Stockport Community Antibiotic Guidelines 2014
Commissioned By Viren Mehta to update these guidelines, we hope you will find them useful. Anything
missing or not clear or controversial please email me (sarah.maxwell@stockport.nhs.uk).
Note we have put a very simplified version for just 3 main conditions (chest/cellulitis/urinary tract) that those of
you who have the care of nursing homes might like to print/down load and use – they are the end of the
guidelines.
Comments
Duration
Illness
Drug
Dose
Upper Respiratory Tract Infections
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals not
Influenza
recommended. Treat ‘at risk’ patients, ONLY within 48 hours of onset & when influenza is circulating in the
community or in a care home where influenza is likely and CMO has indicated prescription is appropriate
At risk: 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular
disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease.
Use 5 days treatment with oseltamivir 75 mg bd or if there is resistance to oseltamivir use 5 days zanamivir 10 mg
BD (2 inhalations by diskhaler).
For prophylaxis, see NICE. (NICE Influenza). Patients under 13 years see HPA Influenza link.
Acute sore
throat
Avoid antibiotics as 90% resolve in 7 days
without, and pain only reduced by 16
hours.
Modified Centor Scoring System involves
the following criteria:







temperature, >38°C: 1 point;
absence of cough: 1 point;
swollen, tender anterior cervical
nodes: 1 point;
tonsillar swelling or exudates: 1 point;
age 3-14 years: 1 point;
age 15-44 years: 0 points;
age 45 years: –1 point
Phenoxymethylpenicillin
500mg QDS
Or
1g BD
10 days
Penicillin Allergy:
Erythromycin
500mg BD/250mg QDS 10 days
If Centor score 3 or 4: consider 2 or 3 day
delayed or immediate antibiotics.
Swab the throat and check with the lab in
24 hours.
Acute Otitis
Media
Optimise analgesia
Avoid antibiotics as 60% are better in 24
hours without: they only reduce pain at 2
days and do not prevent deafness.
Only use antibiotics if high temperature
+/- vomiting.
Consider 2 or 3 day delayed or immediate
antibiotics for pain relief if:
< 2yrs with bilateral AOM
All ages with otorrhoea.
Acute Otitis
Externa
Acute
Rhinosinusitis
Amoxicillin
Child doses
5 days
1month-18years
Penicillin Allergy
Erythromycin
N.B. Some resistant
organisms
Mild otitis externa
First use aural toilet (if available) &
Acetic acid 2%
analgesia.
Refer to ENT when:
 Symptoms persist beyond 7-10 days with theModerate to severe
First line
 use of ear drops
Otomize ear spray
 External auditory canal is completely occluded
 or there is swelling beyond the ear canal. Second Line
If cellulitis or disease extending outside ear Sofradex ear drops
canal start oral antibiotics
See cellulitis guidelines below and refer.
Amoxicillin
Avoid antibiotics as 80% resolve in 14
days without, and they only offer marginal
benefit after 7 days.
Or
Use adequate analgesia
Doxycycline
Consider 7-day delayed or immediate
antibiotic when purulent nasal discharge.
Review after 24-48 hours, if not resolving,
refer.
500mg TDS
For paediatrics
Use amoxicillin or
erythromycin
40mg/kg/day in 3
divided doses. (Max
1.5g daily)
500mg QDS
Child doses
< 2yrs 125mg QDS
2-8yrs 250mg QDS
8-18yrs 250-500mg
QDS
5 days
1 spray TDS
5 days
1 spray TDS
7 days
3 drops TDS
7 days
500mg TDS, increase to 7 days
1g TDS if severe
200mg stat then
100mg daily
7 days total
Lower Respiratory Tract Infections
Note: Low doses of penicillins are more likely to select out resistance. Do not use quinolone (ciprofloxacin, ofloxacin) or cefalexin first line
due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms .N.B. Note C.difficile
risk
Acute Cough,
bronchitis
Antibiotic little benefit if no co-morbidity
Symptom resolution can take 3 weeks.
Consider 7-14 day delayed antibiotic with
symptomatic advice/leaflet.
If really must give
prescription, see under
Acute
exacerbation of
COPD
Treat exacerbations promptly with
antibiotics if purulent sputum and
increased shortness of breath and/or
increased sputum volume. A third of
exacerbations are due to viral infections
amoxicillin
500 mg TDS
5 days
or doxycycline
200 mg stat/100 mg
OD
5 days
Bronchiectasis
Before starting antibiotics send a sputum
sample for culture. Start empirical
antibiotics immediately.
