Management of Infection Guidance for Primary Care in Ireland

GUIDELINES FOR ANTIMICROBIAL PRESCRIBING

IN PRIMARY CARE IN IRELAND

April 2011

Version 2.2

Dr. Brian Carey, Consultant Microbiologist, Waterford Regional Hospital

Ms. Marion Murphy, Research Pharmacist, University College Cork

Professor Colin P. Bradley, Professor of General Practice, University College Cork

Dr Rob Cunney, Consultant Microbiologist, Health Protection Surveillance Centre (HPSC)

Dr. Stephen Byrne, Senior Lecturer, School of Pharmacy, University College Cork

Dr. Nuala O‟ Connor, Irish College of General Practitioners

Dr. Anne Sheehan, Department of Public Health, Health Service Executive

On behalf of SARI Community Antibiotic Stewardship Expert Working Group

MMAANNAAGGEEMMEENNTT OOFF IINNFFEECCTTIIOONN GGUUIIDDAANNCCEE FFOORR PPRRIIMMAARRYY CCAARREE IINN IIRREELLAANNDD –– AAPPRRIILL 22001111

*provisional data in 2010 (European Antimicrobial Resistance Surveillance Network (EARS-Net))

2

INTRODUCTION

Antimicrobial resistance is recognised as a significant threat to public health by compromising our ability to treat infections effectively.

It is widely acknowledged that antibiotic resistance is driven by high rates of antibiotic prescribing.

The continuing problem of antimicrobial resistance has prompted efforts to reduce unnecessary antibiotic use to maximise the lifespan of

these valuable drugs and to strive to prevent a return to the “pre-antibiotic” era.

It is estimated that 80% of all antibiotics consumed by patients are prescribed by general practitioners.

It was established in 2008 that Ireland had relatively high rates of antibiotic prescribing compared to our European counterparts, and one

of only three countries in Europe that community antibiotic consumption was continuing to increase, and in addition had relatively

high levels of “broad spectrum” antibiotic use. - Source - ESAC

Penicillin non-susceptible Streptococcus pneumoniae (PNSP) is a “marker organism” and key indicator of antibiotic resistance in primary

care. In Ireland, non-susceptibility rates to penicillin for this organism have increased from 10.3% in 2004 to 18.2% in 2010.* (See

Europe map on page 3).

Rates of quinolone resistance in E.Coli in Ireland has increased from 5.2% in 2002 to 23.6% in 2010.*

Evidence-based antimicrobial guidelines are a key tool in efforts to improve antibiotic prescribing, reduce the progression of antibiotic

resistance and optimise patient outcomes.

These guidelines have been developed as part of the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI) initiative

which has been ongoing in Ireland since 2001.

Please send comments and queries to:

Ms. Marion Murphy, Research Pharmacist, School of Pharmacy, University College Cork. Tel: 021 4901690 Email: [email protected]


3

Distribution of Penicillin non-susceptible Streptococcus pneumoniae (PNSP) which is a marker for community resistance in Europe

in 2009 (European Antimicrobial Resistance Surveillance Network (EARS-Net))

Aims

to provide a simple, best guess approach to the treatment of common infections

to promote the safe and effective use of antibiotics

to minimise the emergence of bacterial resistance in the community

Principles of Treatment

1. This guidance is based on the best available evidence but its application must be modified by professional judgement.

2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course

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

4. Consider a no, or delayed, antibiotic strategy for acute sore throat, common cold, acute cough and acute sinusitis.

5. Limit prescribing over the telephone to exceptional cases.

6. Try to avoid over-use of broad spectrum antibiotics (eg co-amoxiclav, quinolones and cephalosporins) as this can increase

risk of PNSP, Clostridium difficile, MRSA and resistant UTIs and also limit the future usefulness of these important agents.

Consider use of narrow spectrum agents (e.g. penicillin, amoxicillin, flucloxacillin, trimethoprim) as outlined in these

guidelines for specific indications where clinically appropriate. In particular, try to reserve use of cephalosporins and quinolones

unless there is clear rationale (e.g. where guideline evidence recommends, true allergy with little alternative, specific indication

for agent, and/or based on sensitivity results).

7. Note: Hospital antibiotic guidelines can differ from community guidelines as patients are generally systemically unwell when

hospitalised and may require intravenous and/or broader spectrum agents due to possible recent exposure to antibiotics in the

community and/or failed initial therapy and increased severity of illness.

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

9. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high dose metronidazole (2g). Short-term use of

trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at

term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.

10. Clarithromycin has fewer side-effects than erythromycin. However, erythromycin is preferable to clarithromycin if patient is on

warfarin. Clarithromycin has a greater potential for raising INR. Note, spectrum of activities of these drugs not identical.

Exercise caution when considering concomitant administration of macrolides and statin therapy due to potential risk of

rhabdomyolysis.

11. Where a „best guess‟ therapy has failed or special circumstances exist, seek microbiological advice.


Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on

dosing in children).

Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

5

ILLNESS COMMENTS TREATMENT DOSE DURATION

OF TX

UUPPPPEERR RREESSPPIIRRAATTOORRYY TTRRAACCTT IINNFFEECCTTIIOONNSS:: CCoonnssiiddeerr ddeellaayyeedd aannttiibbiioottiicc pprreessccrriippttiioonnss..AA--

Pharyngitis /

sore throat /

tonsillitis

1. The majority of sore throats are viral; most

patients do not benefit from antibiotics.

Consider a delayed antibiotic strategy and explain

soreness will take about 8 days to resolve. Patients

with 3 of 4 centor criteria (history of fever, purulent

tonsils, cervical adenopathy, absence of cough) or

history of otitis media may benefit more from

antibiotics.A- Antibiotics only shorten duration of

symptoms by 8 hours.A+

2. Antibiotics to prevent Otitis media NNT 200,A+

Quinsy NNT >4000.B-

3. Penicillin for 7 days is more effective than 3

days.B+ Twice daily higher dose can also be used.A-

QDS may be more appropriate if severe.D

4. Phenoxymethylpenicillin suspension is available in

two flavours; Calvepen® (caramel) and Kopen®

(orange).

Symptomatic relief

Discomfort on swallowing – lozenges containing

benzocaine or flurbiprofen

Sore, „tickly‟ throat – demulcent pastilles

Sucking a lozenze or pastille promotes saliva

production which lubricates & soothes the throat.

Main disadvantage; high sugar content though sugar-

free preparations are available.

Local analgesia- anti-inflammatory spray or

mouthwash (e.g. benzydamine)

Consider a no- or delayed-

antibiotic strategy.A+

If antibiotics deemed

clinically indicated:

first line (Adults)

phenoxymethylpenicillin

clarithromycin

if allergic to penicillin

333-666 mg QDS

250-500 mg BD

10 days

5 days

first line (Children)

phenoxymethylpenicillin

suspension (250mg /5ml)

erythromycin

OR clarithromycin


< 1 yr 62.5mg

1-5 yrs 125mg

6-12 yrs 250mg

QDS

< 2 yrs 125mg

2-8 yrs 250mg QDS

< 1 yr 62.5mg

1-5 yrs 125mg

5-12yrs 250mg BD

7-10 days

5 days





6

Otitis media

(child doses) 1. Many are viral. Illness resolves over 4 days in

80% without antibiotics.A+

2. Antibiotics do not reduce pain in first 24 hours,

subsequent attacks or deafness.A+

3.Need to treat 20 children >2y and seven 6-24m old

to get pain relief in one at 2-7 days.A+B+

4. Children with otorrhoea, or <2years with bilateral

acute otitis media, have greater benefit but are still

eligible for delayed prescribing.A+

5. Haemophilus is an extracellular pathogen, thus

macrolides, which concentrate intracellularly, are less

effective treatment.

