Management of infection — guidance for primary care: PHE, January 2017

The spread of multi-drug resistant bacteria in the UK and the lack of new antimicrobial drugs means an increasing risk of infections that cannot be treated. In the UK, 5,000 patients a year die of gram-negative sepsis, half caused by a resistant pathogen.¹ Unless urgent action is taken, more deaths will occur. This means it is more important than ever that antibiotics and antifungal drugs are used sparingly and appropriately.

The current UK strategy is to:

• Prevent people from being infected through effective infection prevention and control
• Preserve the antibiotics we have through good stewardship
• Promote the development of new antimicrobials, new approaches and better diagnostics

Public Health England guidance² to minimise the emergence of bacterial resistance in the community aims to provide a simple, effective, economical and empirical approach to the treatment of common infections, and to target the use of antibiotics and antifungals in primary care.

The guidelines have been produced in consultations with GPs and specialists, and are aligned with other guidance including NICE, SIGN and CKS, and are based on the best available evidence. However, primary care healthcare professionals should use professional judgement and involve patients in management decisions.

PRINCIPLES OF TREATMENT

1. Initiate antibiotics as soon as possible in severe infection

2. Where an empirical therapy as failed, or in special circumstances, seek advice from local microbiology departments

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

4. Consider a ‘no’ or ‘back up/delayed’ antibiotic strategy for acute self-limiting upper respiratory tract infections

5. Limit prescribing over the telephone to exceptional cases

6. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics, e.g. co-amoxiclav, quinolones or cephalosporins when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs

7. The dose and duration of treatment is usually suggested but may need modification for age, weight and renal function. In severe or recurrent cases consider a higher dose or longer course

8. Refer to BNF for further dosing an interaction information (e.g. interaction between macrolides and statins) and check for hypersensitivity

9. Consider lower thresholds for antibiotics in immunocompromised patients or those with multiple morbidities.

10. Avoid widespread use of topical antibiotics, especially those that are also available as systemic preparations

11. In pregnancy, take specimens to inform treatment. Avoid tetracyclines, aminoglycosides, quinolones, high dose metronidazole (2g) unless benefit outweighs risks. Short-term use of nitrofurantoin is unlikely to cause fetal problems (theoretical risk of neonatal haemolysis at term). Trimethoprim is also unlikely to cause harm unless poor dietary folate intake or taking another folate antagonist, e.g. antiepileptic

12. The guidance should not be used in isolation. It should be supported with patient information about delayed antibiotics, infection severity and usual duration, clinical staff education and audit. See RCGP Target website for resources

SUMMARY RECOMMENDATIONS

UPPER RESPIRATORY TRACT INFECTIONS

Influenza

Annual vaccination is essential for all those at risk

Antiviral treatment is not recommended for otherwise healthy adults

Treat at risk patients antivirals, ideally within 48 hours of onset of infection

• Oseltamir 75mg BD for 5 days

Acute sore throat

Avoid antibiotics. 90% resolve in 7 days without, and pain only reduced by 16 hours

Use FeverPAIN score: (Score 1 for each of following). Fever in last 24h, Purulence, Attend rapidly under 3d, severely Inflamed tonsils, No cough or coryza. Score of 0-1 – no antibiotic; Score 2-3, use 3 day back up antibiotic; Score ≥4, use immediate antibiotic if severe or 48hr short back-up prescription. Always share self-care advice and safety net.

• Phenoxymethylpenicillin 500mg QDS or 1g BD for 10 days.

• Penicillin allergy: clarithromycin 250-500mg BD for 5 days

Acute otitis media (AOM)

Optimise analgesia and target antibiotics.

AOM resolves in 60% in 24 hours without antibiotics.

Consider 2 or 3-day delayed or immediate antibiotics if

• Amoxycillin (child doses) 30mg/kg – 500mg (according to age) TDS for 5 days

• Penicillin allergy: erythromycin 125mg – 500mg (according to age) TDS for 5 days

Acute otitis externa

First use analgesia.

Cure rates similar at 7 days for topical acetic acid and antibiotic +/- steroid.