If patient improving continue current
antibiotics, despite sputum culture results.
If not improving and sputum shows
growth discuss with microbiology for
alternative options.
IV antibiotics are available in the
community for appropriate patients
Use CURB65 score to help guide and
review:
Confusion (new)
Urea elevated above 7 mmol/L
Respiratory rate >= 30 breaths/min
Low Blood pressure, < 90 mm Hg systolic
OR =<60 mm Hg diastolic
Age >= 65 years.
Give immediate IM benzylpenicillin or PO
amoxicillin 1g if delayed admission/life
threatening.
IV antibiotics are available for the
treatment of CAP in nursing home
patients
May need additional staphylococcal cover.
Please discuss with microbiology.
Empirical treatment:
doxycycline
100 mg BD
14 days
IF CURB65=0-1 amoxicillin
500mg – 1g TDS
7 days
If atypical organisms
suspected, add
erythromycin.
500 mg QDS
7 days
200 mg stat/100 mg
OD
7 days
Communityacquired
pneumonia treatment in
the community
BTS 2009 Guideline
Pneumonia
post influenza
Meningitis
Suspected
meningococcal
disease
Acute exacerbation of
COPD antibiotics
or doxycycline
CURB65 ≥2 Refer to
hospital
Transfer all patients to hospital
IV or IM benzylpenicillin
Age 10+ years: 1200
immediately.
mg
IF time before admission, give
Children 1 - 9 yrs.: 600 (Ideally give IV.
benzylpenicillin, unless hypersensitive i.e.
mg
Only give IM if
history of difficulty breathing, collapse,
Children <1 yr: 300
vein cannot be
loss of consciousness, or rash.
mg
found)
HPA
If you want to consider alternative agents
please discuss with microbiology.
Prevention of secondary case of meningitis: Only prescribe following advice from Greater Manchester Public Health England on 08442250562
(ask for Duty Specialist) during office hours or outside normal working hours via the Health Protection on-call service who can be contacted
through Tameside Hospital switchboard on 0161 922 6000.
Urinary Tract Infections
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity. Please refer to leaflet Infection prevention guidelines for diagnosing a UTI in an older person.
Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely
Use prophylactic antibiotics for catheter changes if likely history of catheter-change-associated UTI or patient is immunosuppressed
For ESBL UTIs with no oral options for treatment, IV ertapenem is available for treatment at home.
Simple UTIs in
women i.e. no
fever or flank pain.
Complicated
UTIs
(No fever or flank
pain)
Can use urine dipstick to confirm clinical
diagnosis – culture not usually necessary.
Trimethoprim
Or
Nitrofurantoin
(Please note nitrofurantoin
is contraindicated in
eGFR<60ml/min)
For all men and female patients with
Trimethoprim
Diabetes, unresolved/
Or
recurrent/recent UTI, symptoms for > 7
Pivmecillinam
days,
use of diaphragm, age >65 yr, abnormal UT,
renally impaired, advise 7
days treatment with above antibiotics.
200mg BD
3 days
50mg QDS
3 days
200mg BD
7 days
400mg TDS
7 days
It is good practice to send urine for
culture in
these patients.
If resistant organisms or treatment failure
Discuss with microbiology.
N.B. In sexually active young men
consider possibility of Chlamydia therefore
also send urine for PCR testing.
If Chlamydia positive give Azithromycin 1g
stat dose and refer to GUM clinic for
further testing and partner tracing.
In all men also consider prostatic
involvement which may need a longer
course of treatment, see below.
Acute
Prostatitis
Epididymoorchitis
UTI in
pregnancy
UTI in children
Acute
Pyelonephritis
Assume tissue invasion – send a urine
sample for culture. Always treat as
‘complicated UTI.
N.B. In sexually active young men
consider possibility of Chlamydia therefore
send urine for PCR testing and give
Ofloxacin 200mg bd for 4 weeks instead.
If Chlamydia positive refer to GUM clinic
for further testing and partner tracing.
1st line
Ciprofloxacin
Always send urine for culture.
Consider mumps and consider TB if
patient is from a high prevalence country.
If most probably due to STI:
If <35years consider sexually transmitted
infections and send urine for PCR testing.
If >35 years infection will most likely be
due to enteric organisms but always take
a sexual history.
