                           4
ACNE VULGARIS                                                                                     6
BITES (HUMAN/ ALL DOMESTIC ANIMAL)                                                                7
BOILS                                                                                             7
BRONCHITIS (ACUTE)                                                                                8
BRONCHITIS (CHRONIC)/ COPD (ACUTE EXACERBATION)                                                   8
CANDIDIASIS (ORAL)                                                                                9
CANDIDIASIS (VULVO-VAGINAL)                                                                       9
CELLULITIS                                                                                      10
COMMUNITY ACQUIRED PNEUMONIA                                                                    11
CONJUNCTIVITIS                                                                                  12
CROUP                                                                                           12
DERMATOPHYTE NAIL INFECTIONS                                                                    13
DERMATOPHYTE SKIN INFECTIONS                                                                    13
EPIDIDYMO ORCHITIS                                                                              14
HELICOBACTER PYLORI ERADICATION                                                                 14
IMPETIGO                                                                                        15
INFECTIOUS DIARRHOEA                                                                            16
MENINGITIS ADULT                                                                                17
MENINGITIS CHILD                                                                                18
METICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) SCREENING
AND DECOLONISATION                                          19
OTITIS MEDIA                                                                                    21
PROSTATITIS ACUTE)                                                                              21
PELVIC INFLAMMATORY DISEASE                                                                     22
STI’S                                                                                           22
SHINGLES (HERPES ZOSTER)                                                                        22
SINUSITIS                                                                                       23
THROAT INFECTION/ PHARYNGITIS/ TONSILLITIS                                                      24
URINARY TRACT INFECTIONS                                                                        25
DENTAL INFECTIONS                                                                               26




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AIMS
- to provide a simple best guess 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
1. These guidelines are based on the best available evidence but the decision to prescribe an antibiotic rests with individual practitioners
    and is informed by clinical judgement.
2. These guidelines are empiric and do not take away from local decisions on prescribing to address local circumstances. In particular,
    where a microbiologist is aware of an infection with a local emerging pattern of resistance to a first line therapy an appropriate second
    line therapy may be used. Microbiologists can issue guidance to local prescribers on the most appropriate antibiotic in this case.
3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
4. Do not prescribe an antibiotic for viral sore throat, simple coughs and colds.
5. Discourage telephone requests for antibiotics.
6. Limit telephone prescribing of antibiotics to exceptional cases. (Ideally antibiotics should only be prescribed following a face to face
    consultation).
7. The use of new and more expensive antibiotics (e.g. quinolones and cephalosporins) is inappropriate when standard and less
    expensive antibiotics remain effective.
8. Consider use of delayed prescriptions, cough bottles, analgesics, or decongestants as alternative measures.
9. Consider referral to Community Pharmacist where appropriate.
10. Use generic antibiotics whenever possible.
11. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
12. Where empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from your local
    microbiologist via Letterkenny General Hospital switchboard 0749125888.
13. The evidence base for the duration of antibiotic treatment is poor. Whilst this document provides guidance on duration of treatment,
    clinical judgement should be used.
14. Some antibiotics must be avoided in pregnancy. When using this guidance to treat infections in pregnant women, please check the
    suitability of the antibiotics recommended before treating, and choose an alternative where appropriate.
15. Clarithromycin or azithromycin may be used as an alternative for erythromycin intolerant patients.


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16. Take appropriate history in suspected/reported penicillin allergy. Individuals with history of anaphylaxis, angioneurotic oedema, or
    urticarial rash within 72 hours of penicillin administration should not receive any beta-lactam antibiotics including cephalosporins.

All doses are oral unless stated.
For the purposes of these guidelines, adult doses may be used for children over 12 years.




