Document Sample
					                                   Antibiotic Policy

Version                                  1.0
Approving Committee :                    Integrated Governance Committee

Date ratified:                           12.10.2010

Reference Number:                        21

Name/Department of originator/author:    Prescribing Advisor
Name/Title of responsible                Primary Care Commissioning
Date issued:                             10.2010

Review date:                             October 2012 - 2 yrs or sooner if local guidance
Target audience:                         Prescribers

Version                     Date        Control Reason
Draft v0.1              28.04.2008      Issued for comment to the Medicine Management
Draft v0.2              31.03.2010      Reviewed and updated by Joint Pennine Antibiotic

Draft v0.2              22.04.2010      Issued for comment to the Medicines Management
Draft v0.2              12.10.2010      Submitted to the Integrated Governance Committee for
Final V1.0              12.10.2010      Approved by the Integrated Governance Committee


      Aim of the policy                                  5
      General points                                     5
      Hypersensitivity to penicillin                     6
      Pregnancy                                          6
      Contraception                                      6
      Interaction with warfarin and other anticoagulants 7
      Clostridium difficile                              7
      Erythromycin tolerability                          7

Ear, nose and throat infections
      Acute otitis media                                8
      Otitis externa                                    8
      Sinusitis                                         9
      Sore throat                                       9
      Dental infections (acute abscess)                 10
      Oral candidiasis                                  10

Genital tract infections
      Vaginal candidiasis                               11
      Urogenital trichomoniasis                         11
      Bacterial vaginosis                               11
      Pelvic inflammatory disease                       11
      Sexually transmitted disease (STD)                12

Respiratory tract infections
      Acute bronchitis                                  13
      Infective exacerbations of COPD                   13
      Community-acquired pneumonia                      14

Skin and soft tissue infections
      Leg ulcers and pressure sores                     15
      Cellulitis                                        15
      Animal bites                                      16
      Human bites                                       16
      Eczema (infected)                                 17
      Erysipelas                                        17
       Impetigo                                        17
       Skin candidiasis                                18
       Tinea capitis                                   18
       Tinea corporis, cruris and pedis                18
       MRSA Topical Decolonisation Regime              18

Antibiotic Management Policy for MRSA Infections
      Skin and Soft Tissue                             19
      Bone and Joint Infections                        20
      Urinary Tract Infections                         20
      Lower Respiratory Tract Infections               21
      Surgical Site Infection Prophylaxis              21

Urinary tract infections (UTIs)
      Uncomplicated UTI                                22
      Complicated UTI                                  22
      UTI in children                                  23
      Pyelonephritis                                   23
      Catheterised patients                            24
      Prostatitis                                      24

Gastrointestinal Infections
      Bacterial Gastroenteritis                         25
      Diverticulitis                                    25
      Giardiasis                                        25
      Threadworm                                        26
      Clostridium Difficile Associated Diarrhoea (CDAD) 26
             Infection Control                          27
             Treatment                                  27

Acne                                                   28

Fungal Nail Infection
     Onychomycosis                                     29

      Head lice                                        30
      Scabies                                          30

Viral Infection
       Herpes Zoster                                   31
       Chicken Pox                                     31
       Cold sores (Herpes Labialis)                    32

      Genital Herpes                               32

Eye Infections
      Bacterial Conjunctivitis                     32

Meningococcal Infection (Neisseria Meningitidis)   33

Usual Paediatric Dosages                           34

Contacts                                           35
Acknowledgements                                   36


To produce simple, appropriate and cost-effective policies 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 Joint Pennine Medicines Group has developed
this policy for the use of antibiotics.

Doses given are oral doses for adults with normal renal and hepatic
function, unless otherwise stated. Further details of interactions, contra-
indications and side-effects can be found in the British National Formulary.
Ideally, bacteriological specimens should be taken before giving antibiotics,
although it is appreciated that this is not always possible in general practice.

Practices should aim to achieve at least 80% compliance with this policy.

This policy is for guidance only and does not cover every eventuality. Please
be ready to change therapy and / or course-length in the light of:
 Culture and sensitivity results
 Patient non-response / reaction
 Microbiological consultation

General points
 The Department of Health’s Standing Medical Advisory Committee
  (SMAC) has identified four things that can make a difference:
         - 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) will be encouraged.

   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), the Department of
    Health and the 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
         - 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, if required. Topical antibiotics encourage resistance and may
    lead to hypersensitivity. If considered essential select an antibiotic that is
    not used systemically.

Hypersensitivity to penicillin
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. Penicillin-sensitivity should
be clearly documented in the patient’s notes. True penicillin allergy is defined
as anaphylaxis, urticaria, angioedema or rash that occurs immediately after
penicillin administration. These patients are at risk of further immediate
hypersensitivity reactions and they should NOT receive further doses
penicillin or beta-lactam antibiotics including cephalosporins and
carbapenems due to the risk of cross-hypersensitivity.

Patients with a history of minor rash (non-confluent & restricted to a small
body area), or a rash that occurs more than 72 hours after penicillin
administration are probably not allergic to penicillin. In these patients,
penicillins or other beta-lactam related antibiotics should not be withheld for
treatment of serious infections.

The following are felt to be safe in pregnancy:
          - Penicillins
          - Cephalosporins
          - Erythromycin
          - Nitrofurantoin (not in the third trimester)

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 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.

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 advisable
during and after a course of antibiotics until the INR has stabilised again.
Cephalosporins, erythromycin, ciprofloxacin and trimethoprim seem to cause
a particular problem. In these cases contact the anticoagulant clinic for further

Clostridium difficile
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, prolonged /
recurrent courses are associated with the greatest risk.
The antibiotics most commonly associated are the second and third
generation cephalosporins, clindamycin and quinolones.

Erythromycin tolerability
Consider using clarithromycin if patient intolerant to erythromycin.