Send MSU for culture & sensitivity and
start empirical antibiotics
Avoid trimethoprim if low folate status or
on folate antagonist (e.g. antiepileptic or
proguanil)
ESBL positive
UTIs
2 Line
Trimethoprim
If sensitive
Ciprofloxacin
Plus
Doxycycline
200mg BD
4 weeks
500mg single dose
for 14 days
If most probably due to
enteric organisms:
Ciprofloxacin
500mg BD
for 10 days
First line: nitrofurantoin
50mg QDS
(Avoid near to term
approx. 36weeks)
Second line: trimethoprim
Or
cefalexin
Lower UTI: trimethoprim
or nitrofurantoin
Child ≥ 3 months: use positive nitrite to
start antibiotics Send pre-treatment MSU
for all.
if susceptible, amoxicillin
Second line: cefalexin
Imaging: only refer if child <6 months or
atypical UTI or recurrent UTI
Second line: cefixime
If admission not needed, send MSU for
culture & sensitivities and start antibiotics
If no response within 48 hours, admit.
First line
Ciprofloxacin
If the patient has a UTI positive for ESBL
there
are usually not many oral options for
treatment.
If the organism grown is sensitive,
fosfomycin
3g sachets can be used. This is
unlicensed. These may not be stocked by
community pharmacies so the patient
may have to wait a day for them to be
ordered in.
4 weeks
100mg BD
Child <3 months: refer urgently for
assessment
(Non pregnant adults)
500mg BD
nd
200 mg BD (off-label)
Give folic acid if 1st
trimester
All for 7 days
500mg TDS
Lower UTI
See BNF for dosage
3 days
Upper UTI
Upper UTI: co-amoxiclav
7 days
500mg BD
7 days
co-amoxiclav
Fosfomycin
Uncomplicated UTI:
500/125 mg TDS
14 days
Complicated UTI:
3g sachet alternate days
for three doses.
Second line
Renal impairment
eGFR 10-50
3g sachet stat.
3g stat. Can give 3g stat
then 3g after 72 hours for
complicated UTI.
eGFR less than 10
Avoid due to decreased
urinary excretion.
Metronidazole
2g
If the patient needs IV ertapenem they
can be referred for Home IV therapy.
Gastro-intestinal Tract Infections
Remember persistence in sending samples
Giardiasis
will be rewarded as cysts often release
Threadworms
episodically, but this is a condition that
always needs treatment.
Treat all household contacts at the same
time PLUS advise hygiene measures for
2 weeks (hand hygiene, pants at night,
morning shower) PLUS wash sleepwear,
bed linen, dust, and vacuum on day one.
If pregnant use hygiene methods
Day 1 and 8
Or
400mg TDS
>6 months: mebendazole
(off-label if <2yrs)
100mg
5 days
Stat
3-6 mths:
piperazine+senna
2.5ml spoonful
Stat, repeat
after 2 weeks
< 3mths: 6 wks hygiene
especially in 1st trimester.
Eradication of
Helicobacter
pylori
Consider test and treat in persistent
uninvestigated dyspepsia
Do not offer eradication for GORD
Do not use clarithromycin or
metronidazole if used in the past year for
any infection as increased risk of
resistance
It is essential that NO doses are missed
during eradication therapy.
Symptomatic
relapse
DU/GU relapse: retest for H. pylori using
breath or stool test OR consider
endoscopy for culture & susceptibility
First line
PPI (use cheapest) PLUS
clarithromycin (C)
AND
metronidazole (MTZ)
or amoxicillin (AM)
BD
250 mg BD with MTZ
500mg BD with AM
400 mg BD
1g BD
Second line
PPI PLUS
bismuthate (De-nol tab®)
PLUS 2 unused antibiotics
Amoxicillin
Metronidazole
tetracycline
NUD: Do not retest, offer PPI or H2RA
BD
120mg QDS
All for
7 days
Relapse
or MALToma
14 days
(Continue PPI
once daily after
course has been
completed)
1g BD
400mg TDS
500mg QDS
7 days
Diverticulitis
Severely unwell patients will need
hospitalisation.
Co-trimoxazole PLUS
Metronidazole
960mg BD
Cholecystitis/
Ascending
cholangitis
For less severe cases and follow on
treatment after discharge from hospital
the following antibiotics may be useful.
Co-trimoxazole
960mg BD
Infectious
diarrhoea
Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection.