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Indication                            Drug                                       Dose                                     Duration
                Adult 1st line        benzoyl peroxide gel 2.5% increasing       Apply one to two times daily             Review after 2 months
Acne Vulgaris                         to 5% if tolerated
                Adult topical if      A topical retinoid eg adapalene or tretinoin or isotretinoin may be used as an alternative. Benzoyl peroxide or other
                benzoyl peroxide      abrasive cleansers may cause peeling which should be given time to subside before using a topical retinoid.
                not tolerated         Propionibacteria strains resistant to erythromycin are becoming widespread and may explain poor response to
                                      macrolides.
                Adult 1st line        oxytetracycline or tetracycline plus       500mg bd                                 Review in 3 months, but
                systemic therapy      topical treatment                                                                   may take 4-6
                                                                                                                          months

                Adult 2nd line        doxycycline                                     100mg od
                systemic              or erythromycin                                 500mg bd
                Adult 3rd line        Refer to dermatology
                systemic
                therapy




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Indication                               Drug                                  Dose                                       Duration
                  Surgical cleansing is most important. Assess tetanus and rabies risk. Antibiotic prophylaxis advised for puncture wound; bites involving hand,
Bites (Human/ all foot, face, joint, tendon, ligament, immunocompromised, diabetics, elderly, asplenic and in human bites. In human bites, assess HIV/Hepatitis
Domestic          B & C risk. Patients to be reviewed at 24-48 hours
Animal)           Adult 1st line         co-amoxiclav                          625mg tds                                  5 -7 days

                    Adult penicillin     Doxycycline                                      100mg bd                                       5 -7 days
                    allergic or 2nd line +
                                         metronidazole                                    400mg tds
                    Child 1st line       co-amoxiclav                                     1-12 months                                    5 -7 days
                                                                                               0.25ml/kg of 125/31mg susp tds.
                                                                                          For average weight child =
                                                                                               1 month (4.2kg) 1ml
                                                                                               3 months (5.6kg)1.5ml
                                                                                               6 months (7.7kg) 2ml
                                                                                               12 months (10kg) 2.5ml
                                                                                          1-6yrs
                                                                                               5ml of 125/31mg susp tds
                                                                                          6-12yrs
                                                                                               5ml of 250/62mg susp tds

                    Child Penicillin      azithromycin                                    Child over 6 months                            3 days
                    Allergic                                                                   10mg/kg once daily
                    or 2nd line                                                           using 200mg/5ml susp
                                                                                          For average weight child =
                                                                                               6 months (7.7kg) = 2ml
                                                                                               12 months (10kg) = 2.5ml
                                                                                               3 years (15 kg) = 4ml
                                                                                               15-25kg = 5ml
                                                                                               26-35kg = 7.5ml
                    Boils don’t usually respond to antibiotics. Treat with drainage.
Boils




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Indication                                     Drug                                      Dose                                      Duration
                         A cough of less than 2 weeks duration in otherwise healthy adults with no co-morbidities or systemic
Bronchitis (acute)       illness does not require antibiotics. Consider antibiotic use in >60 years or if underlying chest disease.
                         Adult 1st line        amoxicillin                               500mg tds                                 5-7 days
                         Adult penicillin      Clarithromycin                            500mg bd                                  5-7 days
                         allergic or 2nd       or
                         line                  doxycycline                               200mg stat, then 100mg od
                         Child 1st line        amoxicillin                               1month-1yr 62.5mg tds                     5-7 days
                                                                                         1- 5yrs 125mg tds
                                                                                         5-12yrs 250mg tds
                         Child penicillin      Azithromycin                              6months – 3 years (Up to 15kg)            3 days
                         allergic                                                        10mg/kg
                         or 2nd line                                                     3-7 years 200mg od
                                                                                         8-11 years 300mg od
                                               or                                        12-14 years 400mg od
                                               clarithromycin                                                                      5-7 days
                                                                                         1-2 years 62.5mg bd
                                                                                         3-6 years 125mg bd
                                                                                         7-9 years 187.5 mg bd
                                                                                         10–12 years 250mg bd
                                                                                         Children < 8 kg should be dosed on
                                                                                         a per kg basis (approx. 7.5 mg/kg
                                                                                         bid)
                         Antibiotics of unlikely benefit unless 2 or 3 of the following are present
Bronchitis (chronic)/    - increased breathlessness
COPD (acute              - increased sputum volume, new or increased sputum purulence
exacerbation)            Adult 1st line        amoxicillin                               500mg tds                                 5-7 days
                         Adult penicillin      Clarithromycin                            500mg bds                                 5-7 days
                         allergic              or
                                               doxycycline                               200mg stat, then 100mg od
                         Adult 2nd line        co-amoxiclav                              625mg tds - should only be used in        5-7 days
                                                                                         clinical failure to 1st line antibiotics.