6. Antibiotics to prevent mastoiditis NNT>4000.B

Symptomatic relief

Use NSAID or paracetamol.A-

Consider a no- or delayed-

antibiotic strategy.A+


clinically indicated

first line

Amoxicillin

erythromycin

OR clarithromycin


second line

co-amoxiclav

40 mg/kg/day in 3

divided doses (Maximum 1g TDS)

< 2 yrs 125mg

2-8 yrs 250mg QDS

< 1 yr 62.5mg

1-5 yrs 125mg

5-12yrs 250mg BD

< 1 yr max 68mg

1-6 yrs 156 mg

6-12 yrs 312 mg

TDS

5 days

ILLNESS COMMENTS

TREATMENT DOSE DURATION

OF TX

Acute Sinusitis

1. Many are viral. Symptomatic benefit of

antibiotics is small.

2. 80% resolve in 14 days without antibiotics and they

only offer marginal benefit after 7 days (NNT 15).A+

3. Reserve for severeB+ or symptoms (>10 days).

4. Cochrane review concludes that amoxicillin and

phenoxymethylpenicillin have similar efficacy to the

other recommended antibiotics.

5. In persistent infection use an agent with anti-

anaerobic activity e.g. co-amoxiclav.B+

Symptomatic relief

Use NSAID or paracetamolB+

Systemic decongestants: pseudoephredrine

Improve air circulation & mucus drainage

Saline preparations for local irrigation (e.g. nasal

rinses, sprays, drops)

Topical decongestants: oxymetazoline,

xylometazoline

Suitable for most patient groups (hypertensive,

diabetes, pregnant women post first trimester)

Topical route should not be used >7 days due to

rebound congestion

Consider a no or delayed

antibiotic strategyA+


clinically indicated:

amoxicillinA+ OR

doxycycline OR

clarithromycin


second line:

co-amoxiclav

500 mg TDS

200 mg stat/100 mg

OD

250-500mg BD

625 mg TDS

7-10 days





7

ILLNESS

COMMENTS TREATMENT DOSE DURATION

OF TX

LLOOWWEERR RREESSPPIIRRAATTOORRYY TTRRAACCTT IINNFFEECCTTIIOONNSS

NNoottee:: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones ciprofloxacin and ofloxacin have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections.

Moxifloxacin and Levofloxacin has some anti-Gram-positive activity but should not be needed as first line treatment.

Acute cough,

bronchitis

(in otherwise

healthy adults &

children)

In primary care, antibiotics have

marginal benefits in otherwise

healthy adults.A+

Patient leaflets can reduce antibiotic

use.B+

Symptomatic relief

Cough expectorants: guaifenesin

Mucolytic agent: carbocisteine

Cough suppressants:

dextromethorphan

Codeine containing products should

be used with care due to dependence

potential

Consider no antibiotics where

possible.A+

If antibiotics deemed clinically

indicated:

amoxicillin

OR doxycycline

500 mg TDS

200 mg stat/100 mg OD

5 days

Acute

exacerbation of

COPD

30% viral, 30-50% bacterial, rest undetermined.

Use antibiotics if increased dyspnoea and increased purulence of sputum volume.B+

In penicillin allergy use clarithromycin if doxycycline contraindicated.

If clinical failure to first line antibiotics, previous amoxicillin exposure <3 month,

or severe symptoms (also consider hospital referral).

amoxicillin

OR doxycycline

OR clarithromycin

co-amoxiclav

500 mg TDS


250 – 500 mg BD

625 mg TDS

5 days

Community-

acquired

pneumonia

treatment in the

community

(Adults)

Start antibiotics immediately.B- If no response in 48 hours consider admission or

add a macrolide first line or a tetracyclineC to cover Mycoplasma infection (rare in

over 65s).

Assess using the CRB-65 score

(Confusion, Respiratory rate ≥ 30/min, BP ≤90/90, Age ≥ 65)

Score 0: suitable for home treatment;

Score 1-2: consider hospital referral;

Score 3-4: urgent hospital admission.

Consider adding macrolide if CRB=1 and suitable for home treatment (HPA

guidance).

In severely ill give parenteral benzylpenicillin before admissionC and seek risk

factors for Legionella and Staph.aureus infection.D

amoxicillin

OR clarithromycin

doxycycline

500 mg - 1g TDS

500 mg BD


Up to 10 days

Up to 10 days





8

ILLNESS

COMMENTS TREATMENT DOSE DURATION

OF TX

Influenza

Pneumonic and

non-pneumonic

post –influenza

LRTI managed

in the

community

Adults &

Children

Following a recent increase in the level of seasonal influenza including H1N1 (2009) (Swine flu) circulating

in Ireland, the HPSC has issued guidance on influenza including guidance on the use of antiviral drugs for the

management of patients with influenza like illness who are at high risk of developing complications from flu.

Comprehensive guidance can be found on the HPSC website: http://www.hpsc.ie/hpsc/A-

Z/Respiratory/Influenza/SeasonalInfluenza/

(Please make sure to refresh any webpage you visit so that you are seeing the most up-to-date version)

Treatment with antivirals is advised for patients who are particularly ill and for at risk groups. Check HPSC

for use in children & in pregnancy.

This guidance has been prepared by the Health Protection Surveillance Centre, Departments of Public Health

and members of the Pandemic Influenza Expert Group.

At risk groups:

Pregnant women – 14

weeks- 6 weeks after giving

birth

Anyone aged >6 months

and < 65 years who has:

· Long-term lung, cardiac,

kidney, liver or

neurological disease

·Immunosuppression

·Haemoglobinopathies

· Diabetes

· Severely obese (BMI≥40)

1st line:

Oseltamivir

Adult-75mg bd

75mg od

2nd line:

Zanamivir

See BNF for

dosage

5 days (treatment)

10 days (chemo-

prophylaxis)

Consult following documents for clinical guidance:

Interim Algorithm for the primary care: Management of persons with influenza, for use when flu is circulating.

Clinical management of patients with influenza like illness during an influenza pandemic.

Management of secondary bacterial infections in adults and children.