Antibiotic therapy not indicated unless systemically unwell. If systemically unwell and campylobacter suspected (e.g.
undercooked meat and abdominal pain), contact microbiology.
Clostridium
difficile
Stop unnecessary antibiotics and/or PPIs.
Send stool sample ASAP.
1st/2nd episodes
Admit if severe: T >38.5; WCC >15, rising
creatinine or signs/symptoms of severe
colitis
3rd episode/severe
400mg TDS
7 days
Alternative would be doxycycline and
metronidazole but please discuss this with
microbiologist first.
metronidazole (MTZ)
oral vancomycin
400 mg TDS
10 days
125mg QDS
10 days
Do not give antidiarrhoeals
Travellers’
Diarrhoea
Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers’ diarrhoea.
If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private Rx). If quinolone
resistance high (e.g. south Asia): consider bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2
days treatment.
Genital Tract Infections
People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to
STI screening
GUM service. Risk factors: < 25y, no condom use, recent /frequent change of partner or symptomatic partner
Vaginal
candidiasis
Bacterial
vaginosis
All topical and oral azoles give 75% cure
clotrimazole
or oral fluconazole
500 mg pessary
150 mg orally
stat
stat
clotrimazole
100 mg pessary night
6 nights
clotrimazole 2% cream
Apply BD
7 days
Should be diagnosed clinically (fishy
discharge, high pH, positive KOH test)
oral metronidazole
400mg BD or
7 days
Stat
Less relapse at 4 wks with 7 day course of
metronidazole than 2g stat
or if cannot tolerate oral
metronidazole
Pregnancy; avoid oral azole, use
intravaginal for 7 days
Pregnant/breastfeeding: avoid 2g stat
clindamycin 2% cream
Treating partners does not reduce relapse
Trichomoniasis
Pelvic
Inflammatory
Disease
3rd or 4th
degree
perineal tear
post vaginal
delivery
Treat partners and refer to GUM service
In pregnancy or breastfeeding: avoid 2g
single dose metronidazole. Consider
clotrimazole for symptom relief (not cure)
if metronidazole declined or not
appropriate.
Refer woman & contacts to GUM service
Always test for gonorrhoea & chlamydia
28% of gonorrhoea isolates now resistant
to quinolones If gonorrhoea likely (partner
has it, severe symptoms, sex abroad) use
ceftriaxone regimen or refer to GUM
metronidazole
clotrimazole
metronidazole PLUS
ofloxacin
2g
5g applicatorful at
night
7 nights
400 mg BD
or 2 g (preferred)
7 days
stat
100 mg pessary at
night
6 nights
400 mg BD
400 mg BD
14 days
14 days
500 mg IM
400 mg BD
Stat
If high risk of Gonococci
Ceftriaxone PLUS
Metronidazole PLUS
14 days
14 days
doxycycline
100mg BD
Prophylaxis against infection will be provided by the acute trust in the form of single intravenous antibiotics prerepair followed by up to five days of co-amoxiclav when deemed necessary. The patient will be given the full course
from the ward. If infection develops (and this requires antibiotic treatment) please contact microbiology for advice.
Skin Infections
Impetigo
Oral flucloxacillin
For extensive, severe, or bullous impetigo,
use oral antibiotics
Reserve topical antibiotics for very
localised lesions to reduce the risk of
resistance
Reserve mupirocin for MRSA.
Eczema
Cellulitis
Mastitis and
ductal
candidiasis
Leg Ulcers
If penicillin allergic:
oral erythromycin
500 mg QDS
7 days
500 mg QDS
7 days
Topical treatment
Fusidic acid
TDS
5 days
MRSA only Mupirocin
TDS
5 days
If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve
healing. In eczema with visible signs of infection, use treatment as in impetigo
If patient afebrile and healthy other than
cellulitis, use oral flucloxacillin alone
If river or sea water exposure, discuss with
microbiologist.
Be alert for Group A strep. NSAIDS may
mask symptoms, if suspect please discuss
with microbiologist.
If febrile and ill, admit for IV treatment
(IV teicoplainin is available for home IV
treatment for non-facial cellulitis if patient
does not require admission otherwise)
NB if breast abscess, ensure surgeons are
involved as drainage will be needed
Ulcers always colonized. Antibiotics do
not improve healing unless active
infection
If active infection, send pre-treatment
swab
Review antibiotics after culture results.
flucloxacillin
If penicillin allergic:
500 mg QDS
erythromycin
or
clindamycin
500 mg QDS
facial: co-amoxiclav
500/125 mg TDS
Mastitis
Flucloxacillin
Add in clindamycin
if infection is more severe
or not settling
Penicillin allergy –
Clindamycin alone
1g QDS
All for 7 days.