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Indication                                  Drug                                           Dose                                          Duration
                      Adult & Child         nystatin                                       100,000 units qds                             Continue Rx
Candidiasis (oral)    >1mth                                                                (1ml) after food                              for 48 hours
                                                                                                                                         after lesions
                                                                                                                                         have resolved
                      Adult topical         clotrimazole                                   500mg pessary + cream 2%                      use cream 2-3
Candidiasis (vulvo-   therapy                                                                                                            times daily
vaginal)              Adult systemic        fluconazole                                    150 mg stat
                      therapy
                      Pregnant              Use topical therapy only. Advise on careful use of applicator for pessary.




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Indication                         Drug                                        Dose                                       Duration
             Serious or deteriorating cellulitis is an emergency and will need referral for Intravenous (IV) antibiotics.
Cellulitis   For further information refer to Crest Guidelines - www.crestni.org.uk/publications/cellulitis/cellulitis-guide.pdf
             Diabetic feet should only be treated with antibiotics if signs of infection are present.
             Using antibiotics in eczema or adding them to steroids does not improve healing unless there are visible signs of infection
             Consider also PVL Staph aureus in severe/necrotising/recurrent infection -
             http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1218699411960
             Adult 1st line        flucloxacillin                              500mg qds                                  7-14 days

             Adult penicillin      clarithromycin                                  250mg - 500mg bd                               7-14 days
             allergic or 2nd
             line
             Child 1st line        flucloxacillin                                  1mth-2yrs 62.5mg-125mg qds                     7-14 days
                                                                                   2-10yrs 125mg-250mg qds
                                                                                   10-12yrs 250mg-500mg qds

             Child penicillin     Azithromycin                                     6months – 3 years (Up to 15kg)                 3 days
             allergic or 2nd line                                                  10mg/kg
                                                                                   3-7 years 200mg od
                                                                                   8-11 years 300mg od
                                                                                   12-14 years 400mg od
                                   or                                                                                             5-7 days
                                   clarithromycin                                  1-2 years 62.5mg bd
                                                                                   3-6 years 125mg bd
                                                                                   7-9 years 187.5 mg bd
                                                                                   10–12 years 250mg bd
                                                                                   Children < 8 kg should be dosed on a
                                                                                   per kg
                                                                                   basis (approx. 7.5 mg/kg bid)




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Indication                                                  Drug                 Dose                                                             Duration
                                  Review patients within 48hrs or earlier as appropriate
Community Acquired Pneumonia      BTS guidelines available from www.brit-thoracic.org.uk
                                  CRB-65 score useful to assess severity in adults.
                                  Score 1 point for each of: onset of confusion, rapid breathing, low blood pressure or age over 65.
                                  0 = Home Rx 1 or 2 = consider hospital referral 3 or 4 = urgent hospital admission.
                                  Adult 1st line            amoxicillin 500mg -1g tds 7 days
                                                            if no response in 48hrs consider admission or add clarithromycin or doxycycline as below to cover
                                                            mycoplasma infection
                                                            Consider addition of flucloxacillin where staph aureus is suspected (e.g. post-influenza)
                                  Adult penicillin allergic clarithromycin 500mg bd 7 days
                                                            doxycycline 200mg stat then 100mg bd
                                                            if no response in 48hrs consider admission
                                  Child 1st line            Child < 3months old or if vomiting or severely ill - ADMIT
                                                            amoxicillin 3 mths - 1 yr 125mg tds
                                                            1yr - 5yrs 250mg tds 7 days
                                                            5-12yrs 500mg tds
                                                            if no response in 48hrs consider admission or add clarithromycin/azithromycin as below to
                                                            cover mycoplasma infection
                                  Child penicillin allergic Azithromycin         6 months – 3 years (Up to 15kg) 10mg/kg                          3 days
                                                                                 3-7 years 200mg od
                                                                                 8-11 years 300mg od
                                                                                 12-14 years 400mg od