Adults:

doxycycline

OR co-amoxiclav

OR clarithromycin

Children:

co-amoxiclav

OR clarithromycin (if

penicillin allergic)

100 mg OD

625mg TDS

500mg BD

< 1 yr max 68mg

1-6 yrs 156 mg

6-12 yrs 312 mg

TDS

< 1 yr 62.5mg

1-5 yrs 125mg

5-12yrs 250mg

BD

7 – 10 days

MMEENNIINNGGIITTIISS

Suspected

meningococcal

disease

Transfer all patients to hospital immediately. Administer benzylpenicillin prior to admission, unless history

of anaphylaxis,B- NOT allergy. Ideally IV but IM if a vein cannot be found. Prevention of secondary case of

meningitis: Only prescribe following advice from Public Health Doctor. IV or IM benzylpenicillin

Adults and children

10 yr and over: 1200 mg

Children 1 - 9 yr: 600 mg

Children <1 yr: 300 mg

http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/Guidance/

http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/PandemicInfluenza/Guidance/PandemicInfluenzaPreparednessforIreland/File,3261,en.pdf

http://www.hpsc.ie/hpsc/A-Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/GPs/File,4062,en.pdf





9

ILLNESS COMMENTS TREATMENT DOSE DURATION OF TX

UURRIINNAARRYY TTRRAACCTT IINNFFEECCTTIIOONNSS

NNoottee::. Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic bacteriuria; it occurs in 25%

of women and 10% of men and is not associated with increased morbidity.B+

In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell

Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI.B

Uncomplicated

UTI ie no fever

or flank pain

Use urine dipstick to exclude UTI -ve nitrite and leucocyte 95% negative predictive

value.

Note: Choice of empirical therapy should be goverened by local resistance

rates where available. Patterns can vary substantially across the country

For first presentations, low risk of resistant organisms in uncomplicated UTI

consider narrow-spectrum antibiotics that concentrate in the bladder such as

trimethoprim or nitrofurantoin in the first instance.

There is less relapse with trimethoprim than cephalosporins.

Community multi-resistant E. coli with EExxtteennddeedd--ssppeeccttrruumm BBeettaa--llaaccttaammaassee

eennzzyymmeess are increasing so perform culture in all treatment failures. ESBLs are

multi-resistant but remain sensitive to nitrofurantoin. Nitrofurantoin should be

avoided in renal impairment due to inadequate urine concentrations.

Information on local antibiotic resistance rates in urinary pathogens is particularly

important as patterns can vary substantially across the country.

trimethoprimB+

OR nitrofurantoinA-

200 mg BD

50-100 mg QDS

3 daysB+

7 days in men

Consider the following agents also for empiric therapy where appropriate - based on local

resistance rates.

cephalexin, co-amoxiclav

(For uncomplicated UTI reserve quinolones for resistant infections with limited option and

confirmed by results of culture and sensitivity).

UTI in

pregnancy

Send MSU for culture. Short-term use of trimethoprim or nitrofurantoin in

pregnancy is unlikely to cause problems to the foetus.B+Avoid trimethoprim if low

folate status or taking folate antagonist (e.g. antiepileptic or proguanil).

Refer to local resistance patterns for empiric therapy where available and refer to

MSU results.

amoxicillin

OR cephalexin

second line

nitrofurantoin

OR trimethoprim

250 mg TDS

500 mg BD

50 mg – 100 mg QDS

200 mg BD

7 days

Children Refer children <3 months to specialist.

Send MSU in all for culture & susceptibility. If ≤ 3 years, use positive nitrite to

start antibiotics. Refer children post UTI for imaging.

Upper UTI

trimethoprim

OR nitrofurantoin

OR cefalexin

If susceptible,

amoxicillin, co-

amoxiclav

co-amoxiclav

3mth-12 years

4mg/kg BD (max 200mg)

750micrograms/kg QDS

12.5mg/kg BD

< 1 yr max 68mg

1-6 yrs 156 mg

6-12 yrs 312 mg TDS

Lower UTI

3 days

Upper UTI

7-10 days

Acute

pyelonephritis

Send MSU for culture. RCT shows 7 days ciprofloxacin was as good as 14 days

co-trimoxazole.A-

If no response within 24 hours admit.

ciprofloxacinA-

OR co-amoxiclav

If susceptible,

trimethoprim

500 mg BD

500/125 mg TDS

200 mg BD

7 daysA-

14 days

14 days

http://www.hpa.org.uk/infections/topics_az/esbl/default.htm

http://www.hpa.org.uk/infections/topics_az/esbl/default.htm





10

Recurrent UTI

women ≥ 3/yr

Post-coital prophylaxis or standby antibiotic B+

Nightly: reduces UTIs but side effects (antibiotics).

nitrofurantoin

OR trimethoprim

50 mg

100 mg

Stat post-coital (off-label)OR

OD at night





11


OF TX

GGAASSTTRROO--IINNTTEESSTTIINNAALL TTRRAACCTT IINNFFEECCTTIIOONNSS

Eradication of Helicobacter pylori

Managing symptomatic relapse

Eradication is beneficial in DU, GU and low grade MALTOMA, but NOT in GORD.A In NUD,

8% of patients benefit.

Triple treatment attains >85% eradication.A+

Do not use clarithromycin or metronidazole if used in the past year for any infection.A+

DU/GU: Retest for helicobacter if symptomatic

NUD: Do not retest, treat as functional dyspepsia.

In treatment failure consider endoscopy for culture & susceptibility.C Use 14d BD PPI PLUS 2

antibiotics. Consider adding bismuth salt.

first lineA+

PPI

PLUS clarithromycin

AND

metronidazole (MZ)

OR amoxicillin (AM)

Alternative regimensA+

PPI OR

ranitidine bismuth citrate

PLUS 2 antibiotics:

amoxicillin

clarithromycinA+

metronidazole

250 mg BD with MZ

500mg BD with AM

400 mg BD

1g BD

BD

400 mg BD

1 g BD

500 mg BD

400 mg BD

All for 7 daysA

14 days in relapse

or maltoma

Infectious diarrhoea Antibiotic therapy not indicated unless patient systemically unwell or post-antibiotic, suggesting Clostridium difficile.

Clostridium difficile

Stop unnecessary antibiotics and/or PPIs to re-establish normal flora.

70% respond to metronidazole in 5 days; 94% in 14 days.

Severe if T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis.

Consult HPSC website for guidance document:

Surveillance , Diagnosis & Management of Clostridium difficile-associated disease in Ireland

(2008)

1st/2nd episodes

metronidazole

3rd episode/severe

vancomycin

400mg oral TDS

125mg oral QDS

10-14 days

Traveller‟s diarrhoea Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 750 mg single dose) to people travelling to remote areas and for people

in whom an episode of infective diarrhoea could be dangerous.

Threadworms

Treat household contacts. Advise morning shower/baths and hand hygiene.

Use piperazine in children under 6 months.

mebendazole in all >6 mths

or piperazine/senna sachet

100 mg

3 mths- 1yr 2.5ml

1-6 yrs 5mls

>6yrs 1 sachet

stat

stat, repeat after 2

weeks





12


OF TX

GGEENNIITTAALL TTRRAACCTT IINNFFEECCTTIIOONNSS

NNoottee:: STI clinics may also known as STD,GUM & GUIDE clinics

Vaginal

candidiasis

All topical and oral azoles give 80-95% cure.A-

In pregnancy avoid oral azole..B

clotrimazole 10%

OR clotrimazole

OR fluconazole

5 g vaginal cream

500 mg pessary

150 mg orally

stat

Bacterial

vaginosis

A 7 day course of oral metronidazole is slightly more effective than 2 g stat.A+

Avoid 2g stat dose in pregnancy & breastfeeding.

