CNP017 Antibiotic Guide 2013-15

NHS Wiltshire CCG,
BaNES CCG & Swindon CCG
Guidelines for
Antibiotic Prescribing
in the Community
2013-15
Produced in collaboration with:

Dr Susan Murray, Consultant Microbiologist, Royal United Hospital
Bath NHS Trust,
Dr Susan Dawson, Consultant Microbiologist, Great Western Hospitals
NHS Foundation Trust,
Dr Stephen Cotterill, Consultant Microbiologist, Salisbury NHS
Foundation Trust,
Dr Rachel Hobson, Formulary Pharmacist, Wiltshire CCG,
Emma Taylor, Specialist Antibiotic Pharmacist, Salisbury NHS
Foundation Trust,
Sally Tipping, Specialist Antibiotic Pharmacist, Great Western Hospitals
NHS Foundation Trust,
Wendy Lloyd, Specialist Antibiotic Pharmacist, Royal United Hospital
Bath NHS Trust,
Dr Michael Moore, GP Three Swans Surgery, Salisbury,
Dr Elizabeth Tully, GP Northlands Surgery, Calne,
Cathy Dewdney, Specialist Paediatric pharmacist, Great Western
Hospitals NHS Foundation Trust,
Denise Reeves, Specialist HIV pharmacist, Great Western Hospitals
NHS Foundation Trust.
Thanks also to colleagues who commented on the guidance:
Dr Natasha Zurick, Consultant Paediatrician RUH,
Dr Tracey Farnon, Consultant Paediatrician SFT,
Louise Pitman, Paediatric pharmacist, SFT,
Dr Guy Rooney, Consultant in Genito-Urinary Medicine GWH,
Dr Sophie Forsyth, Consultant in Genito-Urinary Medicine GWH,
Dr Arnold Fernandes, Consultant in Genito-Urinary Medicine RUH,
Dr Angus Waddell, ENT Consultant, GWH,
Dr Tim Bates, Consultant Urologist, RUH.
Any comments, please contact: prescribingwiltshire@nhs.net
The format of these guidelines are based on those produced by
NHS Hampshire.
Preparation date: Feb 2013. Review Date: February 2015. Prepared by: Rachel Hobson.
Purpose of these guidelines

1. To provide clear authoritative advice on the empirical antibiotic treatment of common infections
2. To promote the judicious use of antibiotics
3. To minimize the emergence of bacterial resistance.
Decision to prescribe
The decision to prescribe an antimicrobial should always be clinically justified and the reason(s) should be recorded in
the patients medical record. It is important not to prescribe antimicrobials on a just in case basis.
Severe infection: This guide is not intended for use in severe infection when use of IV antibiotics is likely to be
necessary. Antimicrobials prescribed empirically in life-threatening situations where inpatient admission is necessary
should be administered within ONE HOUR of presentation and reviewed early in the light of microbiological results
and clinical progress and if appropriate changed following bacterial sensitivities. On community inpatient units, in
cases of severe infection, it may be more appropriate to follow hospital antibiotic treatment guidelines. All inpatient
prescriptions should have a documented indication and duration to review on the inpatient medicine chart.
Antibiotics should be discontinued only when clinically appropriate after a clinical review.
Plasma level monitoring: Certain IV antibiotics require plasma level monitoring eg Gentamicin,Vancomycin or
Teicoplanin. Please look at your local hospital intranet/formulary webpages for advice.
Individual patient and drug-specific factors
Grading of guidance recommendations
to consider before prescribing antibiotics in
(as per HPA guidance)
all cases include:
The strength of each recommendation is qualified by a
Previous antimicrobial history
letter in superscript.
Allergies (which can be severe and life threatening)
Recommendation
Study design
and side-effects
grade
Previous infection with multi-resistant organisms
Good recent systematic review of studies
A+
One or more rigorous studies, not combined
A Availability of and absorption by oral route.
One or more prospective studies
B+
Risk of development of healthcare associated
One or more retrospective studies
Binfections such as MRSA or C difficile infection
Formal combination of expert opinion
C
Drug interactions
Informal
opinion,
other
information
D
Pregnancy and breast-feeding
Recent travel history including any travel to malarious
areas in the past 2 years.
N.B. If a patient needs admitting to hospital, it is useful for the referral letter
to contain information about recent use (past 6/12) of antibiotics.
page 3
Principles of antibiotic use
13. Prevention of secondary case of meningitis: Only prescribe

following advice from Public Health Doctor.
1. This guidance is based on the best available evidence
South West (North) Health Protection Unit, Rivergate
available at the time of review and is intended for EMPIRICAL
House, 2 Rivergate, Bristol BS1. Contact number 0845
use of antibiotics. Its application must be modified by
504 8668 (option 1) and ask for Wiltshire/Swindon/Avon
professional judgement and patients should be involved in
locality Team (or leave a message).
treatment decisions.
2. A dose and duration of treatment is suggested but may need 14. Where a best guess therapy has failed or special
circumstances exist, microbiological advice can be obtained
modification for age, weight, renal function, liver function,
concomitant drugs and co-pathologies. In severe or recurrent
from the duty microbiologist at the following telephone
cases consider a larger dose or longer course with regular
numbers according to which hospital you refer to (see below):
review.
Great Western Hospitals NHS Foundation Trust
3. Have a lower threshold for antibiotic use in
Microbiology Department: 01793 604800.
immunocompromised patients or those with multiple
Microbiology Handbook: http://www.gwh.nhs.uk/wards-andmorbidities; consider culture and seek microbiological advice
services-a-z/a-to-z/pathology/further-information
if appropriate.
Royal United Hospitals NHS Trust Microbiology Department:
4. Prescribe an antibiotic only when there is likely to be a clear
01225 825428. Microbiology Handbook: http://www.ruh.nhs.
clinical benefit.
uk/For_Clinicians/departments_ruh/Pathology/documents/
5. Consult the BNF for Children for childrens doses of
Bristol_HPA_User_Manual.pdf
antibiotics.
6. Consider a no, or delayed, antibiotic strategy for acute sore
Salisbury Hospital NHS Foundation Trust Microbiology
throat, common cold, otitis media, acute cough, acute
Department: Lab results: 01722 336262 ext 4099 OR direct:
sinusitis and conjunctivitis (see appendix 2 (p70) for the
01722 429099; Clinical discussions (Monday to Friday 9am to
delayed antibiotic strategy patient information leaflet which
5pm): 01722 336262* ext 4105 OR direct: 01722 429105 *You
may be given to patients in consultations.).
can also ask switchboard to page duty consultant microbiologist
7. Limit prescribing over the telephone to exceptional cases.
bleep 1967 Clinical discussions (after 5pm M-F/ weekends/ bank
8. Use targeted antibiotics if possible. Avoid broad spectrum
holidays): Out-of-hours: 01722 336262. Ask switchboard to contact
antibiotics (eg co-amoxiclav, quinolones and cephalosporins)
duty Consultant Microbiologist on-call.
when narrow spectrum antibiotics remain effective, as they
increase risk of Clostridium difficile, MRSA and resistant UTIs. For non-urgent clinical questions or advice GPs can also use our
e-mail enquiry box at: shc-tr.microenquiries@nhs.net
9. Penicillin allergy- patients with a history of anaphylaxis,
Microbiology Handbook: http://nww.icid.salisbury.nhs.
urticarial rash or a rash immediately after penicillin
administration (type 1 allergy) should not receive a penicillin, uk/icid/diagnostics/pathology/pathologyhandbook/
cephalosporin or other beta-lactam antibiotic. Check before pathlabhandbookv32september2009.pdf
prescribing if you are unsure which class an antibiotic
For advice on Infection Control issues for Wiltshire CCG, see
belongs to. Discuss alternative antibiotic treatment with a
infection control resources:
microbiologist if a suitable alternative is not given in this
http://nww.wiltshire.nhs.uk/policiesandprocedures/
document. Also see the penicillin allergy appendix 4, p.85-86
infectioncontrolpolicyandprocedurebath/index.htm
for further information on which antibiotics are safe to use.
10. Avoid widespread use of topical antibiotics (especially those
agents also available as systemic preparations, (e.g. fusidic
acid).
11. In pregnancy AVOID tetracyclines, aminoglycosides,
quinolones, high dose metronidazole. Short-term use of
nitrofurantoin (avoiding use at term, theoretical risk of
neonatal haemolysis) is unlikely to cause problems to the
foetus. Contact your local hospital medicines information for
specialist advice.
12. We recommend clarithromycin as it is generally better
tolerated than erythromycin, patients are more likely to
comply with treatment as taken twice rather than four times
daily and generic tablets are similar cost.
page 4
For advice on Infection Control issues for Swindon CCG, the

SEQOL IP & C team for SEQOL services can be contacted on
01793 465509. The infection prevention and control policy and
procedures are the same for SwICC and community and are
available from: http://seqol.org/
Decontamination
It is important that the guidance given by NHS Wiltshire
and Swindon is followed to ensure that there is effective
decontamination of the working environment. See:
http://nww.wiltshire.nhs.uk/policiesandprocedures/
infectioncontrolpolicyandprocedurebath/2.0_
Decontamination_v1.pdf
Index
Paediatric Section
Adult section
Ear, Nose & Throat Infections

Acute Sore Throat
8-9
Acute Otitis Media
10-11
Respiratory Tract Infections
Influenza & other
respiratory infections
12
Community Acquired
Pneumonia 13-14
Central nervous System
Meningitis or suspected
meningococcal disease
15
Urinary Tract Infections

UTI
16-17
Gastro-Intestinal Infections
Giardiasis
18
Threadworms 19
Skin & Soft tissue Infections
Eczema 20
Impetigo 21
Animal Bites
22
Human Bites

23
Balanitis NEW

24
Ear, Nose & Throat Infections

Acute Sore Throat
25-26
Acute Otitis Externa
27
Acute sinusitis
28
Note about bronchiectasis NEW
Influenza 29
Acute bronchitis
30
COPD acute exacerbation
31
Community Acquired
Pneumonia 32
Central Nervous System
Meningitis or suspected
meningococcal disease
33

Uncomplicated UTI
UTI in pregnancy
Acute pyelonephritis
Cathether associated UTI
Recurrent UTI
35-36
37
38
39
40
Helicobacter pylori 41
Infectious Diarrhoea
42
Giardiasis 43
Clostridium difficile 44
Threadworms 45
Diverticultis NEW 46
Genito-Urinary Infections
Introduction 47
Vulvo vaginal Candidiasis
48
Bacterial Vaginosis
49
Chlamydia Trachomatis
50
Trichomoniasis 51
Pelvic Inflammatory Disease
52
Acute prostatitis
53
Epididymo-orchitis NEW 54
Skin & Soft Tissue Infections

Impetigo 55
Eczema 56
Cellulitis 57
Leg Ulcers
58
MRSA

59
Animal Bites
60
Human Bites
61
Conjunctivitis 62
Scabies 63
Dermatophyte infection of
finger or toenails
64
Dermatophyte infection of skin 65
Varicella Zoster & Herpes Zoster 66
Mastitis NEW 67-68
Dental Infections
Dental Infections NEW 69
Appendices
Appendix 1
Best practice in antimicrobial
drug prescribing
70-71
Appendix 2 NEW
Probiotics in the prevention of
antibiotic-associated diarrhoea
and clostridium difficle infection 72
Appendix 3
Delayed antibiotic
prescription strategy PIL
73-77
Appendix 4 NEW
Penicillin Allergy Chart
78-79
Appendix 5 NEW
Fosfomycin Info
80-81
Appendix 6 NEW
Educational Info.
82
page 5
Paediatric
Section
Paediatric
prescribing guidelines:
Ear Nose and Throat Conditions

Central Nervous System infections
Gastro-Intestinal tract infections
Skin & soft tissue infections
All prescribers are advised to follow

the NICE CG47 (May 2007) Feverish
illness in children Assessment &
initial management in children
younger than 5 years.
See: http://guidance.nice.org.uk/CG47
REMEMBER:
Dont prescribe antibiotics
unless there is a focus
Dont prescribe just because
there is a fever
In order to be able to distinguish
between the very sick and the less
unwell child please refer to the table
on the following page:
Table 1. Traffic light system for identifying likelihood of serious illness

Green low risk
Amber intermediate risk
Red high risk
Colour
N
ormal colour of skin, lips and
tongue
Pallor reported by parent/carer
Pale/mottled/ashen/blue
Activity
Not responding normally to social

cues
Wakes only with prolonged
stimulation
Decreased activity
No smile
No response to social cues

Appears ill to a healthcare
professional
Unable to rouse or if roused does not
stay awake
Weak, high-pitched or continuous cry
Nasal flaring
Tachypnoea:
RR > 50 breaths/minute
age 6-12 months
age > 12 months
Oxygen saturation 95% in air
Crackles
Grunting
Tachypnoea:
Moderate or severe chest indrawing
Reduced skin turgor
Responds normally to social cues

Content/smiles
Stays awake or awakens quickly
Strong normal cry/not crying
Respiratory
Hydration
Normal skin and eyes

Moist mucous membranes
Dry mucous membranes

Poor feeding in infants
CRT 3 seconds
Reduced urine output
Other
N
one of the amber or red symptoms
or signs
Fever for 5 days

Swelling of a limb or joint
Non-weight bearing/not using an
extremity
A new lump > 2 cm
A
ge 0-3 months,
temperature 38C
Age 3-6 months,
temperature 39C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status emilepticus
Focus neurological signs
Focal seizures
Bile-stained vomiting
CRT: capillry refill time

RR: respiratory rate
Table 1: Reproduced from NICE CG47 (May 2007) Feverish illness in children Assessment & initial management
in children younger than 5 years. http://guidance.nice.org.uk/CG47
page 7
PAEDIATRICS
Ear Nose and Throat Infections Acute Sore Throat (page 1 of 2)
Consider a delayed antibiotic strategy (see appendix 3, p.73)
When to treat
The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a 2 or 3 day
delayed strategy or immediate antibiotics depending on the clinical situation.1, A+ 90% of cases resolve in 7 days without
antibiotics & pain is only reduced by 16 hours.2A+ Also consider infectious mononucleosis.
A low centor score (0-2) has a high predictive value (80%) and indicates low chance of Group A Beta Haemolytic
Streptococci (GABHS). The likelihood of GABHS infection increases with increasing score and is between 25-86% with
a score of 4 and 2-23% with a score of 1, depending on age, local prevalence and seasonal variation. If a patient is
unwell with a centor score of 3-4 then the chance of developing Quinsy is 1:60. For patients with 3 or 4 centor criteria or
history of otitis media consider a 2 or 3-day delayed prescription or immediate antibiotics. The centor clinical prediction
score should be used to assist the decision on whether to prescribe an antibiotic, but cannot be relied upon for a precise
diagnosis. GABHS infection is most likely in the 5-15 year old age group and gets progressively less likely in younger or
older patients.
Centor Criteria (N.B. The score is NOT validated for use in children under 3 yrs)
Presence of each clinical feature scores 1 point:
History of fever
Tender anterior cervical lymphadenopathy
Absence of cough
Tonsillar exudates
When to refer
NB Children under the age of three months with a temperature of 38C or higher and children aged 3-6
months with a temperature of 39C or higher should be recognised as being in a high-risk group for
serious illness (see table 1, page 7). Refer to a paediatrician first to exclude more significant pathology
and to assess whether more intensive treatment is required.
When considering whether a patient needs to be referred for consideration of tonsillectomy, please ensure that you
consult the commissioning intentions of NHS Wiltshire (p27):
http://www.wiltshire.nhs.uk/Downloads/Policies/Corporate/Commissioning/055b_Clinical_Priorities_Policy_
Clinical_Content.pdf
or NHS Swindon as appropriate:
http://www.swindon.nhs.uk/Library/Publications/Policies/Clinical_Commissioning/Effective_Clinical_
Commissioning_Polices_List_October_2012.pdf
General advice on when it is appropriate to refer can be found in the SIGN guidance referenced below.
When to
investigate
Throat swabs should not be carried out routinely in the investigation of acute sore throat.
General Advice
Adequate analgesia & fluids will usually be all that is required. In children with sore throat, an adequate dose of paracetamol should be used as first line treatment for pain relief. Ibuprofen may be used as an alternative to paracetamol
but should not be given routinely to children with or at risk of dehydration.
Continued overleaf
page 8
PAEDIATRICS
Treatment
choices
First line:
PHENOXYMETHYLPENICILLIN po
Child 0-6 months: Refer for specialist assessment
Child 6 months - 1 year: 62.5mg QDS
Child 1-6 years: 125mg QDS
For 10 days.
Dose can be increased as per cBNF in severe infection if
necessary.
Available as 125mg/5ml or 250mg/5ml oral solution
If allergic to penicillin:
CLARITHROMYCIN po
Child 6 months-12 years:
Under 8kg: 7.5mg/kg BD
8-11kg: 62.5mg BD
12-19kg: 125mg BD
20-29kg: 187.5mg BD
30-40kg: 250mg BD
CHILD 12-18yrs (and over 40kg): 500mg BD.
For 5 days.
Available as 125mg/5ml or 250mg/5ml suspension
N.B Check for drug interactions!
Cautions
Ampicillin-based antibiotics, including co-amoxiclav virtually always cause maculopapular rashes in people with
glandular fever, and should therefore not be used for blind treatment of a sore throat (people who develop rashes
may mistakenly be labelled as penicillin allergic).
Evidence
The Altamimi meta-analysis shows that short-course (including 5 days clarithromycin) broad-spectrum antibiotics
are as efficacious as 10 day penicillin for sore throat symptom treatment and GABHS eradication. However, 10 day
phenoxymethylpenicillin remains the treatment of choice. 5 day clarithromycin should be reserved for those with true
penicillin allergy. Antibiotics other than phenoxymethylpenicillin and clarithromycin are no more effective and are more
expensive.
Antibiotics to prevent Quinsy NNT >40004BAntibiotics to prevent Otitis Media NNT= 2002A+.
References
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation.
March-October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summary Sore throat-acute www.cks.library.nhs.uk
SIGN (2010) Management of sore throat and indications for tonsillectomy: a national clinical guideline. Scottish
Intercollegiate Guidelines Network www.sign.ac.uk
NICE Clinical Guideline 69. Respiratory Tract Infections-antibiotic prescribing. July 2008. www.nice.org.uk
Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short-term late generation antibiotics versus
longer term penicillin for acute streptococcal pharyngitis in children. Cochrane database of systematic reviews 2012.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004872.pub3/abstract
page 9
PAEDIATRICS
Ear Nose and Throat Infections Acute Otitis Media (AOM) (page 1 of 2)
When to treat
Many are viral. The HPA states that you should avoid antibiotics as 60% are better in 24hrs without: they only reduce
pain at 2 days (NNT=15) and do not prevent deafness.4A+ The HPA suggest that you consider a 2 or 3-day
delayed1A+ or immediate antibiotics for pain relief if:
<2 yrs with bilateral AOM NNT=4 or bulging membrane and 4 marked symptoms 5-7+
All ages with otorrhoea NNT=3 8A+
However, local consensus suggests that Otitis media should not be treated with no antibiotic but with a delayed
prescription and with clear instruction to start the antibiotics after 3 days if the symptoms have not improved or earlier
with worsening symptoms. Rare, serious complications can occur if there is a prolonged delay in patients receiving
antibiotics.
When to refer
Admit for immediate specialist assessment:

Children under the age of three months with a temperature of 38C or higher and children aged 3-6
months with a temperature of 39C or higher should be recognised as being in a high-risk group for
serious illness (see table 1 on page 7). Refer to exclude more significant pathology and to assess
whether more intensive treatment is required.
Children with suspected acute complications of acute otitis media (AOM), such as meningitis, mastoiditis, facial
paralysis or who are systemically unwell.
Consider admitting: Children who are more unwell than might be expected.
Elective referral if: Persistent effusion or discharge, perforation not healed after 6 weeks, four or more episodes of
AOM in 6 months or impaired hearing after 3-6 months.
When to
investigate
No investigations are indicated for a first episode.
General Advice
Use NSAID or paracetamol for pain relief.A Inform the parent/carer that the average total duration of illness for untreated
acute otitis media, before and after seeing a healthcare professional, is 4 days. Offer reassurance that antibiotics are
not usually needed because they are likely to make little difference to symptoms, may have adverse effects (for example,
diarrhoea, vomiting, and rash), and can contribute to antibiotic resistance. Advise the person to re-consult if the condition
worsens or if symptoms are not starting to settle within 3 days of the onset of the illness.
Continued overleaf
page 10
PAEDIATRICS
Ear Nose and Throat Infections Acute Otitis Media (AOM) (page 2 of 2)
Treatment
choices
First Line
Amoxicillin po
Child 0-6 months: Refer for specialist
assessment
Child 6 months-1 year
125mg TDS
Child 1-5 years
250mg TDS
Child 5-18 years
500mg TDS
For 5 days.
Available as 125mg/5ml or 250mg/5ml
suspension
Please note these doses are
higher than those used for other
conditions, in line with BNF and HPA
recommendations. Mg per kg dosing has
been dose banded for ease of use. If child
is markedly underweight use a 40mg/kg
dosage in three divided doses.
Cautions
Admission or immediate referral if: Sudden dizziness with nystagmus, severe hearing loss (except simple
perforation), signs of meningitis, progression to mastoiditis. Elective referral if: Persistent effusion or discharge,
perforation not healed after 6 weeks, 4 or more episodes in 6 months or impaired hearing after 3 to 6 months Note:
children with serious craniofacial abnormalities or immune deficiencies that are not responding to primary care
management are at high risk of developing head and neck complications.
Evidence
Amoxicillin is as effective as other antibiotics in the treatment of AOM in RCTs, provided there has been no recent
treatment with amoxicillin.
Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, are less effective
treatment. There is no advantage in using an antibiotic to cover beta-lactamase producing organisms
(e.g. co-amoxiclav) in the initial treatment of AOM. Antibiotics to prevent mastoiditis NNT> 4000 9B-
References
NHS Clinical Knowledge Summary Otitis Media www.cks.library.nhs.uk

NICE CG47 (May 2007) Feverish illness in children Assessment and initial management in children younger than 5
years. http://guidance.nice.org.uk/CG47
Clarithromycin po
Child 0-6 months: Refer for
specialist assessment
8-11kg: 62.5mg BD
12-19kg: 125mg BD
20-29kg: 187.5mg BD
30-40kg: 250mg BD
CHILD 12-18yrs (and over
40kg): 500mg BD
For 5 days.
Available as 125mg/5ml or
250mg/5ml suspension
Second line
Co-amoxiclav po:
Child 0-6 months: Refer for
specialist assessment
6 months-1yr: 0.25ml/kg of 125/31
suspension TDS
1-6 yrs: 5ml of 125/31 suspension TDS
6-12 yrs: 5ml of 250/62 suspension
TDS
N.B. Above doses may be doubled in
severe infection
12-18 yrs: One 250/125 strength
tablet TDS; increased in severe infection
to one 500/125 strength tablet TDS.
For 5 days.
If patient is penicillin allergic,
please seek specialist advice.
page 11
PAEDIATRICS
Respiratory Tract Infections Influenza HPA Influenza
For treatment of patients under the age of 13 please see the HPA influenza link for the most up to date information:
http://www.hpa.org.uk/infections/topics_az/influenza/seasonal/pdfs/Treatmentflowchart.pdf
For guidance on the treatment of the following respiratory conditions in children please refer to the websites as
per below:
PAEDIATRICS
Other Respiratory Infections
Asthma
British Thoracic Society Guidelines. British Guideline on the management of asthma May 2008 (Revised June 2009):
http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
Clinical Knowledge Summaries http://www.cks.nhs.uk/asthma
Bronchiolitis
Scottish Intercollegiate Guidelines Network (SIGN) 91 Bronchiolitis in children.

http://www.sign.ac.uk/pdf/sign91.pdf
Croup
Clinical Knowledge Summaries. http://www.cks.nhs.uk/croup
Additional guidance that is of relevance:

NICE CG47 (May 2007) Feverish illness in children Assessment and initial management in children younger than
5 years. http://guidance.nice.org.uk/CG47
page 12
PAEDIATRICS
Respiratory Tract Infections Community Acquired Pneumonia (CAP) (page 1 of 2)
When to treat
It is important to consider that significant numbers of CAP cases in children will be of viral origin. However, bacterial and
viral pneumonia cannot be reliably distinguished from each other and so all children with a clear clinical diagnosis of
pneumonia should receive antibiotics.
When to refer
Arrange admission for a child with any high risk features from the assessment (table 1, page 7). Arrange urgent
admission if there are episodes of apnoea or if it is judged that the child is in severe respiratory distress.
For a child with any intermediate risk features, the need for hospital assessment will depend on clinical judgement, but
the threshold for arranging this should be low. Arrange hospital assessment if:
The carers are unable to cope well with the ill child.
There is uncertainty about the diagnosis.
A complication is suspected, such as a secondary bacterial infection in a child with viral wheeze or a foreign body.
The child is unresponsive to treatment, or there is any deterioration in the condition of the child after starting treatment.
The child has significant health problems such as chronic respiratory disease, congenital heart disease or is
immunocompromised.
The child does not improve after 48 hours of treatment.
Children who have oxygen saturations <92% should be referred to hospital for assessment and management.
Auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia
complicated by effusion.
Bacterial pneumonia should be considered in children up to 3 years of age when there is fever >38.5C together with
chest recession, nasal flaring and a respiratory rate >50. If wheeze is present in a pre-school child, primary bacterial
pneumonia is unlikely.
NB. Children under the age of three months with a temperature of 38C or higher and children aged 3-6
months with a temperature of 39C or higher should be recognised as being in a high-risk group for serious
illness (see table 1, page 7). Refer to exclude more significant pathology and to assess whether more
intensive treatment is required.
When to
investigate
There is no indication for microbiological investigation of a child with pneumonia in the community that is being treated.
Chest radiography should not be considered a routine investigation in children thought to have CAP.
General Advice
Treat a child who is feeling miserable with fever with either paracetamol or ibuprofen.
Encourage the child to take fluids regularly. For infants that are breastfed, continue breastfeeding as normal. Check on the
child regularly, including through the night and seek medical advice if the child deteriorates or the carers are unable to cope.
Continued overleaf
page 13
PAEDIATRICS
Respiratory Tract Infections Community Acquired Pneumonia (page 2 of 2)
Treatment
choices
Children 3 months-5 years: Amoxicillin first-line, clarithromycin for penicillin allergic children or if atypicals suspected.
Children 5-18 years: Amoxicillin can be used if S. pneumoniae is the suspected pathogen, but a macrolide may be used if an
atypical causative organism is suspected or known to be circulating in the community (see evidence section below).
Amoxicillin po
OR
Child 3 months-1 year
125mg TDS
Child 1-5 years
250mg TDS
Child 5-18 years
500mg TDS
For 7 days.
(std strengths).
Clarithromycin po
8-11kg: 62.5mg BD
12-19kg: 125mg BD
20-29kg: 187.5mg BD
30-40kg: 250mg BD
CHILD 12-18yrs (and over 40kg): 500mg BD
For 7 days.
Cautions
If staphylococci suspected, e.g. in pneumonia following viral respiratory tract infections e.g. influenza use co-amoxiclav
instead of amoxicillin and treat for 7 days.
Where Streptococcus pneumonia is known to be penicillin resistant or the patient is penicillin allergic, please discuss with
the microbiologist to determine the optimal antibiotic therapy.
Evidence
For children under 5 years of age:

Amoxicillin is the preferred first-line choice in children under 5 years of age because it is effective against the majority of
pathogens which cause community-acquired pneumonia in this group, is well tolerated, and is inexpensive.
A macrolide is considered an appropriate alternative if the child has an allergy to penicillin, because it covers a similar
spectrum of pathogens. However, amoxicillin is preferred for children that can tolerate it because there is significantly more
resistance of Streptococcus pneumoniae to macrolides. In addition macrolides are generally less well tolerated compared with
amoxicillin.
For children over 5 years of age:
Streptococcus pneumoniae is the most common pathogen causing pneumonia, but a significant proportion of pneumonias in
children over 5 years of age are caused by atypical infections. A macrolide is favoured when atypical infections are known to
be circulating in the community, because macrolides are more effective against these infections.
References
BNF for Children 2012-13 www.bnfc.org

NHS Clinical Knowledge Summaries. Cough acute with chest signs in children.
http://www.cks.nhs.uk/cough_acute_with_chest_signs_in_children
British Thoracic Society. Guidelines for the management of Community Acquired Pneumonia in Childhood. Thorax 2011;
66: (Suppl 2) http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAP%20
children%20October%202011.pdf
British Thoracic Society. Recommendations for the Assessment and Management of Cough in Children. Thorax 2008, 63; 1-15.
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Cough/Guidelines/cough_in_children.pdf
Kabra, S.K., Lodha, R. and Pandey, R.M. (2010) Antibiotics for community acquired pneumonia in children (Cochrane
Review). The Cochrane Library. Issue 3. John Wiley and Sons, Ltd. http://onlinelibrary.wiley.com/doi/10.1002/14651858.
CD004874.pub3/abstract;jsessionid=ADBA43EA2C752108CEB4018BD22B8435.d03t01
page 14
PAEDIATRICS
Central Nervous System Infections Meningitis or suspected meningococcal disease
NICE Bacterial meningitis and meningococcal septicaemia CG102
http://guidance.nice.org.uk/CG102/NICEGuidance/pdf/English
(NICE fever guidelines) www.nice.org.uk/cg047
When to treat
Suspected bacterial meningitis without non-blanching rash

Transfer children and young people with suspected bacterial meningitis without a purpuric rash directly to secondary care
without giving parenteral antibiotics. (See table 1, pages 12 & 13 of NICE CG102 (link provided above) for symptoms and
signs of meningitis and meningococcal septicaemia).
If urgent transfer to hospital is not possible (for example, in remote locations or adverse weather conditions), administer
antibiotics to children and young people with suspected bacterial meningitis.
Suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia)
Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, either in primary or
secondary care, but do not delay urgent transfer to hospital to give the parenteral antibiotics.
Treatment
choices
First line:
Benzyl Penicillin
Children <1yr: 300 mg
Children 1-9 yr: 600 mg
Children 10 yr and over: 1200mg
Ideally IV but IM if a vein cannot be found.
Cautions
Benzylpenicillin can be given unless history of anaphylaxis,B- a history of a rash following penicillin is not a
contraindication. Anaphylaxis is more likely if there is a history of immediate allergic reactions (such as difficulty in
breathing, collapse, generalised itchy rash) after previous penicillin administration A
Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia. This is a
legal requirement under the Health Protection (Notification) Regulations 2010.
(see HPA: http://www.hpa.org.uk/servlet/Satellite?c=Pageandchildpagename=HPAweb%2FPage%2FHPA
webAutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper)
Close contacts of meningococcal disease will require chemoprophylaxis following discussion with the HPU.
Evidence
Early treatment of suspected cases with benzyl penicillin is recommended in the UK to reduce case fatality B
References
SIGN 102 Management of invasive meningococcal disease in children and young people, May 2008
www.sign.ac.uk/pdf/sign102.pdf
BNF for children 2012-13. www.bnfc.org
Health Protection Agency Meningococcus Forum with Public Health Medicine Environmental Group, the Scottish Centre
for Infection and Environmental Health, CDSC Wales, CDSC Northern Ireland, the Association of Medical Microbiologists,
and the Community Infection Control Nurses Network. Guidelines for public health management of meningococcal
disease in the UK. Updated February 2011.
http://www.hpa.org.uk/infections/topics_az/meningo/meningococcalguidelines.pdf
NICE Bacterial meningitis and meningococcal septicaemia. CG102. (June 2010) http://guidance.nice.org.uk/CG102
If history of penicillin allergy

(NOT anaphylaxis):
Cefotaxime
Neonates: 50mg/kg
Children 1 month-12yrs:
50mg/kg (max 1g)
Child over 12yrs: 1g
Give as IV bolus or IM if vein cannot be found
page 15
PAEDIATRICS
Urinary Tract Infections (page 1 of 2)
NICE Urinary tract infection in children CG54
When to treat
The most common presentation in infants is an undiagnosed fever. Assess the risk of serious illness in line with Feverish
illness in children (NICE CG47; link in reference section). UTIs in children require prompt treatment to minimise the risk of
renal scarring.
All infants younger than 3 months with suspected UTI should be referred to paediatric specialist care and a urine sample
should be sent for urgent culture. These infants should be managed in accordance with NICE CG47.
Treat mildly unwell children over 3 months of age with oral therapy. Infants and children presenting with unexplained
fever of 38C or higher should have a urine sample tested as soon as possible, before antibiotics are initiated. For
symptoms and signs please refer to table1 in NICE CG54 (link in reference section).
Clinical differentiation between acute pyelonephritis/upper urinary tract infection and cystitis/lower
urinary tract infection:
Infants and children who have bacteriuria and fever of 38C or higher should be considered to have acute
pyelonephritis/upper urinary tract infection.
Infants and children presenting with fever lower than 38C with loin pain/tenderness and bacteriuria should also be
considered to have acute pyelonephritis/upper urinary tract infection.
All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have
cystitis/lower urinary tract infection.
If an infant or child is receiving prophylactic medication and develops an infection, treatment should be with a different
antibiotic, not a higher dose of the same antibiotic.
Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI.
Refer urgently for assessment seriously unwell child over 3 months of age for intravenous therapy. Also send a urine
sample for urgent culture. Refer to NICE CG54 (link in reference section) quick reference guide for the patient flow
pathway.
When to
investigate
Use a urine dipstick on all patients and refer to NICECG54 (table 3 and 4) for urine testing strategy. Only refer children
aged < 6 months or those with recurrent or atypical UTIs for imaging- see NICE CG54 for details (link in reference
section).
Urgent culture is the preferred method for diagnosing UTI in children >3/12 and <3 years; this should be used where
possible. Empirical antibiotics should be started as soon as the sample has been taken in children with specific urinary
symptoms.
For urine testing strategies and guidance on interpretation of microscopy results see NICE guidance CG54 (link in
reference section). See page 18 for which groups of patients need to have a urine sample sent for culture.
How to respond
to a positive lab
report
If urine culture yields a high concentration of a single species a diagnosis of UTI is likely. If culture yields multiple
species or low concentrations suspect contamination.
General advice
The parents or carers should be advised to bring the infant or child for reassessment if the infant or child is still unwell
after 24-48 hours. Children who have had a UTI should be encouraged to drink an adequate amount. Emphasize the
importance of not delaying voiding.
Continued overleaf
page 16
PAEDIATRICS
Urinary Tract Infections (page 2 of 2)
NICE Urinary tract infection in children CG54
Treatment
choices
N.B. Antibiotic
choice should be
guided by midstream culture and
sensitivities results
past and present as
different antibiotics
may be necessary
to those presented
here.
Trimethoprim po
Or
3-6 months: 25mg BD
6 months-6 years: 50mg BD
6-12 years: 100mg BD
12-18 years: 200mg BD
For 3 days if cystitis/uncomplicated lower UTI
50mg/5ml suspension is available.
If known to be susceptible by culture results, amoxicillin
can be used.
References

National collaborating centre for womens and childrens health. Clinical guideline. Urinary tract infection in children.
Diagnosis, treatment and long-term management. NICE CG54 Urinary tract infections in children (August 2007)
http://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdf
NICE CG47 (May 2007) Feverish illness in children Assessment and initial management in children younger than 5
years. http://guidance.nice.org.uk/CG47
Other reference
sources
UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720

ESBLs: www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942126367/
Clinical Knowledge Summary for UTI-children: www.cks.nhs.uk/urinary_tract_infection_children
Cefalexin po
3 months-1 year: 125mg BD
1-5 years: 125mg TDS
5-12 years: 250mg TDS
12-18 years: 500mg BD-TDS
For 3 days if cystitis/uncomplicated lower UTI
125mg & 250mg/5ml suspension or syrup are available.
N.B. Admit/consider referral if child is showing signs of acute pyelonephritis or upper UTI as may need
IV antibiotics-(treatment duration for 7-10 days).
Urine samples should be sent for culture:
In infants and children who have a diagnosis of acute pyelonephritis/upper urinary tract infection
In infants and children with a single positive result for leukocyte esterase or nitrite
In infants and children under 3 years
In infants and children with a high to intermediate risk of serious illness
In infants and children with recurrent UTI
In infants and children with an infection that does not respond to treatment within 2448 hours,
if no sample has already been sent
When clinical symptoms and dipstick tests do not correlate.
Reproduced from NICE Urinary tract infections in children CG54 (August 2007)
http://guidance.nice.org.uk/CG54
page 17
PAEDIATRICS
Gastro-intestinal infections Giardiasis
When to treat
Prescribe antibiotic treatment as detailed below for all children with CONFIRMED Giardiasis.
Paediatric doses of metronidazole are usually given as once daily doses for 3 days.
When to
investigate
Advise the patient to seek medical advice if:

Their condition doesnt improve within 48 hrs of treatment
Symptoms exacerbate or their condition worsens
Warning signs or symptoms develop (such as severe vomiting or dehydration, persistent fever, abdominal distension,
or frank blood in stools).
General advice
Advise parents/carers of the importance of reporting back to the GP if there are ongoing symptoms.
Treatment
choices
Metronidazole po:
Child 1-3 yrs: 500mg OD
Child 3-7 yrs: 600-800mg OD
Child 7-10 yrs: 1g OD
Child 10-18 yrs: 2g OD
For 3 days
(Alternatively, for child 10-18yrs, 400mg TDS for 5 days).
N.B. 200mg/5ml suspension is available.
Cautions
Following up post treatment & 6 weeks later (following a negative sample) is important because a patient may
occasionally need a second course of treatment.
All positive cases of Giardiasis should be notified to the local HPU. See HPA link for further information on notifiable
diseases:
http://www.hpa.org.uk/servlet/Satellite?c=Pageandchildpagename=HPAweb%2FPage%2FHPAweb
AutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper
References

Gastroenteritis management. NHS Clinical Knowledge Summaries.
http://www.cks.nhs.uk/gastroenteritis/management/quick_answers/scenario_adult/clinical_summary_
confirmed_microbiological_pathogen/giardiasis#
page 18
PAEDIATRICS
Gastro-intestinal Infections Threadworms
When to treat
Treat if threadworms have been seen or their eggs have been detected.
When to investigate
If infestation persists after hygiene measures have been continued for the recommended duration and treatment
of household, and if there are frequent recurrences.
How to respond to a Treat all members of the household at the same time (unless contra-indicated) to minimize
positive lab result
re-infestation.
General Advice
All members of the household must be advised to adhere to strict hygiene measures, including morning showers/
baths and hand hygiene for 2 weeks after treatment. Wear pants at night. Wash sleepwear, bed linen, dust and
vacuum on day 1.
Treatment choices
First line:
Mebendazole in all children >6 mths po
100 mg STAT
Repeat in 2 weeks if infestation persists.
N.B. This is OFF-LABEL for use in children under
2 years of age.
100mg/5ml suspension is available.
First-line for children aged 3-6 mths,

otherwise second-line if allergy or
contra-indication to mebendazole:
Piperazine 4g / senna 15.3mg sachet po
Child 3 months-1 year:
2.5ml spoon STAT in the morning, repeat after 2 weeks
Child 1-6 years:
5ml spoonful STAT in the morning, repeat after 2 weeks
Child 6-18 years:
1 sachet STAT in the morning, repeat after 2 weeks
(Make sachet up as per patient information leaflet
with water or milk)
Cautions
Treatment with an anthelmintic is contra-indicated in children <3 months. Use hygiene methods
instead for 6 weeks.
Evidence
Although it is generally accepted that mebendazole and piperazine have comparable efficacy (90-100% curerate), mebendazole is recommended first line based on expert opinion and its relatively better safety profile and
few contraindications compared with piperazine. It is also the drug of choice for children over the age of 6 months
in the childrens BNF, even though it is unlicensed in children under 2 years.
Neither mebendazole nor piperazine kills eggs, therefore adequate personal and environmental hygiene is
essential to prevent reinfestation from recently swallowed eggs, or eggs already in the environment.
References

Threadworms. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/threadworm
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local
adaptation. March-October 2012 www.hpa.org.uk
page 19
PAEDIATRICS
Skin & Soft Tissue Infections Eczema
When to treat
Using antibiotics, or adding them to steroids, in eczema encourages resistance and does not improve healing unless
there are visible signs of infection. If there are localized areas of infection a topical antibiotic in combination with
steroid can be considered. In infected eczema, use treatment as in impetigo section overleaf.
References
CG57 Atopic eczema in children December 2007 http://guidance.nice.org.uk/CG57
Atopic eczema. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/eczema_atopic
page 20
PAEDIATRICS
Skin & Soft Tissue Infections Impetigo
When to treat
For extensive, severe, or bullous impetigo, use oral antibiotics. Initiate empirical first line treatment. Children
less than 1 month of age need to be referred to a paediatric specialist for assessment, hence no
dosage advice given below.
When to investigate
Take swabs for culture if first line treatment fails.
How to respond to
a positive lab result
Alter treatment in response to culture and sensitivity results.
General advice
Educate patient about good hand washing and avoid scratching lesions. Patients should not share towels. Remain
off school for 48 hours after starting treatment. Review if lesions worsening or not improved at end of 7 days
treatment.
Treatment choices:
Generalised infection
First line:
Flucloxacillin po
Child 0-1 month: Refer for specialist assessment
Child 1 month-1 yr: 62.5mg QDS
Child 1-5 yrs: 125mg QDS
Child 6-10yrs: 250mg QDS
Child 10-18yrs: 500mg QDS
For 7 days.
Available as 125mg/5ml or 250mg/5ml oral solution
Please note that these doses differ from the cBNF
slightly in that we provide more specific doses (rather
than a range) according to a narrower age range.
Second line or if Penicillin allergic:

Clarithromycin po
Child 0-1 month: Refer for specialist assessment
Child <8kg: 7.5mg/kg BD
Child 8-11kg: 62.5mg BD
Child 12-19kg: 125mg BD
Child 20-29kg: 187.5mg BD
Child 30-40kg: 250mg BD
Child 12-18 yrs (and over 40kg): 500mg BD
For 7 days.
Localised infection
Fusidic Acid 2% topically TDS

For 7 days.
If MRSA isolated:
Mupiricin 2% ointment topically TDS
For 5 days.
Cautions
As resistance is increasing reserve topical antibiotics for very localised lesionsC or D

Reserve Mupirocin for MRSA.
Evidence
Systematic review indicates topical and oral treatment produces similar results.A+
References
adaptation. March-October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summaries Impetigo. www.cks.library.nhs.uk/impetigo
page 21
PAEDIATRICS
Skin & Soft Tissue Infections Animal Bites
When to treat
If the wound is less than 48 hours old and risk of infection is high. Antibiotics are not generally needed if the wound is
more than 2 days old and there is no sign of local or systemic infection. Children less than 1 month of age need
to be referred to a paediatric specialist for assessment, hence no dosage advice given below. Review at
24 and 48 hours. Surgical toilet most important.
Antibiotic prophylaxis is advised for:
All cat bites.
Bite involving hand, foot, face, joint, tendon, ligament
Wounds requiring surgical debridement;
People who are at risk of serious wound infection:
or suspected fractures.
- Immunocompromised
Wounds that have undergone primary closure.
- Diabetic
People with a prosthetic valve or a prosthetic joint.
- Cirrhotic
Puncture wound
- or asplenic patients
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles,
tendons, bones, the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds
requiring closure; bites that might need reconstructive surgery; devitalized wounds requiring debridement; bites where
the severity is difficult to assess; bites with severe cellulitis; infections not responding to treatment; people with an
increased risk of infection (see above); children with scalp wounds; bites to poorly vascularised areas.
When to
investigate
If there is evidence of infection, send pus or deep wound swab for culture before cleaning the wound.
Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.
How to respond to
General advice
If the wound has just occurred, encourage it to bleed.

Clean and irrigate the wound thoroughly with warm running water.
Treatment choices:
First line:
Co-amoxiclavB po
Child 1 month-1yr: 0.25ml/kg of 125/31 suspension TDS
Child 1-6 yrs: 5ml of 125/31 suspension TDS
N.B. Above doses may be doubled in severe infection
Child 12-18 yrs: One 250/125 strength tablet TDS;
increased in severe infection to one 500/125 strength
tablet TDS.
For 7 days.
Cautions
Assess tetanus and rabies risk. Consider need for tetanus prophylaxis. If it is a primate bite, discuss with virologist.
In the case of unusual animals, please discuss with microbiologist, particularly if persistent infection despite
treatment with co-amoxiclav, or if immunocompromised.
Evidence
Co-amoxiclav is effective against most bacteria isolated from domestic animal bites.
References
NHS Clinical Knowledge Summaries: Animal Bite http://www.cks.nhs.uk/bites_human_and_animal/
management/detailed_answers/managing_an_animal_bite
page 22
If penicillin allergic:
For children under 12 years of age,
contact your local microbiologist for advice.
Child 12-18 years (also see page 66):
Metronidazole po
200-400mg TDS (N.B. 200mg/5ml suspension is available).
PLUS
DOXYCYCLINE po
100mg BD
For 7 days. (N.B. Dispersible 100mg tablets are available).
PAEDIATRICS
Skin & Soft Tissue Infections Human Bites
When to treat
Antibiotic prophylaxis advised for all wounds less than 72 hours old even if there is no sign of infection. Review at
24 & 48 hours. Thorough irrigation is important. Children less than 1 month of age need to be referred to
a paediatric specialist for assessment, hence no dosage advice given below.
When to
investigate
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons,
bones, the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds
requiring closure; bites that might need reconstructive surgery; devitalized wounds requiring debridement; bites where
increased risk of infection (see above); children with scalp wounds; bites to poorly vascularised areas.
If there is evidence of infection, send pus or deep wound swab for culture before cleaning the wound. Admit anyone
who has a severe infection or who is systemically unwell as intravenous antibiotics may be required. Seek immediate
advice from a consultant in microbiology or infectious diseases for anyone considered to be at risk of HIV, hepatitis B or
C. Consider all people to be at risk unless the current status of the biter is known (rare). Consider if tetanus prophylaxis
is required. Tetanus after a human bite is extremely rare.
How to respond to
General advice
If the wound has just occurred, encourage it to bleed.

Clean and irrigate the wound thoroughly with warm running water.
Treatment choices:
First line:
Co-amoxiclavB po
1 month-1yr: 0.25ml/kg of 125/31 suspension TDS
N.B. Above doses may be doubled in severe infection
Child 12-18 yrs: One 250/125 strength tablet TDS;
increased in severe infection to one 500/125 strength
tablet TDS.
For 7 days.
Cautions
Assess HIV, hepatitis B and C risk. Consider need for tetanus prophylaxis.
Evidence
Co-amoxiclav is effective against the most commonly isolated organisms from human bites.
Metronidazole covers beta-lactamase-producing anaerobes. 80% of Eikenella corrodens are resistant to macrolides.
If a bite is 72 hours old and there is no sign that it has become infected, the risk of infection is likely to be low and
prophylactic antibiotics are probably not of value.
References
NHS Clinical Knowledge Summaries Human Bite: http://www.cks.nhs.uk/bites_human_and_animal/
management/detailed_answers/managing_an_animal_bite#-283292
If Penicillin allergic:
Metronidazole po
7.5mg/kg (max. 400mg) every 8 hours
(N.B. 200mg/5ml suspension is available).
PLUS
clarithromycin po
<8kg: 7.5mg/kg BD
8-11kg: 62.5mg BD
12-19kg: 125mg BD
20-29kg: 187.5mg BD
30-40kg: 250mg BD
12-18 yrs: (if over 40kg): 500mg BD
For 7 days.
page 23
PAEDIATRICS
Genital Tract Infections Balanitis NEW
When to treat
When infection is suspected or where symptoms are troublesome or do not resolve with good hygiene.
When to
investigate
A sub-preputial swab is not necessary to make a diagnosis, but can be useful for identifying the underlying cause.
Take a sub-preputial swab if balanitis is severe, recurrent or persists despite treatment.
If balanitis is recurrent and associated with inability to retract the foreskin refer to paediatric urology. If balanitis is
recurrent and no underlying cause can be identified, or balanitis persists despite treatment, refer to paediatric urology.
How to respond to
If symptoms are worsening or do not start to improve within 7 days, advise patient to stop topical hydrocortisone
(if prescribed) and in severe cases consider a sub-preputial swab (if not already done) to exclude or confirm a fungal
or bacterial infection and seek specialist advice.
General advice
Advise daily cleaning under the foreskin with lukewarm water, followed by gentle drying. Soap or other irritants should
not be used on the genitalia. Consider prescribing an emollient (such as emulsifying ointment) as a soap substitute.
If the child is still in nappies, ensure that they are changed frequently.
Treatment choices:
For suspected non-specific dermatitis, with or without candidal colonization:

Prescribe clotrimazole 1% or miconazole 2% cream BD until symptoms settle.
If inflammation is causing discomfort consider prescribing hydrocortisone 1% cream or ointment for up to 14 days
in addition to treatment.
References
1. British Association of Sexual Health and HIV 2008. UK National Guideline on the management of Balanoposthitis
http://www.bashh.org/guidelines
2. Clinical Knowledge Summaries- Balanitis.
http://www.cks.nhs.uk/balanitis/management/scenario_diagnosis_children/identifying_the_
cause#-448964
page 24
Ear Nose and Throat Infections
Adult Section
EN&T
Adult