                                                               Or                     1-2 years 62.5mg bd                                                     5-7 days
                                                               clarithromycin         3-6 years 125mg bd
                                                                                      7-9 years 187.5 mg bd
                                                                                      10–12 years 250mg bd
                                                                                      Children < 8 kg should be dosed on a per kg basis
                                                                                      (approx. 7.5 mg/kg bid)



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Indication                                    Drug                                                     Dose                                                    Duration
                 Most infections are viral and self limiting. Clean with boiled, cooled water.
Conjunctivitis   If persists consider treatment
                 Adult & Child >1mth          Chloramphenicol 0.5% drops +1% ointment.                 2 hrly reducing to qds at night                         Continue to
                                              Drops to be used during the day and ointment to be                                                               use for 48 hrs
                                              applied at night.                                                                                                after healing
                 Neonatal                     In newborn with sticky eyes, continually bathe with boiled and cooled warm water.
                                              Most neonates with sticky eyes do not have an infection.
                                              If not clear in 3-4 days, diagnose by swabbing.
                 No antibiotic required. Mild cases can be managed in community. More severe croup requires hospital admission
Croup            and possibly steroids before transfer. See BNF.




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Indication                                                                Drug                                   Dose                                              Duration
                             Confirm diagnosis with nail clippings before starting treatment.
Dermatophyte Nail Infections Adult systemic therapy                       terbinafine                            250mg od                                          Fingers 6-12
                                                                                                                                                                   wks
                                                                                                                                                                   Toes 3-6 mths
                                  Children                                                            Seek Advice
                                  Skin or hair samples should be taken to confirm diagnosis before treatment.
Dermatophyte Skin                 Adult 1st line topical therapy & Child      2% miconazole           2 times daily                                                Continue to
Infections                        >1mth                                       cream                                                                                apply for 10
                                                                                                                                                                   days after
                                                                                                                                                                   lesions have
                                                                                                                                                                   healed
                                  Adult 2nd line topical therapy                     1% terbinafine cream        thinly 1-2 times per day                          2 weeks &
                                                                                                                                                                   Review
                                  Systemic therapy should be used for intractable conditions in adults only.
                                  Adult 1st line systemic                     terbinafine              250mg od                                                    4 weeks
                                  therapy
                                  Adult 2nd line systemic                     itraconazole             See MIMS or BNF for doses and
                                  therapy                                                              cautions




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Indication                                                  Drug                                              Dose                             Duration
                                                 Consider alternative diagnosis eg testicular torsion.
Epididymo orchitis                               Confirm diagnosis. Consider a Sexually Transmitted Infection (STI) and refer to Genito-urinary Medicine (GUM)
                                                 unless diagnosis of mumps.
                                                 Adult      ciprofloxacin                                     500mg bd                         2 weeks then
                                                                                                                                               review
                                                 For compliance reasons, combination products may be appropriate, when available.
Helicobacter Pylori eradication                  Refer to NICE guidance for scoping patients. http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline.pdf
                                                 One week triple-therapy regimens eradicate H. pylori in over 90% of cases.
                                                 Two week triple-therapy regimens offer the possibility of higher eradication rates but adverse effects are common
                                                 and poor compliance is likely to offset any possible gain.
                                                 Adult      Omeprazole or                                     20mg bd                          7 days
                                                            Lansoprazole                                      30mg bd
                                                            + 2 antibiotics from
                                                            amoxicillin                                       1g bd
                                                            clarithromycin                                    500mg bd
                                                            metronidazole                                     400mg bd
                                                 Child      Refer to specialist




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Indication                                                  Drug                        Dose                                                                       Duration
             Reserve topical antibiotics for very small localised lesions.
Impetigo     Apply Polyfax twice daily & review within 7 days
             Adult 1st line                                 flucloxacillin              500mg qds                                                                  5 -7 days

             Adult penicillin allergic                          clarithromycin          250-500mg bd                                                               5-7 days
             or 2nd line

             Child 1st line                                     flucloxacillin          1mth-2yrs 62.5mg-125mg qds                                                 5-7 days
                                                                                        2-10yrs 125mg-250mg qds
                                                                                        10-12yrs 250mg-500mg qds