Topical treatment gives similar cure ratesA+ but is more expensive.

metronidazoleA+

OR metronidazole

0.75% vag gelA+

OR clindamycin 2% creamA+

400 mg BD

5 g applicatorful at

night

5 g applicatorful at

night

7 days

5 days

7 days

Chlamydia

trachomatis

Treat contacts and consider referral to STI clinic if indicated.

In pregnancy or breastfeeding: azithromycin can be used but is „off label‟.

If erythromycin or amoxicillin is used, retest after 5 weeks, as less effective.

azithromycinA+

OR doxycyclineA+

OR erythromycin A-

OR amoxicillinA+

1 g stat

100 mg BD

500 mg BD

or 500 mg QDS

500 mg TDS

1 hr before or

2 hrs after food

7 days

14 days

7 days

7 days

Trichomoniasis Refer to STI clinic. Treat partners simultaneously.

In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure).

metronidazoleA-

clotrimazole

400 mg BD

or 2 g in single dose

100 mg pessary

5 days

6 days

Pelvic

Inflammatory

Disease

(PID)

Essential to test for N. gonorrhoea (as increasing antibiotic resistance) and chlamydia.

Microbiological and clinical cure are greater with ofloxacin than with doxycycline.A+

Refer contacts to STI clinic.

metronidazole +

ofloxacinB

OR

metronidazole +

doxycyclineB

400 mg BD

400 mg BD

400 mg BD

100 mg BD

14 days

Acute

prostatitis

4 weeks treatment may prevent chronic infection.

Quinolones are more effective, as they have greater penetration into prostate.

ciprofloxacin

OR ofloxacinC

OR trimethoprimC

500 mg BD

200 mg BD

200 mg BD

28 days





13


OF TX

SSKKIINN // SSOOFFTT TTIISSSSUUEE IINNFFEECCTTIIOONNSS

Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus and is associated with persistent recurrent pustules and carbuncles or cellulitis. Send swabs for

culture in these clinical scenarios. On rare occasions it causes more severe invasive infections, even in otherwise fit people. Risk factors include: nursing homes, contact sports, sharing

equipment, poor hygiene and eczema.

Acne vulgaris Topical treatment first line e.g. benzoyl peroxide gel, retinoid or topical antibiotic.

Avoid using topical and oral antibiotics concurrently. However, topical benzoyl

peroxide gel with oral antibiotic reduces risk of antibiotic resistance.

doxycycline

OR lymecycline

OR erythromycin

(OR trimethoprim in

tetracycline

resistance)

100mg OD

408mg OD

500mg BD

300mg BD

Review in 3 months, but may take 4-

6 months

Impetigo

Systematic review indicates topical and oral treatment produces similar results.A+

As resistance is increasing reserve topical antibiotics for very localised lesions.C or D

Reserve Mupirocin for MRSA.

first line -

flucloxacillin

or clarithromycin

fusidic acid

mupirocin (MRSA

only)

Oral 500 mg QDS

Oral 500 mg BD

Topically TDS

Topically TDS

7 days

5 days

Eczema

Using antibiotics, or adding them to steroids, in eczema encourages resistance and does not improve healing unless there are visible signs of infection. In infected eczema, use treatment

as in impetigo.

Cellulitis If patient afebrile and healthy other than cellulitis flucloxacillin may be used as

single drug treatment. If water exposure, discuss with microbiologist.

If febrile and ill, admit for IV treatment

In facial cellulitis use co-amoxiclavC

Flucloxacillin

If penicillin

allergic:

clarithromycin*

alone

OR clindamycin

co-amoxiclav

500 mg QDS

500 mg BD

450mg QDS

500/125 mg TDS

7 – 14 days

Leg ulcers

Antibiotics do not improve healing unless active infection.A+ Culture swabs and antibiotics are only indicated if there is evidence of clinical cellulitis; increased pain; enlarging ulcer or

pyrexia.

Review antibiotics after culture results.

Refer for specialist opinion if severe infection.

Flucloxacillin OR

clarithromycin

500 mg QDS

500mg BD

7 days

and review





14

ILLNESS COMMENTS TREATMENT DOSE DURATION OF TX

Animal bite

Human bite

Surgical toilet most important.

Assess tetanus and rabies risk.

Antibiotic prophylaxis advised for – puncture wound; bite involving hand, foot,

face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic.

Antibiotic prophylaxis advised.

Assess HIV/hepatitis B & C risk.

First line animal &

human

prophylaxis and

treatment

co-amoxiclavB-

If penicillin allergic:

metronidazole

PLUS doxycycline

OR clarithromycin

(human)

375-625 mg TDS

200-400 mg TDS

100 mg BD

250-500 mg BD

7 days

Conjunctivitis

Most bacterial infections are self-limiting (64% resolve on placeboA+). They are

usually unilateral with yellow-white mucopurulent discharge.

Fusidic acid has less Gram-negative activity.

If severe:B+

chloramphenicol

0.5% drops PLUS

1% ointment

fusidic acid

2 hrly reducing to QDS when

infection controlled &

at night

1% gel BD

All for 48 hours after resolution

Scabies

Treat whole body including scalp, face, neck, ears, under nails (BNF

recommendations; manufacturers recommend to exclude head and neck).

All members of the affected household should be treated simultaneously.

permethrinA+

If allergy:

Malathion

5% cream

0.5% aqueous liquid

2 applications one week apart

Dermatophyte

infection of the

proximal

fingernail or

toenail

Take nail clippings: Start therapy if infection is confirmed by laboratory.

Idiosyncratic liver reactions occur rarely with terbinafine. It is more effective than

the azoles.

Itraconazole is also active against yeasts.

In non-dermatophyte moulds use itraconazole.C

For children seek advice.

5% amorolfine nail

lacquerB- (for

superficial)

terbinafineA-

Second line:

itraconazole

1-2x/weekly fingers

toes

250 mg OD fingers

toes

200 mg BD fingers

toes

6 months

12 months

6 – 12 weeks

3 – 6 months

7 days monthly (2 courses)

7 days monthly (3 courses)

Dermatophyte

infection of the

skin

Take skin scrapings for culture if not localised.

Treatment: 1 week terbinafine as effective as 4 weeks azole.A-

If intractable consider oral itraconazole. Discuss scalp infections with specialist.

Topical 1%

terbinafine A+

Topical undecenoic

acid or 1% azoleA+

OD - BD

1-2x/daily

1 weekA+

4 – 6 weeksA+





15

Varicella

zoster/

Chicken pox

&

Herpes zoster/

shingles

If pregnant/immunocompromised seek advice.

Chicken pox: In immunocompetent value of antivirals minimal unless severe pain,

or adult, or on steroids, or secondary household case AND treatment started <24h of

onset of rash.A-

Shingles: Always treat if active ophthalmic, and Ramsey Hunt or eczema.

Non-ophthalmic shingles: Treat >50 yrs if <72h of onset of

rash, as post-herpetic neuralgia rare in <50 yrs but occurs in

20% >50 yrsA+

.

aciclovir

Second line if a

compliance problem

valaciclovir

or

famciclovir

800 mg 5x/day

1 g TDS

750 mg OD

7 days

Disclaimer:

Whilst every effort has been made to ensure the accuracy of the information and material contained in this document, errors or omissions may

occur in the content. We acknowledge that new evidence may emerge that may overtake some of these recommendations. The document will

be reviewed and revised as and when appropriate. Prescribers should ensure that the correct drug and dose is prescribed, as is appropriate for

each individual patient. References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and

the drug data sheets (available on www.medicines.ie). Clinical guidelines are guidelines only and the interpretation and application of the

guidelines remains the responsibility of the individual clinician.