IF cellulitis/disease extending outside ear canal, start antibiotics and refer to exclude malignancy

• First line: acetic acid 2% 1 spray TDS for 7 days

• Second line: neomycin sulphate with corticosteroid 3 drops TDS for min 7 days, max 14 days

Acute rhinosinusitis

Avoid antibiotics – 80% resolve in 14 days without antibiotics

Use adequate analgesia

Consider 7 delayed or immediate antibiotic when purulent nasal discharge

• Amoxycillin 500mg TDS (1mg if severe) for 7 days, or

• Doxycycline 200mg stat then 100mg OD for 7 days, or

• Phenoxymethylpenicillin 500mg QDS for 7 days

For persistent symptoms

• Co-amoxiclav 625mg TDS for 7 days

LOWER RESPIRATORY TRACT INFECTIONS

Acute cough/bronchitis

Antibiotic of little benefit if no co-morbidity

Consider 7 day delayed antibiotic with advice. Symptoms may take 3 weeks to resolve

Consider immediate antibiotics if >80 years and one of:

– hospitalisation in past year

– oral steroids

– diabetes

– congestive heart failure OR

>65 years with 2 of above

Consider CRP test if antibiotic being considered

If CRP <20mg/l, no antibiotic; 20-100mg/l delayed; 100mg/l immediate antibiotic

• Amoxycillin 500mg TDS for 5 days, or

• Doxycycline 200mg stat then 100mg OD for 5 days

• If resistance, co-amoxyiclav 625mg TDS for 5 days

Acute exacerbation of COPD

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume

• Amoxicillin 500mg TDS for 5 days, or

• Doxycycline 200mg stat then 100mg OD for 5 days , or

• Clarithromycin 500mg BD for 5 days

• If resistance, co-amoxyiclav 625mg TDS for 5 days

Community acquired pneumonia

Treatment in the community

Use CRB65 score to guide mortality risk, place of care and antibiotics. Each CRB65 parameter scores 1:

– Confusion (AMT<8)

– Respiratory rate >30/min

– BP systolic < 60mmHg

– Age ≥65 years

Score 0: low risk, consider home-based care

Score 1-2: intermediate risk, consider hospital assessment

Score 3-4: urgent hospital admission

Always safety net.

• IF CRB65 = 0: amoxicillin 500mg TDS, or

• Clarythromycin 500mg BD, or

• Doxycycline 200mg stat then 100mg OD

Use for 5 days. Review at 3 days and extend to 7-10 days if poor response

• If CRB65 = 1 – 2, and at home, clinically assess for dual therapy for atypicals: amoxicillin 500mg TDS AND clarithromycin 500mg BD or doxycycline alone, 200mg stat/100mg OD for 7 – 10 days

URINARY TRACT INFECTIONS (UTI)

UTI in adults (lower)

As antimicrobial resistance and E. coli bacteraemia is increasing, use nitrofurantoin first line. Always give safety net and self-care advice and consider risks for resistance.

All patients – first line antibiotic: nitrofurantoin if GFR >45mls/min; if GFR 30-45, only use nitrofurantoin if resistance and no alternative.

Women with severe/or ≥3 symptoms, treat with antibiotics

Women with mild/≤ 2 symptoms: pain relief and consider back-up/delayed antibiotic

Men: consider prostatitis and send MSU, or if symptoms mild/non-specific use negative dipstick to exclude UTI

>65 years: treat if fever ≥38^oC or 1.5^oC above base 2x in 12 hours AND dysuria OR ≥2 other symptoms

• Nitrofurantoin 100mg m/r BD for 3 days (women) or 7 days (men), or if low risk of resistance

• Trimethoprim 200mg BD for 3 days (women) or 7 days (men)

If 1st line options unsuitable:

• If GFR <45mls/min pivemecilinam 400mg stat the 200mg TDS

• If high risk of resistance: fosfomycin 3g stat in women; men: 2nd 3g dose 3 days later (unlicensed)

• If organism susceptible: amoxicillin 500mg TDS for 3 days (women) or 7 days (men)

UTI in pregnancy

Send MSU for culture; start antibiotics in all with significant bacteriuria even if asymptomatic. Short term use of nitrofurantoin unlikely to harm fetus. Avoid trimethoprim if low folate status or on folate antagonist

• First line: nitrofurantoin 100mg m/r BD for 7 days

• If susceptible, amoxicillin 500mgs for 7 days

• Second line: trimethoprim 200mg BD (off licence) for 7 days; give folate if 1st trimester

• Cefalexin 500mg BD for 7 days

UTI in children

Child < 3 months: refer urgently for assessment

Child ≥3 months: use positive nitrite to guide.

Start antibiotics, send pre-treatment MSU

Imaging: only refer if child < 6months, or recurrent or atypical UTI

• Lower UTI: trimethoprim or nitrofurantoin (check child doses) for 3 days

• If susceptible, amoxicillin (check child doses) for 3 days

• Second line: cephalexin (check child doses) for 3 days

• Upper UTI: co-amoxiclav for 7-10 days

• Second line: cefixime (check child doses) for 7-10 days

Acute prostatitis

Send MSU for culture and start antibiotics

4 week course may prevent chronic prostatitis

• Ciprofloxacin 500mg BD 28 days, or

• Ofloxacin 200mg BD for 28 days

• Second line: trimethoprim 200mg BD for 28 days

Acute pyelonephritis

If admission not needed, send MSU for culture and susceptibility testing. Start antibiotics. If no response within 24 hours, seek advice. If ESBL risk and with microbiology advice consider IV antibiotic via outpatients (OPAT).