             Child penicillin allergic or 2nd line              Azithromycin            6 months – 3 years (Up to 15kg) 10mg/kg                                    3 days
                                                                                        3-7 years 200mg od
                                                                                        8-11 years 300mg od
                                                                                        12-14 years 400mg od

                                                                or                      1-2 years 62.5mg bd
                                                                clarithromycin          3-6 years 125mg bd                                                         5-7 days
                                                                                        7-9 years 187.5 mg bd
                                                                                        10–12 years 250mg bd
                                                                                        Children < 8 kg should be dosed on a per kg basis
                                                                                        (approx. 7.5 mg/kg bid)




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Indication                       Drug                                     Dose                                     Duration
             Antibiotic therapy not indicated unless patient systemically unwell or post-antibiotic, suggesting Clostridium difficile.
Infectious   Clostridium         Stop unnecessary antibiotics and/or PPIs to re-establish normal flora. 70% respond to metronidazole in 5 days; 94% in
diarrhoea               st    nd
             difficile 1 or 2    14 days.
             episode (non-       Severe (contact Microbiologist) if T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis.
             severe)             N.B. Vancomycin can only be prescribed by a Consultant Physician, please discuss with Consultant Microbiologist.
                                 metronidazole                            400 or 500 mg oral TDS                   10-14 days

             Clostridium           vancomycin                                      125mg oral QDS                                 10-14 days
             difficile 3rd
             episode or severe
             Traveller’s           Limit prescription of antibacterial to be carried abroad and taken if illness develops to people travelling to remote areas
             diarrhoea             and for people in whom an episode of infective diarrhoea could be dangerous.
                                   ciprofloxacin                               750 mg                                    Stat
                                   In areas of high ciprofloxacin resistance (Asia) can advise prophylactic bismuth subsalicylate (Pepto Bismol) 2 tablets
                                   QDS.




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Indication                                                                    Drug                            Dose                                            Duration
                   Transfer all patients to hospital immediately.
Meningitis Adult   Administer antibiotic stat while arranging transfer.
                   Treatment should ideally be administered IV
                   Adult 1st line                                       benzylpenicillin IV/IM                1.2g                                            Stat

                   Adult penicillin allergic                                  cefotaxime IV/IM                1g                                              Stat

                   Or if history of anaphylaxis with penicillin               chloramphenicol IV              25mg/kg                                         Stat
                                                                                                              Approximate doses for weights
                                                                                                              40kg/6st 4lbs = 1000mg (1g)
                                                                                                              60kg/9st 6lbs = 1500mg (1.5g)
                                                                                                              80kg/12st 8lbs = 2000mg (2g)
                                                                                                              100kg/15st10lbs = 2500mg (2.5g)




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Indication                                 Drug                                                Dose                                      Duration
                   Transfer all patients to hospital immediately.
Meningitis Child   Administer antibiotic stat while arranging transfer.
                   Treatment should ideally be administered IV
                   Child 1st line          benzylpenicillin IV/IM                              <1yr 300mg                                Stat
                                                                                               1-9yrs 600mg
                                                                                               10yrs and over 1.2g

                   Child penicillin         cefotaxime IV/IM                                   1mth-12yrs 50mg/kg                        Stat
                   allergic
                                               Age                approx weight     dose
                                               1 month            9lbs/ 4kg         200mg
                                               3 months           13lbs/ 6kg        300mg
                                               6 months           18lbs/ 8kg        400mg
                                               12 months          22lbs/ 10kg       500mg
                                               3 years            2st5lbs/ 15kg     750mg
                                               6 years            3st2lbs/ 20kg+    1g
                                               at 20 KG and
                                               above dose is 1g




                   Or if history of         chloramphenicol IV                                 1mth-12yrs 25mg/kg                        Stat
                   anaphylaxis with
                   penicillin                  Age                approx weight     dose
                                               1 month            9lbs/ 4kg         100mg
                                               3 months           13lbs/ 6kg        150mg
                                               6 months           18lbs/ 8kg        200mg
                                               12 months          22lbs/ 10kg       250mg
                                               3 years            2st5lbs/ 15kg     375mg
                                               6 years            3st2lbs/ 20kg     500mg
                                               9 years            4st 10lbs/ 30kg   750mg
                                               12 years           6st 4lbs/ 40kg    1g




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Meticillin Resistant Staphylococcus aureus (MRSA) Screening and Decolonisation

When is primary care involved?
GPs may be asked to screen and decolonise patients prior to certain surgical procedures in some acute health care facilities.