If slow response
continue for a
further 7 days
600mg TDS
600mg TDS
Total duration
7-14 days
depending on
severity and
response.
600mg TDS
If active infection:
flucloxacillin
500 mg QDS
or erythromycin
500 mg BD
Grade 0-1 infection
Flucloxacillin +
Metronidazole
1g QDS
400mg TDS
Doxycycline +
Metronidazole
100mg BD
400mg TDS
All for 7 days.
If slow response
continue for a
further 7 days
It is active infection if cellulitis/increased
pain/pyrexia/purulent exudate/odour
Diabetic feet
If a wound is suspected to be infected, a
wound swab should be taken (or if
possible pus in a pot) and sent to
Microbiology for investigation. Antibiotic
cover may be requested at this time if it is
suspected that the wound is deteriorating.
A broad-spectrum antibiotic should be
prescribed, which should then be
changed if the Microbiology report
identifies the presence of a different
organism causing the infection.
If infection is grade 4 patient should be
admitted to hospital for intravenous
antibiotics
MRSA
Grade 2 (>2cm cellulitis)
Co-amoxiclav
Penicillin allergy / High C
diff risk
Doxycycline +
Rifampicin
Grade 3 Infection
Probes to bone
Ciprofloxacin +
Clindamycin
If high C diff risk
Doxycycline +
Rifampicin
625mg TDS
100mg BD
300-600mg BD
750mg BD
600mg TDS
Antibiotics may
be needed for 2
weeks, and
much longer if
osteomyelitis is
present or
suspected.
100mgs BD
300-600mgs BD
For MRSA screening and suppression, see Infection Prevention and control site.
For active MRSA infection:
Use antibiotic sensitivities to guide
treatment.
If severe infection or no response to
monotherapy after 24-48 hours, seek
advice from microbiologist on
combination therapy.
PVL S. aureus
Penicillin allergy:
7 days should
be prescribed
initially,
and
continued
as
necessary,
according
to
clinical signs of
infection
and
inflammatory
markers.
If active infection, MRSA confirmed by lab results, infection not severe
and admission not required
If active infection
confirmed
doxycycline
For 7 days
100 mg BD
Panton-Valentine Leucocidin (PVL) is a toxin produced by 2% of S. aureus. Can cause severe invasive infections in
healthy people. Send swabs and request to look for PVL producer if recurrent boils/abscesses or if not responding to
flucloxacillin. People most at risk are those with a close contact in communities, sport or poor hygiene. If worried re
this contact Microbiology urgently!
Bites
(Human, cat and
dog)
Scabies
Fungal
infection – skin
Fungal
infection –
fingernail or
toenail
Herpes
Zoster/Chicken
Pox and
Varicella
Zoster/Shingles
Headlice
Surgical toilet is very important. In the
case of animal bites a risk assessment of
tetanus and rabies should be made. For
human bites the risk of HIV/hepatitis B
and C should be assessed.
Special care and monitoring should be
given to those at greater risk e.g. elderly,
immunocompromised, asplenic and
diabetic patients.
Treat all home & sexual contacts within
24h.
Treat whole body from ear/chin
downwards and under nails. If under
2/elderly, also face/scalp
Terbinafine is fungicidal so treatment time
shorter than with fungistatic imidazoles.
If candida possible, use imidazole
If intractable: send skin scrapings. If
infection confirmed, use oral
terbinafine/itraconazole
Scalp: discuss with specialist
NHS Stockport only commissions
treatment for fungal nail infection if
1. The patient is immunocompromised; or
2. the patient has peripheral vascular
disease; or
3. the patient is diabetic; or
4. the nail is painful; or
5. the patient is due to undergo surgery
on that limb;
AND
6. There has been mycological
confirmation.
When terbinafine is the drug of choice
only oral terbinafine should be prescribed
as topical terbinafine has inferior efficacy.
Please ensure that BNF guidelines for
monitoring patients are followed and that
patients do not continue treatment for
longer than the recommended duration
in The BNF.
Terbinafine is more effective than azoles
Liver reactions rare with oral antifungals
If candida or non-dermatophyte infection
confirmed, use oral itraconazole
For children, seek specialist advice
If
pregnant
seek
advice
from
microbiologist (also seek advice if
pregnant patient in contact with chicken
pox case).
