Empirical guidance on the management of infection in primary care in adults

Empirical Guidance on the Management of Infection in Primary Care in adults
Aims ♦To provide a simple, best guess approach to the treatment of common infections. ♦To minimise the emergence of bacterial resistance in
the community ♦To promote the safe, effective and economic use of antibiotics
Principles of treatment
1. This guidance is based on the best available evidence but professional judgment should be used and patients should be involved in the
2. Antibiotics should be reviewed based on culture results. 3. A dose and duration of treatment for adults is suggested but may need modification for age, weight, height and renal function, always check for hypersensitivity history. In severe or recurrent or complicated cases send samples for microbiology and consider a larger dose or longer course. All treatments are oral or topical unless specified. Please refer to BNF for further dosing and interaction information. 4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 5. There is a lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice. 6. Consider a no, or delayed, antibiotic strategy for acute sore throat, common cold, acute cough and acute sinusitis. 7. Limit prescribing over the telephone to exceptional cases 8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA, ESBLs and other resistant organisms. 9. Avoid widespread use of topical antibiotics (especially those agents available as systemic preparations (eg fusidic acid) 10. Please refer to BNF for update on antibiotics in pregnancy and in breast feeding, take specimens to guide treatment , AVOID tetracycline’s, quinolones or high dose metronidazole (2g) unless specialist advice. 11. Where a "best guess" therapy has failed or special circumstances exist, microbiological advice can be obtained on 01908 243106/3404 12. Penicillin allergy: please take proper history and distinguish between anaphylaxis, just rash and intolerance. Important to inform patients and include in any letter to other healthcare workers. Comments
Tx duration
Upper Respiratory Tract Infections: Consider delayed antibiotic Prescriptions and Patient Information Leaflet
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, the use of antivirals is not
Influenza
recommended. Treat "at risk" patients only when influenza is circulating in the community, within 48 hours of start of symptoms. At risk: pregnant (including up to two weeks post partum), those 65 years or over, chronic respiratory disease including asthma & COPD, significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Patients over 13 years use oseltamivir 75mg oral capsule BD unless pregnant or there is resistance to oseltamivir, then use zanamivir 10mg (2 inhalations by diskhaler) and seek advice. For patients 13 years and under – seek further advice from the HPA Antivirals may be used for post-exposure prophylaxis during localized outbreaks in at risk people living in long-term residential or nursing homes on advice from the HPA/local microbiologist. (see NICE Influenza http://guidance.nice.org.uk/TA158) Majority of sore throats are viral; Avoid antibiotics as 90% resolve in 7 days without and pain is only reduced by 16
Pharyngitis/
hours. Patients with 3 or 4 centor criteria (Hx of fever, purulent tonsils, cervical adenopathy, absence of cough) have a 40%
Sore throat/
chance of Group A Beta Haemolytic Streptococci (GABHS) infection and wil benefit more from antibiotics, for these patients, Tonsillitis
consider offering a 2 or 3 day delayed prescription or immediate prescription NICE Clinical guideline 69
You need to treat 200 patients to prevent one case of otitis media or over 4000 patients to prevent one case of quinsy
Peterson et al. BMJ 2007;335:982-4. Spinks A et al. Cochrane Database of systematic reviews 2006
Treatment for 10 days with penicillin. Under treatment
500mg QDS or 1g BD
may lead to treatment failure or increased bacterial resistance. Amoxicillin should be avoided due to high risk Use ibuprofen or paracetamol to optimal effect. Acute Otitis
Illness resolves in 66% in 24 hours and antibiotics
Media (Child
have no effect. Antibiotics do not reduce pain in first 24
hours, subsequent attacks, perforation or deafness. Consider 2 or 3 day delayed or immediate antibiotic if: <2 years AND bilateral AOM (NNT4) or bulging You need to treat >4000 patients to prevent 1 case of mastoiditis Thompson et al Pediatrics 2009;123(2):424-30
First use aural toilet (if available) and analgesia.
Acute Otitis
Cure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid, therefore use as second line therapy if Neomycin sulphate Oral antibiotics are not as effective and should only be given if cellulitis or disease extending outside ear canal, then start oral antibiotics for cellulitis or refer.