Contact the Community Infection Control Nurse or Consultant Microbiologist if you have any queries on the management of MRSA

Which patients should be screened for MRSA?
Prior to elective surgery when notified by the patient or acute health care facility. Such patients are likely to include those at:
1. high risk of suffering serious MRSA infections (includes surgical procedures such as prosthetic implant) or on units with a high proportion of MRSA
    infections among colonised patients (includes intensive care, burns, transplantation, cardiothoracic, orthopaedic, trauma, vascular surgery, renal & referral
    centres).
2. high risk of MRSA carriage - previous MRSA infection or colonisation, frequent readmission to healthcare facilities, recent inpatient/resident at hospital or
    care facility with known or likely high MRSA prevalence

How do I screen a patient for MRSA?
In most cases, patients should be swabbed as close to elective admission as possible, allowing sufficient time for decolonisation therapy and rescreening if
required
   - Swab anterior nares (nose). (Wipe a swab around inside rim of each nostril for 5 seconds)
   - Groin or perineum, and
   - any skin lesions or wounds.
   - Label the bacteriology form “Pre-operative MRSA screen”.


Interpreting the laboratory report.
Only MRSA will be looked for when swabs are labelled “MRSA screen”.
Positive cultures are reported as “MRSA isolated”. Negative cultures are reported as “MRSA not isolated”.
After the first swab, the full range of antibiotic susceptibilities is not usually reported.

Decolonisation of MRSA
Regimens aim to clear or reduce MRSA below detection level at time of risk, to decrease chance of infection and spread, it may not be successful in the long
term.

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Always advise admitting ward of patient’s MRSA status, to allow appropriate pre-operative preparation and prophylaxis.
To reduce persistent MRSA carriage, treat underlying skin conditions (e.g. eczema, dermatitis), remove and/or replace invasive devices and treat skin breaks.
Choice of skin regimen for patients with underlying skin conditions should consider the potential for skin irritation. Where necessary, seek advice from
Dermatologist.
See Table below for decolonisation regimen.

Indication                                 Drug                                      Dose                                     Duration
MRSA                Nasal                  Apply pea-sized amount to inner surface of each nostril. Patients should be able to taste mupirocin at back of throat.
decolonisation                             2% mupirocin in paraffin base             3 times a day                            5 days
                    Skin                   Moisten skin and apply undiluted antiseptic then rinse.
                                           Particularly apply to known carriage sites (axilla, groin & perineum). Wash hair using antiseptic body-wash/shampoo.
                                           After washing, use clean towels, sheets & clothing.
                                           Launder items separately from other family members, using as high a temperature as fabric allows.
                                           4% chlorhexidine gluconate body-          Daily                                    5 days
                                           wash/shampoo


How do I know if a patient has been decolonised successfully?
Where necessary, perform 3 screens (as above), one week apart. Begin at least 48 hrs after end of antiseptic & antibiotic therapy. If decolonisation fails, seek
advice from the Consultant Microbiologist or Community Infection Control Nurse Manager.

What do I do if a patient is discharged from hospital MRSA positive?
Generally, MRSA-positive patients do not require special treatment after discharge.
Where practical, standard infection control procedures should be followed. MRSA-positive patients undergoing medical or nursing procedures in primary care
(e.g. wound dressings, minor surgery) should be seen at the end of the list.