When to treat
The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a 2 or 3
day delayed strategy or immediate antibiotics.1, A+ 90% of cases resolve in 7 days without antibiotics and pain is only
reduced by 16 hours.2A+ Suspect glandular fever in a patient with a sore throat that fails to resolve within several days.
Use Centor clinical prediction score to decide whether to prescribe an antibiotic. A low Centor score (0-2) has a high
predictive value (80%) and indicates low chance of Group A Beta -haemolytic Streptococci (GABHS). The likelihood of
GABHS infection increases with Centor score and is between 2-23% with a score of 1, and 25-86% with a score of
4, depending on age, local prevalence and seasonal variation. If a patient is unwell with a Centor score of 3-4 then
the chance of developing Quinsy is 1 in 60. Patients with 3 of 4 Centor criteria or history of otitis media consider a 2
or 3 day delayed prescription or immediate antibiotics.
Centor Criteria (presence of each clinical feature scores 1 point):
History of fever
Tender anterior cervical lymphadenopathy
Absence of cough
Tonsillar exudates
When to refer
When considering whether a patient needs to be referred for consideration of tonsillectomy, please ensure that you
consult the commissioning intentions of NHS Wiltshire CCG (p27): http://www.wiltshire.nhs.uk/Downloads/
Policies/Corporate/Commissioning/055b_Clinical_Priorities_Policy_Clinical_Content.pdf
or NHS Swindon CCG as appropriate: http://www.swindon.nhs.uk/Library/Publications/Policies/Clinical_
Commissioning/Effective_Clinical_Commissioning_Polices_List_October_2012.pdf
General advice on when it is appropriate to refer can be found in the SIGN guidance referenced below.
When to investigate
Throat swabs should not be carried out routinely in the investigation of acute sore throat.
General advice
Adequate analgesia and fluids will usually be all that is required. Ibuprofen 400mg three times a day is recommended
for relief of fever, headache and throat pain in adults with sore throat. If the patient is intolerant to ibuprofen or
should avoid NSAIDs, paracetamol 1g four times a day when required is recommended for symptom relief.
Treatment choices
First line:
Phenoxymethylpenicillin (Penicillin V) po
500mg QDS
For 10 days.
Pregnancy/
Breastfeeding
In pregnancy or breastfeeding, use phenoxymethylpenicillin (penicillin V) or erythromycin (rather than

clarithromycin).
Cautions
Ampicillin-based antibiotics, including co-amoxiclav virtually always cause maculopapular rashes in people with
glandular fever, and should therefore not be used for blind treatment of a sore throat (those who develop rashes
may also mistakenly be labelled as penicillin allergic).
Clarithromycin po
250-500mg BD
For 5 days. N.B Check for drug interactions!
Continued overleaf
page 25

Evidence
The Altamimi meta-analysis shows that short-course (including 5 days clarithromycin) broad-spectrum antibiotics
are as efficacious as 10 day penicillin for sore throat symptom treatment and GABHS eradication. However, 10 day
phenoxymethylpenicillin remains the treatment of choice. 5 day clarithromycin should be reserved for those with
true penicillin allergy. Antibiotics other than phenoxymethylpenicillin and clarithromycin are no more effective and
are more expensive.
Antibiotics to prevent Quinsy NNT >40004BAntibiotics to prevent Otitis Media NNT= 2002A+
References
NHS Clinical Knowledge Summary Sore throat-acute http://www.cks.nhs.uk/sore_throat_acute#
SIGN (2010) Management of sore throat and indications for tonsillectomy: a national clinical guideline. Scottish
Intercollegiate Guidelines Network. www.sign.ac.uk
Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short-term late generation antibiotics
versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane database of systematic
reviews 2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004872.pub3/abstract
page 26
Ear Nose and Throat Infections Acute Otitis Externa

When to
treat
Bacterial infection is usually secondary and commonly caused by Staphylococcus aureus or Pseudomonas aeruginosa. Upon
presentation symptoms are commonly itchiness of the ear canal and occasionally a painful ear canal. The treatment choices
described below apply to this presentation.
First use aural toilet (if available) and analgesia.
Consider
referral:
Refer to ENT consultant:

IMMEDIATELY if patient is systemically unwell and/or if acute complications of otitis media are suspected,
eg. meningitis, mastoiditis or facial paralysis.
Extensive cellulitis (and consider initiating oral antibiotics: Flucloxacillin 500mg QDS OR Clarithromycin 500mg BD for
1 week)2A+
Extreme pain, considerable discharge or swelling of the auditory canal and microsuction or ear wick insertion is required
Recurrent discharging and unexplained treatment failure, especially in diabetics and immunocompromised patients.
Admit urgently if malignant otitis externa is suspected, eg. if pain is more severe than the clinical signs suggest,
there is granulation tissue at the bone-cartilage junction of the ear canal or exposed bone in the ear canal or paralysis
of the facial nerve. Investigations are rarely useful. However if treatment strategy fails or otitis externa recurs frequently,
consider taking an ear swab for bacterial and fungal microscopy and culture. A swab is best taken from the medial aspect
of the ear canal under visualisation to reduce contamination.
How to
respond to a
positive lab
report
Interpretation is difficult: Reported bacterial susceptibility may not correlate with clinical outcomes as sensitivities are
determined for systemic not topical administration which achieves higher concentrations of antibiotic. Culture results do
not indicate if organisms are causing the disease or are contaminants. Fungal overgrowth is likely after using antibacterial
drops.
Treatment
choices
First line ear drops:

Ear-calm spray (acetic acid 2%) is an alternative for mild otitis
externa and can be purchased OTC for less than a prescription
charge for patients that pay for prescriptions.
Instil two to three drops TDS
For 7 days.
Second-line ear drops:

Otomize ear spray (neomycin 3250 units/ml/
dexamethasone 0.1%)
Instil two to three drops TDS
For 7 days (14 days if symptoms persist)
Pregnancy/
There is inadequate safety evidence of these products in pregnancy and breastfeeding. Use in pregnancy and lactation
Breastfeeding should only occur when it is considered to be essential by the physician, after careful assessment of the potential risks and
benefits. EMC: http://www.medicines.org.uk/emc/
Cautions
Aminoglycosides are contra-indicated with perforated eardrum but may be used cautiously by some specialists.
Antibacterial or corticosteroid drops should be used for about a week due to risk of secondary fungal infection or
sensitisation.
Evidence
Cure rates are similar at 7 days for topical acetic acid or antibiotic +/- steroid1A+ Recommendations are pragmatic and are
based on expert opinion. Since virtually all of the bacteria recovered are sensitive to the high concentrations of antibiotic
available in topical ear medications it is unnecessary to routinely culture specimens from the ears of people with acute
otitis externa.
References
March-October 2012 www.hpa.org.uk
NHS Clinical Knowledge Summaries. Otitis Externa. http://www.cks.nhs.uk/otitis_externa
page 27
Ear Nose and Throat infections Acute Sinusitis

When to treat
Many are viral. Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after
7 days NNT=15. 2,3A+ Consider 7-day delayed or immediate antibiotic when purulent nasal discharge (NNT=8 1,2A+),
maxillo-facial pain, fever and/or severe pain.
When to refer
Admit to hospital if there is severe systemic infection, or if a complication of sinusitis is suspected:

Intra-orbital involvement if there is peri-orbital oedema, a displaced globe, double vision, ophthalmoplegia, or reduced
visual acuity.
Intracranial involvement if there is a severe frontal headache, frontal swelling, symptoms or signs of meningitis, or
focal neurological signs.
C
onsider urgent referral to an ENT department if the person is suspected of having a sinonasal tumour (persistent
unilateral symptoms, such as bloodstained discharge, crusting, non-tender facial pain, facial swelling, or unilateral
nasal polyps).
C
onsider routine referral to ENT department if the person has frequent recurrent episodes of sinusitis which are
troublesome (such as more than three episodes requiring antibiotics in a year).
Consider referral for unremitting or progressive facial pain or if second line treatment has been ineffective.
Refer to dentist if suspected dental origin.
When to
investigate
Routine diagnostic tests are not helpful in the initial assessment of acute sinusitis.
Plain X-rays, blood tests, nasal swabs, sinus puncture, and transillumination of the sinuses are of limited value in primary
care, and are not recommended. Referral for computed tomography is not routinely recommended.
General advice Use adequate analgesia.

Treatment
choices
FOR SEVERE
CASES ONLY
First line:
AmoxicillinA po
1g TDS
For 7 days.
Pregnancy/
Breastfeeding
In pregnancy or breastfeeding, use amoxicillin or erythromycin (if penicillin allergy). Co-amoxiclav is also suitable if
appropriate. Monitor closely and refer for IV antibiotics if no improvement. BNF http://bnf.org/bnf/index.htm
Cautions
= high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients).
Admit if there are suspected complications (e.g. periorbital infection).
Evidence
Amoxicillin has similar efficacy to other recommended antibiotics.

Doxycycline has activity similar to amoxicillin. In persistent infection use an agent with additional anti-anaerobic activity,
eg. co-amoxiclav. 6B+ Erythromycin is less effective against Haemophilis influenzae, but recommended in pregnancy/
breastfeeding women due to its safety record.
References
NHS Clinical Knowledge Summary Sinusitis www.cks.library.nhs.uk/sinusitis

page 28
If allergic to Penicillin:
Doxycycline po
200mg STAT then 100mg OD
(200mg daily for severe infections)
For 7 days.
Persistent symptoms:
Co-Amoxiclav po
625mg tds
For 7 days.
If penicillin allergic and other options suggested have
been tried, contact microbiology for advice.

Bronchiectasis:
For guidance on how to treat
Bronchiectasis, please refer to the BTS
guideline for non-CF Bronchiectasis
a quick reference guide:
http://www.brit-thoracic.org.uk/
Portals/0/Guidelines/Bronchiectasis/
BronchiectasisQFG_web.pdf
Adult Section
RTI
Adult
Respiratory Tract Infections Influenza HPA Influenza

When to treat
Annual vaccination is essential for all those at risk of serious complications of influenza. Immunize
between September to early November ideally. For otherwise healthy adults, antivirals are not recommended. Treat at
risk patients, only when influenza is circulating in the community or in a care home where influenza is likely, within
36/48 (zanamivir/oseltamivir) hours of onset. For post exposure prophylaxis, please consult most recent HPA guidance:
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131466016
At risk:
65 years or over
Chronic respiratory disease (including COPD and asthma)

Chronic cardiovascular disease (not hypertension)
Immunocompromised
Diabetes mellitus
NHS staff dealing face to face with patients
Chronic neurological disease

Renal or liver disease
Pregnant (including up to 2 weeks post partum)
Residents in care/nursing homes
Household contacts of immunocompromised individuals
When to
investigate
Routine follow up in otherwise healthy patients is not necessary, but advise the person they should:
Return if no improvement after 1 week or they are deteriorating;
Seek urgent medical attention if they develop shortness of breath, pleuritic chest pain or haemoptysis;
Have a low threshold for seeking help if they are caring for a young child or baby with influenza, as children cannot
accurately communicate their symptoms.
In at risk groups, consider follow up (particularly in frail people) after 1 week to confirm symptoms are improving and to
exclude the development of secondary complications.
Treatment
choices
First line:
Oseltamivir Tablets po:
Treatment dose: 75mg BD
For 5 days.
Prophylaxis dose: 75mg OD
For 10 days (See NICE Influenza).
Pregnancy/
Breastfeeding
Oseltamivir and Zanamivir should not be used in pregnancy unless the expected benefit to the mother is thought to
outweigh any possible risk to the foetus.
In breastfeeding, consider the pathogenicity of the circulating influenza virus strain and the underlying condition of the
lactating woman. Administration of oseltamivir may be considered, where there are clear potential benefits to lactating
mothers. Use of Zanamivir is not recommended in breastfeeding due to there being no information available. See SPC
for further information: EMC http://www.medicines.org.uk/emc/
Cautions
Ensure you have looked at the most up to date information via the HPA influenza link provided in this monograph.
Evidence
After immunisation, antibody levels may take up to 10 to 14 days to reach protective levels.
In healthy individuals, seasonal influenza is an unpleasant but usually self-limiting disease with recovery in 2-7 days.
Treatment after 48 hours from symptom onset is an off-label use of oseltamivir and clinical judgement should be exercised.
References
If there is resistance to oseltamivir or severely

immunocompromised:
Zanamivir Diskhaler:
Treatment dose: 10mg (2 inhalations) BD
For 5 days. (10 days if resistance is suspected)
Prophylaxis dose: 10mg (2 inhalations) OD
For 10 days.
Other reference HPA seasonal influenza:

sources
http://www.hpa.org.uk/infections/topics_az/influenza/seasonal/pdfs/Treatmentflowchart.pdf
NICE Influenza (prophylaxis) www.nice.org.uk/guidance/index.jsp?action=byIDando=11736
page 29
Respiratory Tract Infections Acute Bronchitis

When to treat
Consider 7 day delayed antibiotic with symptomatic advice/leaflet. 1,5A- Care should be taken to exclude
a differential diagnosis of pneumonia. Antibiotics are NOT indicated in people who are otherwise well. Routine
follow up is not necessary. However patients should be advised to seek advice if their condition deteriorates
significantly or symptoms persist for longer than 3 weeks.
Consider antibiotics for those with pre-existing conditions that impair their ability to fight infection or are likely to
deteriorate with acute bronchitis.
Consider immediate antibiotics if >80 years of age with one of the following:
Hospitalisation in the past year
Diabetic
On oral corticosteroids
CHF
OR >65 years of age with 2 of the above.
When to investigate
Not normally necessary. Re-examine if people have deteriorated to exclude pneumonia.
General advice
Patients should be advised to use paracetamol or ibuprofen as required, drink plenty of fluids and to stop
smoking. Advise patients that resolution of symptoms can take up to 3 weeks.
Treatment choices
First line:
Amoxicillin po
500mg TDS
For 5 days.
Pregnancy/
Breastfeeding
Amoxicillin is suitable to use in pregnancy and breastfeeding.

Contact microbiology if this is not effective or is unsuitable due to penicillin allergy.
Evidence
RCT evidence suggests a moderate benefit from antibiotics in acute bronchitis which is a self-limiting condition.A+
This should be considered in the wider context of drug-induced adverse effects, and the likelihood of resistance
developing. There is no evidence from controlled trials to support the use of one antibiotic over another. Choice
should reflect in vitro efficacy against likely pathogens especially S. pneumoniae and H. influenzae. Amoxicillin covers
most bacteria involved in acute bronchitis, including penicillin-intermediate resistant S. pneumoniae. Doxycycline is
active against most of the bacteria that cause bronchitis, including H. influenzae and, less commonly encountered,
Mycoplasma pneumoniae.
Low doses of penicillins are more likely to select for resistance. The quinolones ciprofloxacin and ofloxacin have poor
activity against pneumococci.
Patient leaflets can reduce antibiotic use.B+ There is also more evidence to suggest that delayed prescriptions appear
to be effective in modifying reconsultation behaviour, particularly in those with a prior history of antibiotic prescription
for LRTI.
References
National Library for Health Clinical Knowledge Summary Chest infections.

http://www.cks.nhs.uk/chest_infections_adult
Moore M, Little P, Rumsby K, Kelly Jo, Watson L, Warner G, Fahey T, Williamson Ian. Effect of antibiotic prescribing
strategies and an information leaflet on longer-term reconsultation for acute lower respiratory tract infection. Br J
Gen Pract. 59; (567) October 2009 : 728-734(7)
page 30
Second line if allergic to Penicillin:

Doxycycline po
200mg stat then 100mg OD
For 5 days.
Respiratory Tract Infections COPD Acute Exacerbation

When to
treat
Origin: 30% viral, 30-50% bacterial, rest undetermined. Treat exacerbations with antibiotics promptly if there is purulent
sputum AND increased shortness of breath and/or increased sputum volume. Patients with exacerbations without more
purulent sputum do not need antibiotic therapy unless there is consolidation on a CXR or clinical signs of pneumonia.
Most people do not need follow up during the exacerbation, but if there are signs of deterioration reassess to see if
admission to hospital is appropriate. Routine follow up in less severe exacerbations (if needed) could be via telephone.
When to
investigate
Sending sputum samples for culture in primary care is of very limited value and not routinely recommended because
empirical therapy is effective and should be prescribed promptly if the sputum is purulent. Pulse oximetry is of value if
there are clinical features of a severe exacerbation. Consider hospital admission if oxygen saturation <90%.
Treatment
choices
First line:
Amoxicillin po
500mg TDS
For 5 days.
Second line or if allergic

to penicillin:
Doxycycline po
(200mg OD for severe
infections)
For 5 days.
If allergic to penicillin
& tetracyclines
contra-indicated:
Clarithromycin po
500mg BD
For 5 days.
N.B Check for drug
interactions!
If clinical failure to first line

antibiotics or if resistant risk
factors (see evidence section):
Co-Amoxiclav po
625mg tds
For 5 days.
= high risk for causing C. Difficile
infection (see page 70 (appendix 1) for
information on high-risk patients).
Pregnancy/
In pregnancy or breastfeeding, use amoxicillin or erythromycin (rather than clarithromycin). Co-amoxiclav is also suitable if
Breastfeeding appropriate. BNF http://bnf.org/bnf/index.htm
Cautions
Assess severity of exacerbation. Measure blood pressure, respiratory rate, and oxygen saturation (by pulse oximetry), and
assess the need for hospital admission based on the clinical findings and social circumstances. The following physical signs
are features of a severe exacerbation (consider hospitalisation): marked dyspnoea and tachypnoea; pursed-lip breathing;
use of accessory muscles at rest; acute confusion; new-onset cyanosis or peripheral oedema; marked reduction in activities
of daily living.
Evidence
A meta-analysis of 21 double-blind RCTs involving 10,698 patients, concluded that a short course (5 days) of antibiotic
treatment was as effective as the traditional longer treatment in patients with mild to moderate exacerbations of chronic
bronchitis and COPD (see HPA document below for reference). Risk factors for antibiotic resistant organisms include comorbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months. Comparative trials have not shown one
antibiotic to be superior to another. Evidence suggests the worse the severity of exacerbation (lung function impairment,
purulence of sputum) then the greater the degree of benefit from antibiotics.
References
National Library for Health Clinical Knowledge Summary Chronic Obstructive Pulmonary Disease
http://www.cks.nhs.uk/chronic_obstructive_pulmonary_disease/management/scenario_acute_exacerbation
March- October 2012. www.hpa.org.uk
Chronic Obstructive Pulmonary Disease. National clinical guideline on management of chronic obstructive pulmonary
disease in adults in primary and secondary care Thorax 2004:59 (Suppl. 1);i1-232. www.thorax.bmj.com
Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care (partial update).
NICE Clinical Guideline CG101 June 2010. http://www.nice.org.uk/nicemedia/live/13029/49397/49397.pdf
Global Initiative for Chronic Obstructive Lung Disease. Guidelines for COPD.
http://www.goldcopd.org/Guidelines/guidelines-resources.html
page 31
Respiratory Tract Infections Community Acquired Pneumonia BTS BTSpdf

When to treat Assess CRB-65 score:
Each scores 1:
Confusion (AMT <8)
Respiratory rate 30 breaths/min
BP systolic 90mmHg or diastolic
60mmHg
Age 65 yrs
Score 3-4 admit urgently

Score 1-2 arrange same day secondary care assessment or admission
Score 0 likely to be able to treat at home but use clinical judgement
Start antibiotics immediately.B If no response in 48 hours consider admission or
add clarithromycin to amoxicillin.
Give immediate IM benzylpenicillin 1.2g or 1g amoxicillin poD if delayed
admission/life threatening. If patient is penicillin allergic, IM cefotaxime can be
given if non-severe penicillin allergy.
N.B. If aspiration is suspected, add metronidazole to antibiotic regimen.
When to
investigate
Routine microbiological investigations are not recommended. Examination of sputum for M. tuberculosis should be
considered for patients with a persistent productive cough, especially if malaise, weight loss or night sweats, or risk
factors for tuberculosis (e.g. ethnic origin, social deprivation, the elderly) are present. Send sputum sample if possible,
PRE-treatment. If atypical cause is suspected consider doing serology (acute AND convalescent 10-14 days later) OR
urinary antigen testing (e.g. legionella/pneumococcal) for example during epidemic mycoplasma years, or when there is a
particular clinical or epidemiological reason (mycoplasma and Q fever).
Treatment
choices
IF CRB65=0:
AMOXICILLINA+ po
500mg-1g TDS
For 7 days.
OR
IF CRB65=1 and AT HOME:

AMOXICILLIN
AND
500mg-1g TDS
For 7-10 days.
CLARITHROMYCINA- po
OR
500mg BD
For 7 days.
Doxycycline D po
For 7 days.
OR
CLARITHROMYCIN
500mg BD
For 7-10 days.
Doxycycline alone
For 7-10 days.
Pregnancy/
In pregnancy or breastfeeding, use amoxicillin and/or erythromycin (according to CRB-65 score).
Breastfeeding BNF http://bnf.org/bnf/index.htm
Cautions
In elderly patients, the classic symptoms and signs of pneumonia are less likely, and non-specific features especially confusion
are more likely. In addition, absence of fever is more common compared to younger patients with CAP. Aspiration pneumonia is
more common in elderly patients, particularly nursing home residents or those in long term care facilities.
Evidence
Amoxicillin has a broad spectrum of activity and most common pathogens involved are still susceptible to it. Atypical
pathogens will need treatment with a macrolide or doxycycline, but these tend to be rare causes of CAP, and will often
illicit symptoms severe enough for referral or admission. Macrolides have a similar spectrum of activity to amoxicillin.
Mycoplasma infection is rare in the over 65s.
References
NHS Clinical Knowledge Summary Community Acquired Pneumonia:

http://www.cks.nhs.uk/chest_infections_adult/management/scenario_community_acquired_pneumonia
July 2010. www.hpa.org.uk
BTS Guidelines for the Management of Community Acquired Pneumonia in Adults: update 2009 Guidelines (pdf) Thorax
Oct 2009;64: (suppl. III) http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/
Guidelines/CAPGuideline-full.pdf
page 32
Central Nervous System
CNS
Adult Section
Adult
Central Nervous System Infections Meningitis or Suspected Meningococcal Disease

When to treat
Transfer all patients to hospital immediately. Administer single dose parenteral antibiotics prior to admission if
there is time. Give IV benzylpenicillin or cefotaxime unless hypersensitive i.e. history of difficulty breathing, collapse, loss
of conciousness or rash.1B-
Treatment
choices
First line:
Benzyl Penicillin
1.2g
IV or IM.
Pregnancy/
Breastfeeding
Benzylpenicillin & Cefotaxime can be used in pregnancy and breastfeeding.