Acute otitis media
 Viral infection common.
 Resolves spontaneously in 80%, usually within 3 days of presentation.
 Consider symptomatic treatment, e.g. pain relief (ibuprofen, paracetamol),
  and waiting 24-48 hours before treating if no improvement. The benefits of
  using antibiotics must be weighed against the possible side effects of
 Consider for deferred script.
 Although antibiotics should not be routinely prescribed, the following
  indications may support their selective use:
          - Child under 2 years of age
          - Bilateral Acute Otitis Media
          - Systemic symptoms, including high temperature (more than
             38.5°C) or vomiting
          - Local signs that suggest the infection is severe, such as a
             particularly bulging or inflamed tympanic membrane

1st line:                    Amoxicillin
                             < 10 years: 125-250mg tds
                             > 10 years: 250-500mg tds
                             Treat for 5 days

If allergic to penicillin:   Erythromycin
                             < 2 years: 125mg qds
                             2-8 years: 250mg qds
                             > 8 years: 250-500mg qds
                             Treat for 5 days

2nd line:                    Co-amoxiclav
                             1-6 years: 5ml of 125/31 tds
                             6-12 years: 5ml of 260/62 tds
                             > 12 years: 375mg tds
                             Treat for 5 days

Otitis externa
 Keep ear(s) clean and dry.
 Do not pick.
 Pain relief if required, e.g. paracetamol.
 Avoid antibiotics wherever possible.
 Acetic acid spray 2% (such as EarCalm) may be helpful.
 Topical steroid preparations (Gentisone HC Ear Drops® 3 drops 3-4 times
   daily and at night) may be helpful in reducing itchiness and inflammation.
 For Candida fungal infections, use Clotrimazole 1% solution 2-3 times
   daily continuing for at least 14 days after symptoms have resolved.
 Swab severe cases and diabetic patients.

If severe or if boil is present:

1st line:                    Flucloxacillin 250-500mg qds for 5 days

If allergic to penicillin:   Erythromycin 250-500mg qds for 5 days

In chronic otitis externa no antibacterials or antifungals are needed. Keep
ear(s) clean and dry.

 Many cases resolve spontaneously.
 Encourage drainage with steam inhalations.
 Consider not giving antibiotics or waiting 7 days before treating if no
 Symptomatic benefit of antibiotics is small

If persistent or severe:     Amoxicillin 500mg tds for 7 days

If allergic to penicillin:   Erythromycin 250-500mg qds or 500mg bd for 7
                             Doxycycline 200mg stat then 100mg od (adults
                             only) for 7 days

(SMAC guidance suggests treatment for 3 days is sufficient however most
evidence relates to trials of 7 or 10 days of treatment ‘WeMeRec’)

Sore throat
Antibiotics are rarely needed. Most sore throats are viral and self-limiting
Symptoms resolve within 3 days in 40% of people and within 1 week in 85%
of people, irrespective of whether or not the sore throat is due to a
streptococcal infection [Del Mar et al, 2004]. (lasting up to 7 days) and do not
respond to antibiotics. Patients with 3 of 4 centor criteria (history of fever,
purulent tonsils, cervical adenopathy, and absence of cough) or history of
otitis media may benefit more from antibiotics. Recommend analgesia, e.g.
paracetamol or ibuprofen. Anecdotally salt water or aspirin gargles (adults
only) have been reported to provide some relief. Alternatively paracetamol
and warm drinks can be used for children.

1st line:                    Phenoxymethylpenicillin
                             Under 1 year 62.5mg qds
                             Age 1-5: 125 mg qds
                             Age 5-12: 250 mg qds
                             Adult 500mg qds

If allergic to penicillin:Erythromycin
                          Up to 2 years: 125 mg qds
                          Age 2 plus: 250 mg qds
                          Adult 500mg qds
Consider clarithromycin 500mg bd if intolerant to erythromycin.

(Treat for 10 days to ensure eradication of haemolytic streptococci). The
Health Protection Agency recommends either twice- or four-times-daily
dosing, lasting 7-10 days for penicillin and 5-10 days for erythromycin [HPA,

Dental infections

Acute abscess:
1st line:                    Amoxicillin 500mg tds for 5 days
           OR                Amoxicillin 3g sachets 8 hours apart (two doses

If allergic to penicillin:   Erythromycin 500mg qds for 5 days

For severe abscesses, e.g. involving external facial swelling:
      Add metronidazole 200mg-400mg tds for 3-7 days
      (If severe give the higher dose)

   Referral to a dentist must always be considered, especially if not

Oral candidiasis
Miconazole oral gel 5ml-10ml qds
(Children: 4mths - 2 years 2.5ml bd, 2-6 years 5ml bd, over 6-12 years 5ml
qds, 12-18 years 5-10ml qds)
(continued for 48 hours after lesions have resolved)
Nystatin oral suspension 1ml (≡100 000 units) qds usually for 7 days
(continued for 48 hours after lesions have resolved). Swill round the mouth for
1 minute then swallow.

If oral lesions are not responding to the above:
         Fluconazole 50mg od for 7-14 days

Vaginal candidiasis
Clotrimazole 10% vaginal cream, insert 5g as a single dose
Clotrimazole 500mg pessary inserted at night as a single dose
Fluconazole orally 150mg as a single dose for refractory cases or where the
use of vaginal tablets would be inappropriate. Avoid in pregnancy and breast
Repeated relapses, consider treatment of sexual partners.

Urogenital trichomoniasis
Metronidazole 400mg bd for 5-7 days OR 2g as a single dose
Avoid 2g dose in pregnancy.

Bacterial vaginosis
The commonest infective cause of vaginal discharge. It is a synergistic
infection between anaerobic bacteria and Gardnerella vaginalis.