Many are viral, optimize analgesia. 80% resolve in 14
days without antibiotics and they only offer marginal benefit Sinusitis
after 7 days (NNT15). Consider 7 day delayed or immediate antibiotics if purulent nasal discharge (NNT8), fever>38, maxillary toothache or raised ESR. Anaerobes are more common in persistent rhinosinusitis, therefore in chronic infection, use an agent with anti- Ciprofloxacin WITH 250-500mg BD
Comments
Tx duration
Lower Respiratory Tract Infections
Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones (ciprofloxacin
and ofloxacin) should not be used 1st line as they have poor activity against pneumococci. Reserve all quinolones including
levofloxacin for PROVEN resistant organisms. Bronchiectasis infective exacerbations: please see Map of Medicine.
Antibiotics have marginal benefits in healthy adults. Acute cough, Reserve use for patients with co-morbidities, consider 7-14
Bronchitis
day delayed antibiotic (from symptom onset) with advice, i.e. patient leaflet, and explain symptom resolution can take Doxycycline 3 weeks. Consider immediate antibiotics if >80 years and one of: hospitalization in last year, oral steroids, diabetic, congestive heart failure OR >65 with two of above. Small but significant benefit to antibiotic use. Use promptly if increased dyspnoea and increased purulent sputum exacerbation
If clinical failure to 1st line antibiotics or resistance factors eg: severe COPD, frequent exacerbations, 1st line antibiotics in last 3 months, co-morbid disease Use CRB65 score to help guide therapy. Each scores 1: Community
Confusion (AMT<8);
acquired
Respiratory rate >30/min;
pneumonia -
BP systolic <90 or diastolic ≤ 60;
treatment in
65 (age over 65)
community
Score 1-2: hospital assessment or admission Score 3-4: URGENT hospital admission
(Mycoplasma is rare in over 65's and epidemics occur every 4 years). Add Flucloxacillin for 14-21 days for Amoxicillin AND
suspected infection with staphylococci (in influenza or Urinary Tract Infections
Note: People >65 years: do not treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with
increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria and treatment may cause harm; only treat if
systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter –change associated UTII/
sepsis. Amoxicillin should not be used empirically as resistance is over 50% locally.
Uncomplicated
In women with severe or with 3 or more symptoms treat. In UTI in women
women with mild or 2 or less symptoms, use urine dipstick to exclude UTI. (-ve nitrite, leucocyte and blood gives 76% negative predictive value.) In women <65, cloudy urine, or +ve dipstick (nitrite with either blood or leucocytes has
92% positive predictive value), indicates treatment. 2nd Line depends on susceptibility of organism isolated. Multi-resistant bacteria producing ESBLs are increasing, perform UTI in men:
Consider prostatitis if recurrent UTI or if febrile UTI. Always urine cultures in treatment failures. Pivmecillinam/Mecillinam may send PRE-TREATMENT MSUs for all men. If symptoms be recommended if no history of penicillin allergy. Avoid
are mild/non-specific use negative nitrite and leucocytes to cephalosporins and quinolones, especially in the over 60s.