BNF: http://bnf.org/bnf/index.htm
Cautions
Benzylpenicillin can be given unless history of anaphylaxis- a history of delayed rash following penicillin is NOT a
contraindication.
Anaphylaxis is more likely if there is a history of immediate allergic reactions (such as difficulty in breathing, collapse,
generalised itchy rash) after previous penicillin administration.A
Notify a proper officer of the local authority urgently on suspicion of meningitis or meningococcal septicaemia.
This is a legal requirement under the Health Protection (Notification) Regulations 2010. (see HPA:
AutoListNameandcid=1191942172947andp=1191942172947andpagename=HPAwebWrapper)
Close contacts of meningococcal disease will require chemoprophylaxis following discussion with the HPU.
Evidence
Early treatment of suspected cases with benzyl penicillin is recommended in the UK to reduce case fatality.B
References
SIGN 102 Management of invasive meningococcal disease in children and young people, May 2008
www.sign.ac.uk/pdf/sign102.pdf
NICE Bacterial meningitis and meningococcal septicaemia (for children younger than 16 years). CG102. (June 2010)
Health Protection Agency Meningococcus Forum with Public Health Medicine Environmental Group, the Scottish Centre
for Infection and Environmental Health, CDSC Wales, CDSC Northern Ireland, the Association of Medical Microbiologists,
and the Community Infection Control Nurses Network. Guidelines for public health management of meningococcal
disease in the UK. Updated August 2006
http://www.hpa.org.uk/infections/topics_az/meningo/meningococcalguidelines.pdf
If history of penicillin allergy (NOT anaphylaxis):

Cefotaxime
1g
IV or IM.
The meningitis research foundations website has some very useful information. See the following algorithm on
Early management of suspected bacterial meningitis and meningococcal septicaemia in immunocompetent adults:
http://www.meningitis.org/assets/x/51738 and Meningococcal meningitis and septicaemia guidance notes
(endorsed by the BMA) 2011: http://www.meningitis.org/assets/x/50631
page 33
UTI
Adult Section
Adult
Urinary Tract Infections Uncomplicated UTI in men and (non-pregnant) women, no fever or flank pain.
(page 1 of 2) HPA UTI quick reference guide ESBLs CKS UTI
When to
treat
Patients with asymptomatic bacteriuria should not be treated with an antibiotic as it is not associated with increased morbidity.
Women with symptomatic UTI should receive empirical antibiotics. Women with severe/ 3 symptoms (frequency, urgency, dysuria,
polyuria, suprapubic tenderness, haematuria): treat.1,2C Women with mild/ 2 symptoms: use dipstick on cloudy urine to guide
treatment (morning specimen most reliable). Prescribers should be aware of local resistance patterns when prescribing antibiotics.
Use urine dipstick to guide treatment. Nitrite and blood/leucocytes has 92% positive predictive value; -ve nitrite, leucocytes and
blood has a 76% negative predictive value.3A- Although the probability of UTI is reduced to less than 20% by a negative dipstick
test, the evidence suggests that women still derive symptomatic benefit from antibiotics (NNT=4). If negative nitrite and positive
leucocyte; treat if symptoms severe or consider delayed antibiotic prescription.
Men: consider prostatitis, chlamydial infection and epididymitis as differential diagnosis. In elderly men (over 65yrs of age),
treatment of asymptomatic bacteriuria does not reduce mortality or significantly reduce symptomatic episodes. Antibiotic
treatment significantly increases the risk of adverse events, such as rashes and gastrointestinal symptoms (NNH=3).
When to
investigate
Do not routinely culture for urinary symptoms in adult women <65 yrs. In sexually active young women, consider
Chlamydia trachomatis. Do not send urine for culture in asymptomatic elderly with positive dipsticks; only send urine for
culture if two or more signs of infection, especially dysuria, fever >38C or new incontinence. Perform culture (mid-stream
urine) if failed antibiotic treatment or persistent symptoms or recurrent infections.
Men: UTI in men is generally regarded as complicated (it results from an anatomic or functional abnormality).
Send pre-treatment MSU for culture in all symptomatic men.1,4C OR if symptoms mild/non-specific, use -ve nitrite and
leucocytes to exclude UTI. 5C
Consider further investigation for men who have:
Features of urinary obstruction (e.g. in older men, enlarged prostate) A history of pyelonephritis, calculi, or
Failed to respond to appropriate antibiotic therapy
previous genitourinary tract surgery
Recurrent UTI (e.g. two or more episodes within one or two years)
Persistent haematuria
How to
respond to a
positive lab
report
Single organism 104 CFU/ml or 105 mixed growth with one predominant organism indicates UTI. If suprapubic any growth is
significant Modify empirical treatment if necessary. If culture yields multiple species or low concentrations suspect contamination.
If culture yields multiple species or low concentrations suspect contamination. In adults no white cells present indicates no
inflammation & reduces culture significance. Epithelial cells/mixed growth indicates perineal contamination, reducing significance
of culture. Consider excluding chlamydia infection in a sexually active man with urinary symptoms, especially if he has sterile
pyuria, or the dipstick test is negative for nitrite and positive for leukocyte esterase. Follow up after 48hrs (or according to the
clinical situation) to check response to treatment and the urine culture results in men.
Treatment
choices
First line:
OR
NitrofurantoinA- po
50-100mg QDS OR 100mg M/R BD
For 3 days in women.B+
For 7 days in men.
Trimethoprim B+ po
200mg BD
For 3 days in women.B+
For 7 days in men.
Second line:
Perform culture in all treatment failures.1B Further
treatment should be based on culture results. If further
empirical treatment is necessary consider nitrofurantoin
(if failed on trimethoprim) If failed on nitrofurantoin
consider an oral first generation cephalosporin such as
CEFALEXIN (most cost-effective) or if a cephalosporin is
not suitable, co-amoxiclav.
Pregnancy/
See UTI in pregnancy monograph overleaf. In breastfeeding, short-term use of trimethoprim is not known to be harmful.
Breastfeeding Co-amoxiclav would also be suitable as a second-line alternative if no penicillin allergy is present.
BNF http://bnf.org/bnf/index.htm
Continued overleaf
page 35
Urinary Tract Infections Uncomplicated UTI in men and (non-pregnant) women, no fever or flank pain.
(page 2 of 2) HPA UTI quick reference guide ESBLs CKS UTI
Cautions
Nitrofurantoin should not be used in patients with a history of, or suspected renal failure (GFR <60ml/min).
Do not advise alkalinising agents (e.g. potassium citrate) in combination with nitrofurantoin. Community multi-resistant
E. coli with Extended-spectrum Beta-lactamase (ESBL) enzymes are increasing so perform culture in all treatment failures.
ESBLs are multi-resistant but many remain sensitive to nitrofurantoin. If patient has had recent MSU culture positive for
ESBL, check sensitivities and if sensitive use nitrofurantoin 50-100mg qds for 7 days and await repeat culture results.
Fosfomycin (unlicensed) 3g stat in women, 2nd 3g dose in men 3 days later, can alternatively be used ONLY on the advice of a
microbiologist see appendix 5, (p.87) for further information. Quinolones should not be used for first line empiric treatment
of uncomplicated UTI. In recurrent UTI or febrile UTI in men, there is a high risk of prostate involvement which may lead to
complications such as prostatic abscess or prostatitis. Suggest 14 days of ciprofloxacin in such cases.
Trimethoprim is not recommended in men if they have used it in the past 12 months because use of trimethoprim up to
1 year previously is associated with increased risk of infection with a resistant organism.
At least 50% of men with recurrent UTI and over 90% of men with febrile UTI have prostate involvement, which may lead to
complications such as prostatic abscess or chronic bacterial prostatitis. Suggest 14 days of CIPROFLOXACIN in such cases.
Evidence
If dysuria and frequency are present the probability of UTI is > 90%. No high quality evidence for treatment of bacterial
UTI has been identified in men..
References
HPA UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947330877
ESBLs: www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ/1191942126367/
CKS UTI: www.cks.nhs.uk/urinary_tract_infection_lower_women www.cks.nhs.uk/uti_lower_men
SIGN guidance 88. Management of suspected bacterial urinary tract infection in adults. A national clinical guideline.
Updated July 2012. http://www.sign.ac.uk/pdf/sign88.pdf
Notes on sending appropriate information to microbiology labs with urine samples:

Dipstick strip results are NOT appropriate clinical details when sending any urine sample for culture, they are simply an indicator
to support suspicion of a non-catheter UTI. Please ensure that requesters provide relevant clinical symptoms, signs or suspected
diagnosis (e.g. pyelonephritis) as well as any antibiotics that have been prescribed as this may be important in how the laboratory
interprets results and which sensitivities are reported.
Please state clearly if the patient has a catheter in situ (see guidance for treatment of Catheter Associated UTI on page 42).
page 36
Urinary Tract Infections UTI in pregnancy

When to treat Symptomatic bacteriuria occurs in 17-20% of pregnancies. Pregnant women with mild to moderate symptomatic UTI
should be treated with an antibiotic. Asymptomatic bacteriuria detected in pregnancy should also be treated with an
antibiotic (3-7 days), asymptomatic bacteriuria is associated with pyelonephritis and premature delivery. If the patient is
pregnant and pyrexial, admit her to hospital.
When to
investigate
MSU should be performed routinely at the first antenatal visit. If bacteriuria is reported it should be confirmed with a
second MSU. Send MSU for culture before starting antibiotics. Dipstick testing is not sufficiently sensitive to be used
for screening for bacteriuria in pregnant women. Send MSU for culture before starting antibiotics. Given the risks of
asymptomatic and symptomatic bacteriuria in pregnancy, a urine culture should be performed 7 days after completion of
antibiotic treatment as a test of cure.
How to
respond to a
positive lab
report
Single organism 104 colony forming units (CFU)/mL or 105 mixed growth with one predominant organism in a
symptomatic patient a diagnosis of UTI is likely. Modify empirical treatment if necessary. If culture yields multiple species or
low concentrations suspect contamination. In adults no white cells present indicates no inflammation and reduces culture
significance. Epithelial cells/mixed growth indicates perineal contamination, reducing significance of culture.
Women with bacteriuria confirmed by a second urine culture should be treated and have a repeat urine culture at each
antenatal visit until delivery.
Treatment
choices
First line:
Nitrofurantoin po
50mg qds OR 100mg M/R BD
For 7 days.
N.B. AVOID at term- may produce neonatal haemolysis.
Use cefalexin instead.
Cautions
Nitrofurantoin should not be used in patients with a history of, or suspected renal failure (GFR<60ml/min).
Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus.B+ But do not use at term
(see note in treatment choices section). If none of these antibiotics are suitable, please contact your local microbiology
department. Consider the possibility of pyelonephritis as a differential diagnosis.
If patient has had recent MSU culture positive for ESBL, check sensitivities and if sensitive use nitrofurantoin
50-100mg qds for 7 days and await repeat culture results. = high risk for causing C. Difficile infection (see page 70
(appendix 1) for information on high-risk patients).
Evidence
Untreated upper UTI in pregnancy carries an increased risk of morbidity and rarely mortality. A systematic review concluded that
antibiotic treatment of asymptomatic bacteriuria in pregnancy reduces the risk of upper UTI and low birth weight babies. There is
no clear evidence that any particular antibiotic regimen has any advantage over others.
Nitrofurantoin has been associated with haemolysis in people with 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. The efficacy and safety profiles of nitrofurantoin are supported in a recent large multicentre study
undertaken by the World Health Organization in which 778 pregnant women with asymptomatic bacteriuria were treated with
nitrofurantoin [Lumbiganon et al, 2009]. A cure rate of 86% was achieved with a 7-day course.
References
Management of suspected bacterial urinary tract infection in adults. SIGN Guidelines Updated July 2012.
Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database of Systematic
Reviews 2011, Issue 1.
http://summaries.cochrane.org/CD002256/treatments-for-symptomatic-urinary-tract-infections-during-pregnancy
Smaill F, Vazquez JC. Antibiotics for asymptomatic bacteriuria. Cochrane Database of Systematic Reviews 2007 issue 2
http://apps.who.int/rhl/reviews/CD000490.pdf
Clinical Knowledge Summaries; Urinary Tract Infection lower women: UTI in pregnancy. http://www.cks.nhs.uk/urinary_
tract_infection_lower_women/evidence/supporting_evidence/uti_during_pregnancy
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation. MarchOctober 2012. www.hpa.org.uk
Second line OR upper tract symptoms:

Cefalexin po
500mg BD OR 250mg QDS
For 7 days.
If upper tract/systemic symptoms treat for 10-14 days.
page 37
Urinary Tract Infections Acute Pyelonephritis

When to treat
Upper urinary tract infection is defined as: evidence of urinary tract infection with symptoms suggestive of
pyelonephritis (loin pain, flank tenderness, fever, rigors or other manifestations of systemic inflammatory response).
Upper urinary tract infection can be accompanied by bacteraemia, making it a life threatening infection.
Admit to hospital people who:
Are significantly dehydrated or who are unable to take oral fluids and medications.
Have signs of sepsis, including:
A temperature greater than 38C or less than 36C, and
Marked signs of illness (such as impaired level of consciousness, perfuse sweating, rigors, pallor, significantly
reduced mobility), or
Significant tachycardia, hypotension, or breathlessness.
Are pregnant and pyrexial.
Are frail, elderly residents in care homes who have recently been hospitalised or who have had recurrent UTI.
Fail to improve significantly within 24 hours of starting antibiotics.
When to
investigate
Dipstick test the urine for leucocyte esterase and nitrite for evidence of a UTI.
If the nitrite test is positive, with or without a positive leucocyte esterase test, a UTI is highly (90%) likely.
If the leucocyte esterase test alone is positive, a UTI is moderately (50%) likely.
If both dipstick tests are negative, a UTI is unlikely (5%). Consider and exclude other causes of loin pain and/or
fever including: pelvic inflammatory disease; appendicitis; renal calculi.
If hospital admission not needed, send MSU for culture and sensitivities and start antibiotics.
How to respond
to a positive lab
report
Modify empirical treatment if necessary.

If no response within 24 hours admit.
Treatment
choices
First line
Co-Amoxiclav
625mg TDS
For 14 days.
Cautions
Increasing bacterial resistance means that no antibiotic is sufficiently reliable for empiric treatment of upper UTI
(upper urinary tract infections). Nitrofurantoin is ineffective in upper UTI as it does not achieve effective concentrations
in blood. = high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk
patients).
Evidence
RCT shows 7 days ciprofloxacin is as effective as 14 days of co-trimoxazole.AEvidence about the effectiveness of less than 2 weeks treatment with co-amoxiclav is lacking.
References
Management of suspected bacterial urinary tract infection in adults. SIGN Guidelines Updated July 2012
NHS Clinical Knowledge Summaries. Acute pyelonephritis. http://www.cks.nhs.uk/pyelonephritis_acute#-367791
page 38
po
Second line if penicillin allergic:

Ciprofloxacin A po
500mg BD
For 7 days.
Urinary Tract Infections Catheter associated UTI *SYMPTOMATIC PATIENTS ONLY*

When to treat Between 2-7% of patients with indwelling catheters acquire bacteriuria each day, even with the application of best practice
for insertion and care of the catheter. All patients with a long-term indwelling catheter are bacteriuric, often with two or
more organisms. In the presence of a catheter antibiotics will not eradicate bacteriuria. Do not routinely prescribe antibiotic
prophylaxis to prevent symptomatic UTI in patients with catheters. Treatment of asymptomatic bacteriuria does not reduce
mortality or prevent symptomatic episodes and causes harms: increased short-term frequency of symptomatic infection and
re-infection with antimicrobial-resistant organisms.
One of the following symptoms should prompt initiation of antibiotic therapy:
Loin pain
New-onset delirium
Rigors
Fever> 37.9C or 1.5C above baseline on two occasions during 12 hours
Change catheter during course of antibiotic treatment. Asymptomatic patients should NOT be treated.
Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI3B
Investigations Symptomatic catheter-associated UTI (CA-UTI) cannot be differentiated from asymptomatic bacteriuria on the basis of urine
analysis with dipstick tests. Dipstick testing should not be used to diagnose UTI in catheterised patients. Urine
samples should only be sent for laboratory culture if the patient has clinical sepsis, not because the appearance or smell of the
urine suggests that bacteriuria is present.
A urine specimen for culture should be obtained prior to initiating antimicrobial therapy for presumed CA-UTI because of the
wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance.
If an indwelling catheter has been in place for >2 weeks at the onset of CA-UTI and is still indicated, the catheter should
be replaced to hasten resolution of symptoms and to reduce the risk of subsequent CA-UTI. The urine for culture should be
obtained from the freshly placed catheter prior to the initiation of antimicrobial therapy.
In patients with short-term catheterisation, it is recommended that specimens be obtained by sampling through the
catheter port using aseptic technique or, if a port is not present, puncturing the catheter tubing with a needle and syringe.
Culture specimens should not be obtained from the drainage bag.
How to
respond to a
positive lab
report
If urine culture shows that the organism is resistant to the current antibiotic, and:
If symptoms have not resolved, change to an antibiotic that the organism is sensitive to.
If symptoms have resolved, consider continuing with the current antibiotic.
If symptoms recur, start treatment with an antibiotic shown in the culture to cover the infecting organism.
Treatment
choices
Presumed Upper Tract Infection or

Presumed Bacteraemia:
Co-Amoxiclav
625mg TDS po
OR
Ciprofloxacin
500mg BD po
OR If sensitivity has been shown previously:
Trimethoprim
200mg BD po
For 7-14 days.
Evidence
When changing catheters in patients with a long-term indwelling urinary catheter: do not offer antibiotic prophylaxis
routinely. Consider antibiotic prophylaxis for patients with a history of symptomatic UTI after catheter change or who
experience trauma during catheterisation. = high risk for causing C. Difficile infection (see page 70 (appendix 1) for
information on high-risk patients).
References
Management of suspected bacterial urinary tract infection in adults. SIGN Guidelines Updated July 2012
HPA UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947330877
If known previous MRSA

Bacteriuria:
Trimethoprim
200mg BD po
For 7 days.
N.B. If used empirically, check actual
sensitivities and confirm that the
infection is trimethoprim sensitive.
Do NOT use co-amoxiclav or
quinolones due to resistance.
Recent MSU with

previous multi-resistant
bacteriuria:
Consult a microbiologist.
page 39
Urinary Tract Infections PROVEN Recurrent UTI in non-pregnant Women 3/yr

When to
treat
Continuous or postcoital antimicrobial prophylaxis should be considered to prevent recurrent uncomplicated cystitis in
women in whom non-antimicrobial measures have been unsuccessful. Ensure that the need for antibiotic prophylaxis
is reviewed at 6 months as the evidence base only supports patient benefit when used for up to 6 months
duration.
In appropriate women with recurrent uncomplicated cystitis, self-diagnosis and self-treatment with a short course
stand-by regimen of an antimicrobial agent should be considered.
When to
investigate
Positive urine culture is needed to confirm a microbial cause for at least one episode of urinary tract infection (before
commencing long-term prophylactic treatment). Urine culture and sensitivity tests are helpful to manage breakthrough
infections.
How to
respond to
a positive
lab report
Modify empirical treatment if necessary. If culture yields multiple species or low concentrations suspect contamination.
Send an MSU if a patient with recurrent UTIs has an acute infection. Discuss the case with a urologist and/or microbiologist
BEFORE prescribing prophylaxis in case the woman needs investigating to exclude an underlying cause. Base prophylactic
drug choice on previous MSU results. Eradication of a previous UTI should be confirmed by a negative urine culture 1-2
weeks after treatment.
General
advice
If cystitis is related to sexual intercourse, advise: Using a different contraceptive method if a diaphragm is being used;
voiding soon after intercourse; using a lubricant if symptoms could be due to mild trauma rather than infection.
Treatment
choices
Prophylactic for 6 month trial:

Nitrofurantoin po
50mg-100mg ON OR STAT post-coital dose to be taken
within 2hrs of intercourse (off-label use)
Cautions
Monitor patients on long term nitrofurantoin for signs of pulmonary fibrosis. Avoid nitrofurantoin if GFR<60ml/min; risk of
peripheral neuropathy; ineffective due to inadequate urine concentrations. Review need to continue prophylaxis every six
months, if ineffective, treatment choices will need review in the light of latest sensitivity of pathogens. Length of antibiotic
treatment has been found to be a risk factor for development of C.difficile infection.
Evidence
Post coital prophylaxis is as effective as prophylaxis taken nightly. If treatment is given nightly, although it reduces UTIs there
is greater risk of adverse effects1A+ and the development of resistance. Nightly prophylaxis: pooled data from 10 RCTs of
poor methodological quality calculated a Relative Risk of having one microbiological recurrence was 0.21 (95% CI 0.13 to
0.34), favouring antibiotic and the NNT was 1.85 over 612 months. But adverse effects do occur and 30% of women did
not adhere to treatment. The evidence that the benefit of cranberry juice for preventing UTI is small, and therefore it cannot
currently be recommended for the prevention of UTIs.
References
Jepson RG, Williams G and Craig JC, Cranberries for preventing urinary tract infection. Cochrane Database of Systematic
Reviews Oct 2012 Issue 1. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001321.pub5/abstract
National Library for Health Clinical Knowledge Summary UTI (lower) women
www.cks.nhs.uk/urinary_tract_infection_lower_women
European Association of Urology. Guidelines on Urological Infections 2011.
http://www.uroweb.org/guidelines/online-guidelines/
page 40
OR
Trimethoprim po
100mg ON OR STAT post-coital dose to be taken within 2hrs
of intercourse (off-label use)
Adult
GII
Adult Section
Gastro-intestinal infections Eradication of Helicobacter pylori

When to
treat
The presence of H. pylori should be confirmed before starting eradication therapy.

Eradication is beneficial in Duodenal Ulcer (DU), Gastric Ulcer (GU) and low grade MALT lymphoma, but NOT in Gastro-Oesophageal
Reflux Disease (GORD).A For Non-Ulcer Dyspepsia (NUD), the Numbers Needed to Treat (NNT) is 14 for symptom relief.3A+
In chronic NSAID user without ulcer history, Helicobacter pylori (HP) eradication will reduce peptic ulcers and/or bleeding but will
not remove all risk. Urgently refer patients >55 years with new, unexplained and persistent recent-onset dyspepsia for endoscopy.
Who to
investigate
P atients with uncomplicated dyspepsia unresponsive to lifestyle change, antacids, H2 receptor antagonists or 1 month Proton
Pump Inhibitor (PPI) and without alarm symptoms
Patients with a past history of GU or DU who have not previously been tested.
Test eligible patients using a urea breath test, a stool antigen test or lab serology testing. The urea breath test is preferred
in patients who have undergone previous H. pylori eradication therapy. Stop PPI use 14 days prior to breath or stool testing.
Withhold breath/stool testing for 28 days after antibiotic treatment. DU/GU relapse: retest for H. pylori using breath or stool test
OR consider endoscopy for culture and susceptibility.
NUD relapse: Do not retest, offer PPI or H2RA.
Patients with complicated peptic ulcer or MALT lymphoma should be retested (using breath test) 4 weeks after treatment.
Refer for endoscopy culture and sensitivity testing:
Patients who have had metronidazole and clarithromycin for any infection and are allergic to amoxicillin or tetracycline;
Patients who have received two courses of eradication and still test positive.
Seek microbiology or gastroenterology advice for third line options
Routine testing is not recommended in patients with GORD.A
Treatment
choices
First lineA+ cheapest option:

N.B. Do not use clarithromycin or metronidazole if already used in the past year for any infection.C
Lansoprazole po 30mg BD
PLUS
Clarithromycin po 250mg BD if with metronidazole, 500mg BD if with amoxicillin
AND
Metronidazole po 400mg BD
Or Amoxicillin po 1g BD
For 7 days.
(14 days for maltoma) N.B Check for drug interactions if clarithromycin is used!
Cautions
There is usually no need to continue PPI/H2RA unless large ulcer, haemorrhage or perforation- continue for 3 weeks.
For alternative treatment regimens see the BNF.
Evidence
Helicobacter test and treat strategies will benefit patients with ulcer disease, 8% of patients with functional dyspepsia, and
reduce future risk of ulcer disease, gastric cancer and risks of long-term PPIs.
References
SIGN Dyspepsia guideline (68) 2003. Available at http://www.sign.ac.uk/guidelines/fulltext/68/index.html

NICE dyspepsia guidance. August 2004. Available at: http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline.pdf
March to October 2012. www.hpa.org.uk
Clinical Knowledge Summaries: dyspepsia. http://www.cks.nhs.uk/dyspepsia_unidentified_cause
HPA Diagnosis of H Pylori in dyspepsia document. Quick reference guide for primary care (updated Sept 2012):
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947347671
page 41
Gastro-intestinal infections Infectious Diarrhoea

When to treat
Definition of acute diarrhoea: 3 or more episodes a day, <14d and sample takes shape of pot. Empirical treatment for
patients well enough to be managed in primary care is not usually recommended because the majority of illnesses seen in
the community do not have an identifiable bacterial cause.
For Campylobacter, Salmonella and Shigella, antibiotic treatment is not normally indicated. If the patient is systemically
unwell and of clinical concern, discuss with a microbiologist. Treatment of E.coli 157 with antibiotics is positively contraindicated.
Bear in mind that diarrhoea may not reflect enteritis and may be a symptom of other conditions. Consider other
differential diagnoses especially in patients returning from abroad.
Urgently refer all previously healthy children with acute painful, bloody diarrhoea or confirmed E.coli O157.
When to
investigate
Send a stool specimen for culture and sensitivity if:

Systemically unwell; blood or pus in the stool;
Immunocompromised;
Recent antibiotics or hospitalisation (also request C. difficile test);
Diarrhoea occurs after high risk foreign travel (also request tests for ova, cysts, and parasites);
Diarrhoea is persistent (e.g. >1week).
If the diarrhoea has stopped, culture is rarely indicated, as recovery of the pathogen is unlikely. Consult local HPU if:
Suspected public health hazard; outbreaks of diarrhoea in the family or community; infected with certain organisms
(e.g. E. coli O157) where there may be serious clinical sequelae to an infection.
How to
respond to a
positive lab
report
Most patients in whom pathogens are detected will NOT require specific treatment unless systemically unwell or
treatment is advised by a microbiologist or consultant in communicable disease control.
Campylobacter: Antibiotic therapy has little effect on duration of symptoms unless given very early in illness course.
Giardia lamblia and Entamoeba histolytica should be treated according to sensitivity results.
Unless symptoms persist, Blastocystis and Dientamoeba fragilis do not usually require treatment if otherwise healthy.
C.difficile see recommendations on p48.
Treatment
choices
Fluid replacement. Do not treat with antibiotics without discussing case with a microbiologist first of all.
Cautions
Notify and seek advice on exclusion of patients from Public Health Doctor/Health Protection.
Evidence
There are no routine methods for detecting enterotoxigenic E. coli, the commonest cause of travellers diarrhoea.
Quinolones are not recommended because there is increasing resistance in Campylobacter to quinolones.
References
Infectious Diarrhoea: The Role of Microbiological Examination of Faeces Quick Reference Guide for Primary Care for
consultation and local adaptation (July 2010):
CKS Gastroenteritis: http://www.cks.nhs.uk/gastroenteritis#-392747
page 42
Gastro-intestinal infections Giardiasis

When to treat
Prescribe antibiotic treatment as detailed below for all people with confirmed giardiasis.
When to
investigate
Advise the patient to seek medical advice if:

Their condition doesnt improve within 48 hrs of treatment
Symptoms exacerbate or their condition worsens
Warning signs or symptoms develop (such as severe vomiting or dehydration, persistent fever,
abdominal distension, or frank blood in stools).
General Advice Advise patients/carers of the importance of reporting back to the GP if there are ongoing symptoms.
Treatment
choices
First line options:

Metronidazole po
2g OD for 3 days
OR
400mg tds for 5 days
Pregnancy/
Breastfeeding
In pregnancy do not use tinidazole, instead use metronidazole at the lower dose (400mg tds). The lower dose
metronidazole can also be used during breastfeeding.
Cautions
Following up post treatment and 6 weeks later (following a negative sample) is important because a patient may
occasionally need a second course of treatment.
All positive cases of Giardiasis should be notified to the local HPU. See HPA link for further information on notifiable
diseases:
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References
NHS Clinical Knowledge Summaries. Gastroenteritis management: Giardiasis.
http://www.cks.nhs.uk/gastroenteritis/management/scenario_adult/confirmed_microbiological_
pathogen/giardiasis#
OR
Tinidazole po
2g STAT
page 43
Gastro-intestinal infections Clostridium difficile See appendix 1 (p70) for further information
When to
treat
When patient is symptomatic and has a positive C. difficile test from a stool sample.
If a patient has severe symptoms and is causing concern, discuss with microbiology and consider admission if clinically unwell.
Mild: No increased white cell count (WCC) and typically associated with <3 episodes of loose stools/day.
Moderate: Increased WCC (but <15 x 109/L) and typically associated with 3-5 loose stools per day.
Severe: WCC >15 x 109/L, or an acutely increased serum creatinine concentration (>50% above baseline), or a temperature
>38.5C, or evidence of severe colitis. The number of stools may be a less reliable indicator of severity.
Life-threatening: Signs and symptoms include hypotension, partial or complete ileus, or toxic megacolon.
When to
investigate
One episode of diarrhoea in an at-risk patient not attributable to any other cause including medicines.
Patient has diarrhoea conforming to types 5-7 on the Bristol Stool Chart
Sample takes the shape of the container used to sample it
A
t-risk patient: older patient (>65yrs) + recent antibiotic treatment (2 months) + recent exposure to patients infected
with or environment contaminated with C. difficile.
Document the following details on the stool sample request form: Clinical features, recent antibiotic or proton pump inhibitor,
or hospital admission, contact with other affected individuals or outbreak, state if the test was requested by the HPU or a
Consultant in Communicable Disease Control. Do not send a repeat sample within 28 days if initial test is positive.
How to
respond to a
positive lab
result
Initiate treatment as below and isolate the patient if in a care/nursing home.