1st line:
              Metronidazole 400mg bd for 7 days OR 2g as a single dose (if
              compliance is an issue)

2nd line:
              Clindamycin 2% gel / cream 5g application at night for 7 days

       During pregnancy avoid high-dose regimens of metronidazole (thus
        avoid the 2g stat dose).

Pelvic inflammatory disease (PID)
It is important to test for STDs prior to commencing therapy and if positive
refer to GUM clinic.
Refer pregnant patients.

Cefixime 400mg stat AND Ofloxacin 400mg bd AND Metronidazole 400mg bd
for 14 days.

Doxycycline 100mg bd for 14 days can be used to replace ofloxacin.

Sexually transmitted disease (STD)
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
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

N.B. Pregnant patients need follow-up to ensure successful eradication of
infections. (Ideally by GUM clinic.)

       Azithromycin 1g single dose
       Doxycycline 100mg bd 7 days (avoid in pregnancy / breast feeding)
Pregnancy / breast-feeding:
Erythromycin 500mg bd for 14 days OR 500mg qds for 7 days

Cefixime has been recommended due to increasing levels of resistance.
However, if isolates are sensitive to agents like ciprofloxacin these agents
should be used. Azithromycin may be given to cover Chlamydia.

       Cefixime 400mg single dose
       Ciprofloxacin 500mg single dose (if allergic to cephalosporins)

Pregnancy / breast-feeding:
Cefixime can be used in pregnancy, but ciprofloxacin should be avoided.
N.B. Pregnant patients need follow-up to ensure successful eradication of
infections. (Ideally by GUM clinic.)
Alternative agent may be used if possibility of pharyngeal infection: IM
Ceftriaxone 250mg.


Acute bronchitis
 Antibiotics are of marginal benefit in otherwise healthy adults; most
  cases are viral.
 Explanation of the likely course of the illness is recommended.
 Cough commonly persists for 2-3 weeks regardless of whether an
  antibiotic has been given.
 In patients over 60 years old and those with significant co-existing disease,
  the likelihood of bacterial infection appears greater and the risk of
  morbidity higher and so an early antibiotic may be considered.

1st line:                    Amoxicillin 500mg tds

If allergic to penicillin:   Erythromycin 500mg qds
                             Doxycycline 200mg stat, then 100mg od
                             (Not for pregnancy or children under 12 years)

2nd line:                    Co-amoxiclav 625mg tds

Treat for 5 days

Infective exacerbations of COPD
 Higher percentage of Haemophilus infections in this group.
 Antibiotics are most valuable if shortness of breath with increased sputum
   volume and purulence.
 Recurrent problems: Consult local microbiologist.
N.B. Quinolones should not be prescribed first line. Only use on the basis of
sensitivity results. (Poor activity against Strep. pneumoniae)

1st line:       Amoxicillin 500mg-1g tds

Alternatives: Erythromycin 500mg qds


                Doxycycline 200mg stat, then 100mg od (not for use in children
                or pregnant or breast-feeding women)

2nd line:       Co-amoxiclav 625mg tds

Cephalosporins should be reserved for very severe cases, which probably
require admission to hospital

Treat for 5 days.

Community-acquired pneumonia (CAP)
[BTS Guideline for the management of community-acquired pneumonia in
adults 2001 and 2004 update].
Any of:
• Confusion – defined as a Mental Test Score of 8 or less, or new
disorientation in person, place or time.
* Urea > 7mmol/l
• Respiratory rate ≥ 30 breaths/min
• Blood pressure: systolic < 90 mmHg or diastolic ≤ 60 mmHg
• Age ≥ 65 years
Score one point for each feature present.

CURB-65 score           0-1                   2                        3
Management plan         Likely suitable for   Consider hospital-       Manage in hospital
                        home treatment        supervised               as severe
                                              treatment. Option        pneumonia.
                                              may include
                                                  a) short
                                                      inpatient stay
                                                  b) hospital

1st line:                        Amoxicillin 500mg – 1gram tds

                                 ADD Erythromycin 500mg qds if atypical infection
                                 suspected (mycoplasma) or if no response in 24-
                                 48 hours

                                 ADD Flucloxacillin 500mg qds if staphylococcal
                                 infection suspected, e.g. following influenza or
                                 other viral illness

If allergic to penicillin:       Erythromycin 500mg qds

If Intolerant of Erythromycin consider Clarithromycin 500mg BD

Treat for at least 7 days

For very severe infections, particularly in young adults, resistant PVL strains
may be a cause and management should be discussed with a microbiologist.


Leg ulcers and pressure sores
 A wide range of organisms including MRSA can colonise broken skin.
 Avoid topical antibiotics as these will only select out multi-resistant
 Use local cleansing and topical antiseptics.
 Antibiotics are only indicated if signs of clinical infection or cellulitis are

Likely caused by Group A / C Streptococci and Staphylococcus aureus.

1st line                     Flucloxacillin 500mg-1g qds for 7-14 days

If allergic to penicillin:   Erythromycin (mild infection)
                             500mg qds (or clarithromycin 500mg bd if
                             intolerant of erythromycin) for 7-14 days
                             Clindamycin (moderate / severe)
                             300-450mg qds

If severe or facial cellulitis
Consider Co-amoxiclav 625mg tds or add Metronidazole 400mg tds

Review patient if no improvement within 48 hours.
Failure to respond may necessitate urgent parenteral antibiotics.

Animal bites
 Surgical toilet is most important.
 If the skin is not broken just clean the wound

If infected:    Co-amoxiclav 375-625mg tds for 7 days

Penicillin allergy alternative

Doxycycline 100mg bd PLUS Metronidazole 400mg tds for 7 days

   If not infected and presenting within 24 hours of injury, give antibiotics as
    for infected bites ONLY IF high risk of infection, i.e.:
            - Deep puncture-type bite that cannot be cleaned easily (e.g. cat
            - Suspicion of bone or joint involvement
            - Severe bite to hand(s) / face
            - At-risk     patient,    e.g.      asplenic,    diabetic,   elderly,

   Ask questions:
          - Is tetanus immunisation up-to-date?
          - Is anti-rabies prophylaxis required?