• Co-amoxiclav 500/125mg TDS for 7 days, or

• Ciprofloxacin 500mg BD for 7 days

• If lab report shows sensitive, trimethoprim 200mg BD for 14 days

Recurrent UTI in non-pregnant women

2 in 6 months or ≥3 UTIs/year

First line: advise simple measures including hydration and analgesia. Cranberry products work for some women but good evidence is lacking

Second line: Standby or post-coital antibiotics

Third line: Antibiotic prophylaxis (methenamine if no renal or hepatic impairment)

• First line: Nitrofurantoin 100mg at night or post coital stat (off-label)

• Second line: Pivmecillinam 200mg at night or post coital stat (off-label)

• If recent culture sensitive: trimethoprim 200mg at night or post coital stat (off-label)

All for 3-6 months, then review recurrence rate and need

• Third line: methenamine hippurate 1g BD for 6 months

MENINGITIS

Transfer all patients to hospital immediately. If time before hospital admission and non-blanching rash, give IV benzylpenicillin or cefotaxime unless definite history of sensitivity. Give IM if vein cannot be found

• IV or IM benzylpenicillin. Age 10+ years: 1200mg; Children 1-9 years: 600mg; Children

• IV or IM cefotaxim. Age 12+ years: 1g; Child

GASTROINTESTINAL TRACT INFECTIONS

Oral candidiasis

Rare in immunocompetent adults: consider undiagnosed risk factors including HIV

• Miconazole oral gel 20mg/ml QDS for 7 days or 2 days after symptoms resolve

• If miconazole not tolerated, nystatin suspension 100,000 units/ml QDS for 7 days or 2 days after symptoms resolve

• If extensive/severe, fluconazole oral tablets, 50mg OD for 7 days + further 7 days if symptoms persist

• In HIV or immunosuppression, fluconazole 100mg OD for 7 days + further 7 days if symptoms persist

Eradication of Helicobacter pylori

Always use proton pump inhibitor (PPI)

• PPI with amoxicillin 1g BD for 7 days, or

• PPI with clarithromycin 500mg BD for 7 days, or

• PPI with metronidazole 400mg BD for 7 days

• Penicillin allergy/previous clarithromycin, PPI with tripotassium dicitrateobismuthate 240mg BD for 7 days, or

• Bismuth subsalicytate 525mg QDS + metronidazole 400mg BD + tetracycline 400mg QDS, for 7 days

Infectious diarrhoea

Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli infection

Antibiotic therapy usually not indicated unless systemically unwell. If campylobacter suspected, consider clarithromycin 250-500mg BD for 5-7 days (if treated with 3 days of onset).

Clostridium difficile

Stop unnecessary antibiotics and/or PPIs.

70% respond to metronidazole in 5 days, 92% in 14 days.

If severe (temperature >38.5^oC, or WCC >15, or rising creatinine or signs/symptoms of severe colitis) oral vaconmycin

• First episode: metronidazole 400mg or 500mg TDS, for 10-14 days

• Second episode/severe/type 027: oral vancomycin 125mg QDS for 10-14 days

Traveller’s diarrhoea (TD)

Only consider standby antibiotics for remote areas or for people at high risk of severe illness with TD.

• If standby treatment appropriate, ciprofloxacin 500mg BD for 3 days (private prescription).

• If quinolone resistance high, e.g. south Asia, consider bismuth subsalicylate 2 tablets QDS as prophylaxis or treatment for 2 days

Threadworm

Treat all household contacts at the same time

Advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower [include perianal area] plus launder sleepwear and bed linen, and dust and vacuum on day 1.

• Mebendazole 100mg stat, repeat in 2 weeks if infection persists

• Child

GENITAL TRACT INFECTIONS

Screen people with risk factors for chlamydia, gonorrhoea, HIV, syphilis.

Risk factors:

Refer individuals and partners to GUM service

Chlamydia, trachomatis/urethritis

Opportunistically screen all aged 15-25 years. Treat partners and refer to GUM.