Clinical value of antivirals is minimal unless
secondary household case of chicken pox,
facial/ophthalmic shingles, or severe pain
and IF TREATMENT IS STARTED LESS
THAN
2
DAYS
AFTER
THE
COMMENCEMENT OF THE RASH.
Be wary of Group A Streptococcus
secondary infection in these patients.
Predictors of shingles post-herpetic
neuralgia include >50 years, severe pain,
severe skin rash and prolonged prodromal
pain.
Dimeticone is effective against head lice
and acts on the surface of the organism.
Malathion, an organophosphorus
insecticide, is an alternative, but resistance
has been reported.
A contact time of 8–12 hours or overnight
treatment is recommended for lotions and
liquids; a 2-hour treatment is not sufficient
to kill eggs.
In general, a course of treatment for head
Co-amoxiclav
625mg TDS
7 days
Doxycycline +
Metronidazole
100mg BD
400mg BD
7 days
permethrin
5% cream
malathion
0.5% aqueous liquid
2 applications
1 week apart
Topical terbinafine
BD
1-2 weeks
or topical imidazole
or (athlete’s foot only):
BD
topical undecanoates
(Mycota®)
BD
for 1-2 wks after
healing
(i.e. 4-6wks)
First line; terbinafine
250mg OD
fingers
toes
6-12 weeks
3-6 months
Second line: itraconazole
200mg BD
fingers
toes
7 days per
month
2 courses
3 courses
Superficial only:
amorolifine 5% nail
lacquer
1-2x/week
fingers
toes
Pencicillin allergy
If allergy:
If indicated:
aciclovir
Second line for shingles if
compliance a problem, as
ten times cost
800 mg five times a
day
valaciclovir
6 months
12 months
7 days
7 days
1 g TDS
(For children’s doses
see BNFC)
1st line
Dimeticone 4% lotion
2nd line
Malathion 0.5% liquid
Apply to dry hair and
leave for at least 8
hours then shampoo
Repeat
treatment after
7 days
Herpes Simplex
Genital / Lip
lice should be 2 applications of product 7
days apart to kill lice emerging from any
eggs that survive the first application. All
affected household members should be
treated simultaneously.
Head lice can be mechanically removed by
combing wet hair meticulously with a
plastic detection comb (probably for at
least 30 minutes each time) over the
whole scalp at 4-day intervals for a
minimum of 2 weeks, and continued until
no lice are found on 3 consecutive
sessions; hair conditioner or vegetable oil
can be used to facilitate the process.
http://www.insectresearch.com/ps_faqlic
e.htm
(Lip)
Topical aciclovir
5 times daily
Acute/reoccurrence (genital)
Aciclovir
400mg TDS
OR 200mg 5 times
daily
Prevention of recurrence (genital)
Aciclovir
5 days
Max 1 year
400mg BD
Eye Infections
Conjunctivitis
Most bacterial conjunctivitis is self-limiting.
Fusidic acid has no Gram-negative activity
and is not usually recommended as
increased risk of resistance
If severe: chloramphenicol
0.5% eye drops and
1% ointment
Second line:
Fusidic acid 1% gel
2 hourly for 2 days
then
4 hourly (whilst
awake)
at night
All for 48 hours
after resolution
BD
Dental Infections – For dental prescribers only
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 dental specialist. GPs should not be involved in dental treatment and advice should be sought from the patient’s
dentist. If they don’t have a usual dentist they can call the Stockport dental helpline on 0161 476 9649, or if out of hours NHS Direct on 0161 337
2246 or by calling 111 from a land line telephone.
Simple saline mouthwash
½ tsp salt dissolved in
Always spit
Temporary pain and swelling relief can be
Mucosal
glass warm water
out after use.
attained with saline mouthwash
ulceration and Use antiseptic mouthwash:
Rinse mouth for 1
Chlorhexidine 0.12-0.2%
Use until
If more severe & pain limits oral hygiene to (Do not use within
minute BD with 5 ml
inflammation
lesions
treat or prevent secondary infection.
diluted with 5-10 ml
30
mins
of
toothpaste)
(simple
resolve or less
water.