   NB: Asplenic patients are prone to overwhelming sepsis following dog

   Consult Microbiologist if advice is required.

Human bites
 Surgical toilet is most important.
 If the skin is not broken just clean the wound

Antibiotics (for all patients): Co-amoxiclav 375-625mg tds for 7 days

Penicillin allergy alternative

Doxycycline 100mg bd PLUS Metronidazole 400mg tds for 7 days

If pregnancy / breast feeding: erythromycin 250-500mg qds only for 7 days.

   Ask: Is tetanus immunisation up-to-date?
   Assess risk of HIV / hepatitis B and C.
   Consult Microbiologist if advice is required.

Eczema (infected)


Under 1          62.5mg qds for 7-14 days
Age 1 to 5       125mg qds for 7-14 days
Age 5+           250mg qds for 7-14 days
Adult            500mg qds for 7-14 days



Under 1          125mg qds for 7-14 days
Age 1 to 5       250mg qds for 7-14 days
Age 5+           250mg qds for 7-14 days
Adult            500mg qds for 7-14 days

1st line            Penicillin V 500mg qds
Add                 Flucloxacillin to cover Staph. aureus if response is poor.
Penicillin allergy Erythromycin 500mg qds
Treat for 7-14 days then review.

Remove crusts by soaking before topical treatment.

Minor infections may be treated with topical Fusidic acid cream / ointment tds-
qds for 7 days
Children should be kept off school or nursery until the spots have stopped
blistering or crusting, or until 48 hours after antibiotic treatment has been


Under 1          62.5mg qds for 7 days
Age 1 to 5       125mg qds for 7 days
Age 5+           250mg qds for 7 days
Adult            500mg qds for 7 days



Under 1          125mg qds for 7 days
Age 1 to 5       250mg qds for 7 days
Age 5+           250mg qds for 7 days
Adult            500mg qds for 7 days

Skin candidiasis
Clotrimazole 1% cream applied 2-3 times daily for 14 days
Nystatin cream applied 2-4 times daily continuing for 7 days after lesions have

Tinea Capitis (Dermatophyte infection of the scalp)
Drug treatment only if infection is confirmed by microscopy / culture.
Selenium or ketoconazole shampoo used twice weekly for 2 weeks may
reduce spread of infective spores.

1st line:    Terbinafine 250mg daily
2nd line:    Itraconazole 100mg daily
(Above treatments are not licensed for tinea capitis).

Treat for 4-6 weeks. Review after 2 weeks. Continue for at least 2 weeks after
all signs of infection have disappeared.

Tinea corporis, cruris, pedis (Dermatophyte infection of the body, groin,
Patients should be reassured that infections may still respond even after
treatment course has finished.

1st line:    Terbinafine 1% cream apply twice daily
Consider oral therapy if poor response

Treat for 1 week in tinea pedis and 1-2 weeks in tinea corporis / cruris.

MRSA Topical Decolonisation Regime
   BACTROBAN (Mupirocin) nasal ointment three times daily in both
    N.B. Naseptin Nasal Cream QDS can be used where the strain of
    MRSA is resistant to mupirocin.

      AQUASEPT (Triclosan 2%) body wash once daily
       N.B. Hibiscrub (4% Chlorhexidine) will be used as an alternative where
       Aquasept is commercially unavailable or patients are hypersensitive to

      Chlorhexidine 0.2% mouthwash 10ml twice daily

The treatment course is FIVE days, stop for two days and re-screen. Restart
second course only if screen positive for up to a maximum of two courses. For
persistent positive results, contact Infection Control or Microbiology for advice.

       Ref: JAC (2006) 57; 4: 589-608

This is an additional policy for treatment of confirmed or suspected MRSA
infections, which should be used in conjunction with the current Trust
Antibiotic Policy for empirical management of the infections. Treatment
choices should be modified according to the antibiotic susceptibility reports.
Discussion with a microbiologist is strongly recommended.

It is important to distinguish MRSA colonisation from infection. Antibiotics that
are active against MRSA must not be started to treat MRSA colonisation if it is
not causing an infection. The MRSA topical eradication regime should be
started in order to decolonise the MRSA loads carried by the patients for the
protection of themselves and other severely ill patients in areas that are
categorised as high-risk.

This Policy provide the antibiotic treatment of MRSA for the following
infections based on the recommendations from the Joint Working Party of the
British Society for Antimicrobial Chemotherapy, Hospital Infection Society and
Infection Control Nurses Association (JAC (2006) 57; 4: 589-608)

Skin and Soft Tissue Infections
(i.e. cellulitis and surgical site infection)

For superficial, non-severe infections and patients who are not at risk of
         - Use a combination of TWO of the following oral agents, the
             choice of which must be guided by the antibiotic susceptibility
             reports; patient’s renal and hepatic functions; or other medical
             conditions that may render the chosen drug unsuitable.

                     i.      Clindamycin 300mg to 450mg QDS – must not be
                             used if MRSA is resistant to erythromycin
                     ii.     Sodium Fusidate 500mg TDS
                     iii.    Rifampicin 300mg – 600mg BD
                     iv.     Trimethoprim 200mg BD
                     v.      Doxycycline 100mg BD

For severe infections and / or patients at risk of bacteraemia – treatment in
secondary care advised.

Topical antibiotic preparations
          - The use of topical antibiotics e.g. mupirocin, fusidic acid is
              discouraged due to the emergence of bacterial resistance when
              used in the presence of a large bacterial population in the
              absence of any appropriate systemic therapy.
          - At the discretion of the Microbiologist, appropriate topical
              antibiotics may be used at small superficial sites, e.g. pressure
              sores for a maximum of 7 days – please discuss with
              Microbiologist for advice.