A patient information leaflet is available from http://www.hpsc.ie/hpsc/A-
Z/MicrobiologyAntimicrobialResistance/EuropeanAntimicrobialResistanceSurveillanceSystemEARSS/ReferenceandEducationalResourceMaterial/SaureusMRSA/
Factsheets/AdviceforthoseAffectedbyMRSAOutsideofHospital/File,3245,en.pdf




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Indication                                                     Drug                  Dose                                                  Duration
                     Many are viral. 80% of cases resolve without antibiotics. Consider delayed prescription.
Otitis Media         If no improvement in 48 hrs, or recurrent, or systemically ill, or bilateral acute otitis media in children younger than 2 years use antibiotics.
                     Adult 1st line                            amoxicillin           Max. 1g tds                                           5 days

                     Adult penicillin allergic                     clarithromycin        500mg bd                                                  5 days
                     or 2nd line

                     Child 1st line                                amoxicillin           1mth-5yrs 125mg tds                                       5 days
                                                                                         6-12yrs 250mg tds

                     Child penicillin allergic or 2nd line         Clarithromycin        1-2 years 62.5mg bd                                       3 days
                                                                                         3-6 years 125mg bd
                                                                                         7-9 years 187.5 mg bd
                                                                                         10–12 years 250mg bd
                                                                                         Children < 8 kg should be dosed on a
                                                                                         per kg basis (approx. 7.5 mg/kg bid)
                                                                   or                                                                              5-7 days
                                                                   Azithromycin          Children < 8 kg should be dosed on a
                                                                                         per kg basis (approx. 7.5 mg/kg bid)
                                                                                         6 months – 3 years (Up to 15kg) 10mg/kg
                                                                                         3-7 years 200mg od
                                                                                         8-11 years 300mg od
                                                                                         12-14 years 400mg od


                     Adult                                         Ciprofloxacin         500mg bd                                                  Confirm with urine culture
Prostatitis acute)                                                 Or                                                                              4 weeks then review
                                                                   Trimethoprim          200mg bd




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Indication                                                   Drug                    Dose                                                                        Duration
                  Outpatient treatment should be limited to patients with:
Pelvic               - temperature < 38°C
Inflammatory         - WCC < 11,000 per mm3
Disease              - Minimal evidence of peritonitis, active bowel sounds and able to tolerate oral nourishment.
                  Outpatient regimen                         Ceftriaxone             250mg IM or IV                                                              x1 Stat
                                                             Plus
                                                             Doxycycline             100mg bd                                                                    14 days
                                                             Plus or minus
                                                             Metronidazole           400 or 500 mg bd                                                            14 days
                  For suspected sexually transmitted infections (STIs), refer patients to local GUM clinic
STI’s
                  To be effective treatment should begin within 72 hours of onset of rash.
Shingles          Adult 1st line                            aciclovir tablets       800mg 5 times daily                                                          7 days
(Herpes Zoster)   Adult 2nd line where compliance           famciclovir             750mg od                                                                     7 days
                  is a problem.
                  Immuno                                                            Seek expert help
                  compromised
                  or pregnant
                  Child                                                             Seek expert help




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Indication                                                        Drug                         Dose                                   Duration
             Many cases are viral and the symptomatic benefit of antibiotics is small. Reserve for severe cases or where symptoms present for more
Sinusitis    than 7 days. There is little evidence about duration of treatment but usually 5 days.
             Adult 1st line                                       Amoxicillin                  500mg tds                              5-7 days
                                                                  or
                                                                  doxycycline                  200mg stat, 100mg od
             Adult penicillin allergic or 2nd line                Clarithromycin               500mg bd                               5-7 days
                                                                  or
                                                                  doxycycline                  200mg stat, 100mg od

             Child 1st line                                             amoxicillin                     1month-1yr 62.5mg tds                           tds 5-7 days
                                                                                                        1- 5yrs 125mg tds
                                                                                                        5-12yrs 250mg tds
             Child penicillin allergic or 2nd line                      Azithromycin                    6months – 3 years (Up to 15kg) 10mg/kg          3 days
                                                                                                        3-7 years 200mg od
                                                                                                        8-11 years 300mg od
                                                                                                        12-14 years 400mg od

                                                                        or
                                                                        clarithromycin                  1-2 years 62.5mg bd                             5-7 days
                                                                                                        3-6 years 125mg bd
                                                                                                        7-9 years 187.5 mg bd
                                                                                                        10–12 years 250mg bd
                                                                                                        Children < 8 kg should be dosed on a
                                                                                                        per kg basis
                                                                                                        (approx. 7.5 mg/kg bid)