Discontinue therapy with the inciting antibiotic(s) as soon as possible, as this may influence the risk of recurrence. Review
need for continuing antibiotics, if still required consider changing to another antibiotic which is less likely to cause C. difficile
(see appendix 1, page 77).
Review the need for PPIs and stop where it is felt safe to do so.
Stop any laxatives.
Stop any anti-motility drugs (e.g. codeine and loperamide) due to risk of ileus and toxic megacolon.
Initiate treatment as below and isolate the patient if in a care/nursing home.
Review patients regularly for fluid resuscitation, electrolyte replacement and nutrition as necessary and monitor for signs of
increasing disease severity.
Treatment
choices
First and second episode:

Metronidazole po
400mg tds
For 10-14 days.
Third episode or severe symptoms:

Vancomycin po
125mg QDS
For 10-14 days.
Pregnancy/
Refer/seek specialist advice.
Breastfeeding
Cautions
Mild cases dont necessarily need antibiotic treatment. Cessation of other antibiotics the patient is taking may be adequate. If
unsure, discuss with a microbiologist.
Evidence
70% respond to metronidazole in 5 days; 92% in 14 days.

If severe, use vancomycin due to relatively high failure rates with metronidazole.
Recurrences: the majority or recurrences are due to re-infection rather than relapse and the same antibiotic that has been used
initially can be used to treat a first recurrence.
References
Health Protection Agency. Management of Infection Guidance for Primary Care for consultation and local adaptation.
DH C. difficile How to deal with the problem 2009
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093218.pdf
Other
reference
sources
HPA/ Department of Health: C. Difficile infection: How to deal with the problem:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093220
CKS: Diarrhoea- antibiotic associated. www.cks.nhs.uk/diarrhoea_antibiotic_associated
UKMI Clostridium difficile infection- which antimicrobials are implicated? Medicines QandAs. Nov 2012.
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Clostridium-difficile-infection--whichantimicrobials-are-implicated/
page 44
Gastro-intestinal Infections Threadworms

When to treat
Treat if threadworms have been seen or their eggs have been detected.
When to
investigate
If infestation persists after hygiene measures have been continued for the recommended duration and treatment of
household, and if there are frequent recurrences.
How to respond to Treat all members of the household at the same time (unless contra-indicated) to minimize re-infestation.
General Advice
All members of the household must be advised to adhere to strict hygiene measures, including morning showers/
baths and hand hygiene for 2 weeks after treatment. Wear pants at night. Wash sleepwear, bed linen, dust and
vacuum on day 1.
Treatment choices
First line:
Mebendazole po
100 mg STAT
Repeat in 2 weeks if infestation persists.
Pregnancy/
Breastfeeding
Treatment with an anthelmintic is contra-indicated in women in the first trimester of pregnancy. During pregnancy,
hygiene methods alone are preferred for 6 weeks.
If drug treatment is considered necessary in the second or third trimester give mebendazole (off-licence indication).
See CKS link below for further information.
During breastfeeding, hygiene methods are generally preferred.
Evidence
Neither mebendazole nor piperazine kills eggs, therefore adequate personal and environmental hygiene is essential
to prevent reinfestation from recently swallowed eggs, or eggs already in the environment.
It is generally accepted that mebendazole and piperazine have comparable efficacy (90100% cure-rate),
however mebendazole has few contraindications and post-marketing surveillance has revealed no serious safety
concerns. Therefore piperazine should only be used in patients who cannot take mebendazole (see BNF for dosage
instructions).
References
Threadworms. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/threadworm

page 45
Gastro-intestinal infections Diverticulitis NEW

When to treat
Antibiotic treatment is recommended for the routine management of diverticulitis, either at home or as an inpatient.
People with mild, uncomplicated diverticulitis can be managed at home with paracetamol, clear fluids and antibiotics.
Arrange admission for people with diverticulitis when:
Pain cannot be managed with paracetamol
Hydration cannot be easily maintained with oral fluids
Oral antibiotics cannot be tolerated
The person is frail or has a significant co morbidity that is likely to complicate their recovery (particularly if
immunocompromised)
The person has any of the following suspected complications: rectal bleeding that may require transfusion, perforation
and peritonitis, intra-abdominal abscess, fistula.
When to
investigate
If symptoms persist after 48hrs despite conservative management at home. Admit patient to hospital.
General advice
Review within 48hrs or sooner if symptoms deteriorate. Arrange admission if symptoms persist or deteriorate. Prescribe
paracetamol for pain. Recommend clear liquids only. Gradually reintroduce solid food as symptoms improve over 2-3 days.
Treatment
choices
First line
Co-Amoxiclav
625mg TDS
For 7 days.
Pregnancy/
Breastfeeding
In pregnancy or breastfeeding, seek specialist advice. Co-amoxiclav is suitable to use if appropriate. Seek advice from
microbiologist if the patient is allergic to penicillins.
Cautions
po
Second-line or if allergic to penicillins:

METRONIDAZOLE po
400mg TDS For 7 days
PLUS
Ciprofloxacin A po
500mg BD For 7 days.
Evidence
A recent Cochrane review2 has found that the most recent evidence from one RCT says there is no significant difference
between antibiotics versus no antibiotics in the treatment of uncomplicated diverticulitis. Previous RCTs have only
suggested non-inferiority between different antibiotic regimes and treatment lengths. This new evidence needs
confirmation from more RCTs before it can be implicated safely in clinical guidelines. Ongoing RCTs will be published in
the years to come and more are needed. The role of antibiotics in the treatment of complicated diverticulitis has not been
investigated yet.
Non-steroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics have been identified as risk factors for diverticular
perforation and are probably best avoided in the management of people with acute diverticulitis.
References
NHS Clinical Knowledge Summaries. Acute Diverticulitis.

http://www.cks.nhs.uk/diverticular_disease/management/scenario_acute_diverticulitis#-319655
Shabanzadeh DM, Wille-Jrgensen P. Antibiotics for uncomplicated diverticulitis. Cochrane Database of Systematic Reviews
2012, Issue 11. Art. No.: CD009092. Published 28/11/12.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009092.pub2/pdf
page 46
Adult
GUI
Adult Section
Genito-Urinary Infections
Genital Tract Infections Criteria for Referring Patients to Specialist Care

Patient risk
factors
Refer patients with risk factors for STIs to Sexual Health Services or General Practices with level 2 or 3 expertise in Sexual
Health Services: 1,2
<25yrs
no condom use or inconsistent use
recent (<12mth) or frequent change of sexual partner.
previous STI
symptomatic partner
high risk sexual practices e.g. gay or bisexual men, IV drug users and their partners and patients with confirmed STIs.
If your patient has symptoms suggestive of any STI, refer to the sexual health clinic. Guidance on treatment of these
conditions can be found at the BASHH website (see link in reference section).
Diseases
Syphilis- always refer to Sexual Health Services

Gonorrhoea- always refer to Sexual Health Services (N.B. The previous treatment monograph on this condition in older
versions of this guidance has been removed as this should always be treated by specialist sexual health services).
Genital Herpes- Treat on suspicion (as per http://www.bashh.org/documents/115/115.pdf)
and refer to Sexual Health Services
Evidence
See HPA and British Infection Association Quick Reference Guide to Management and Laboratory Diagnosis of
Abdominal Vaginal Discharge for useful flowchart.3
References
1. BASHH Clinical Effectiveness Group Guidelines (updated 7th Dec 2012) http://www.bashh.org/guidelines
2. National Chlamydia Screening Programme http://www.chlamydiascreening.nhs.uk/ps/index.asp
3. H
PA/BIA: Quick Reference Guide for primary Care Management of Abnormal Vaginal Discharge in Women
(amended 26.09.11) http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947408846
page 47
Genital Tract Infections Vulvo Vaginal Candidiasis

When to treat
Symptoms suggestive of episodic vulvovaginal candidiasis include external dysuria, vulval pruritus, swelling or
redness. Signs include vulval oedema, fissures, excoriation, or thick curdy discharge. The vaginal pH is usually normal
(<4.5). Treatment on the basis of symptoms alone is common clinical practice but results in the over-treatment of
a large number of women. There is no evidence to support the treatment of asymptomatic male sexual partners in
either episodic or recurrent vulvo vaginal candidiasis (VVC).
When to investigate
Testing is recommended for episodic VVC whenever possibleB and for complicated VVC. This includes; severe episodic
VVC infection, recurrent VVC (> 4 attacks per yr) and those with underlying host abnormality,
e.g. pregnancy, HIV infection and diabetes.C If a patient has failed treatment with appropriate anti-fungals discuss
options with microbiology.
How to respond to a The possibility of Candida being an innocent bystander needs to be considered.C Isolation of Candida is common in
positive lab report
asymptomatic women. Treatment is not indicated in the absence of symptoms.B
General Advice
Advise the woman to return if symptoms have not resolved within 7-14 days. Refer, or seek specialist advice, if:
symptoms are not improving and treatment failure is unexplained; treatment fails again; if diagnosis is unclear.
Recommend routine use of vulval moisturizers (e.g. aqueous cream or epaderm ointment) as soap substitute and
regular skin conditioner (instruct the patient that this does not constitute internal use).
Avoid tight fitting synthetic clothing. Avoid local irritants e.g. perfumed products.
Treatment choices
First line choices

Clotrimazole pv
10% vaginal cream (5g) STAT
Pregnancy/
In pregnancy avoid oral azole.B Pregnant women need a longer duration of treatment to clear the infection. Use
intravaginal treatment for 7 days3A+, 2,4 BDuring pregnancy extra care should be taken when using the applicators with the clotrimazole100mg pessaries
or miconazole 2% vaginal cream (5g BD pv for 7 days) to prevent the possibility of mechanical trauma. Pregnant
women may wish to insert the pessary or cream without using the applicator.
http://www.medicines.org.uk/emc/
Breastfeeding
OR
Clotrimazole pv
500mg pessary STAT (nocte)
OR
Fluconazole po
150mg po STAT
N.B. Check for drug interactions!
Cautions
Women with chronic symptoms need a careful history and examination. Pay particular attention to alternative
diagnoses, most commonly vulval eczema/dermatitis. Other possibilities include other causes of vaginal discharge
e.g. recurrent bacterial vaginosis, recurrent herpes, vulval vestibulitis syndrome and other vulvar dermatoses.B More
than one condition may occur and this may vary with time e.g. the patient may cycle between bacterial vaginosis
and VVC. A general skin examination can be helpful.C Topical azoles can cause vulvovaginal irritation consider if
symptoms worsen or persist.
Evidence
All topical and oral azoles give 75% cure.1A+
References
United Kingdom National Guideline on the Management of Vulvovaginal Candidiasis (2007) Clinical Effectiveness
Group.
British Association of Sexual Health and HIV. http://www.bashh.org/guidelines
Clinical Knowledge Summaries, Candida, female genital, management:
http://www.cks.nhs.uk/candida_female_genital/management/scenario_uncomplicated_infection/
treating_vulvovaginal_candidiasis
page 48
Genital Tract Infections Bacterial Vaginosis

When to treat
Treatment is indicated for: symptomatic women (offensive fishy-smelling vaginal discharge, not associated with soreness,
itching, or irritation); women undergoing some surgical procedures; and some pregnant women. Symptomatic pregnant
women should be treated in the usual way and asymptomatic pregnant women may be considered for treatment.
Routine screening and treatment of male partners is not indicated.
When to
investigate
Examination and further tests may be omitted and empirical

treatment for bacterial vaginosis (BV) started in women with
characteristic symptoms of BV if all of the following apply:
The woman is not at high risk of a sexually transmitted infection (STI).
The woman does not have symptoms of other conditions causing vaginal
discharge (e.g. itch, abdominal pain, abnormal bleeding, dyspareunia, fever).
The woman is not pregnant, post-natal, post-miscarriage, or post-termination.
Symptoms have not developed after a gynaecological procedure.
Symptoms have not recurred soon after treatment for BV or persisted following
treatment for BV
If empirical treatment is not

considered appropriate, or if the
diagnosis is uncertain:
Perform a speculum examination.
If pH paper is available, test the
pH of the vaginal fluid (pH > 4.5 is
consistent with a diagnosis of BV).
Take a high vaginal swab (or use a
self-taken low vaginal swab) for Gram
staining and to exclude other causes
of vaginal discharge.
General Advice Advise patients to avoid vaginal douching, use of shower gel, and use of antiseptic agents or shampoo in the bath. C
Treatment
choices
First line treatment:

MetronidazoleA+ po
400mg BD
For 5-7 days (preferred dose regime in terms
of efficacy. Use this dose in pregnancy.)
OR
METRONIDAZOLEA+ po
2g STAT
(AVOID 2g dose in pregnancy/breastfeeding)
For 7 days.
Consider suspension formulation at night
for better tolerability compared to tablets.
Topical treatments:
MetronidazoleA+ pv
0.75% vaginal gel 5g applicatorful ON
For 5 days.
OR
ClindamycinA+ pv 2% vaginal cream, 5g applicatorful ON
For 7 days.
(N.B. Product weakens condoms advise against use during treatment)
Pregnancy/
Breastfeeding
Oral Metronidazole at the 400mg bd dose regimen is recommended during pregnancy and breastfeeding.
BNF: www.bnf.org/bnf/current/index.htm EMC: www.emc.medicines.org.uk
Evidence
All treatments have been shown to have cure rates of 70-80%. A 7 day course of oral metronidazole is slightly more
effective than 2 g stat.3A+ Topical treatment gives similar cure rates1A+ but is more expensive. Treating partners does not
reduce relapse.5B+
References
National Guideline For The Management Of Bacterial Vaginosis (2012) Clinical Effectiveness Group
British Association for Sexual Health and HIV www.bashh.org/guidelines
Clinical Knowledge Summaries. Bacterial Vaginosis management.
http://www.cks.nhs.uk/bacterial_vaginosis
page 49
Genital Tract Infections Chlamydia trachomatis

When to treat In people with signs or symptoms strongly suggestive of Chlamydia, start treatment without waiting for laboratory
confirmation (after testing for other sexually transmitted infections as appropriate) Sexual partners should be offered treatment
and referred to sexual health services. The patient and partner should be advised to abstain from sex for the next 7 days.
Partners must be treated even if they have a negative test result. In the absence of treatment, 10-40% of infected
women will develop pelvic inflammatory disease (PID).
N.B. Azithromycin (Clamelle) is available to buy over-the-counter (OTC) from pharmacies without a prescription, post positive
sample.
When to
investigate
Offer all positive patients and contacts a full STI screen by referral to Sexual Health Services clinic. If a patient refuses to/cant
attend or the GP has specialist training in Sexual Health medicine, ensure that contact tracing is done via the GP practice.
Opportunistically screen all aged 15-25 yrs.
How to
respond to a
positive
lab report
Treat if there is a positive confirmed reactive nucleic acid amplification technique (NAAT) test. Note: In high-risk populations,
tests are not confirmed with culture. Beware of false positive test results in low risk populations. Patients with reactive
unconfirmed NAAT tests should also be offered treatment. Encourage all patients diagnosed with C. trachomatis to have
screening for other STIs, including an HIV test and, where indicated hepatitis B screening and vaccination.
General
advice
Abstain from genital, oral or anal sex, even with condom, until both index patient and partner(s) have completed treatment.
Abstain for one week after treatment with Azithromycin.
First line:
OR
Doxycycline po
Azithromycin po
100mg BD
1g STAT
For 7 days.
(1hr before or 2hrs after food) N.B Check for drug interactions!
Pregnant or breastfeeding: (Also see advice in pregnancy/breastfeeding section below)
Most effective option is
OR
OR
AZITHROMYCIN but it is OFF-LABEL
Erythromycin po
AMOXICILLIN po
use (dose as stated above).
500mg BD
500mg TDS
For 14 days.
For 7 days.
Retest after 6 weeks.
Retest after 5/52 as less effective.
Retest after 5/52 as less effective.
Treatment
choices
Pregnancy/
Refer all pregnant patients to Sexual Health Services. However, if the patient wont/cant attend, advice on what
Breastfeeding antibiotic to prescribe is given above. Advice should also be sought from the local Sexual Health Service. In pregnancy or
breastfeeding: azithromycin can be used but is off label. It is recommended by WHO and USA CDC and is more effective than
erythromycin and amoxicillin. The BNF however, recommends its use only if no alternative is available.
Due to more frequent positive Chlamydia tests after treatment in pregnancy, attributed to either less efficacious treatment
regime, non compliance or re-infection, it is recommended that pregnant women must have a test of cure 6/52 after
completing therapy with azithromycin. If erythromycin or amoxicillin is used, retest after 5 weeks.
Erythromycin or amoxicillin should ONLY be used to treat special groups such as in pregnancy as they are
less effective.
Evidence
Comparative studies of doxycycline and azithromycin have shown similar efficacy at 2-5 week follow-up, with >95% being
Chlamydia-negative retesting. However, there is evidence to suggest that with longer follow-up >10% will be positive on
retesting. NAATs may remain positive for up to 5 weeks, even if treatment has been successful.
References
UK National Guideline for the Management of Genital Tract Infection with Chlamydia trachomatis) Clinical Effectiveness Group
British Association for Sexual Health and HIV 2006 www.bashh.org/guidelines
Clinical Knowledge Summaries. Chlamydia -uncomplicated genital: http://www.cks.nhs.uk/chlamydia_uncomplicated_
genital/management/scenario_diagnosis/screening_for_chlamydia
page 50
Genital Tract Infections Trichomoniasis

When to treat
Refer to Sexual Health Services. Treat partners simultaneously. Laboratory confirmed diagnosis, or may be
diagnosed in sexual health clinic on a wet preparation.
When to investigate
All symptomatic patients: Yellow, green frothy discharge. Fishy/offensive odour +/- pruritis, vaginitis, dysuria.
Screening of asymptomatic patients is not recommended
How to respond to a Screening for coexistent sexually transmitted infections should be undertaken in both men and women.
positive lab report
General advice
Sexual partner(s) should be treated simultaneously. Patients should be advised to avoid sexual intercourse
(including oral sex) until they and their partner(s) have completed treatment and follow-up.
Treatment choices
First line:
MetronidazoleA- po
400mg BD
For 5-7 days.
Pregnancy/
Breastfeeding
In pregnancy or breastfeeding: avoid 2g single dose metronidazole. Consider clotrimazole (100mg pessaries ON for
6 days) for symptom relief (not cure) if metronidazole declined.
Cautions
The single dose has the advantage of improved compliance and being cheaper; however there is some evidence to
suggest that the failure rate is higher, especially if partners are not treated concurrently.
Evidence
Most strains of T. vaginalis are highly susceptible to metronidazole and related drugs (approx. 95% cure rate).
There is a spontaneous cure rate in the order of 20-25%. Treating partners does not decrease relapse.
References
United Kingdom National Guideline on the Management of Trichomonas vaginalis (2007) Clinical Effectiveness
Group, British Association of Sexual Health and HIV www.bashh.org/guidelines
OR
MetronidazoleA- po
2g STAT
(AVOID 2g dose in pregnancy/breastfeeding)
Consider suspension formulation at night for better tolerability compared to tablets.
page 51
Genital Tract Infections Pelvic Inflammatory Disease (PID)

When to treat
Signs include: Lower abdominal tenderness which is usually bilateral; adnexal tenderness on bimanual vaginal examination;
cervical motion tenderness on bimanual vaginal examination; fever (>38C). Delaying treatment may increase the risk
of long term sequelae such as ectopic pregnancy, infertility and pelvic pain. Because of this, and the lack of definitive
diagnostic criteria, a low threshold for empiric treatment of PID is recommended. Start treatment and refer patient
and contacts to Sexual Health Service clinic. If gonorrhoea (GC) likely use ceftriaxone treatment regime via sexual
health service referral.
High risk for GC:
Has had GC in the past Severe PID/ severe clinical symptoms
Partner has GC
Sex abroad
When to
investigate
ALWAYS test for Gonorrhoea and Chlamydia as positive result supports PID diagnosis. However, a negative result does not
exclude PID. Elevated ESR or C reactive protein also supports diagnosis.
How to respond All patients should be offered a pregnancy test to help exclude an ectopic pregnancy and screening for sexually transmitted
to a positive lab infections. Refer contacts to GUM/Sexual Health Services clinic.
report
General advice
Rest is advised for those with severe disease.C Appropriate analgesia should be provided. Patients should be advised to
avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up.C Useful patient
information leaflet from BASHH can be found here: http://www.bashh.org/guidelines
Treatment
choices
If low risk of Gonococcal infection:

Metronidazole po
OR
400mg BD
+
DOXYCYCLINE
po 100mg BD
OR
Ofloxacin po
400mg BD
For 14 days.
Pregnancy/
Breastfeeding
If it is known or suspected that the patient is pregnant, they should be referred urgently to a sexual health specialist.
Management of the patient depends upon gestation and clinical severity and hence each patient will need to be dealt with
individually on a case by case basis.
Cautions
In both regimens metronidazole is included to improve coverage for anaerobic bacteria. Anaerobes are of relatively greater
importance in patients with severe PID and metronidazole may be discontinued in those patients with mild or moderate
PID who are unable to tolerate it. Ofloxacin should be avoided in patients who are at high risk of gonococcal PID because
of increasing quinolone resistance in the UK ~28% of gonorrhoea isolates now resistant to quinolones, therefore get
advice from Sexual Health Specialist.3B+ If you have a patient where you are unsure as to whether they have GC and
the sexual health clinic is closed, a NAAT test can be undertaken (along with other necessary tests) PRIOR to starting
antibiotics and you can specify that you wish for GC to be tested. Oral treatment should be initiated and the patient
referred to sexual health clinic where IM Ceftriaxone can be administered if necessary and screening undertaken.
References
United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease (2011) Clinical Effectiveness
Group, British Association of Sexual Health and HIV www.bashh.org/guidelines
page 52
If high risk of GC (endemic risk)

(see when to treat section above for defn):
CEFTRIAXONE IM 500mg STAT (this is given at the sexual health
clinic, therefore any pts at risk of GC must be referred)
+
Metronidazole po 400mg BD
+
Doxycycline po 100mg BD
For 14 days.
Genital Tract Infections Acute Prostatitis (where STI not suspected)

When to treat
Acute prostatitis should be suspected in a man who presents with a feverish illness of sudden onset; irritative urinary
voiding symptoms or acute urinary retention; perineal or suprapubic pain; exquisitely tender prostate on rectal
examination. Empirical treatment should be started immediately after urine cultures have been obtained. Treatment
should be selected according to the clinical condition of the patient. Most prostatitis is caused by urinary tract
pathogens not STIs.
When to
investigate
All patients >35 years need mid-stream urine sample for dipstick testing and culture for bacteria and antibiotic
sensitivity. Blood culture for bacteria and antibiotic sensitivity. First catch urine sample for NAATs. An STI is much more
likely in men <35 years.
Admit to hospital if the man is unable to take oral antibiotics, has acute urinary retention or is severely ill. Refer
urgently if the man has a pre-existing urological condition and consider urgent referral if the man has diabetes or is
immunocompromised.
How to respond to Reassess after 24-48 hours: Review the culture results and ensure that an appropriate antibiotic is being used.
a positive lab result However cultures are often negative. If there is deterioration or failure to respond to oral therapy, urgent admission
and parenteral therapy should be arranged; prostatic abscess may need to be excluded or treated.
There is no need to treat partners unless a positive STI is diagnosed. Refer to sexual health clinic if STI is suspected.
General advice
Adequate hydration should be maintained, rest and use of analgesics encouraged.