Differences between different Bactroban® topical products
           Mupirocin 2% in paraffin base (Bactroban® Nasal Ointment) –
             used as part of the topical eradication regime for eradication of
             nasal carriage.
           Mupirocin 2% in polyethylene glycol base (Bactroban®
             ointment) – it is an effective agent against multi-resistant
             staphylococcal bacteria when applied to infected skin lesions
             such as eczema and small superficial pressure sores. However,
             it should not be used on large burns or large raw areas due to
             the potential absorption of the polyethylene glycol which can
             cause nephrotoxicity. It is also not suitable for the insertion sites
             of central venous catheters or other plastic devices due to the
             possible damage caused to the catheter material by the
             polyethylene glycol base.

Bone and Joint Infections
Consult microbiologist for advice

Urinary Tract Infections
For mild and moderate - treat with one of the following. The treatment choice
depends upon the susceptibility result.

            i      Trimethoprim 200mg BD
            ii.    Nitrofurantoin 100mg QDS
            iii.   Doxycycline 200mg STAT, then 100mg DAILY

Seek Microbiologist advice if all of the above are inappropriate.
Severe infection e.g. pyelonephritis or septicaemia – treat in secondary care.

Lower Respiratory Tract Infections
Note: MRSA isolated in sputum may represent a colonisation, as distinct from
an infection. Careful clinical assessment is required in the diagnosis of MRSA
pneumonia / chest infection. Do not treat MRSA colonisation in sputum if
patients are clinically well and have no signs of lower respiratory tract
infections. Micro-organisms such as enterococci, yeasts, pseudomonas
species and MRSA are commonly isolated as contaminants in patients that
have previously received antibiotics.

For COPD or non-severe pneumonia without any signs of systemic infection

             Doxycycline 200mg STAT then 100mg DAILY for 7 days

For infections in bronchiectasis without pneumonia – discuss with
microbiologist regarding antibiotic regime for MRSA

For confirmed MRSA pneumonia – in the presence of X-Ray changes and
isolation of MRSA from sputum – treat in secondary care

Surgical Site Infection Prophylaxis
All patients should be offered pre-operative screening for MRSA. Patients who
are known to be colonised and / or infected with MRSA and are to be admitted
for elective surgical and orthopaedic procedures should be given the topical
MRSA decolonisation regime pre-operatively in an attempt to eradicate the
MRSA carriage to prevent subsequent MRSA infection.


(Prodigy recommends: Follow local policies if available. Take local rates
of bacterial resistance into account when choosing antibiotics.)

Uncomplicated UTI (e.g. cystitis) in otherwise healthy non-pregnant
UTI can only be proven bacteriologically in 50% of women; others have
inflammation of the urethra. Routine urine culture is unnecessary. Use dipstick
urine tests to reduce antibiotic use and unnecessary investigations.

   Limit prescribing to a 3-day course of oral antibiotics:

1st line:            Trimethoprim 200mg bd for 3 days
                     Nitrofurantoin 50-100mg qds for 3 days
                     (Avoid in 3rd trimester or patients with G6PD deficiency)

                     Amoxicillin 500mg tds for 5 days

2nd line:            Only after MSU culture and sensitivity results

   There is no need to repeat urine culture after treatment unless the patient
    is still symptomatic.
   Reserve cefalexin 500mg bd for 2nd line therapy due to risk of C.difficile.

Complicated UTI
Applies to pregnant women, men, recurrent infection, infection ascending to
the upper tract.
Catheterised patients - Do not give an antibiotic unless the patient is
symptomatic as bacteria are unlikely to clear while catheter is in situ.
 MSU essential. Treatment depends on MSU culture and sensitivity
 Asymptomatic bacteruria in pregnancy can lead to pyelonephritis and
   should therefore be treated. A urine culture should be performed 7 days
   after antibiotic treatment as a test of cure.

              Trimethoprim 200mg bd 7 days
              Nitrofurantoin 50mg qds for 7 days
              (Avoid in patients with G6PD deficiency)

Always obtain a sample for microbiological testing prior to treatment

Pregnant women:
           Cefalexin 500mg tds 7 days
           Amoxicillin 500mg tds 7 day

Complicated ascending urinary tract infection:
            Always obtain a sample for microbiological treating prior to
            Ciprofloxacin 250-500mg bd for 7 days
            Co-amoxiclav 625mg tds for 7 days

If recurrent prophylaxis might be required

UTI in Children
Refer infants < 3 months of age immediately to specialist care.
Refer for further investigation following first proven UTI. Consider low-dose
antibiotic prophylaxis after recurrent UTI until paediatric out-patient
Collection of one or more urine samples for culture and sensitivity testing
prior to drug treatment is essential.

1st line:     Trimethoprim for 5-7 days
              Trimethoprim 4mg/kg (maximum 200mg) BD for 3 days
              An alternative antibiotic should be used if the child is already on
              trimethoprim prophylaxis (in which case the trimethoprim should
              be stopped), has had it in the last 3 months or has had previous
              infections resistant to it
2nd line:     Nitrofurantoin for 5-7 days (> 3 months old only).

Recent NICE guidance suggests 3 days treatment for lower UTI; however if
the child is still unwell after 24 - 48 hours, therapy needs reviewing.

Reserve cefalexin therapy as risk of C.difficile.
Can use amoxicillin if organism known to be sensitive.