If necessary seek advice from the Microbiology Laboratory. Recurrent
Cranberry products, post coital or stand by antibiotics may reduce recurrence. Nightly prophylaxis is effective, but women 3
increases adverse effects and resistance. Cranberry Please see local guidance, breakthrough acute UTIs may indicate change in therapy according to culture results. Catheter
Only treat if symptomatic, send urine for culture as per local infections
Send MSU for culture and start empirical antibiotics. Short term use of Nitrofurantoin in pregnancy is unlikely to cause pregnancy
problems to the foetus. Avoid Trimethoprim in 1st trimester, Or Trimethoprim (not 200mg BD (off label) low folate status or taking folate antagonist (e.g. antiepileptic or proguanil). And avoid Nitrofurantoin at term – may produce neonatal haemolysis. If pregnant or penicillin allergy, please state on request form. Cefalexin use is not contra-indicated in pregnancy; however there is a small risk of C difficile infection. May require a test of cure 7 days after completion of Comments
Tx duration
Refer all children <3months old on basis of positive nitrite Lower UTI:
Children
to specialist immediately for IV antibiotics In all children 3 months or over, send MSU for culture and susceptibility, use positive nitrite to start antibiotics. Only refer children for subsequent imaging if <6 months old, or Upper UTI:
Pyelonephritis: Consider referral to paediatric
Consider admission, send MSU for culture and sensitivities Ciprofloxacin Pyelonephritis
and start antibiotics. Review culture results immediately and change antibiotics appropriately. If no response within Send MSU for culture and start antibiotics. 4 weeks prostatitis
treatment may prevent chronic infection. Quinolones are more effective due to greater penetration into prostate. Genital Tract Infections – Contact UKTIS for information on foetal risks if patient is pregnant 0844 8920909
Note: Refer patients with risk factors for STIs (<25 years, no condom use, recent (<12 month) or frequent change of sexual partner, previous
STI, symptomatic partner) to REACH sexual health services 0300 3038273 or Brook 0808 8021234 for screening and advice.

All topical and oral azoles give 75% cure. Candidiasis
In pregnancy, avoid oral azole, use intravaginal product A 7 day course of oral metronidazole is slightly more Bacterial
effective than 2g stat. Avoid 2g stat dose in pregnancy and Vaginosis
Topical treatment gives similar cure rates but is more expensive. Treating partners does not reduce relapse. Treat patient & refer to Sexual Health for follow up and Chlamydia
trachomatis/
In pregnancy or breastfeeding, azithromycin is most Urethritis
effective, but use is “off-label”. Tetracyclines are contraindicated in pregnancy. Due to lower cure rate in pregnancy, test for cure 6 weeks after treatment. Could be due to STD infections or enteric pathogens. Suspected
Appropriate samples need to be taken –MSU, samples for Epididymitis/
Chlamydia & Gonococcus if appropriate. orchitis
Refer to sexual health if due to STDs or under 35 years of Send MSU for culture and start antibiotics. 4 weeks prostatitis
treatment may prevent chronic infection. Quinolones are more effective due to greater penetration into prostate. Refer to Sexual Health. Treat partners simultaneously. In pregnancy or breastfeeding, avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure), consider if metronidazole declined. Essential to test for N. gonorrhoea (increasing antibiotic resistance), chlamydia and other organisms. Refer patient Inflammatory to Sexual Health for follow up and contact tracing.
Disease (PID)
If severe disease or if high risk of gonorrhoea eg partner has it, sex abroad, severe symptoms, multiple partners refer for IM Ceftriaxone. Uncomplicated infection only, for complicated cases seek Gonococcal
infection
Consider co-infection with Chlamydia & Gonococcus Patients need to be referred to Sexual Health for full STD screen and follow up. Comments
Tx duration
Skin / Soft Tissue Infections
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staph. Aureus (positive in MRSA & MSSA). It is associated with persistent
recurrent pustules and carbuncles or cellulitis. Send swabs for bacterial culture with request for PVL detection in these clinical scenarios. On
rare occasions it causes severe invasive infections, even in fit people. Risk factors include: close contact environments, contact sport, sharing
equipment, poor hygiene, travel and compromised skin integrity.
MRSA
Contact CHS Infection Control Team for advice on decolonization strategy. If active infection confirmed by laboratory, use sensitivities to guide treatment. If severe infection or no response to appropriate monotherapy from sensitivities after 48 hours, For extensive, severe or bullous impetigo use oral Impetigo
As resistance is increasing reserve topical antibiotics for very localised lesions. Reserve mupirocin for confirmed Mupirocin MRSA only
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. See local Guidance on Infected Eczema. If patient afebrile and healthy other than cellulitis, Cellulitis
flucloxacillin may be used as single drug treatment. If wound has been exposed to non-chlorinated water, (river, lake or sea) discuss with microbiologist. If febrile and ill, admit for IV treatment. STOP IF DIARRHOEA
In facial cellulitis only, use co-amoxiclav to cover Haemophilus influenzae from buccal microbes. Bacteria will always be present. Antibiotics do not improve healing unless active infection. Send properly taken culture
Leg Ulcers
swabs prior to empirical therapy. Antibiotics are only indicated if there is evidence of clinical cellulitis; increased pain;
enlarging ulcer, purulent exudate, foul odour or pyrexia. Treat as cellulitis above, refer to tissue viability team.