Please send comments and queries to;

Marion Murphy, Research Pharmacist, School of Pharmacy, University College Cork.

Tel: 021 4901690 Email: [email protected]

The following references were used when developing these guidelines: This guidance was initially developed in 1999 by practitioners in South Devon, England, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing

Group. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The guidance has been modified for use in Ireland.

Grading of guidance recommendations The strength of each recommendation is qualified by a letter in parenthesis.

Study design Recommendation

grade

Good recent systematic review of studies A+


16

One or more rigorous studies, not combined A-

One or more prospective studies B+

One or more retrospective studies B-

Formal combination of expert opinion C

Informal opinion, other information D


17

UPPER RESPIRATORY TRACT INFECTIONS

Pharyngitis/sore throat/tonsillitis

Centor RM, Whitherspoon JM Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decision Making 1981;1:239-46. Scoring system for sore throats.

Spinks A, Glasziou PP, Del Mar C. Antibiotics for sore throat. Cochrane Database of systematic reviews 2006, Issue 4.Art. No CD000023.DOI:10.1002/14651858.CD000023.pub3.

Altamimi S, Khali A, Khalaiwa KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database of

systematic reviews 2009, Issue 1. Art No.: CD004872. DOI: 10/1002/14651858.CD004872.pub2.

Del Mar C. Sore throats and antibiotics: Applying evidence on small effects is hard; variations are probably inevitable. Brit Med J 2000;320:130-1. Editorial covering treatment.

Del Mar C & Glasziou P. Sore Throat. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:516-17.

Lan AJ, Colford JM, Colford JMJ. The impact of dosing frequency on the efficacy of 10 day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analysis. Pediatr

2000;105(2):E19. Meta-analysis showed BD and QDS dose equivalent.

McIsaac WJ, Goel V, Slaughter PM, Parsons GW, Woolnough KV, Weir PT, Ennet JR. Reconsidering sore throats. Part 2: Alternative approach and practical office tool. Can Fam Physician

1997;43:495-500. Review of scoring system that supports Centor.

Petersen, I.Johnson, A. M.Islam, A.Duckworth, G.Livermore, D. M.Hayward, A. C. (2007). "Protective effect of antibiotics against serious complications of common respiratory tract infections:

retrospective cohort study with the UK General Practice Research Database." BMJ 335(7627): 982.

Zwart Sjoerd, Sachs APE, Ruijs G, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults.

Brit Med J 2000;320:150-4. RCT showing 7 days penicillin V at 500 mg was better than 3 days in terms of time of symptom resolution, bacterial resolution and relapse. Also confirms validity of Centor

criteria.

Otitis media

Damoiseaux RAMJ, Van Balen FAM, Hoes AW, Verhiej TJM, de Melker RA. Primary care-based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged

under 2 years. Brit Med J 2000;320:350-4.

Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. Brit Med J 1997;314:1526-9. Search date 1966 to August 1994;

primary sources Medline, current contents.

Froom J, Culpepper L, Jacobs M, de Melker RA, Green LA, Van Buchem L, Grob P, Heeren T. Antimicrobials for acute otitis media? A review from the International Primary Care Network. Brit M J

1997;315:98-102.

Glasziou IP, Del Mar CB, Sanders SC, Hayem M. Antibiotics for acute otitis media in children (Cochrane Review). In: The Cochrane Library 2006. Issue 4. Chichester, UK: John Wiley & Sons, Ltd

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000219/pdf_fs.html Accessed 20.04.11.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000219/pdf_fs.html


18

Kozyrskyj AL, Hildes Ripstein GF, Longstaffe SE, et al. Short-course antibiotics for acute otitis media. Cochrane Database Syst Rev 2000;(2):CD001095.

Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 2001;322:336-42.

Little P. Gould C, Moore M, Warner G, Dunleavey J. Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ

2002;325:22-26.

Thompson PL, Gilbert RE, Long PF, Saxena S, Sharland M, Wong IC. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United Kingdom general

practice research database. Pediatrics 2009;123(2):424-30.

Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, Gaboury I, Little P, Hoes AW. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet

2006;368:1429-35. Shows that patients with otorrhoea, or children <2 years with bilateral acute otitis media benefited more from antibiotics (NNT 3 and 4 respectively).

Rovers MM, Glasziou P, Appleman CL, Burke P, McCormick DP, Damoiseaux RA, Little P, Le Saux N, Hoes AW. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not

treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics 2007;119(3):579-85

Rhinosinusitis

de Ferranti SD, Lonnidis JPA, Lau J, Anniger WV, Barza M. Are amoxicillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. Brit Med J 1998;317:632-7.

Search date May 1998; primary sources Medline 1966 – May 1998; manual search of Excerpta Medica: recent abstracts for Interscience Conference on Antimicrobial Agents & Chemotherapy 1993-

1997 and references of all trails review articles and special issues for additional studies.

Ah-See KW, Evans AS. Sinusitis and its management. BMJ 2007:334:358-61

Hansen JG, Schmidt H, Grinsted P. Randomised, double blind, placebo controlled trial of Penicillin V in the treatment of acute maxillary sinusitis in adults in general practice. Scan J Prim Health Care

2000;18:44-47.

Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomised

trials. British Journal of Clinical Pharmacology2009;67(2):161-71.

Thomas M, Yawn B, Price D, Lund V, Mullol J, Fokkens W. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal

Polyps 2007 – a summary. Primary Care Respiratory Journal2008;17(2):79-89.

Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:

CD000243. DOI: 10.1002/14651858.CD000243.pub2.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000243/frame.html Accessed 20.04.11

Young J, De Sutter A, Merenstein D, van Essen GA, Kaiser L, Varonen H, Williamson I, Bucher HC. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual

patient data. Lancet. 2008;371:908-914.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000243/frame.html%20Accessed%2020.04.11


19

Hansen JG, Hojbjerg T, Rosborg J. Symptoms and signs in culture proven acute maxillary sinusitis in general practice population. APMIS 2009;117(10):724-9.

LOWER RESPIRATORY TRACT INFECTIONS

Woodhead M, Blasi F, Ewig S, Huchon G, Leven M, Ortqvist A, Schabert T, Torres A, can der Jeijden G, Werheij TJM. Guidelines for the management of adult lower respiratory tract infection. Eur

Respir J 2005;26:1138-80. http://www.erj.ersjournals.com/contents-by-date.0.shtml Accessed 20.04.11.

Acute bronchitis

Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. In: The Cochrane Library, 2006, Issue 4. Chichester, UK: John Wiley & Sons, Ltd

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000245/pdf_fs.html Accessed 20.04.11. Studies in primary care showed antibiotics reduced symptoms of cough and feeling ill by

less than one day in an illness lasting several weeks in total.