Children with recurring UTIs as well as a first attack in children < 1 year
require prophylaxis. This is usually trimethoprim or nitrofurantoin. Discuss with

Ciprofloxacin 500mg bd
(250mg bd in moderate to severe renal impairment. Avoid use in pregnancy or
Treat for 7-14 days

Catheterised patients
 Most patients with catheters develop bacteriuria.
 Catheterised patients with asymptomatic bacteruria should not
   receive antibiotic treatment. Attempts at complete eradication by
   antimicrobials will lead to colonization with more resistant organisms.
   Therefore antimicrobials should be reserved for cases of clinical infection
   in the presence of fever, leucocytosis and abdominal pain. In
   asymptomatic patients with a free-flowing catheter, antibiotics are not
 In short-term catheter (e.g. catheterization to relieve retention arising from
   infection), suggest removal of the catheter after 48 hours of therapy (if
   clinically feasible).
 Bladder washouts with antiseptics, e.g. chlorhexidine, are rarely
   indicated. They rarely eradicate organisms, may introduce infection,
   select out multi-resistant organisms, can cause inflammation of the
   bladder wall and therefore increase the likelihood of systemic invasion and
   they may also cause damage to the catheter. Saline bladder washouts are
   available as an alternative.

Mild to moderate infection
Co-amoxiclav 625mg tds for 5-7 days
Nitrofurantoin 50mg qds for 5-7 days
(Avoid in patients in suspected or known to have glucose-6-phosphate
dehydrogenase deficiency).

Alternative treatment
Ciprofloxacin 250mg bd for 5-7 days

Acute Prostatitis
Send a MSU off for culture and prescribe empirical antibiotics. Review
antibiotic therapy when sensitivity results come back.

1st line:     Trimethoprim 200mg bd
              Treat for at least 28 days

Alternative: Ciprofloxacin 500mg bd for 28 days is recommended.
Consider referral to urology

1st line:     Trimethoprim 200mg bd
              Treat for at least 28 days

Alternative: Ciprofloxacin 500mg twice a day for 28 days is recommended.
Consider referral to urology


Faeces specimens should be sent to the local microbiology department.
Please state clinical details as special investigations are carried out if: history
of foreign travel, blood in stool or previous antibiotic treatment.

Bacterial gastroenteritis
   Antibiotic therapy is best avoided. Fluid replacement is the mainstay
   If you are considering antibiotic therapy please contact the
   Antibiotics are contraindicated if E. coli 0157 is a possibility.

Traveller’s diarrhoea (Pathogenic E.coli / Aeromonas species)
Antibiotic not usually indicated.
Contact microbiologist if in doubt.

For an infective exacerbation of known diverticulosis which does not require
hospital admission.

1st line:                            Co-amoxiclav 625mg tds for 7-14 days
2nd line or Penicillin allergy:      Ciprofloxacin 500mg bd + metronidazole
                                     400mg tds for 7-14 days

    It can take 2 to 3 specimens to confirm giardiasis
    It is one of the few GI infections for which antimicrobial treatment is
      generally of benefit.

       Metronidazole        400mg tds for 5 days
       (Discuss with microbiologist before starting therapy

Helicobacter pylori eradication regimen
Amoxicillin 1g bd + Clarithromycin 500mg bd + Omeprazole 20mg bd for 7

Alternative regimen
Metronidazole 400mg bd + Clarithromycin 500mg bd + Omeprazole 20mg bd
for 7 days

Discuss with Consultant Gastroenterologist for further advice of necessary.

    At any one time up to 30% of children may have threadworm so
     patients can be reassured they are not alone.
    Hand washing after using the toilet and keeping fingernails short are
     just as important as drug therapy to break the life cycle of the worms.

       All members of the family require treatment

       Two years or over
       Mebendazole 100mg stat
       Repeat treatment if required after 14 days
       Under 2 years
       Piperazine / Sennosides (Pripsen) oral powder for children
       One level 2.5ml spoonful in the morning and repeat after 14 days (3
       months to 1 year)
       One level 5ml spoonful in the morning and repeat after 14 days (1-2

      Pregnant women should wait until after delivery before being treated.

Clostridium Difficile Infection (CDI)
No antibiotic is exempt. The commonest predisposing antibiotics
associated with CDI are cephalosporins, clindamycin and quinolones.

Confirmed or clinical suspected case of CDI – for 1st or 2nd episode:
STOP antibiotics if clinically possible or switch to a low-risk alternative for
causing CDI, e.g. narrow spectrum antibiotics. All anti-motility agents should

Disease Severity Assessment
    Fever ≥ 38ºC
    WBC ≥ 15 x 109/L
    CRP > 50mg/L
    Albumin < 25g/L
    Creatinine 50% increase from baseline / new oliguria
    Serum lactate > 2.2mg/L
    Deterioration in mental status not explicable by other illnesses.
      Presence of ≥ 2 markers suggests severe CDI.

Non-severe CDI

Metronidazole 400mg tds for 10-14 days

Daily assessment and use of Bristol stool chart
Symptoms improving – diarrhoea should resolve in 1-2 weeks
Symptoms NOT improving or worsening or relapsed at the discontinuation of
the course

Switch to:
Vancomycin 125-250mg qds for 10-14 days

Severe CDI

Vancomycin 250mg qds for 10-14 days

Daily assessment and use of Bristol stool chart
Symptoms NOT improving or worsening after one week of treatment
Seek surgical / microbiology / gastrointestinal advice. Review all antibiotics
and proton pump inhibitors (PPIs) and stop all unnecessary ones

In consultation with microbiologist consider:
Vancomycin 250-500mg qds + Metronidazole 400mg tds for 10 days

Failure to respond and in consultation with microbiologist consider:
Vancomycin 250-500mg qds + Rifampicin 300mg bd for 10 days

   Recurrence of C.difficile infections (3rd or subsequent episode)
   STOP all non-C.difficile treatment antibiotics if clinically possible to allow
   normal intestinal flora to be re-established.
   Conduct disease severity assessment (as above)

   Non-severe CDI
   Vancomycin 250mg qds for 14 days

   Severe CDI
   Use above treatments for severe CDI of 1st or 2nd episode

   Daily assessment and use of the Bristol Stool Chart
   Discuss clinical progress with microbiologist

   For multiple recurrences and relapsing cases, especially in evidence of
   malnutrition and wasting, consider vancomycin tapering / pulse therapy
   over 4-6 weeks. Please discuss with microbiologist.