The primary cause for mucosal ulceration
pain allows
gingivitis)
or inflammation (aphthous ulcers, oral
Hydrogen peroxide 6%
oral hygiene
lichen planus, herpes simplex infection,
Rinse mouth for 2
(spit out after use)
oral cancer) needs to be evaluated and
mins TDS with 15ml
treated.
diluted in ½ glass
warm water
Commence
metronidazole
and
refer
to
Metronidazole
400 mg TDS
3 days
Acute
dentist for scaling and oral hygiene advice
necrotising
Use in combination with antiseptic
Chlorhexidine or
see above dosing in
Until oral
mouthwash if pain limits oral hygiene
hydrogen peroxide
mucosal ulceration
hygiene
ulcerative
possible
gingivitis
Pericoronitis
Dental abscess
Refer to dentist for irrigation &
Amoxicillin
500 mg6 TDS
3 days
debridement.
If persistent swelling or systemic
Metronidazole
400 mg TDS
3 days
symptoms use metronidazole.
Chlorhexidine or
see above dosing in
Until oral
Use antiseptic mouthwash if pain and
hydrogen peroxide
mucosal ulceration
hygiene
trismus limit oral hygiene
possible
Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of
antibiotics for abscess are not appropriate; Repeated antibiotics alone, without drainage are ineffective in preventing
spread of infection.
Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications.
Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway
obstruction, Ludwigs angina. Refer urgently for admission to protect airway, achieve surgical drainage and IV
antibiotics
The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for
most dental patients and should only be used if no response to first line drugs when referral is the preferred option.
If pus drain by incision, tooth extraction or Amoxicillin2 or
500 mg TDS
via root canal. Send pus for microbiology.
Phenoxymethylpenicillin
500 mg – 1g QDS
Up to 5 days
True penicillin allergy: use clarithromycin
review at 3days
True penicillin allergy:
or clindamycin if severe.
Clarithromycin
500 mg BD
If spreading infection (lymph node
Severe infection add
involvement, or systemic signs i.e. fever or
Metronidazole or if allergy 400 mg TDS
5 days
malaise) ADD metronidazole
Clindamycin
5 days
300mg QDS
Illness
Comments
Nursing home antibiotic guidelines
Drug
Dose
Duration of TX
Nursing home patients are at very high risk of Clostridium difficile infection so caution must be used when prescribing antibiotics. Antibiotics must
only be prescribed if absolutely indicated and for the shortest possible time.
Where possible, do not use the following classes of antibiotics which have been found to be more likely to give rise to Clostridium difficile infection:
Clindamycin, Cephalosporins, Quinolones, Beta lactam / beta lactamase inhibitors e.g. co-amoxiclav
Every patient prescribed PPIs should have these reviewed. If there is not a good indication for their use they should be stopped in a safe manner or
the dose reduced or changed to an H2 receptor antagonist. For certain conditions, patients can have once or twice daily IV antibiotics if
appropriate to avoid being admitted to hospital. See the table below for the options available.
As the patient is resident in a nursing
Doxycycline
100mg BD on day one
For 7 days
Pneumonia
home, pneumonia should be treated
then 100mg daily
as a hospital acquired pneumonia, as
thereafter.
including
IV treatment
different bacteria could be responsible
Review at 24-48hours
Ertapenem
aspiration
for the infection than in a simple
1g OD
community acquired pneumonia.
pneumonia
Cellulitis
Flucloxacillin
Or
Doxycycline
Or
Azithromycin
IV treatment
Teicoplanin
UTI
Trimethoprim
Or
Pivmecillinam
1g QDS
100mg BD
500mg OD
5 days then review
and may need a
further five days
1.2g stat then 600-800mg
OD
Review after 48hours
200mg BD
200mg tds
IV treatment
If ESBL positive UTI and
patient does not require
hospital admission
Ertapenem
7-14 days depending
on severity and
response
Treat for total 7 days in
women and 14 days in
men
1g OD
Antibiotic group August 2014
Review date August 2015
Adapted from HPA – Management of infection guidance for primary care for consultation and local adaptation.
Originally produced 2000, last reviewed Nov 2012, last revised Feb 2013.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1279888711402
References can be provided on request
Contact details for microbiologist at Stepping Hill Hospital Tel:01614194491 or email non urgent queries to
snt-tr.pathologyenquiries@nhs.net
IV antibiotics are available for certain conditions. To discuss treatment options or any concerns, please discuss with
microbiology.
For training resources and patient information leaflets please see RCGP Target antibiotics toolkit
(http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx)
Useful links
NICE clinical knowledge summaries CKS
British association for sexual health and HIV BASHH