Review antibiotics after culture results Refer for specialist opinion if severe infection Surgical toilet most important. Assess tetanus and rabies Animal Bite
risk. Antibiotic prophylaxis advised for: cat bite/ puncture wound; bite involving hand, foot, face, joint, tendon, ligament, or in immunocompromised, diabetic, elderly, asplenic or cirrhotic patients. Macrolides are not If penicillin allergic:
recommended for animal bites because they do not adequately cover pasturella. Seek specialist advice for children under the age of 12 years (doxycycline Or Clarithromycin
Human Bite
Thorough irrigation is important. Antibiotic prophylaxis advised. Assess HIV/Hepatitis B&C and tetanus risk. Treat whole body from ear/chin down and under nails. If under 2/elderly, also include scalp, face and ears. Treat all household and sexual contacts within 24 hours. Dermatophyte Take nail clippings: start therapy ONLY if infection is confirmed by laboratory, (only 50% cases of nail dystrophy are fungal). Seek specialist advice in children. Use 5% amorolfine nail lacquer for superficial infection. Idiosyncratic liver reactions occur rarely with terbinafine. It seek specialist Itraconazole is also active against yeasts eg candida and Terbinafine is fungicidal, therefore shorter treatment time Dermatophyte than with a fungistatic imidazole. If candida possible, use infection of the imidazole. If intractable: send skin scrapings. If infection confirmed, use oral terbinafine/itraconazole. Discuss scalp infections with specialist. Community Dermatology Comments
Tx duration
Pregnant / immunocompromised / neonate seek URGENT Varicella
specialist advice for VZIG and antiviral treatment. Chicken pox: If >14yrs, immunocompromised, or severe
chickenpox
pain, or dense/oral rash, or secondary household case, or on steroids or smoker, consider aciclovir if treatment Herpes zoster/shingles: Always treat if ophthalmic
shingles
2nd line for shingles if compliance is a Non-ophthalmic shingles – treat if >50 yrs old AND <72
hours of onset of rash, (as post-herpetic neuralgia rare in <50 yrs), or Ramsey Hunt or eczema associated. Chickenpox direct contacts – If pregnant /
immunocompromised / neonate seek advice urgently. Local link for varicella zoster gammaglobulin (VZIG) use: Cold sores
Cold sores resolve after 7-10 days without treatment. Topical antivirals applied prodromally reduce duration by 12-24 hours. Gastro-Intestinal Tract Infections
Drugs fully absorbed (fluconazole, ketoconazole Antifungal agents absorbed from the gastrointestinal tract and itraconazole), however only fluconazole on the formulary Candidiasis
prevent oral candidiasis in patients receiving treatment for for unrestricted use. Drugs partially absorbed (miconazole and clotrimazole) are effective compared with placebo or no treatment. See BNF for licensed dosage

Eradication
Beneficial in DU, GU and low grade MALTOMA but not in GORD. In NUD, NNT is 14 for symptom relief. PPI full dose Plus
Helicobacter
Consider test and treat in persistent uninvestigated pylori
dyspepsia. Do not offer eradication for GORD. Do not use clarithromycin or metronidazole if used in past year for any PPI full dose PLUS
DU/GU Retest for Helicobacter using breath or stool test,
Managing
or consider endoscopy for culture and sensitivity. symptomatic
NUD: Do not retest, treat as functional dyspepsia with PPI
PLUS 2 unused
Send stool samples for cultures. Consider E coli 0157 in previously healthy children/adults with acute painful or bloody Infectious
diarrhoea and refer if clinically indicated. Antibiotic therapy not indicated unless patient systemically unwell Diarrhoea
/immunocompromised or antibiotic associated colitis, suggestive of Clostridium difficile (see below) infection. If campylobacter suspected (eg undercooked meat and abdominal pain), consider oral Erythromycin 250-500mg QDS for 5-7 days if indicated Send stool samples in suspected C difficile cases. In Clostridium
suspected/confirmed CDI stop unnecessary antibiotics difficile