Wark P. Bronchitis (acute). In: Clinical Evidence. London. BMJ Publishing Group. 2008;07:1508-1534

Francis N et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled

trial. BMJ, 2009;339:2885

Chronic cough due to acute bronchitis. Chest. 2006;129:95S-103S.

Treatment of cough available in Clinical Knowledge Summaries website: http://www.cks.nhs.uk/chest_infections_adult/management/scenario_acute_bronchitis Accessed 20.04.11

COPD

Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Int Med 1987;106:196-204.

Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet 2003;362:1053-61. Excellent review on pathophysiology and management of COPD. Little detailed information on antibiotic

treatment.

Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. Management of exacerbations. Updated December 2009

Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care. NICE Clinical Guideline 12 February 2004. http://guidance.nice.org.uk/CG101 Accessed

20.04.11

Community-acquired pneumonia

BTS guidelines for the management of community-acquired pneumonia in adults. Thorax 2009;64(Suppl III):III 1-55.

http://www.erj.ersjournals.com/contents-by-date.0.shtml


http://www.cks.nhs.uk/chest_infections_adult/management/scenario_acute_bronchitis

http://guidance.nice.org.uk/CG101


20

Loeb M. Community-acquired pneumonia. In: Clinical Evidence. London BMJ Publishing Group. 2008;07:1503-1516.

Levy, M. L., I. Le Jeune, et al. (2010). "Primary care summary of the British Thoracic Society Guidelines for the management of community acquired pneumonia in adults: 2009 update." Primary Care

Respiratory Journal 19(1): 21-27.

MENINGITIS

NICE. Bacterial meningitis and meningococcal septicaemia. National Collaborating Centre for Women’s and Children’s health 2009. http://guidance.nice.org.uk/CG102/Guidance Accessed 20.04.11.

SIGN. Management of invasive meningococcal disease in children and young people. Scottish Intercollegiate Guidelines Network. 2008 http://www.sign.ac.uk/guidelines/fulltext/102/index.html

Accessed 20.04.11.

INFLUENZA

Health Protection Surveillance Centre (HPSC) See http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/ Accessed 21.04.11

Infection prevention and control for patients presenting to Emergency Departments or GP practices with signs and symptoms of influenza-like illness (ILI)

http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/AdviceforGPshospitalcliniciansandpharmacists/ Accessed 21.04.11.

Vaccination Information (vH1N1) http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/Vaccination/ Accessed 21.04.11.

Management of secondary bacterial infections in adults and children http://www.hpsc.ie/hpsc/A-

Z/Respiratory/Influenza/PandemicInfluenza/Guidance/PandemicInfluenzaPreparednessforIreland/File,3261,en.pdf Accessed 21.04.11.

http://guidance.nice.org.uk/CG102/Guidance

http://www.sign.ac.uk/guidelines/fulltext/102/index.html

http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/

http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/AdviceforGPshospitalcliniciansandpharmacists/

http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/Vaccination/

http://www.hpsc.ie/hpsc/A-Z/EmergencyPlanning/AvianPandemicInfluenza/SwineInfluenza/AdviceforHealthProfessionals/GPs/File,4062,en.pdf




21

URINARY TRACT INFECTIONS

Elderly

Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory

women? Ann Int Med 1994:827-33.

Nicholl LE. Urinary tract infection. In: Infection Management for Geriatrics in Long-term Care Facilities. Eds Yoshikawa TT, Ouslander JG. Marcel Dekker. New York. 2002:173-95.

Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1-

110.

Uncomplicated UTI

Christiaens TCM, Meyere M De, Vershcraegen G. Peersman W, Heytens S. Maeseneer JM De. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary

tract infection in adult women. Brit J Gen Pract 2002;52:729-34.

Davey PG, Steinke D. MacDonald TM, Phillips G, Sullivien F. Not so simple cystitis: How should prescribers be supported to make informed decisions about the increasing prevalence of infections

caused by drug resistant bacteria? Brit J Gen Pract 2000;50:143-46.

Dobbs FF & Fleming DM. A simple scoring system for evaluating symptoms, history and urine dipstick testing in the diagnosis of urinary tract infections. J Roy Col Gen Pract 1987;37:100-4.

Gossius G Vorland L. The treatment of acute dysuria-frequency syndrome in adult women: double blind randomized comparison of three day versus ten day trimethoprim therapy. Curr Ther Res

1985;37(1):34-42.

Falagas, M.E., Kotsantis, I.K., Vouloumanou, E.K. and Rafailidis, P.I. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials.

Journal of Infection 2009;58(2):91-102.

Hiscoke C, Yoxall H, Greig D, Lightfoot NF. Validation of a method for the rapid diagnosis of urinary tract infection suitable for use in general practice. Brit J Gen Pract 1990;40:403-5.

Hummers-Pradier E. Kocken MM. Urinary tract infections in adult general practice patients. Brit J Gen Pract 2002;52:752-61.

Livermore D, & Woodford N. Laboratory detection of bacteria with extended-spectrum beta-lactamases. CDR Weekly

2004;14 No. 27.

Little P, Turner S, Rumsby K., Warner G, Moore M, Lowes JA, Smith H, Hawke C, Turner D, Leydon GM, Arscott A, Mullee M. Dipsticks and diagnostic algorithms in urinary tract infection:

development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technology Assessment 2009;13(19):1-96.

McCarty JM, Richard G, Huck W, Tucker RM, Toxiello RL, Shan M, Heyd A, Echols RM. A randomised trial of short-course ciprofloxacin, ofloxacin or trimethoprim/sulfamethoxazole for the

treatment of acute urinary tract infection in women. Am J Med 1999;106:292-9.


22

Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance epidemiology in Females with Cystitis (ARESC):

implications for empiric therapy. European Urology 2008;54:1164-1175.

Milo G, Katchman EA, Paul M, Christiaens T, Baerheim A, Leibovici L. Duration of antibacterial treatment for uncomplicated

urinary tract infection in women. Cochrane Database Review. The Cochrane Library 2006, Issue 2.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004682/pdf_fs.html Accessed 21.04.11. Review showing there is no difference in outcome between 3 day, 5 day or 10 day

antibiotic treatment course for uncomplicated UTI.

Spencer RC, Moseley DJ, Greensmith MJ. Nitrofurantoin modified release versus trimethoprim or co-trimoxazole in the treatment of uncomplicated urinary tract infection in general practice. J

Antimicrob Chemother 1994;33(Suppl A):121-9.

UTI in pregnancy

UKTIS. The treatment of infections in pregnancy. The UK Teratology Information Service. 2008. (Tel: 0844 892 0909, www.toxbase.org)

Trimethoprim: : trimethoprim is a folate antagonist. Folate supplementation during the first trimester reduces the risk of neural tube defects in offspring of pregnant women treated with trimethoprim.

In women with normal folate status, who are well nourished, trimethoprim is unlikely to cause folate deficiency. However, it should not be used by women with established folate deficiency or low

dietary folate intake, or by women taking other folate antagonists (e.g. antiepileptic drugs or proguanil).

Nitrofurantoin: : significant placental transfer of nitrofurantoin does not occur. Nitrofurantoin has not been associated with an increased risk of congenital malformations. Nitrofurantoin has been

associated with haemolysis in people with glucose-6-phosphate dyhydrogenase (G6PD) deficiency. However, the risk seems very small because placental transfer is so low. There is only one reported

case of haemolytic anaemia in a newborn whose mother was treated at term with nitrofurantoin.