Most men treated appropriately for acute prostatitis will recover completely within 2 weeks (but treatment should be
continued for at least a further 2 weeks). Following recovery, refer for investigation to exclude structural abnormality of
the urinary tract.
Treatment choices
First line:
Ciprofloxacin po
500mg BD
OR
Ofloxacin C po
200mg BD
For 28 days.
Cautions
If there is deterioration or failure to respond to therapy urgent admission to hospital should be arranged.
Evidence
Quinolones are more effective, as they have greater penetration into prostate.2 4 weeks treatment may prevent
chronicity.
References
United Kingdom National guideline for the management of prostatitis (2008) Clinical Effectiveness Group
British Association of Sexual Health and HIV www.bashh.org/guidelines
Second line or if allergic or intolerant to quinolones:

TrimethoprimC po
200mg BD
For 28 days.
page 53
Genital Tract Infections Epididymo-Orchitis NEW

When to treat1
Most common causes are chlamydia and GC in under 35s and E.coli in over 35s. Have a very low threshold for admitting
immediately to exclude testicular torsion. If symptoms are severe or the man or boy is very unwell, consider admitting to hospital,
particularly if he has diabetes or is immunocompromised. Refer for same-day or next-day assessment by a sexual-health
specialist. If this is not possible: Obtain a mid-stream urine for dipstick, microscopy, and culture and test for sexually-transmitted
infections. Urine should be tested for chlamydia & GC NAAT. After test samples are taken, Empirical therapy should be
given to all patients with epididymo-orchitis before laboratory results are available.2 Consider other (rare) causes,
such as mumps orchitis (may be parotid swelling), Bechets syndrome (if recurrent epididymitis), tuberculosis, and amiodarone.
When to
investigate
All patients with sexually transmitted epididymo-orchitis should be screened for other sexually transmitted infections.2 If a urinary
tract infection is confirmed, refer to a urologist to investigate for an underlying structural abnormality or urinary tract obstruction.1
How to respond Tailor treatment according to culture and sensitivity results. If lab tests have been ordered in primary care and the patient
to a positive lab was gonorrhoea positive, ensure patient is referred to sexual health services. A test of cure should be performed at least 72
result
hrs after completion of antibiotics.2
General advice1 Bed rest, scrotal elevation (such as supportive underwear) and analgesia. If symptoms worsen, or do not begin to improve
within 3 days, return for assessment. BASHH pt info leaflet on epididymo-orchitis can be found here:
Treatment
choices
First line:
DOXYCYCLINE po
100mg BD For 10-14 days
Cautions
Epididymo-Orchitis related to a sexually transmitted infection (generally under 35s):

If you suspect the patient is at high risk for gonorrhoea (previous gonorrhoea infection, known contact of a person with
gonorrhoea, purulent urethral discharge, men who have sex with men, black ethnicity) then the patient MUST be referred to
sexual health services in order to be given Ceftriaxone 500mg STAT IM.
If you have a patient where you are unsure as to whether they have GC and the sexual health clinic is closed, a NAAT test
can be undertaken (along with other necessary tests) PRIOR to starting antibiotics and you can specify that GC is to be
tested for. Oral treatment should be initiated and the patient referred to sexual health clinic where IM Ceftriaxone can be
administered if necessary.
If it is suspected that the cause of the epididymo-orchitis is related to a sexually transmitted organism (most likely in
patients who are less than 35yrs of age, >1 sexual partner in the past 12 months, any urethral discharge) the patient should
be instructed that there should be no intercourse until review. Notify Partner (sexual health services can do contact tracing
once patient is referred).1
If a patient has GC identified as the causative organism, a GC test of cure is recommended at least 2 weeks after a positive
NAAT (or 72hrs for culture). Ensure that patients go back to their sexual health clinic to have this done.
Epididymo-orchitis related to an enteric organism (generally over 35s):
If it is suspected that the patients epididymo-orchitis is related to an enteric organism (low risk sexual history, age>35yrs,
history of penetrative anal intercourse, recent urological instrumentation or catheterization) such as E. coli, Ciprofloxacin
500mg bd for 10 days OR Ofloxacin 200mg BD for 14 days is recommended.3 If a quinolone is contraindicated, treat
with Co-amoxiclav 500/125 mg three times daily for 10 days.1
= high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients). Avoid
quinolones in people with a history of tendon disorders related to quinolones, or a history of seizures or conditions that
predispose to seizures.1
References
1. C
KS- scrotal swellings- management http://www.cks.nhs.uk/scrotal_swellings/management/scenario_
diagnosis/identifying_the_cause/causes_of_scrotal_swelling_clinical_features#-404534
2. British Association of Sexual Health and HIV 2010. United Kingdom national guideline for the management of epididymoorchitis. http://www.bashh.org/guidelines
3. B ritish Association of Sexual Health and HIV 2011. Clinical care pathway for management of epididymo-orchitis.
4. B ritish Association of Sexual Health and HIV 2011. UK National Guideline for the management of Gonorrhoea in Adults.
page 54
If allergic to tetracyclines:
OFLOXACIN po
200mg BD For 14 days
Adult
SSTI
Adult Section
Skin and Soft Tissue Infections
Skin & Soft Tissue Infections Impetigo

When to treat
Although usually self-limiting, treatment is recommended for all cases, as untreated impetigo is highly contagious
and there is a risk it may become generalised. Topical antibiotics should be reserved for very localised lesions and
oral antibiotics used for extensive, severe or bullous impetigo.
Non-bullous impetigo is the most common form. Lesions begin as vesicles or pustules, which rapidly burst and evolve
into gold-crusted plaques. The area around the mouth and nose is most commonly affected.
Bullous impetigo, which commonly affects neonates, presents with flaccid, fluid-filled vesicles and blisters. These
easily burst leaving raw skin, and eventually form thin, flat, brown-to-golden crusts. Tends to involve the axillae, neck
folds, and nappy area. Lesions are usually painful, are often multiple and spread rapidly.
When to investigate
Skin swabs are not necessary to diagnose impetigo. Take a swab (for bacterial identification and sensitivity) if the
infection is: very extensive or severe; recurrent (consider nasal swab for staphylococcal carriage); suspected as being
a community outbreak; suspected as being caused by MRSA. Advise the person to attend a follow-up appointment if
there is no significant improvement after 7 days..
How to respond to a
positive lab result
General advice
Educate patient about good hand washing technique and to avoid scratching lesions. Advise that hygiene measures
are important to aid healing and stop the infection spreading to other sites on the body and to other people.
First line:
Generalised infection Flucloxacillin po
500mg QDS
For 7 days.
Second line or if penicillin allergic:

Clarithromycin po
250-500mg BD
For 7 days.
N.B. Check for drug interactions!
Localised infection
Fusidic Acid 2% topically TDS

For 7 days.
If MRSA isolated:
Mupiricin 2% ointment topically TDS
For 5 days.
Cautions
As resistance is increasing, reserve topical antibiotics for very localised lesions. Reserve Mupirocin for MRSA.
Evidence
Systematic review indicates topical and oral treatment produces similar results.
References
Koning S et al. Interventions for impetigo. Cochrane Database of Systematic Reviews 2012, Issue 1.
http://summaries.cochrane.org/CD003261/interventions-for-the-skin-infection-impetigo
NHS Clinical Knowledge Summaries. Impetigo. www.cks.library.nhs.uk/impetigo
Treatment choices:
page 55
Skin & Soft Tissue Infections Eczema

When to treat
Using antibiotics, or adding them to steroids, in eczema encourages resistance and does not improve healing
unless there are visible signs of infection. If there are localized areas of infection a topical antibiotic in
combination with steroid can be considered for no longer than two weeks.
In more generalised infected eczema, use treatment as in impetigo (i.e. first line flucloxacillin)
Refer immediately (same day) to hospital if eczema herpeticum is suspected.
Signs of eczema herpeticum are:
areas of rapidly worsening, painful eczema;
clustered blisters consistent with early-stage cold sores;
punched-out erosions (circular, depressed, ulcerated lesions) usually 13 mm in diameter that are uniform in
appearance (these may coalesce to form larger areas of erosion with crusting);
possible fever, lethargy, or distress.
Refer urgently (within 2 weeks) to a dermatologist if infected eczema has not responded to treatment.
References
Atopic eczema. NHS Clinical Knowledge Summaries. http://www.cks.nhs.uk/eczema_atopic
page 56
Skin & Soft Tissue Infections Cellulitis

When to treat
Cellulitis presents with an acute onset of red, painful, hot, swollen, and tender skin, with possible blister formation. Fever,
malaise, nausea, shivering and rigors may also occur. Differential diagnoses include DVT and varicose eczema. Most
cases are attributed to an infective cause. Initiate empirical first line treatment. If patient has risk factors for colonisation
with MRSA (e.g. recurrent abscesses, contact with military personnel, engages in contact sports, healthcare worker,
recent admission to hospital) consider doxycycline. If cellulitis is in a diabetic patient or associated with recent abdominal
surgery, gram negatives and even anaerobes may be involved and a broader spectrum antibiotic may be needed. In such
cases, discuss with a microbiologist and/or diabetologist for further advice.
When to
investigate
Swabs from intact skin are of no value as they are frequently contaminated and provide a poor yield of pathogens.
Swabs of broken skin or of an obvious portal for microbial entry may help guide antibiotic choice if empirical treatment
fails. Swabs should be taken before commencing treatment. The yield is often poor, however, with pathogens isolated
from only 25% of swabs in some studies. Consider a wide range of non-infective causes in cases of treatment failure.
Consider admission for patients with severe or rapidly deteriorating cellulitis; an uncertain diagnosis with sinister signs or
symptoms (e.g. possible necrotizing fasciitis); severe systemic illness; comorbidities that may complicate or delay healing;
facial or periorbital cellulitis; lymphoedema; or for the very young, elderly or frail people.
How to respond to Alter treatment in response to culture and sensitivity results of potential pathogens. Refer people who fail to respond to
a positive lab result oral antibiotics or have frequent recurrence of cellulitis, for example more than two episodes at the same site.
General advice
Before treatment, draw around the extent of the infection with a permanent marker pen for future comparison.
Elevation of the affected area speeds improvement by promoting gravity drainage of the oedema/inflammatory substances.
Treatment choices
First line:
Flucloxacillin po
500mg QDS
For 7 days.
If there is continuing clinical response but
incomplete resolution continue for a further
7 days or longer 1C
Facial Cellulitis
Co-Amoxiclav po This is required to cover organisms from mouth and sinuses. If pen allergic, discuss with microbiology.
625mg TDS For 7-14 days.
Pregnancy/
Breastfeeding
In pregnancy or breastfeeding, use flucloxacillin or erythromycin instead of clarithromycin. Clindamycin is not known
to be harmful in pregnancy. In breastfeeding, the amount of clindamycin absorbed is probably too small to be
harmful but bloody diarrhea reported in 1 infant (BNF Sept 2012).
Cautions
= high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients).If
patient afebrile and healthy other than cellulitis, flucloxacillin or clarithromycin may be used as single drug treatment.
If exposure to river or sea water, discuss with microbiologist to consider causes such as aeromonas, atypical
mycobacteria, etc. If febrile and ill, admit for IV treatment. For pre-existing wound or leg ulcer see next monograph
overleaf.
Evidence
There is little evidence to guide the choice of antibiotic. Most trials comparing antibiotics have been small,
inconclusive and often hospital-based. Topical antibiotics should not be prescribed. There is no published evidence to
support their use and widespread use is likely to increase antibiotic resistance.
References
NHS Clinical Knowledge Summaries Cellulitis http://www.cks.nhs.uk/cellulitis_acute
Clarithromycin po N.B Check for drug interactions!
500mg BD
OR
Clindamycin po
300mg-450mg QDS (higher dose if severe)
For 7 days.
N.B. STOP clindamycin if diarrhoea occurs and send a stool
sample for C. Difficile testing.
If there is continuing clinical response but incomplete resolution
continue for a further 7 days or longer1C
page 57
Skin & Soft Tissue Infections Leg Ulcers

When to treat Venous leg ulcers affect 1.7% of those 65 years. All venous leg ulcers contain bacteria; most are colonisers, but some
cause clinical infection. Antibiotics are only indicated if there is evidence of clinical infection such as cellulitis,
increased pain, enlarging ulcer or pyrexia. If ulcer is in a diabetic patient gram negatives and even anaerobes may be
involved and a broader spectrum antibiotic may be needed. In such cases, discuss with a microbiologist and /or diabetologist
for further advice. Also see local guidance on diabetic footcare pathways:
SFT: http://www.icid.salisbury.nhs.uk/ClinicalManagement/Diabetes/Pages/DiabeticFootcareICP.aspx
RUH: http://www.bathdiabetes.org/index2.php?section_id=225andredirect=654
GWH: www.sdpreview.co.uk this diabetes website is being developed and diabetic foot ulcer info will be added to it
shortly.
When to
investigate
Microbiology investigations should only be undertaken when there are clinical signs of infection. Tissue biopsy is the gold
standard, but wound swabs are easier. Take swabs before starting antibiotics. Use a swab with transport medium and
charcoal, to aid survival of fastidious organisms. Cleanse the wound with tap water or saline to remove surface contaminants.
Slough and necrotic tissue should also be removed. Swab viable tissue displaying signs of infection. Rotate the swab. Review
antibiotics after culture results. Refer for specialist opinion if severe infection. Arterial or mixed venous/arterial ulcer: refer
people to a specialist tissue viability or leg ulcer nurse for further assessment. Take a swab for all infected venous leg ulcers
before prescribing an antibiotic.
How to
respond to a
positive lab
result
Swab results determine organisms present and antimicrobial susceptibilities-they do not determine the presence of infection.
Significance of organisms depends on presence of clinical criteria for infection. Group A beta-haemolytic streptococci can be
associated with significant infection and delay healing. Other bacterial contamination is not considered to adversely affect
healing. Inclusion of antibiotic susceptibilities does not necessarily mean an organism is significant or that it requires antibiotic
treatment. Seek microbiological advice if colonised with MRSA.
General
advice
Advise patients to keep mobile, elevate legs when immobile, avoid trauma and wear appropriate footwear, use an
emollient frequently even after the ulcer has healed, examine legs regularly for deterioration and wear compression
bandages or stockings as advised. The use of a topical antiseptic, for example an iodine-based product, may be used as an
adjunct to systemic treatment.
Treatment
choices
If active infection (cellulitis/increased pain/pyrexia/

purulent exudates/odour)2C:
If anaerobes are suspected

ADD-IN:
METRONIDAZOLE po
OR CLARITHROMYCIN po
500mg BD
400mg TDS
For 7 days.
For 7 days.
N.B Check for drug interactions if clarithromycin chosen!
If there is continuing clinical response but incomplete resolution continue for a further 7 days or longer1C
FLUCLOXACILLIN po
500mg QDS
For 7 days.
Pregnancy/
Flucloxacillin is suitable to use in pregnancy and breastfeeding. If penicillin allergic, use erythromycin (rather than
Breastfeeding clarithromycin) Metronidazole at the suggested dosage is suitable for use as well if necessary.
References
page 58
Health Protection Agency Venous Leg Ulcers: Infection Diagnosis and Microbiology Investigation Quick Reference Guide for Primary
Care 2009 http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance/#VLegUlcers
NHS Clinical Knowledge Summaries: Leg Ulcers
http://www.cks.nhs.uk/leg_ulcer_venous/management/quick_answers/scenario_infected_venous_leg_ulcer#-316797
OMeara S, Al-Khurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic
Reviews. 2010. Issue 1. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003557/frame.html
Skin & Soft Tissue Infections Methicillin-Resistant Staphylococcus aureus (MRSA) (active treatment)
For screening & suppression, see HPA MRSA quick reference guide
When to treat For active MRSA infection: Use antibiotic sensitivities to guide treatment.
More complex infections such as worsening chest infection or associated with an infected prosthetic infection may require
combination therapy (seek advice from microbiologist) or referral to hospital for assessment. If there is no response to
monotherapy after 24-48 hours, seek advice from microbiologist.
Monitor for signs of sepsis, cellulitis, pneumonia, urinary infection, and osteomyelitis (such as fever, spreading infection).
Do not give systemic antibiotics to patients with minor skin and soft tissue infections or small abscesses (<5 cm). Incise and
drain small abscesses without cellulitis and do not give antibiotic therapy.
MRSA infections most commonly affect the skin presenting as boils; abscesses; styes; carbuncles; cellulitis; impetigo; wound
infections. If MRSA enters the blood stream it can affect almost any part of the body.
Diagnosing active infection: Swab for pathogens including MRSA, or obtain a specimen if appropriate, if the person has
an active infection and one or more of the following risk factors: elderly or debilitated people with critical or chronic illness;
surgical wounds, open ulcers, intravenous lines, or catheter lines; infected pressure sore; history of MRSA colonisation or
infection; recent surgery; recent hospital discharge; regular nursing home contact or a nursing home resident; recent antibiotic
use (especially cephalosporins, fluoroquinolones, and macrolides); dialysis; permanent urinary catheter.
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus. It can rarely cause severe
invasive infections in healthy people. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or
sport; poor hygiene.
If active infection, MRSA confirmed by lab results, infection not severe and admission not required then
treat as below. 1,2B+
When to refer C
onsider admitting people who are MRSA positive if they have worsening signs of infection (for example, sepsis, worsening
cellulitis, fever, or tachycardia), particularly if they are likely to require parenteral antibiotic therapy and/or surgical drainage.
Do not refer people who are MRSA positive if they do not have an active infection (that is they are colonized with MRSA),
or another reason for admission.
General advice R eassure that infection with meticillin-resistant Staphylococcus aureus (MRSA) does not present a risk to healthy people in
the community.
Advise the person or their carer to:
Keep wounds, cuts, and abrasions covered until they are healed and dry.
Wear disposable gloves when changing dressings (and to dispose of them safely, and not to re-use them).
Dispose of dressings carefully so that the risk of infection is reduced.
Wash their hands regularly, especially before and after wound care, even if gloves are worn.
Treatment
choices
ENSURE SENSITIVITIES ARE CHECKED BEFORE INITATING TREATMENT!

DOXYCYCLINE po
100mg BD
For 7 days.
OR
CLINDAMYCIN po
300mg-450mg QDS
For 7 days.
N.B. STOP clindamycin if diarrhoea occurs and send a stool sample for C. Difficile testing.
Pregnancy/
Check sensitivities first. Seek advice from microbiologist.
Breastfeeding
Cautions
References
Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation. MarchOctober 2012. www.hpa.org.uk
NHS Clinical Knowledge Summaries. MRSA:
http://www.cks.nhs.uk/mrsa_in_primary_care/management/scenario_diagnosis#344309006
page 59
Skin & Soft Tissue Infections Animal Bites

When to treat
If the wound is less than 48 hours old and risk of infection is high. Antibiotics are not generally needed if the wound is more
than 2 days old and there is no sign of local or systemic infection. Review at 24 and 48 hours. Thorough irrigation is most
important.
Antibiotic prophylaxis is advised for:
All cat bites.
Wounds requiring surgical debridement; or suspected fractures.
Wounds that have undergone primary closure.
People with a prosthetic valve or a prosthetic joint.
Puncture wound
Bite involving hand, foot, face, joint, tendon, ligament
People who are at risk of serious wound infection: Immunocompromised
Cirrhotic

Diabetic
Asplenic patients
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons, bones,
the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds requiring closure;
bites that might need reconstructive surgery; devitalized wounds requiring debridement; bites where the severity is difficult
to assess; bites with severe cellulitis; infections not responding to treatment; people with an increased risk of infection (see
above); children with scalp wounds; bites to poorly vascularised areas.
When to
investigate
If there is evidence of infection, send pus or deep wound swab for culture before cleaning the wound.
Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.
How to respond Alter treatment in response to culture and sensitivity results.

to a positive lab
result
General advice
If the wound has just occurred, encourage it to bleed. Clean and irrigate the wound.
Treatment
choices
First line:
Co-Amoxiclav
625mg TDS
For 7 days.
po
Metronidazole po
200-400mg TDS
PLUS
Doxycycline po
100mg BD
For 7 days.
Assess tetanus and rabies risk. If any risk of rabies contact the HPA (tel: 020 8327 6017).
Consider need for tetanus prophylaxis.
Pregnancy/
Breastfeeding
Co-amoxiclav is suitable to use in pregnancy & breastfeeding. If penicillin allergic, contact microbiology for advice.
Cautions
= high risk for causing C. Difficile infection (see page 70 (appendix 1) for information on high-risk patients). Regarding
tetanus and rabies risk, if it is a primate bite, discuss with virologist. In the case of unusual animals, please discuss with
microbiologist, particularly if persistent infection despite treatment with co-amoxiclav, or if immunocompromised.
Evidence
Non-human bites that are low risk and that do not involve the hand have infection rates <2%. Macrolides are not recommended
for animal bites because they do not adequately cover Pasteurella. Co-amoxiclav is effective against most bacteria isolated from
domestic animal bites. Metronidazole (in addition to tetracyclines) covers beta-lactamase-producing anaerobes.
References
NHS Clinical Knowledge Summaries: Animal Bite http://www.cks.nhs.uk/bites_human_and_animal/management/
quick_answers/scenario_managing_a_cat_or_dog_bite
page 60
Skin & Soft Tissue Infections Human Bites

When to treat
Antibiotic prophylaxis advised for all wounds less than 72 hours old even if there is no sign of infection. Thorough
irrigation of the wound is important. Review at 24 and 48 hours.
The following require secondary care referral: Penetrating wounds involving arteries, joints, nerves, muscles, tendons,
bones, the CNS; facial wounds (unless very minor); systemic illness; possibility of foreign body presence; wounds
requiring closure; bites that might need reconstructive surgery; devitalised wounds requiring debridement; bites where
increased risk of infection (e.g. diabetic, cirrhotic, immunosuppressed, asplenic); bites to poorly vascularised areas.
When to
investigate
Where infection suspected, send a pus or deep wound swab for culture before cleaning the wound and starting
antibiotics. Advise all patients to attend urgently for review if the infection worsens or if they feel increasingly unwell.
Seek immediate advice from a consultant in microbiology or infectious diseases for anyone considered to be at risk of
HIV, hepatitis B or C. Consider all people to be at risk unless the current status of the biter is known (rare). Consider if
tetanus prophylaxis is required. Tetanus after a human bite is extremely rare.
How to respond
to a positive lab
result
General advice
If the wound has just occurred, encourage it to bleed. Clean and irrigate the wound thoroughly with warm running water.
Treatment
choices
First line (prophylaxis or treatment): If penicillin allergic (prophylaxis or treatment):

CO-AMOXICLAV
625mg TDS
For 7 days.
po
Metronidazole po
200-400mg TDS
Plus
Doxycycline po Or Clarithromycin po
100mg BD
250-500mg BD
For 7 days.
For 7 days. N.B Check for drug interactions!
Pregnancy/
Breastfeeding
Co-amoxiclav is suitable to use in pregnancy & breastfeeding. If penicillin allergic, contact microbiology for advice.
Cautions
Assess HIV, hepatitis B and C risk. Antiseptic cleansers are not necessary and there is some concern that they damage
tissue and delay wound healing.
Evidence
Co-amoxiclav is effective against the most commonly isolated organisms from human bites. Doxycycline, but not
clarithromycin is active against Eikenella species, which is commonly isolated from human mouths. Metronidazole
covers beta-lactamase-producing anaerobes. 80% of Eikenella corrodens are resistant to macrolides. If a bite is 72
hours old and there is no sign that it has become infected, the risk of infection is likely to be low and prophylactic
antibiotics are probably not of value.
References
NHS Clinical Knowledge Summaries Human Bite: http://www.cks.nhs.uk/bites_human_and_animal/
management/quick_answers/scenario_managing_a_cat_or_dog_bite#-282212
page 61
Skin & Soft Tissue Infections Conjunctivitis

When to
treat
Only treat if severe, as most infections are viral or self-limiting. Bacterial conjunctivitis is usually unilateral and also selflimiting; therefore a wait and see or delayed prescription approach is likely to be most appropriate. Consider starting treatment if
no improvement after 3 days.
Conjunctivitis is characterised by red eye with mucopurulent, not watery, discharge.
Consider offering a topical ocular antibiotic to a person with infective conjunctivitis when:
Infective conjunctivitis is severe, or likely to become severe, providing serious causes of a red eye can be confidently excluded.
Schools and childcare organizations require treatment before allowing a child to return.
They understand the limitations of treatment but still prefer treatment.
When a topical ocular antibiotic is prescribed because of the persons preference for treatment, consider advising them to delay
starting treatment for 3 days to see if the condition will resolve spontaneously.
N.B. Chloramphenicol 0.5% eye drops and 1% ointment can now be bought over-the-counter at pharmacies for adults and
children over the age of 2 years.
When to
If any of the following symptoms are present, refer the patient for specialist same-day assessment to exclude acute glaucoma,
investigate keratitis, iritis or orbital cellulitis: Significant photophobia; reduced visual acuity; pain deep in the eye; recent eye surgery;
absent or sluggish pupil response; irregular pupils; corneal damage or opacity on fluorescein staining; restricted or painful eye
movements; history of head/eye trauma.
Swab the eye to identify the infective cause when infective conjunctivitis is hyper-acute or persistent. This is not usually
considered useful for people with acute infective conjunctivitis.
Patients should be advised to seek medical advice if symptoms do not settle within 7 days, or if there is visual disturbance,
significant eyelid swelling, photophobia or pain in the eye. In cases where conjunctivitis persists for >2 weeks, take swabs for
bacteria and chlamydia.
General
Advice
Warn patient to not wear contact lenses whilst having this treatment and for 24hrs after finishing treatment. Patients should
be advised to wash hands regularly, particularly after touching infected secretions, and avoid sharing pillows and towels.
Treatment
choices
If Severe, First line:

Chloramphenicol
0.5% eye-drops
2hrly for 2 days, then reducing to four hourly (whilst awake)
Plus
1% eye ointment
AT NIGHT and for 48hrs after resolution of symptoms
Pregnancy
Fusidic acid is the treatment of choice during pregnancy. See CKS
Cautions
Consider the differential diagnoses of blepharitis.
Evidence
65% of infections resolve on placebo by day five. Fusidic acid has less Gram-negative activity. Hence use for Staphylococcus
aureus eye infections ONLY. A double-blind placebo-controlled RCT in children showed, at day 7, 83% clinical cure with placebo
compared with 86% with chloramphenicol.
Delayed prescribing of antibiotics appears to reduce antibiotic use (almost 50%) with similar symptom control to immediate prescribing.
Second-line, for Staphylococcus-aureus eye infections Only:

Fusidic Acid
1% topical gel
BD
and for 48hrs after resolution of symptoms.
References Health Protection Agency. Management of Infection Guidance for Primary Care for Consultation and local adaptation.
March-October 2012 www.hpa.org.uk
NHS Clinical Knowledge Summaries http://www.cks.nhs.uk/conjunctivitis_infective#
Management of acute infective conjunctivitis. Drug and Therapeutics Bulletin 2011; 49(7): 78-80
Rose PW et al. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care. The Lancet 2005;
366(8479): 37-43
Everitt H, Little P, Smith P. A randomised controlled trial of management strategies for acute infective conjunctivitis in general
practice. BMJ 2006; 333(7563): 32
page 62
Skin & Soft Tissue Infections Scabies

When to
treat
The main symptom is generalised itch especially at night. Characteristic silvery lines may be seen in the skin where mites
have burrowed. Erythematous papular or vesicular lesions are often associated with the burrows. Typical sites include the
interdigital folds, wrists, elbows and around the nipples in women.
Treat whole body from chin and ears downwards, including under the nails. People who are immunosuppressed, the very
young and elderly should apply the insecticide to the whole body including the face and scalp. Treat all household, close
contacts and sexual contacts even in the absence of symptoms within 24hrs. Scabies persists indefinitely if not treated.
When to
investigate
Finding the mite or its products confirms, but is not necessary for making a diagnosis of scabies. Consider referral to a
dermatologist if the diagnosis is in doubt, or after continued treatment failure (e.g. if two courses of an insecticide have failed).
Seek specialist advice from a consultant dermatologist for the management of anyone presenting with crusted scabies.
Admission may be required.
Consider referral to a genito-urinary medicine clinic for specialist advice, diagnostic services, partner notification, and contact
tracing if there is a history of risk behaviour for sexually transmitted infections: Contact tracing of partners from the previous 2
months should be undertaken.
Refer institutionalised outbreaks of scabies (e.g. schools, long-stay nursing homes, and prisons) to the Health Protection
Agency, as control measures are necessary to deal with all residents, staff and healthcare workers.
Review if symptoms have not cleared within 6 weeks after the first application of treatment.
Scabies is rare in children under 2 months of age. Seek specialist advice (e.g. from a paediatric dermatologist) if treatment is
required for this age group.
General
Advice
Consider symptomatic treatment for itching (e.g. topical crotamiton). Consider a sedating antihistamine at night-time if
itching is particularly problematic. Machine wash (at 50C or above) clothes, towels, and bed linen, on the day of application
of the first treatment. Advise to avoid close body contact with others until their partners and close contacts have been treated.
Apply the treatment to cool dry skin (i.e. not after a hot bath). Allow the lotion or cream to dry before dressing.
Wash the treatment off after prolonged contact with the skin: Permethrin: 8 to 12 hours. Malathion: 24 hours.
Reapply treatment if it is washed off during the treatment period (e.g. after hand washing). Advise the patient that the itching
may take several weeks to resolve.
Treatment
choices
First line:
PermethrinA+
5% topical cream
2 applications one week apart
If allergic to Permethrin:
Malathion
0.5% aqueous liquid topically
2 applications one week apart
Pregnancy/
The first choice treatment is permethrin in pregnancy or breastfeeding (due to there being more evidence of safety) but if the
Breastfeeding patient is allergic to permethrin, malathion can be used. Both products are poorly absorbed following topical application and
are widely recommended for use during pregnancy. Neither malathion nor permethrin are specifically licensed for use during
pregnancy or breastfeeding, however there is no indication that either product poses any risk to the fetus or child.
Breastfeeding mothers should remove the liquid or cream from the nipples before breastfeeding, and reapply treatment
afterwards.
Evidence
There is more evidence for the effectiveness of permethrin than malathion. Expert opinion is that two treatment sessions are
needed to treat scabies effectively (HPA). The SPC states that: Approximately 90% of individuals are cured with a single application
of cream. If necessary, a second application may be given not less than 7 days after the initial application, if there are no signs of
the original lesions healing or if new lesions are present.
References
NHS Clinical Knowledge Summaries. Scabies. http://www.cks.nhs.uk/scabies
BASHH. United Kingdom National Guideline on the Management of Scabies infestation (2007)
http://www.bashh.org/documents/27/27.pdf
page 63
Skin & Soft Tissue Infections Dermatophyte infection of the proximal fingernail or toenail
When to treat Take nail clippings: Start therapy only if infection is confirmed by laboratory. Self care alone may be appropriate for people who
are not bothered by the infected nail or who wish to avoid the possible adverse effects of drug treatment. For children with
such infections, seek specialist advice.
Consider drug treatment if:
Walking is uncomfortable.
Abnormal-looking nails are causing significant psychological distress.
The person has diabetes, vascular disease, or a connective tissue disorder (because of a higher risk for secondary bacterial
infections and cellulitis).
The nail infection is thought to be the source of fungal skin infection.
The person is, or is likely to become, severely immunocompromised (for example with haematological malignancy or its treatment).
When to
investigate
If the diagnosis is uncertain

If treatment is unsuccessful
If the person is immunocompromised, refer to dermatology.
False-negative rates are high (about 30%). Therefore repeat the test if the result is negative, and there is high clinical suspicion
that the nail is infected.
General
Advice
Advise the person to avoid or minimize exposure to situations which predispose to, or aggravate, fungal nail infection, for example:
Prolonged or frequent exposure to warm, damp conditions.
Occlusive footwear.
Damaging the nails.
Keep nails trimmed short and filed down.
Wear well fitting shoes.
Consider seeing a podiatrist if the nails are causing discomfort when walking.
Treatment
choices
Treatment options:
Amorolfine nail lacquerB- 5%
1-2x/week
Fingernails: 6 months treatment
Toenails: 12 months treatment
Most suitable if infection is mild and superficial
OR
TerbinafineA- po
250mg OD
Fingernails: 6-12 weeks
Toenails: 3-6 months
If candida or non-dermatophyte
infection is CONFIRMED use:
ITRACONAZOLE po
200mg BD for 7 days, subsequent courses
repeated after 21 day interval.
Fingernails: 2 courses
Toenails: 3 courses
Pregnancy/
None of these treatments are recommended to be used during pregnancy and breastfeeding.
Breastfeeding
Cautions
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 Unpleasant adverse effects can occur. These include headache,
itching, loss of the sense of taste, gastrointestinal symptoms, rash, and fatigue. Although abnormal liver function tests are not
uncommon, liver failure and other serious adverse effects are rare.
Evidence
Treatment does not always cure the infection. Cure rates range between approximately 6080%. Treatment that eradicates the
infection sometimes does not restore the nails appearance to normal. The HPA Mycology Reference Laboratory recommends
itraconazole for non-dermatophyte infections because although some of the infecting organisms are not particularly
susceptible to this agent in vitro, it does reach high concentrations in nail tissue. It can be given as a pulse therapy regimen
rather than continuous treatment.
References
HPA Fungal skin and nail infections. Quick Reference Guide.2011.
NHS Clinical Knowledge Summaries. Fungal nail infection.
http://www.cks.nhs.uk/fungal_nail_infection/drugs_in_this_topic/scenario_fungal_nail_infection#-378744
page 64
Skin & Soft Tissue Infections Dermatophyte infection of the skin (body and groin)
When to treat
The rash typically presents as one or more red or pink, flat or slightly raised, patches of skin which enlarge to become
ring-shaped lesions with red, scaly borders with a clear central area.
If candida possible, use imidazole. If intractable: send skin scrapings. If infection confirmed, use oral terbinafine/
itraconazole.
Scalp: discuss with specialist
When to
investigate
Refer patient to a dermatologist if they are immunocompromised.

Take samples for microscopy and culture if:
The diagnosis is unclear
The infection has not responded to standard topical antifungals
Oral antifungals are being considered.
Samples are not needed for uncomplicated athletes foot, mild infections of the groin or mild skin ringworm.
If samples are needed, scrape skin from the advancing edge of lesion. Use a blunt scalpel blade or similar. 5mm of skin
flakes are needed for microscopy and culture. Do not refrigerate.
How to
respond to a
positive lab
result
Treat if positive lab cultures. Susceptibility testing of dermatophytes is not required, as antifungal resistance is unusual
and there is no known correlation between antifungal susceptibilities and outcome. For non-dermatophyte moulds other
than Candida sp, seek the advice of a microbiologist or dermatologist.
General
Advice
Advise the person to:

Wash the affected skin daily and dry thoroughly afterwards; particularly in the skin folds
Wash clothes and bed linen frequently to eradicate the fungus.
Not share towels and to wash them frequently
Wear loose fitting clothes made of cotton or similar material.
Treatment
choices
First-line options:
TerbinafineA+
1% topical cream
BD
For 1-2 weeks.4A+
Pregnancy/
Breastfeeding
In pregnancy and breastfeeding a topical azole can be used.
Evidence
Terbinafine is fungicidal, so treatment time shorter than with fungistatic imidazoles. A Cochrane review found little
difference between terbinafine and azoles in standard courses at 2 weeks after baseline however at 6 weeks, treatment
failure was lower with terbinafine.
References
NHS Clinical Knowledge Summaries. Fungal skin infection.
http://www.cks.nhs.uk/fungal_skin_infection_body_and_groin
HPA Fungal skin and nail infections. Quick Reference Guide.2011.
Cochrane Summaries. Crawford F, Hollis S Creams, lotions and gels (topical treatments) for fungal infections of the skin
and nails of the foot. July 2009.
http://summaries.cochrane.org/CD001434/creams-lotions-and-gels-topical-treatments-for-fungalinfections-of-the-skin-and-nails-of-the-foot
OR
IMIDAZOLE (Topical) 4A+
BD
For 1-2 weeks after healing
(i.e. total duration of 4-6 wks).
For athletes foot only:

UNDECANOATE (Topical) 4B+
Paint
BD
For 1-2 weeks after healing (i.e. total duration of 4-6 wks).
page 65
Skin & Soft Tissue Infections Varicella Zoster (chickenpox) and Herpes Zoster (shingles)
When to treat Chickenpox: Consider prescribing aciclovir if they present within 24 hours of the onset of the rash and >14yrs or severe pain
or dense/oral rash or secondary household case or steroids or smoker.2-4
Shingles: Start an anti-viral drug within 72 hours of rash onset for anyone over the age of 50, those with non-truncal
involvement or moderate or severe pain or rash. If the person presents up to 1 week after rash onset, consider prescribing
treatment if they are at higher risk of severe shingles or complications.
Always treat if active ophthalmic, and Ramsey Hunt syndrome or eczema. Post-Herpetic Neuralgia rare if <50yrs7BCold sores resolve after 710 days without treatment. Topical antivirals applied prodomally reduce duration by 12-24hrs 1,2,3B+,4
When to
investigate
Chickenpox: Admit to hospital if serious complications are suspected (pneumonia, encephalitis).

Chickenpox and Shingles: If the patient is immunocompromised seek specialist advice.
Shingles: Patients who have had 2 episodes of shingles or if there is a diagnostic uncertainty or if there is ophthalmic
involvement, seek specialist advice/refer.
General
Advice
Chickenpox: Offer paracetamol or ibuprofen for pain and fever. To relieve itch consider topical calamine lotion or oral
chlorphenamine. Encourage adequate fluid intake.
The most infectious period is 1-2 days before the rash appears, but infectivity continues until all the lesions have crusted
over (~5-6 days after onset).
Shingles: Only people who have not had chickenpox or varicella vaccine can catch chickenpox from someone with shingles.
Shingles can only be passed on by direct skin contact with the affected area. Offer paracetamol and /or ibuprofen for pain.
Patients with chickenpox or shingles should be advised to avoid contact with the immuncompromised,
pregnant women and neonates.
Treatment
choices
First line:
ACICLOVIR po
800mg 5x /day
For 7 days.
Pregnancy/
In pregnancy seek specialist advice.
Breastfeeding In breastfeeding seek specialist advice regarding whether the mother should continue to breastfeed if she has chickenpox.
Consider prescribing aciclovir if the woman presents within 24 hours of the onset of rash (particularly if severe chickenpox
or risk of complications).
Evidence
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.ANon-ophthalmic shingles: Treat >50 yrsA+ if <72h of onset of rash, as post-herpetic neuralgia rare in <50 yrs but
occurs in 20% >50 yrsA+. In a review in children and adolescents, aciclovir within 24h of rash onset shortened fever by
approximately one day and reduced the maximum number of lesions but did not reduce the complication rate.
References
March to October 2012. www.hpa.org.uk
NHS Clinical Knowledge Summaries: Chickenpox. http://www.cks.nhs.uk/chickenpox#-308226
NHS Clinical Knowledge Summaries: Shingles and postherpetic neuralgia. http://www.cks.nhs.uk/post_herpetic_neuralgia
page 66
Skin & Soft Tissue Infections Mastitis NEW (page 1 of 2)

When to treat Clinical features of mastitis include: a painful breast, fever, general malaise and a tender, red, swollen and hard area of the
breast, usually in a wedge-shaped distribution.
It is not possible to distinguish clinically between non-infectious mastitis and infectious mastitis. Suspect and treat
infectious mastitis if:
Symptoms do not improve or are worsening after 12-24 hours despite effective milk removal.
The woman has a nipple fissure that is infected.
Bacterial culture is positive (if done: see when to investigate section)
Be aware and rule out other differential diagnoses before treatment.
When to refer If you suspect there is a breast abscess, refer urgently to a general surgeon to confirm the diagnosis and treat. Suspect a
breast abscess if the woman has:
A history of recent mastitis
A painful swollen lump in the breast with redness, heat and swelling of the overlying skin
Fever and malaise (may have subsided if the woman has taken antibiotics)
On examination, the lump may be fluctuant with skin discolouration
Refer if there is an underlying mass, or ductal cancer or if inflammatory breast cancer (a rapid onset of warmth of the
breast, diffuse redness (varies from a faint blush to bright red) and oedema causing an orange skin [peau dorange]
appearance) is suspected. Arrange urgent investigation or referral.
It is unlikely that the infant will become unwell but, if staphylococcal or streptococcal infection is confirmed, observe the
infant for signs of infection and seek the advice of a paediatrician if the child becomes unwell.
When to
investigate
Investigations are not routinely required. Culture the breast milk when:
Antibiotic have been prescribed and there has been no response after 48 hours.
Mastitis is severe before any antibiotics prescribed.
History of recurrent mastitis.
Hospital-acquired infection is likely.
The patient is unable to take standard antibiotics (such as flucloxacillin and erythromycin).
There is severe deep burning breast pain (indicative of ductal infection).
To collect a sample of breast milk into a sterile container, clean the nipple of the affected breast, express a small amount
of milk by hand and discard it (to avoid skin decontamination) and express milk into a sterile container, avoiding touching
the inside of the container with the nipple or hands.
General
Advice
To relieve pain and discomfort, offer paracetamol. Also advise the patient to place a warm compress on the breast, or bathe or
shower in warm water (to relieve pain and help milk flow). Rest (if possible) and do not wear a bra (especially at night).
Advise to continue to breastfeed, refer to a breastfeeding specialist if necessary. If the affected breast is not completely
empty after feeding advise to express the remaining milk by hand or pump until breastfeeding can be resumed. Encourage
to drink plenty of fluids.
Advise to contact a healthcare professional if symptoms worsen, antibiotics have not been prescribed and symptoms have
not settled within 12-24 hours or if symptoms fail to settle after 48 hours of antibiotic treatment.
The following patient information leaflet from the Breastfeeding Network may be of use:
http://www.breastfeedingnetwork.org.uk/pdfs/BFN_Mastitis.pdf
page 67
Skin & Soft Tissue Infections Mastitis NEW (page 2 of 2)

Treatment
choices
First line:
FLUCLOXACILLIN
500mg QDS For 14 days.
ERYTHROMYCIN
250-500MG QDS For 14 days.
If the results of breast milk culture are available, prescribe an antibiotic according to the sensitivities of the organism that
has been identified.
Pregnancy/
Antibiotics are only excreted in milk in very small amounts. Usually the infant is not affected, but occasionally stools may
Breastfeeding be looser or more frequent than usual or the infant may be more irritable.
Cautions
If symptoms fail to settle after 48 hours of antibiotic treatment, ensure compliance with medication, send a sample of
the milk for culture and change the antibiotic to co-amoxiclav 500/125mg TDS. Seek specialist advice if the patient
is penicillin allergic. Review antibiotic choice once culture results are available. = high risk for causing C. Difficile
infection (see page 70 (appendix 1) for information on high-risk patients).
Evidence
Expert opinion is that relapse is more common with shorter courses of treatment.2,3
References
1. \Mastitis and breast abscess. Clinical Knowledge Summary.

www.cks.nhs.uk/mastitis_and_breast_abscess#417587006
2. WHO (2000) Mastitis. Causes and management. World Health Organisation. www.who.int (Free full-text)
3. Academy of Breastfeeding Medicine (2008) ABM Clinical protocol #4: mastitis. Revision, May 2008. Breastfeeding
Medicine 3(3), 117-180.
page 68
Adult
DI
Adult Section
Dental Infections
Emergency Treatment of Dental Infections NEW

(derived from the Scottish Dental Clinical Effectiveness Programme 2011 SDCEP Guidelines)
Dental infections are always best treated by a dentist. 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 routinely be
involved in dental treatment and, if possible, advice should be sought from the patients dentist, who should have an answer-phone message
with details of how to access treatment out-of-hours, or NHS Direct on 0845 4657.
Illness
Drug
Adult
Mucosal
Temporary pain and swelling relief can be attained
ulceration
with saline mouthwash1C
and
Use antiseptic mouthwash:
inflammation
If more severe and pain limits oral hygiene to treat
(simple
or prevent secondary infection.2-8C
gingivitis)
The primary cause for mucosal ulceration or
inflammation (aphthous ulcers, oral lichen planus,
herpes simplex infection, oral cancer) needs to be
evaluated and treated.
Comments
Simple saline mouthwash1C

(spit out after use)
Chlorhexidine 0.2%2-6A+
(Do not use within 30 mins of
toothpaste, spit out after use)
tsp salt dissolved in

glass warm water.
Rinse mouth for 1 minute
BD with 5 ml diluted with
5-10 ml water.
Hydrogen peroxide 6%6-8A(spit out after use)
Dilute 15ml in glass of

warm water and rinse in
mouth for 2 minutes.
Acute
necrotising
ulcerative
gingivitisC
Metronidazole1-7C
400 mg TDS
3 days
Chlorhexidine or hydrogen
peroxide
see above dosing in

mucosal ulceration
Until oral hygiene

possible
Amoxicillin
500 mg6 TDS
3 days
Metronidazole1-7C
Chlorhexidine or hydrogen
peroxide
400 mg TDS
see above dosing in
mucosal ulceration
3 days
Until oral hygiene
possible
Commence metronidazole1-7 and refer to dentist for

scaling and oral hygiene advice.C
Use in combination with antiseptic mouthwash if
pain limits oral hygiene.
Pericoronitis1B Refer to dentist for irrigation and debridement.1C

If persistent swelling or systemic symptoms use
metronidazole.1-5A
Use antiseptic mouthwash if pain and trismus limit
oral hygiene.
Dental
abscessB
Duration of TX
Use until lesions

resolve or less pain
allows oral hygiene
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;1 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.2,3
S evere 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
T he empirical use of cephalosporins,9 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.6,12C
If pus drain by incision, tooth extraction or via root

canal.4-7B Send pus for microbiology.
True penicillin allergy: use clarithromycin or
clindamycinC if severe.
If spreading infection (lymph node involvement,
or systemic signs ie fever or malaise) ADD
metronidazole8-10C
Amoxicillin2 or
Phenoxymethylpenicillin2
True penicillin allergy:
Clarithromycin
500 mg2 TDS

500 mg2 - 1g QDS
Up to 5 days review
at 3d11
500 mg BD
Severe infection add

Metronidazole8-10 or if allergy 400 mg TDS
Clindamycin 3,8-11
300mg QDS
5 days
5 days11
N.B. STOP Clindamycin if diarrhoea occurs and send a stool sample for C. Diff testing.
page 69
Appendix 1
Best practice in antimicrobial drug prescribing

Clostridium difficile infection (CDI) is associated with antimicrobial use.
Prescribing antimicrobials wisely can reduce the incidence.
Clostridium difficile infection (CDI)
Antimicrobials to avoid where possible
C. difficile is a bacterium present in the gut flora in

some people.
The antimicrobials most strongly associated with CDI are:
Antimicrobials disturb the balance of the gut flora,

allowing C. difficile to multiply and cause infection.
Second and third generation cephalosporins: cefaclor,

cefuroxime, cefixime and cefpodoxime are examples
for oral use
Symptoms of CDI can vary from mild diarrhoea to fatal Clindamycin

Quinolones (associated with the virulent 027 strain of
bowel inflammation.
C. difficile): ciprofloxacin, levofloxacin, moxifloxacin,
C. difficile spores are shed in the faeces. The spores
ofloxacin, norfloxacin.
can survive for long periods in the environment.
Long courses of amoxicillin, ampicillin, co-amoxiclav or
If ingested, they can transmit infection to others.
co-fluampicil.
Prudent antimicrobial prescribing
Only prescribe antimicrobials when indicated by

the clinical condition of the patient or the results of
microbiological investigation.
Do not prescribe antimicrobials for sore throat, coughs
and colds in patients at low risk of complications.
Consider delayed prescriptions in case symptoms
worsen or become prolonged.
If an antimicrobial is required, follow local guidelines.
Choose a narrow-spectrum agent where possible and
prescribe a short course.
Generally, no more than 5-7 days treatment is
required.
Three-day courses are appropriate in some cases.
Broad-spectrum antimicrobials should be reserved for
the treatment of serious infections when the pathogen
is not known.
Antimicrobials to choose
All antimicrobials are associated with CDI, but
those with lower risk are trimethoprim, penicillin V,
tetracyclines and aminoglycosides.
If antimicrobials are required, prescribe a short course
and follow the local formulary.
Where therapy has failed or there are special
circumstances, obtain advice from a local
microbiologist.
CDI and primary care

CDI has commonly been associated with hospital stay but
it is being recognised that many cases originate in the
community, due to indiscriminate use of antibiotics.
Patients most at risk are the elderly, particularly if
they have medical conditions and are in close contact
with others, e.g. in a care home, residential treatment
centre or hospital.
Reference: Clostridium difficile infection- which antimicrobials are implicated? Medicines Q and As UKMI. Nov 2012.
http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Clostridium-difficile-infection--whichantimicrobials-are-implicated/
page 70
How we use antimicrobials affects the whole community

Which patients are most at risk of CDI?
Patients are more at risk of CDI if they are:
Elderly
Suffering from severe underlying diseases
Immunocompromised
In an environment where they are in close contact
with one another (e.g. in a care home), particularly
if hygiene is lacking.
Have been in hospital in the previous 6 months.
Have finished a course of antibiotics in the previous 30
days.
Other factors that increase the risk of CDI are:
Long duration of antimicrobial treatment, use of multiple
courses and use of combinations of antimicrobials.
Recent gastrointestinal procedures
Presence of a nasogastric tube
The use of proton pump inhibitors (PPIs) might
increase the risk of CDI. Only prescribe PPIs when
indicated and review.
Reducing the risk of CDI

Prudent antimicrobial prescribing
Broad-spectrum antimicrobials are strongly
associated with CDI.
Isolating infected patients
Isolating patients with CDI reduces the spread of
infection in care homes and other places where people
are in close contact with one another.
Good hygiene
Everyone should wash their hands with soap and water
before and after each contact with a CDI-infected
patient, including at home
Alcohol gel is effective against MRSA but not
against C. difficile spores
The National Patient Safety Agencys Clean Your
Hands campaign has been rolled out to primary care
see www.npsa.nhs.uk/cleanyourhands
Carers of CDI-infected patients should wear gloves
and aprons.
When can broad-spectrum antibiotics be

recommended?
There are few indications for broad-spectrum
cephalosporins or quinolones in primary care.
The following situations are the only indications for their
first-line use.
Acute pyelonephritis
Co-amoxiclav or
Ciprofloxacin
Acute prostatitis
Ciprofloxacin or ofloxacin
Animal bite or human bite
Co-amoxiclav
Suspected meningitis in
penicillin-allergic patient
Cefotaxime
When using broad spectrum antimicrobials, counsel

patients at risk to be alert for signs of CDI and to stop
their antimicrobial and seek medical help if diarrhoea
develops.
If prescribing antimicrobials to patients with a history of
CDI, refer to the CCGs Clostridium difficile guidelines.
Bottom line
Clindamycin and broad spectrum antimicrobials are
associated with CDI.
Dont prescribe antimicrobials when theyre not
needed.
If antimicrobial is indicated, prescribe a short course
of a narrow-spectrum agent at the appropriate dose,
as outlined in this guidance.
page 71
Appendix 2
NEW
Probiotics in the prevention of antibiotic-associated

diarrhoea and clostridium difficle infection.
Probiotics have been advocated in the prevention and

treatment of antibiotic associated diarrhoea (AAD). A recent
systematic review and meta-analysis1 has found that using
probiotics as an adjunct therapy reduces the risk of antibiotic
associated diarrhoea, with a relative risk of 0.58. The
treatment effect equates to an NNT of 13. Another recent
systematic review and meta-analysis investigated the use of
probiotics for the prevention of clostridium difficile associated
diarrhoea (CDAD).2 Probiotics reduced the incidence of CDAD
by 66%. The results indicate that in a population with a 5%
incidence of antibiotic-associated CDAD, probiotic prophylaxis
would prevent 33 episodes per 1000 persons with the
evidence being rated as moderate quality.
as yet unknown and may vary between strains of bacteria.