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Indication                                                      Drug                       Dose                                                     Duration
                    The majority of sore throats are viral: most patients do not benefit from antibiotics. Patients with 3 or more of the following are more
Throat Infection/   likely to benefit from antibiotics: fever, purulent tonsils, cervical adenopathy, absence of cough. Consider antibacterial if history of
Pharyngitis/        valvular heart disease, if marked systemic upset, if peritonsillar cellulitis or if at increased risk from acute infection e.g.
Tonsillitis         immunocompromised or diabetes.
                    Adult 1st line                              penicillin V               500mg qds                                                10 days

                    Adult penicillin allergic or 2nd line         clarithromycin               250-500mg bd                                                    10 days

                    Child 1st line                                penicillin V                 1mth-1yr 62.5mg qds                                             5-10 days
                                                                                               1-6yrs 125mg qds
                                                                                               6-12yrs 250mg qds

                    Child penicillin allergic or 2nd line         Azithromycin                 6 months – 3 years (Up to 15kg) 10mg/kg                         3 days
                                                                                               3-7 years 200mg od
                                                                                               8-11 years 300mg od
                                                                                               12-14 years 400mg od

                                                                  or                           1-2 years 62.5mg bd
                                                                  clarithromycin               3-6 years 125mg bd                                              5-7 days
                                                                                               7-9 years 187.5 mg bd
                                                                                               10–12 years 250mg bd
                                                                                               Children < 8 kg should be dosed on a per kg basis
                                                                                               (approx. 7.5 mg/kg bid)




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Indication                    Drug                                              Dose                                                 Duration
           Acute uncomplicated UTI occurs in premenopausal women and often resolves in a few days without treatment.
Urinary    Urine dipstick tests may be useful if diagnosis uncertain. Symptomatic treatment or a delayed prescription may be appropriate.
Tract      Complicated UTI treatment should be led by MSU result
Infections Adult Female       Trimethoprim                                      200mg bd                                             3 days
           (uncomplicated) or nitrofurantoin                                    50-100mg qds                                         5-7 days

             Adult Male          Trimethoprim                                              200mg bd                                                       14 days
                                 or nitrofurantoin                                         50-100mg qds                                                   14 days
                                                                                           Investigate if appropriate

             Pregnant            Treat initially with                                    500mg 8 hourly                                            7 days
             (asymptomatic       Cefalexin and send
             bacteruria)         MSU simultaneously.
                                 Then treat on the
                                 basis of sensitivity
             Child 1st line      If not systemically unwell, dipstick urine and if nitrites and leucocytes are positive, infection is highly likely. Both negative make
                                 infection unlikely. False positives in urine culture for children is high therefore a repeat sample is important. If infection is
                                 suspected, prompt antibacterial treatment to minimise renal scarring. All children with loin pain, pyrexia, family history of renal
                                 problems or who are severely ill should be referred. All children under 3 months and those who are seriously unwell should be
                                 transferred to hospital. All children less than 6 months old should have an ultrasound carried out within 6 weeks
                                 Treat initially with trimethoprim then on basis of 4mg/kg which is approx                                         7 days
                                 sensitivity                                             1-3mths 20mg (2ml) bd
                                                                                         3-6mths 30mg (3ml) bd
                                                                                         6-12mths 40mg (4ml) bd
                                                                                         1-5yrs 50mg (5ml) bd
                                                                                         6-12yrs 100mg (10ml) bd




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Dental infections – This section is intended for use by dental practitioners

Indication                                Drug                                                Dose                                Duration
Dental         Dental abscess are treated in the first instance by drainage. Antibiotics are only required when there is spreading
Abscess        infection (cellulitis, lymph node involvement or swelling) or systemic involvement (pyrexia, malaise). In severe spreading
               infection a combination of amoxicillin and metronidazole can be used and they should be referred to a hospital.
               Adult 1st line             Amoxicillin                                         500mg tds                           5 days

               Adult 2nd line            Metronidazole                                                200mg tds                                5 days

Pericoronitis Adult 1st line             Metronidazole                                                200mg tds                                3 days
Acute         Adult 1st line             Metronidazole                                                200mg tds                                3 days
ulcerative
gingivitus




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