110.

Children

Hodson EM, Willis NS, Craig JC. Antibiotics for acute pyelonephritis. Cochrane Database of Systematic Reviews 2007.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003772/frame.html Accessed 20.04.11.

National collaborating centre for women‟s and children‟s health. NICE Clinical guideline. Urinary tract infection in children. Diagnosis, treatment and long-term management.

http://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdf Accessed 21.04.11) Comprehensive guidance with summaries and flow charts.

Acute pyelonephritis

Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, Reuning-Scherer J and Church DA. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute

uncomplicated pyelonephritis in women. A randomized trial. JAMA 2000;283:1583-90. Evidence for 7 days ciprofloxacin.


110.

http://www.toxbase.org/

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003772/frame.html


23

Recurrent UTI in non-pregnant women

Albert X, Huertas I, Pereiró I, Sanfélix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database of Systematic Reviews 2004,

Issue 3, Art No. CD001209. DOI: 10.1002/14651858.CD001209.pub2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001209/frame.html This is an excellent review of

prophylaxis. It shows that it is very effective (NNT2). However 30% do not comply. Benefit lost as soon as prophylaxis stops and prophylaxis after intercourse is as effective as daily prophylaxis.


110.

GASTRO-INTESTINAL TRACT INFECTIONS

Eradication of Helicobacter pylori

Bazzdi F. Pozzato P. Rokkas T. Helicobacter pylori: the challenge in therapy. Helicobacter 2002;7 (Suppl 1):43-49.

Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ

2010;340:c2096.

de Boer WA, Tytgat GNJ. Treatment of Helicobacter pylori infection. Brit Med J 2000;320:31-4.

Delaney B, Moayyedi P, Forman D. Helicobacter pylori infection. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:184-188

Moayyedi P, Soo S, Deeks JJ, Delaney B, Harris A, Innes M, Oakes R, Wilson S, Roalfe A, Bennett C, Forman D. Eradication of Helicobacter pylori for non-ulcer dyspepsia. The Cochrane library

2006. Issue 2 http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002096/frame.html Accessed 19.04.11

NICE dyspepsia guidance. August 2004. Evidence indicates once daily PPI plus metronidazole 400mg BD + clarithromycin 250mg BD is as effective as using BD PPI or 500mg clarithromycin. This

regimen is cheaper than using BD PPI or higher dose clarithromycin. http://www.nice.org.uk/pdf/CG017fullguideline.pdf Accessed 20.04.11

Luther J, Higgins PDR, Schoenfield PS, Moayyedi P, Vakil N, Chey WD. Empiric quadruple vs. triple therapy for primary treatment of Helicobacter pylori infection: systematic review and meta-

analysis of efficacy and tolerability. Am J Gastroenterol 2010;105:65-73.

Clostridium difficile

Linsky A, Gupta K, Lawler EV, Fonda JR, Hermos JA. Proton pump inhibitors and risk for recurrent Clostridium difficile infection. Arch Intern Med 2010;170:772-778.

Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F, Johnson S. Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Infect 2007;55:495-

501. Of 83% of patients who don’t respond to 5 days metronidazole, 30% do respond by 14 days.


http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002096/frame.html

http://www.nice.org.uk/pdf/CG017fullguideline.pdf


24

HPSC Surveillance, Diagnosis and Management of Clostridium difficile - associated disease in Ireland (2008) http://www.hpsc.ie/hpsc/A-

Z/Gastroenteric/Clostridiumdifficile/Publications/File,2936,en.pdf Accessed 21.04.11

Gastroenteritis

de Bruyn G. Diarrhoea in adults (acute). In: Clinical Evidence. London. BMJ Publishing Group 2006;15:1031-48. Summarises evidence for a single dose or 3 days of ciprofloxacin in treatment of

traveller’s diarrhoea.

Farthing M, Feldman R, Finch R, Fox R, Leen C, Mandal B, Moss P, Nathwani D, Nye F, Percival A, Read R, Ritchie L, Todd WT, Wood M. J of Infect 1996;33:143-52. The management of infective

gastroenteritis in adults. A consensus statement by an expert panel convened by the British Society for the Study of Infection.

Goodman LJ, Trenholme GM, Kaplan RL el al. Empiric antimicrobial therapy of domestically acquired acute diarrhoea in urban adults. Arch Intern Med 1990;150:541-6.

Traveller’s diarrhoea

Dupont HL. Systematic review: prevention of travellers‟ diarrhoea. Aliment Pharmacol Ther 2008;27:741-51.

Spira AM. Travel Medicine 1: Preparing the traveller. Lancet 2003;361:1368-81. Summarises treatment of traveller’s diarrhoea in a simple table.

Dupont HL. Systematic review: prevention of travellers‟ diarrhoea. Aliment Pharmacol Ther 2008;27:741-51.

Threadworm

CKS (2007) Threadworm. Clinical Knowledge Summaries. http://www.cks.nhs.uk/search?&page=1&q=threadworm&site=0 Accessed 21.04.11.

GENITAL TRACT INFECTIONS

Vaginal Candidiasis

Nurbhai M, Grimshaw J, Watson M, Bond CM, Mollison JA, Ludbrook A. Oral versus intravaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush).

Cochrane Database of Systematic Reviews 2007, Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002845/frame.html Accessed 21.04.11.

UKTIS. Use of fluconazole in pregnancy. The UK Teratology Information Service. 2008. (Tel: 0844 892 0909, www.toxbase.org)

Data on the outcomes of over 1,700 pregnancies exposed to low-dose fluconazole (150 mg stat) show no increased incidence of spontaneous abortions, malformations, or patterns of defects. However,

there may be an increased risk of malformations associated with high-dose chronic therapy (>400 mg/day). First-line treatment of candidal infection in pregnancy should be with an imidazole.

However, fluconazole (150mg stat) may be a suitable second-line treatment if clotrimazole is ineffective.

http://www.hpsc.ie/hpsc/A-Z/Gastroenteric/Clostridiumdifficile/Publications/File,2936,en.pdf



http://www.cks.nhs.uk/search?&page=1&q=threadworm&site=0


http://www.toxbase.org/


25

Young GL, Jewell D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4.


Bacterial vaginosis

Joesoef MR, Schmid GP, Hillier SL. Bacterial vaginosis: review of treatment options and potential clinical implications for therapy. Clin Infect Dis 1999;28(suppl 1):S57-S65.

McDonald HM, Brocklehurst P, Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 1.


Joesoef MR & Schmid G. Bacterial vaginosis. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:533-35.

Chlamydia trachomatis

SIGN. Management of genital Chlamydia trachomatis infection: a national clinical guideline. Scottish Intercollegiate Guidelines Network 2009.

http://www.sign.ac.uk/guidelines/fulltext/109/index.html Accessed 20.04.11.

Low N. Chlamydia (uncomplicated, genital) In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:536-38

Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomised controlled trials.

Brocklehurst P, Rooney G. Interventions for treating genital Chlamydia trachomatis infection in pregnancy. Cochrane Database of Systematic Reviews 1998. Issue 4.