and/or PPIs to re-establish normal flora. Do not use antiperistaltics due to risk of toxic megacolon. Review and discontinue any constipating i.e. opioid component of current analgesia/antitussives if possible. 70% respond to metronidazole in 5 days; 92% in 14 days. Severe if temp>38.5, WCC>15, rising creatinine or signs/symptoms of severe colitis, need hospital admission. Ensure patient is adequately re-hydrated. Cases who relapse may require tapering dose of antibiotic – discuss with Consultant Microbiologist and CHS IPC Team Only consider standby for people travelling to remote areas and for people in whom an episode of infective diarrhoea could be Traveller's
dangerous. If appropriate a PRIVATE prescription for Ciprofloxacin 500mg BD for 3 days can be supplied. In areas of high Diarrhoea
ciprofloxacin resistance (Asia), consider prophylactic bismuth subsalicylate (Pepto Bismol) 2 tablets QDS or for 2 days as treatment, this can be brought OTC. Patients developing diarrhoea should be advised to see a local doctor if no improvement or symptoms get worsen’’ Treat household contacts at the same time. Threadworms
On day 1: wash sleepwear, bed linen, vacuum and dust Advise morning shower/baths, hand hygiene and wearing Patient <3 months, extra hygiene precautions for 6 weeks. Comments
Tx duration
Meningitis
Suspected
Transfer all patients to hospital immediately. If time
Meningococcal before admission, and non-blanching rash, administer
Adult & child 10 yrs & over -
benzylpenicillin or cefotaxime, unless definite history of anaphylaxis, NOT intolerance/allergy. Ideally IV but IM if Age 12+ years -1g Child<12 years - 50mg/kg Prevention of secondary case of meningitis: Only prescribe following advice from local Health Protection Unit (0845 2799879) (9am-5pm)
Out of hours contact the on-call Public Health doctor via MKHFT switchboard on (01908) 660033
Conjunctivitis
Most bacterial infections are self-limiting (65% resolve
Conjunctivitis
on placebo by day 5). Treat if severe, symptoms usually
start unilaterally with red eye and yellow-white 0.5% drops plus
Fusidic acid has less Gram-negative activity DENTAL INFECTIONS – derived from the Scottish Dental Clinical Effectiveness Programme This guidance is not designed to be a definitive guide to oral conditions. It is for GPs for the management of acute oral conditions pending being
seen by a dentist or specialist. GPs should not routinely be involved in dental treatment, if possible, advice should be sought from the patient’s
dentist, who should have an answer-phone message with details of how to access treatment out-of-hours, or call 111
 Temporary pain and swelling relief can be ulceration and
inflammation
If more severe & pain limits oral hygiene to  The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen cancer) needs to be evaluated and treated. Acute necrotising Commence metronidazole and refer to dentist Metronidazole
ulcerative
gingivitis
Use in combination with antiseptic mouthwash peroxide Refer to dentist for irrigation & debridement. Pericoronitis
If persistent swelling or systemic symptoms Use antiseptic mouthwash if pain and trismus  Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics Dental abscess
for abscess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing spread of  Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications. odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction, Ludwig’s angina. Refer urgently for admission to protect airway, achieve surgical drainage and IV antibiotics If pus drain by incision, tooth extraction or via If spreading infection (lymph node involvement, or systemic signs i.e. fever or Metronidazole or if allergy Based on Guidance issued by the Health Protection Agency, 2001 comprehensively reviewed October 2012. Amended for local use by Naomi Fleming, Antibiotic Pharmacist contact 01908 243082, & Dr L Ragunathan, Consultant Microbiologist, MKHFT. First Issued: October 2000. Last Review: December 2012-March 2013. Review Date: March 2015.

Source: http://www.mkchs.nhs.uk/assets/_managed/editor/file/Infection%20Prevention%20&%20Control/policy%20&%20procedures/Empirical%20Guidance%20on%20the%20Management%20of%20Infection%20in%20Primary%20Care%20in%20adults%20%20Mar13.pdf