Oral preparations should be used in moderate - severe cases or if topical
preparations have proved inadequate. Where possible use non-antibiotic
antimicrobials (e.g. benzoyl peroxide), azelaic acid (Skinoren®) or a topical

      First line treatment is topical benzoyl peroxide but many patients will
       have self treated for some time before presenting to primary care.
      Continue topical benzoyl peroxide with oral antimicrobials to prevent
       bacterial resistance

1st Line:           Oxytetracycline   500mg bd*
Alternative:        Doxycycline 100mg od* OR Lymecycline 408mg od*

Please note that tetracyclines are contraindicated in the under 12s and
should not be given to breastfeeding or pregnant women.

Reserve the following agents as 3rd line:
Minocycline 100mg od* due to side effect profile.
Erythromycin 500mg bd due to increasing resistance.

      The length of treatment is subject to review
      Results of antimicrobial treatment may not be seen until a couple of
       months have elapsed.
      Change antibiotic if <70% improvement after 3 months.
      Maximum improvement usually after 4 to 6 months, but in severe cases
       may need 2 years or longer.

   Take nail clippings of suspected dermatophyte infection
   Only start treatment if infection is confirmed by microscopy or culture
   Re-assure patients that their nail infection will continue to respond,
     after the course has finished.

1st Line:    Terbinafine         250mg daily 6-12 weeks (fingers)
                                             3-6 months (toes)
             Itraconazole*       200mg daily 2 months (fingers)
                                             3 months (toes)
             Itraconazole*       200mg bd for 7 days then 3 weeks
                                 treatment free.
                                 Give 2 cycles of treatment (fingers)
                                 Give 3 cycles of treatment (toes)

* Useful where infection is due to Candida species, other non-dermatophyte
mould infections and mixed infections.

Idiosyncratic liver reactions occur rarely with terbinafine.
Itraconazole can also be prescribed continuously as a once daily dose (see
BNF). LFTs are necessary for continuous treatment longer than 1 month.
The pulsed regimen may reduce the risk of liver problems.
The continuous regimen may be better tolerated – lower daily dose.

In superficial infection (distal nail ends) or where oral treatment is
               Amorolfine (Loceryl) paint 1-2 weekly 6 months (fingers)
                                                        12 months (toes)
Note there is a lack of evidence regarding topical therapy.
It may take 3-6 months for finger nails and 6-12 months for toe nails before
the nail returns to normal.
     Treatment failure or children should be referred to dermatologist

Head Lice
   Only treat if live lice present
   Check close contacts for live lice and treat all those infected.
   Use lotions (not shampoos) and prescribe enough for two applications
     one week apart.
   Short hair needs about 50ml application. Even insecticides may only
     work first time in about three quarters of cases.
   Parents will return with what they claim are re-infections but these are
     almost always inadequate treatment either because the lotion has not
     been left on long enough, too little insecticide applied or there is some
     resistance or poor ovicidal activity.
   If there is treatment failure try a different insecticide. Most preparations
     (malathion, permethrin and phenothrin) are available over the counter.
   Alcohol based lotions are generally more effective than aqueous based
     liquids but the latter are preferred in very young children and those with
     severe asthma.
   Avoid permethrin in pregnancy. Carbaryl is only available on
     prescription. It is safe and effective.
     Malathion 0.5% aqueous solution or
•    Phenothrin 0.5% aqueous solution
     Apply to dry hair, wash off after 12 hours and repeat in 7 days
     (unlicensed use – based on expert opinion). 200ml should be sufficient
     for an adult to have 2 treatments.
     Treatment failure maybe due to resistance, reinfection from another
     household member or poor treatment technique.
   Dimeticone lotion 4% is a non-insecticidal alternative which has been
     shown to be more effective than malathion lotion in a small trial. Apply
     overnight and repeat after 7 days.

    The very old and the very young and the immunosuppressed may not
      present with typical scabies rashes making this particularly problematic
      in nursing and residential homes where outbreaks are common.
    Prescribe in brand names to avoid prescribing the wrong preparation of

Lyclear Dermal Cream (1st line)
Derbac M or Quellada M liquid (Alternative)

      Symptomatic cases need two treatments 1 week apart
      Atypical or crusted (also known as Norwegian) scabies may need 3 or
       4 applications. Always treat the head and neck (excluding eyes and
       mouth) despite the patient information sheet.
      Advise to re-apply if hands are washed during treatment period. There
       is no need to bathe before or after treatment. Household contacts

      Avoid permethrin in pregnancy.


Herpes zoster (Shingles)
    Seek advice from Microbiologist or Infectious Diseases Consultant if
     patient is pregnant or immunocompromised
    Oral antiviral drugs, started within 72 hours of onset of the shingles
     rash, reduce the duration of rash and associated pain, and reduce the
     risk of developing postherpetic neuralgia (PHN)
    Only start antiviral treatment (if indicated) in people who present within
     72 hours of the onset of rash.
    Oral antiviral drugs are not indicated in healthy young adults with
    Oral antiviral drugs are indicated in people who are 50 years or older,
     have ophthalmic involvement, or who are immunocompromised
    Post herpetic neuralgia is rare under 50 years but occurs in 20% of
     subjects over 60 years [HPA].
    Clinical value of aciclovir is minimal unless there is a likelihood of
     complications, facial / ophthalmic shingles or severe pain and
     treatment started within three days of onset of rash. If treating use:

       Aciclovir 800mg 5 times daily for 7 days.