Data indicate that Lactobacillus strains in particular seem to
be effective; however the largest body of evidence is for the
yeast S. boulardii and also for L. rhamnosus.4
A recent Cochrane review5 of the use of probiotics to prevent
AAD in children states that S. boulardii and L. rhamnosus at a
high dosage of 5-40 billion CFU/day may prevent the onset of
AAD, with no serious side-effects, however this benefit needs
to be confirmed in a large randomised study.
Therefore there is a growing evidence base to suggest that
the use of probiotics to prevent AAD is efficacious in terms
of reducing the risk of AAD occurring. However, significant
heterogeneity and low quality trials require conduct of
An earlier meta-analysis also found that administration of
further well-designed randomized trials that directly compare
probiotics led to a statistically significant relative risk reduction probiotics.
of 44% for AAD and 71% for CDAD.3
Meanwhile, until further evidence is available, for
AAD can occur up to 2-3 weeks following cessation of
high risk patients (see appendix 1, p77) it might be
antibiotic therapy rather than during treatment. Clostridiumuseful to suggest that they buy their own supply of
difficile associated diarrhoea (CDAD) is responsible for 10probiotics (especially those containing S. boulardii or L.
20% of all cases of AAD and it can occur up to 8 weeks after rhamnosus, if available) to take whilst having courses
antibiotic therapy.4
of antibiotics.
Researchers have proposed that probiotics may prevent
Lactobacillus casei is contained in both Yakult & Actimel
diarrhoea by interrupting either of the potential mechanisms; (Danone) and both are widely available and should
by maintaining the flora of the gut and on-going
be taken twice a day. Various internet suppliers can
carbohydrate fermentation; and/or by competitively inhibiting specifically supply oral versions of S. boulardii or L.
rhamnosus.
the growth of pathogens. The exact mechanism of action is
Reference:
1. Hempel S et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhoea.
A systematic review and meta-analysis. JAMA May 9th, 2012; 307:18; 1959-1969
http://ods.od.nih.gov/pubs/ebrp.probiotics_for_the_prevention_and_treatment_of_antibiotic-associated_diarrhea.pdf
2. Johnston BC et al. Probiotics for the prevention of clostridium difficile-associated diarrhoea: A systematic review and metaanalysis. Ann Intern Med. 18th Dec 2012; 157 (12):878-888. https://annals.org/article.aspx?articleid=1390418
3. Avadhani, A and Miley H. Probiotics for prevention of antibiotic-associated diarrhoea and clostridium difficile associated disease
in hospitalized adults a meta analysis. J of Am Acad of Nurse Prac 23 (2011) 269-274.
http://www.ncbi.nlm.nih.gov/pubmed/21649768
4. Hickson M. Probiotics in the prevention of antibiotic-associated diarrhoea and clostridium difficile infection. Ther Adv
Gastroenterol (2011) 4(3) 185-197 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3105609/
5. Johnston BC, Goldenberg JZ, Vandvik PO, Sun X and Guyatt GH. Probiotics for the prevention of paediatric antibiotic-associated
diarrhoea (AAD). Cochrane Summaries. Nov 9th 2011. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004827.pub3/pdf
Further reading:
Canadian Agency for Drugs and Technologies in Health. Rapid Response Report: Summary with critical appraisal. Probiotics for
antibiotic-associated diarrhoea, Clostridium difficile infection and irritable bowel syndrome: A review of clinical evidence and safety.
17th Jan 2013: http://www.cadth.ca/en/products/rapid-response/publication/3635
page 72
Appendix 3
page 73
Notes for prescribers1
Care pathway for respiratory tract infections
At the first face-to-face contact in primary care, including walk-in centres and emergency
departments, offer a critical assessment including:
history (presenting symptoms, use of over-the-counter or self medication, previous medical history,
relevant risk factors, relevant comorbidities).
examination as needed to establish diagnosis.
Address patients or parents/carers concerns and expectations when agreeing the use of
the three antibiotic strategies (no prescribing, delayed prescribing and immediate prescribing).
Agree a no antibiotic or delayed antibiotic prescribing
strategy for patients with acute otitis media, acute
sore throat/acute pharyngitis/acute tonsillitis,
common cold, acute rhinosinusitis or acute cough/
acute bronchitis.
No antibiotic
prescribing
Offer patients:
reassurance that
antibiotics are not
needed immediately
because they will
make little difference
to symptoms and
may have side
effects, for example,
diarrhoea, vomiting
and rash
a clinical review if
the RTI worsens or
becomes prolonged.
Delayed antibiotic prescribing

Offer patients:
reassurance that antibiotics are
not needed immediately because
they will make little difference
to symptoms and may have side
effects, for example, diarrhoea,
vomiting and rash
advice about using the delayed
prescription if symptoms do not
settle or get significantly worse
advice about re-consulting
if symptoms get significantly
worse despite using the delayed
prescription.
The delayed prescription with
instructions can either be given to the
patient or collected at a later date.
However, also consider

an immediate prescribing
strategy for the following
subgroups, depending on
the severity of the RTI.
The patient is at risk of developing complications.
No antibiotic, delayed
antibiotic prescribing
or immediate antibiotic
prescribing
Depending on clinical assessment
of severity, also consider an
immediate prescribing strategy for:
children younger than 2 years
with bilateral acute otitis media
children with otorrhoea who have
acute otitis media
patients with acute sore throat/
acute pharyngitis/acute tonsillitis
when three or more Centor
criteria1 are present.
1
Centor criteria are: presence of
tonsillarexudate, tender anterior
cervical lymphadenopathy or
lymphadenitis, history of fever and
an absence of cough.
Immediate antibiotic prescribing or further

investigation and/or management
Other immediate antibiotics or further investigation/
management for patients who:
are systemically very unwell
h ave symptoms and signs suggestive of serious illness
and/or complications (particularly pneumonia, mastoiditis,
peritonsillar abscess, peritonsillar cellulitis, intraorbital or
intracranial complications)
a re at high risk of serious complications because of preexisting comorbidity. This includes patients with significant
heart, lung, renal, liver or neuromuscular disease,
immunosuppression, cystic fibrosis, and young children
who were born prematurely.
are older than 65 years with acute cough and two or more
of the following, or older than 80 years with acute cough
and one or more of the following:
- hospitalisation in previous - type 1 or type 2 diabetes
year
- history of congestive heart - current use of oral
failure
glucocorticoids
Offer all patients:

advice about the usual natural history of the illness and average
total illness length:
- acute otitis media: 4 days
- acute sore throat/acute pharyngitis/acute tonsillitis: 1 week
- common cold: 1 weeks
- acute rhinosinusitis: 2 weeks
- acute cough/acute bronchitis: 3 weeks
advice about managing symptoms including fever (particularly

analgesia and antipyretics). For information about fever in
children younger than 5 years, refer to Feverish illness in
children (NICE clinical guideline 47)
Prescribers: if you do need to treat a patient with an antibiotic,

please follow the Wiltshire and Swindon Guidelines for antibiotic prescribing in the community.
nww.wiltshire.nhs.uk/policiesandprocedures/Wiltshire_MedicinesManagementGuidance/CNP017_Antibiotic_guide_Jan_10.pdf
page 74
Delayed Antibiotic Prescriptions

Information for patients
(To be completed by the prescriber)
Please collect your antibiotic prescription on

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (dd/mm/yy)
ONLY if your symptoms do not improve.
Clostridium difficile infection (CDI)

Delayed or if needed prescriptions are written on the
basis that they are not to be used straight away, but
can be collected from the surgery a few days later (as
specified by the health care professional you see) if your
symptoms get worse or have not improved.
Why have I been offered a delayed

prescription?
All colds and most coughs, cases of sinusitis, otitis
media (earache) and sore throats are caused by viruses.
Antibiotics do not work against infections which are
caused by viruses. Viral infections are much more
common than bacterial infections.
Evidence shows that coughs and colds get better just as
quickly without antibiotics. If we do not use antibiotics
unnecessarily, they are more likely to work when we do
need them.
Why should antibiotics only be taken when

they are needed?
Antibiotics can cause side-effects such as diarrhoea,
sickness and rash.
Antibiotics can upset the natural balance of bacteria
in your body allowing numbers of other bacteria to
increase. Bacteria such as Clostridium difficile (C. Diff) can
cause severe illness in this way.
Bacteria can adapt and find ways to survive the effects of
an antibiotic. They become antibiotic resistant so that
the antibiotic no longer works. The more often we use an
antibiotic, the more likely it is that bacteria will become
resistant to it. Some bacteria that cause infections in
hospitals and community, such as Methicillin Resistant
Staphylococcus Aureus (MRSA), are resistant to several
antibiotics.
When should you re-visit the GP practice/

contact NHS Direct?
If your cough or cold is lasting longer than as expected in
the table overleaf and you are getting worse.
If your earache is lasting longer than as expected in the
table overleaf and you are getting worse.
If you develop chest pain or start coughing up a large
amount of green or yellow phlegm from your lungs.
If the back of your throat or your tonsils are covered in
lots of white spots.
If you develop severe headaches, vomiting or unusual
rashes.
page 75
When will I start to feel better?
Illness
Which could last for (average)
Times may vary depending on age (if for a child) and

the number of symptoms you have:
Ear infection
days
Sore throat
week
Common cold
weeks
Sinusitis
weeks
Cough/bronchitis
weeks
Useful tips to help you deal with viral

illnesses such as common colds, coughs and
sore throats:
Drink plenty of water-based fluids so that you do not
get dehydrated.
Take paracetamol if you have fever or aches and
pains. Read the package instructions for dosage
information. Before taking paracetamol make sure
you are not taking any other medicines which
contain paracetamol. Ask your local community
pharmacist for advice on this and for other suitable
over-the-counter remedies that you might find
helpful if necessary.
page 76
Useful telephone numbers:

Out of hours service (Wiltshire Medical Services):
0300 111 5717
NHS Direct: 0845 4647 www.nhsdirect.nhs.uk
If you have any comments about this leaflet,
please contact:
Medicines Management, Southgate House, Pans Lane,
Devizes SN10 5EQ
Telephone: 01380 733881
E-mail: prescribing@wiltshire.nhs.uk
Please re-order these leaflet pads from Medicines Management, NHS Wiltshire on:
01380 733881 or prescribing@wiltshire.nhs.uk
If you have any comments please contact the author Rachel.Hobson@wiltshire.nhs.uk
page 77
Appendix 4
Penicillin Allergy
Penicillin and Cephalosporin antibiotics are often the cornerstone of antibiotic prophylaxis. If a patient has
been wrongly attributed with a penicillin allergy, optimal management may be compromised.
Allergic reactions to penicillins occur in 1-10% of exposed individuals; true anaphylactic reactions (which
may be fatal) occur in fewer than 0.05% of treated patients. However patients with a history of atopic
allergy (e.g. asthma, eczema, hay fever) are at a higher risk of anaphylactic reactions to penicillins.
Investigating and Recording Drug Allergies

All available drug sensitivity issues should be recorded. It is important to clarify the nature of the reaction. Check
with the patient and the medical notes prior to all prescribing. Do NOT label a patient as being allergic to an
antibiotic on the basis of side effects of a drug (e.g. nausea, diarrhoea, etc.).
Type 1 reaction Immediate anaphylaxis (IgE mediated)

Individuals with a history of immediate hypersensitivity following penicillin administration clinically
recognisable by features of urticaria, laryngeal oedema, bronchospasm, hypotension or local swelling within
72 hours of administration should NOT receive a penicillin.
Patients who are allergic to one penicillin will be allergic to all because the hypersensitivity is related to the
basic penicillin structure.
Patients with a history of immediate hypersensitivity to penicillins may also react to the cephalosporins and
other beta-lactam antibiotics. They should not receive these antibiotics.
Type 2 reaction Delayed reaction (non-IgE mediated)

Individuals with a DEFINITE history of NON-URTICARIAL RASH allergy to penicillin SHOULD NOT receive
a penicillin but the likelihood of serious cross sensitivity with Cephalosporins or Carbapenems is very low, so
other non-penicillin beta-lactam antibiotics can still be used in these individuals.
Other cases
Individuals with a history of a minor rash (i.e. non-confluent, non-pruritic rash restricted to a small area of
the body) or a rash that occurs more than 72 hours after penicillin administration are probably not allergic to
penicillin and in these individuals a penicillin should not be withheld unnecessarily for serious infections; the
possibility of an allergic reaction should, however, be borne in mind. Other beta-lactam antibiotics (including
Cephalosporins) can be used in these patients.
NOTE: T he principal side-effect of the Cephalosporins is hypersensitivity and about 0.56.5%

of penicillin-sensitive patients will also be allergic to the Cephalosporins.
page 78
Treating Penicillin-allergic Patients:

These Antibiotic Guidelines contain alternative empirical treatment options for indications
in which Penicillins are the first-line choice. If you are unsure about treatment options in
Penicillin allergy please obtain guidance from the local Consultant Microbiologist.
Contra-Indicated
Caution
Avoid if serious Type 1 penicillin allergy
(e.g. anaphylaxis / angioedema)
Use with caution if non-severe allergy
(e.g. minor rash only)
Amoxicillin
Ampicillin
Co-amoxiclav (Augmentin)
Flucloxacillin
Penicillin G (Benzylpenicillin)
Penicillin V (Phenoxymethyl-penicillin)
Piperacilin
Piperacillin plus tazobactam (PipTazo, Tazocin)
Ticarcillin
Ticarcillin plus clavulanic acid (Timentin)
Cefaclor Cefradine
Cefalexin Ceftaroline
NOTE: Risk of allergic reaction is

greater in -lactams most similar to
penicillins in underlying structure.
Cefixime Ceftazidime
Cefotaxime Ceftriaxone
Cefuroxime
Imipenem plus cilastin (Primaxin)
Meropenem
Aztreonam
Considered Safe
Amikacin
Azithromycin
Chloramphenicol
Ciprofloxacin
Clarithromycin
Clindamycin
Colistin
Co-trimoxazole
Daptomycin
Doxycycline
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Lymecycline
Metronidazole
Minocycline
Moxifloxacin
Nitrofuratoin
Norfloxacin
Ofloxacin
Oxytetracycline
Rifampicin
Sodium Fusidate
Sulfadiazine
Synercid
Teicoplanin
Tigecycline
Trimethoprim
Tobramycin
Vancomycin
For further information please contact Medicines Management on 01380 733881 or refer to the latest edition of the BNF.
Adapted for use with permission from Great Western Hospital Trust by: Dr Rachel Hobson (Formulary Pharmacist) Date: February 2013 Review date February 2015
page 79
Appendix 5
NEW
Fosfomycin Indication and Licensing

To be used on advice of microbiologist ONLY;
For symptomatic Extended Spectrum Beta-Lactamases (ESBLs) ONLY.
When is Fosfomycin indicated?

Lower UTI due to ESBL-producing micro-organisms on
recommendation of consultant medical microbiologist.
Fosfomycin is not indicated for the treatment of
ESBL pyelonephritis or peri-nephric abscess (admit to
hospital for IV antibiotics).
What is an ESBL?
ESBLs are bacterial enzymes (usually plasmid-mediated)
that confer resistance to a broad range of beta-lactam
antibiotics including co-amoxiclav and cephalosporins.
What is Fosfomycins licensing status in the UK?

Fosfomycin is licensed in the UK. However no UKpackaged product is currently available and thus all
supplies must be obtained from abroad and hence are
unlicensed in the UK.
Where is Fosfomycin licensed?

Fosfomycin is currently licensed and can be sourced
from Germany, France, Italy and Spain.
Fosfomycin Prescribing Information

Mode of action
Fosfomycin is a bactericidal antibacterial. Fosfomycin
inactivates the enzyme pyruvyl transferase required
for the biosynthesis of peptidoglycan in bacterial cell
walls. Fosfomycin is concentrated in the bladder and is
active against E. coli, Proteus sp. and Enterococci.
Pregnancy
Animal data show no teratogenic effects. Several
published reports studied the efficacy and safety of
oral fosfomycin in all stages of pregnancy. In these
studies fosfomycin did not cause harm to a foetus.
Dosing: Uncomplicated UTI in females

Fosfomycin 3 gram sachet as a single oral dose is
effective in the treatment of uncomplicated lower urinary
tract infections in adult females. Single dose therapy
(3 gram) was equivalent to 7-day course of norfloxacin in
a randomised, blinded study (de Jong Z et al. 1991 Urol
Int). The microbiologist would advise on dosage and
duration in such cases, follow their advice.
Contraindications
Hypersensitivity to fosfomycin.
Suspected bacteraemia.
Different brands and different forms (capsules vs
sachets) of Fosfomycin have different requirements
in terms of renal function and minimum weight of
patient required to take this drug safely. Individual
hospital pharmacy departments will therefore be
able to advise what form they stock and whether
it can be used safely if the patient has renal
impairment or has a low weight.
page 80
Fosfomycin Prescribing Information

Dosing: Complicated UTI or male patients
Fosfomycin calcium 500mg capsules are licensed at 500mg-1gram
every 8 hours. Fosfomycin 3g sachets have been administered
once every 48-72 hours. A 7-day course (minimum) is
recommended for male patients and for complicated lower urinary
tract infections (e.g. catheter-associated UTI) without bacteraemia
(Moroni M 1987 Eur Urol). The microbiologist would advise on
dosage and duration in such cases, follow their advice.
Dosing in renal impairment:
The microbiologist will advise on dosage and
duration in such cases, follow their advice
(also see information in contra-indications
box).
Interactions
No significant drug-drug interactions.
Food intake can slow down the absorption
of fosfomycin with, as a result, lower
concentrations in the urine. Fosfomycin
should, therefore, be administered while
fasting or 2 or 3 hours before meals.
Side Effects
More common than 1%:
Rare Serious Reactions:
Diarrhoea/Abdominal pain (10%) Serious hypersensitivity reactions

Nausea/Indigestion (5%)
Impairment of hepatic function
Headache (3-10%)
Aplastic anaemia
Skin rashes (1%)
Vaginitis (5%)
Asthenia (1%)
Fosfomycin Supplies
If a prescriber is contacted by a microbiologist to recommend this for their patient, then local arrangements have
been made whereby the hospitals keep this in stock. The GP still needs to write a FP10 prescription for the supply
(and possibly a proforma for some hospitals- see individual guidance below), which is given to the patient/carer
to collect the supply from the local acute trust who are recommending the treatment (this will avoid an admission
for IV antibiotics, so most patients/carers are happy to go and collect the medication). It may be possible for some
hospitals to send supplies via their tilley service to GP practices, but depends on when the next service is running as
may not be convenient. The patient MUST NOT be advised to take the script to a local community pharmacy as the
drug would then be ordered as a special which may incur a large cost and also a delay in obtaining the supply. The
local acute trusts can provide this treatment for approximately 20, for which the CCG is invoiced. The prescriptions
are NOT sent onto the Prescription Pricing Department (PPD) for charging but are merely used in order to provide a
legal prescription for supply.
For further information on the supply arrangements from individual acute trusts see:
RUH: http://nww.banes-pct.nhs.uk/GPsDentistsPharmacists/BCAPPrescribingandTherapeutics/Pages/AntibioticInfectionControl.aspx
GWH: Guidance being agreed and written. Will be added to this section of the formulary pages shortly: http://nww.gwh.nhs.uk/SMNHS/
Departments/Pharmacy/FormularyRelatedGuidelines.aspx
SFT: Guidance being agreed and written. Will be added to ICID formulary webpages shortly. http://www.icid.salisbury.nhs.uk/Pages/home-l.aspx
If you need any further help/advice with getting hold of supplies, please contact the medicines management team on: 01380 733881 or
prescribingwiltshire@nhs.net if you need to send us confidential patient information.
page 81
Appendix 6
Educational resources
Probiotics
This is accredited by the royal pharmaceutical society and the British dietetic society:
http://www.probioticsinpractice-elearning.co.uk/rps-bda/index.php
TARGET toolkit
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx
This antibiotic information leaflet in the Target toolkit is also useful:
http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit/~/media/Files/CIRC/TARGET/
Patient-Antibiotic-leaflet.ashx
HPA: http://www.hpa.org.uk/Publications/
page 82
page 83
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NHS Wiltshire CCG,

BaNES CCG & Swindon CCG

Produced in collaboration with:

Purpose of these guidelines

Principles of antibiotic use

13. Prevention of secondary case of meningitis: Only prescribe

For advice on Infection Control issues for Swindon CCG, the

Ear, Nose & Throat Infections

Urinary Tract Infections

Ear, Nose & Throat Infections

Urinary Tract Infections

Skin & Soft Tissue Infections

Ear Nose and Throat Conditions

All prescribers are advised to follow

Table 1. Traffic light system for identifying likelihood of serious illness

Amber intermediate risk

Red high risk

Pallor reported by parent/carer

Not responding normally to social

No response to social cues

Reduced skin turgor

Responds normally to social cues

Normal skin and eyes

Dry mucous membranes

Fever for 5 days

CRT: capillry refill time

Admit for immediate specialist assessment:

No investigations are indicated for a first episode.

NHS Clinical Knowledge Summary Otitis Media www.cks.library.nhs.uk

Scottish Intercollegiate Guidelines Network (SIGN) 91 Bronchiolitis in children.

Clinical Knowledge Summaries. http://www.cks.nhs.uk/croup

Additional guidance that is of relevance:

For children under 5 years of age:

BNF for Children 2012-13 www.bnfc.org

Suspected bacterial meningitis without non-blanching rash

If history of penicillin allergy

BNF for Children 2012-13 www.bnfc.org

UTI quick reference guide: http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947404720

Urine samples should be sent for culture:

Advise the patient to seek medical advice if:

BNF for Children 2012-13 www.bnfc.org

First-line for children aged 3-6 mths,

BNF for Children 2012-13 www.bnfc.org

Take swabs for culture if first line treatment fails.

Alter treatment in response to culture and sensitivity results.

Second line or if Penicillin allergic:

Fusidic Acid 2% topically TDS

As resistance is increasing reserve topical antibiotics for very localised lesionsC or D

Alter treatment in response to culture and sensitivity results.

If the wound has just occurred, encourage it to bleed.

Alter treatment in response to culture and sensitivity results.

If the wound has just occurred, encourage it to bleed.

For suspected non-specific dermatitis, with or without candidal colonization:

Ear Nose and Throat Infections

Ear Nose and Throat Infections Acute Sore Throat (page 1 of 2)

In pregnancy or breastfeeding, use phenoxymethylpenicillin (penicillin V) or erythromycin (rather than

Ear Nose and Throat Infections Acute Sore Throat (page 2 of 2)

Ear Nose and Throat Infections Acute Otitis Externa

Refer to ENT consultant:

First line ear drops:

Second-line ear drops:

Ear Nose and Throat infections Acute Sinusitis

Admit to hospital if there is severe systemic infection, or if a complication of sinusitis is suspected:

General advice Use adequate analgesia.

13. Prevention of secondary case of meningitis: Only prescribe

Not responding normally to social

Urinary Tract Infections Catheter associated UTI SYMPTOMATIC PATIENTS ONLY