Trichomoniasis

Forna F, Gulmezoglu MU. Interventions for treating trichomoniasis in women. Cochrane Database of Systematic Reviews. 2003. Issue 2.


Pelvic Inflammatory Disease

RCOG. Management of Acute Pelvic Inflammatory Disease. Green Top Guideline No.32. Royal College of Obstetricians & Gynaecologists. 2008. http://www.rcog.org.uk/womens-health/clinical-

guidance/acute-pelvic-inflammatory-disease-pid Accessed 20.04.11

Acute prostatitis

BASHH. UK National Guidelines for the Management of Prostatitis. British Association for Sexual Health and HIV. 2008. http://www.bashh.org/guidelines Accessed 20.04.11



http://www.sign.ac.uk/guidelines/fulltext/109/index.html



http://www.rcog.org.uk/womens-health/clinical-guidance/acute-pelvic-inflammatory-disease-pid

http://www.rcog.org.uk/womens-health/clinical-guidance/acute-pelvic-inflammatory-disease-pid

http://www.bashh.org/guidelines


26

SKIN/SOFT TISSUE INFECTIONS

Impetigo

Koning S, Verhagen AP, van Suijlekom-Smit LWA, Morris AD, Butler C, van der Wouden JC. Interventions for impetigo. Cochrane Database of Systematic Reviews. 2003. Issue 2.


Denton M, O‟Connell B, Bernard P, Jarlier V, Williams Z, Santerre Henriksen A. The EPISA study: antimicrobial susceptibility of Staphylococcus aureus causing primary or secondary skin and soft

tissue infections in the community in France, the UK, and Ireland. J Antimicrob Chemother 2008;61:586-588.

Eczema

Birnie AJ, Bath-Hextall FJ, Ravenscroft JC, Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema. Cochrane Database of Systematic Reviews. 2008. Issue 3.


National Collaborating Centre for Women's and Children's Health (2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years (full NICE guideline).

National Institute for Health and Clinical Excellence. www.nice.org.uk Accessed 20.04.11.

Cellulitis

Dilemmas when managing cellulitis. Drugs & Therapeutic Bulletin 2003;41:43-46. (Review of the management of cellulitis)

Eron LJ, Lipsky BA, Low DE, Nathwani D, TiceAD, Volturo GA. Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother 2003;52

(Suppl S1):i3-17.

Leg ulcer

O‟Meara S, Al-Khurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews. 2010. Issue 1.


Jeffcoate WJ, Harding KG. Review: Diabetic foot ulcers. Lancet 2003;361:1545-51.

Animal/human bites

Anderson CR. Animal bites. Guidelines to current management. Postgraduate Medicine 1992;92:134-49.

Goldstein EJC. Bites. In: Mandell GL, Bennett JE, Dolin R Eds. Principles and Practice of Infectious Diseases. Churchill Livingstone. 2000;2:3202-05.



http://www.nice.org.uk/



27

Medeiros I, Saconat H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). In: The Cochrane Library, 2006 Issue 4. Chichester. John Wiley & Sons Ltd.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001738/pdf_fs.html Accessed 20.04.11

CKS. Bites – human and animal. Clinical Knowledge Summaries. 2007. http://www.cks.nhs.uk/bites_human_and_animal Accessed 20.04.11. Clinical Knowledge Summaries: bites.

Conjunctivitis

Sheikh A and Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews 2006. Issue 2.


Rose PW, Harnden A, Brueggemann A, Perera R, Skeikh A, Crook D, Mant D. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind

placebo-controlled trial. Lancet 2005;366:37-43.

Reitveld RP, ter Riet G, Bindels PJ, Bink D, Sloos JH, van Weert HC. The treatment of acute infectious conjunctivitis with fusidic acid: a randomised controlled trial. Br J Gen Pract 2005;55:924-930.

Scabies

Strong M, Johnstone P. Interventions for treating scabies. Cochrane Database of Systematic Reviews. 2007. Issue 3


Dermatophytes

Crawford F and Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database of Systematic Reviews 2007. Issue 3.


Bell-Syer SEM, Hart R, Crawford F, Torgerson DJ, Tyrrell W, Russel I. Oral treatments for fungal infection of the foot. Cochrane Database of Systematic Reviews. 2002. Issue 2

www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003584/frame.html Accessed 20.04.11.

Evans EGV & Sigurgeirsson B for the LION Study Group. Double blind randomised study of continuous terbinafine compared with intermittent itraconazole in treatment of toenail onychomycosis. Brit

Med J 1999;318:1031-5.

Chung CH, Young-Xu Y, Kurth T, Orav JE, Chan AK. The safety of oral antifungal treatments for superficial dermatophytosis and onychomycosis: a meta-analysis. Am J Med 2007;120:791-798.

Chickenpox/shingles

Klassen TP and Hartling L. Aciclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database of Systematic Reviews. 2005. Issue 4.


Hope-Simpson RE. Postherpetic neuralgia. Brit J Gen Pract 1975;25:571-75. Study showing that incidence of post-herpetic neuralgia in a general practice population increases with age and is much

more common in over 60 year olds.


http://www.cks.nhs.uk/bites_human_and_animal







28

Johnson RW.Herpes zoster – predicting and minimizing the impact of post-herpatic neuralgia. J Antimicrob Chemother 2001;47:Topic T11-8.

Swingler G. Chicken Pox. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:267-79.

Wareham D. Postherpetic neuralgia. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:306-8.

Wood MJ, Kay R, Dworkin RH, Soong S-J, Whitley RJ. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: A meta-analysis of placebo-controlled trials. Clin Inf Dis

1996;22:341-7. Meta-analysis showing that oral acyclovir reduced post herpetic neuralgia pain. In patients over 50 years pain resolution occurred on average twice as fast.


29

Prescribing for children

Weight and height

The table below shows the mean values for weight and height by age;

these values may be used to calculate doses in the absence of actual

measurements. However, the child‟s actual weight and height might

vary considerably from the values in the table and it is important to see

the child to ensure that the value chosen is appropriate.

In most cases the child‟s actual measurement should be obtained

as soon as possible and the dose re-calculated. (Adapted from BNF for children 2006)

Approximate conversions and units

Age Weight

kg

Height

cm

Full-term neonate 3.5 50

1 month 4.2 55

2 months 4.5 57

3 months 5.6 59

4 months 6.5 62

6 months 7.7 67

1 year 10 76

3 years 15 94

5 years 18 108

7 years 23 120

10 years 30 132

12 years 39 148

14 years 50 163

Adult male 68 173

Adult female 56 163

lb kg stones kg ml fl oz

1 0.45 1 6.35 50 1.8

2 0.91 2 12.70 100 3.5

3 1.36 3 19.05 150 5.3

4 1.81 4 25.40 200 7.0

5 2.27 5 31.75 500 17.6

6 2.72 6 38.10 1000 35.2

7 3.18 7 44.45

8 3.63 8 50.80

9 4.08 9 57.15

10 4.54 10 63.50

11 4.99 11 69.85

12 5.44 12 76.20

13 5.90 13 82.55

14 6.35 14 88.90

15 95.25

Management of Infection Guidance for Primary Care in Ireland

Documents

Transcript of Management of Infection Guidance for Primary Care in Ireland