Varicella zoster (Chickenpox)
There is evidence that there are minor benefits if treatment is started within 24
hours of the onset of the rash, with time to appearance of last new lesions or
time to cessation of fever reduced by about 1 day. Main benefit seen in
immunocompromised patients, severe pain, adult on steroids and secondary
household cases.

In adults:
       Aciclovir 800mg 5 times daily for 7 days
In adult cases consider referral to Virology or Infectious Diseases Consultant

Seek advice for pregnant women with clinical chickenpox. For
immunosuppressed or susceptible pregnant contacts of chickenpox seek

Herpes Simplex
Severe cases only. Treatment should begin as early as possible after the
start of an infection.
        Aciclovir 200mg 5 times daily for 5 days

For cold sores (herpes labialis) topical treatment is effective only if started at
the onset of symptoms.
      Aciclovir 5% cream 5 times a day for 5 days. A 2g tube is normally

Genital herpes
Refer to GUM clinic


Bacterial Conjunctivitis
Most cases of acute conjunctivitis are self-limiting.
If recurrent infection, exclude chlamydia.
Fusidic acid 1% is in a gel basis, which liquefies on contact with the eye and
can be applied twice daily.

1st line:             Chloramphenicol 0.5% drops. Instill 1 drop every 2 hours,
                      reducing frequency as infection controlled.

Alternatively:        Chloramphenicol 1% ointment can be used at night and
                      the drops during the day or use ointment alone 3-4 times
                      a day.
2nd line:             Gentamicin 0.3% drops or fusidic acid 1% drops (gel)

Use all products for 48 hours after healing.


Rapid admission to hospital is highest priority when meningococcal
disease is suspected. There is now good evidence that early administration
of benzyl penicillin (which all GPs should carry) while waiting for the
ambulance can be life-saving in invasive meningococcal disease. Penicillin
should only be withheld if there is a history of penicillin anaphylaxis
(immediate allergic reaction after previous penicillin administration). A
simple rash or intolerance to penicillin is not a contra-indication. If there is a
true history of anaphylaxis get the patient to hospital as quickly as possible.
Remember, meningism may not be a feature of meningococcal disease and
young children rarely show typical signs of meningitis.

Occasionally Neisseria meningitides will appear unexpectedly in throat swabs.
In the absence of invasive disease this is part of the normal flora of the throat
and does not need treatment. Meningococci from conjunctival swabs need
public health action. Seek the advice of the Consultant in Communicable
Disease Control (Health Protection Agency) if this happens.

Benzyl penicillin     under 1year 300mg
                      1-9 years 600mg
                      10 years and over 1200mg

GPs do not need to carry an alternative antibiotic. However, if other
antibiotics are available, a 3rd generation cephalosporin may be used.

Alternative if true penicillin anaphylaxis:

Cefotaxime            Under 12 years 50mg/kg
                      12 years and over 1000mg (1g)

IV administration recommended unless a vein cannot be found, in which case
IM administration may be used.

If there is history of immediate allergic reactions to penicillin or
cephalosporins, chloramphenicol may be used: Chloramphenicol 25mg/kg IV

Prophylaxis of Meningococcal Infection
Prophylaxis should be given to all close / household contacts of the patient. It
is important that all family members should have prophylaxis at the same
time, so that the organism can be eradicated ‘at a stroke’. Health care workers
need prophylaxis only when engaged in mouth-to-mouth resuscitation of the
patient. Take advice from microbiology or public health.

For adults           Rifampicin               600mg            Every 12 hours for 2
                     Ciprofloxacin            500mg            Single dose

For children
(up to 1 year)         Rifampicin               5mg/kg             Every 12 hours for 2
(1 – 12 years)         Rifampicin               10mg/kg            Every 12 hours for 2
For         pregnant   Ceftriaxone              250mg              Single intramuscular
contact                (dissolved in 3.5ml of                      dose
                       1%           lidocaine

                       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

Penicillin V               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 and Central Manchester and
Manchester Children’s University Hospitals Antibiotic Policys.
Doses may need to be doubled in severe infections.

Refer to BNFC or Summary of Product Characteristics for further prescribing
* Consider Clarithromycin if intolerant to Erythromycin.

Andrew Martin Programme Director - Medicines Management
Bury Primary Care Trust: 0161 7782105

Robert Hallworth Prescribing Support Pharmacist - Medicines Management
Oldham Primary Care Trust: 0161 622 6522

Jennifer Bartlett Medicines Management Pharmacist
Manchester Primary Care Trust: 0161 217 4337

Elaine Radcliffe, Prescribing Advisor, Medicines Management
Heywood, Middleton and Rochdale Primary Care Trust: 01706 652828

David Reece, Prescribing Advisor, Medicines Management
Heywood, Middleton and Rochdale Primary Care Trust: 01706 652844

Further information is available on request from the Medicines
Management Team at your local PCT.


Ivor Cartmill: Birch Hill, Rochdale Infirmary

Reeta Burman: Fairfield General, Bury

Hari Panigrahi: North Manchester General

Naeem Khattak: Royal Oldham Hospital

Microbiology – Pennine Acute Hospitals Trust (Oldham): 0161 627 8360

General Practitioners

Dr Richard Orr

Dr Jagjit Kapur

Dr Rob Stokes

Dr Kiran Patel

Dr Stephen Bowers

PRODUCED: March 2010               REVIEW DATE: March 2012


These guidelines have been developed based on the opinion and approval of
the Pennine Antibiotic Working Group and draws largely from existing
antibiotic policies:

Antibiotic Policy for Adult Patients – The Pennine Acute Hospitals NHS Trust
– Version 3 (October 2009)
Antibiotic Prescribing Guidelines for Paediatric and Neonatal Patients –
Central Manchester and Manchester Children’s University Hospitals NHS

Health Protection Agency Management of Infection Guidance in Primary Care


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