Lower cure rate in pregnancy – test for cure 6 weeks after treatment

• Azithromycin 1g stat, or

• Doxycycline 100mg BD for 7 days

• Pregnant or breastfeeding azithromycin 1g stat (off label use, but most effective option) or

• Erythromycin 500mg QDS for 7 days, or

• Amoxicillin 500mg QDS for 7 days

Vaginal candidiasis

All topical and oral azoles give 75% cure

In pregnancy, avoid azoles and give intravaginal treatment for 7 days

• Clotrimazole 500mg pessary or 10% cream stat, or

• Oral fluconazole 150mg stat

• Pregnant: clotrimazole 100mg pessary at night for 6 nights, or

• Miconazole 2% cream 5g intravaginally BD for 7 days

Bacterial vaginosis

Oral metronidazole is as effective as topical treatment but cheaper

Less relapse with 7 day than 2g stat at 4 weeks

Pregnant/breastfeeding: avoid 2g stat

Treating partners does not reduce relapse

• Oral metronidazole 400mg BD for 7 days or 2g stat, or

• Metronidazole 0.75% vaginal gel, 5g applicator at night for 5 nights, or

• Clindamycin 2% cream, 5g applicator at night for 7 nights

Gonorrhoea

Antibiotic resistance now very high. Use IM ceftriaxone plus azithromycin and refer to GUM

• Cefriaxone 500mg IM stat PLUS

• Arithromycin 1g stat

Trichomoniasis

Treat partners and refer to GUM

In pregnancy or brestfeeding avoid metronidazole 2mg single dose

Consider clotrimazole for symptom relief (not cure) if metronidazole declined

• Metronidazole 400mg BD for 5-7 days, or 2g stat

• Clotrimazole 100mg pessary at night for 6 nights

Pelvic inflammatory disease

Refer woman and contacts to GUM

Culture for gonorrhoea and chlamydia

• Metronidazole 400mg BD PLUS ofloxacin 400mg BD or doxycycline 100mg BD for 14 days

• If high risk of gonorrhoea (partner has it, sex abroad, severe symptoms) ADD ceftriaxone 500mg IM stat

SKIN INFECTIONS

Impetigo

For extensive, severe or bullous impetigo, use oral antibiotics

Reserve topical antibiotics for very localised lesions to reduce risk of resistance

Reserve mupirocin for MRSA

• Oral flucloxacillin 500mg QDS for 7 days

• If penicillin allergic, oral clarithromycin 250-500 BD for 7 days

• Topical fusidic acid TDS for 5 days

• MRSA only, mupirocin TDS

Eczema

If no visible signs of infection, use of antibiotics (with or without steroids) encourages resistance and does not promote healing

If visible signs of infection use treatment as for impetigo, above.

Cellulitis

Class I: afebrile and otherwise well, use oral flucloxacillin alone

Class II: febrile and ill, or comordidity, admit or refer for outpatient IV treatment (OPAT) if available

Class III: toxic appearance, admit

• Flucloxacillin 500mg QDS for 7 days. If slow response, continue for further 7 days

• If penicillin allergic, clarithromycin 500 mg BD for 7 days. If slow response, continue for further 7 days

• If on statins, doxycycline 200mg stat then 100mg OD for 7 days. If slow response, continue for further 7 days

• If failure to resolve, clindamycin 300-450mg QDS for 7 days. If slow response, continue for further 7 days

• If facial, co-amoxiclav 500/125mg TDS for 7 days. If slow response, continue for further 7 days

Leg ulcer

Antibiotics do not improve healing unless active infection – cellulitis, increased pain, pyrexia, purulent exudate, odour.

If active infection

• Flucloxacillin 500mg QDS for 7 days. If slow response, continue for further 7 days, or

• Clarithromycin 500mg BD for 7 days. If slow response, continue for further 7 days

Bites

Human

Thorough irrigation is important. Assess risk of tetanus, rabies, HIV, hepatitis B/C.

Antibiotic prophylaxis advisable

Cat or dog

Give prophylaxis if cat bite/puncture wound, or

Bite to hand, foot, face, joint, tendon, ligament; or if

Immunocompromised, diabetic, asplenic, cirrhotic, presence of prosthetic valve or prosthetic joint

Prophylaxis or treatment

• Co-amoxiclav 375-625mg TDS, for 7 days

• If penicillin allergic, metronidazole 400mg TDS PLUS (cat/dog/human) doxycline 100mg BD, for 7 days, or

• metronidazole 200-400mg TDS PLUS (human) clarithromycin 250-500mg BD, for 7 days, AND

• Review at 24 and 48 hours.

Scabies

Treat whole body from ear/chin downwards and under nails. If >2 years/elderly, also face/scalp.

Treat all home and sexual contacts within 24 hours

• Permethrin 5% cream, 2 applications, 1 week apart

• If allergy, malathion 0.5% aqueous liquid, 2 applications, 1 week apart

Dermatophyte infection – skin

Terbinafine is fungicidal. Treatment time shorter than with fungistatic imidazoles.

If possibility of candida, use imidazole

If intractable, send skin scrapings, and if infection confirmed, use oral terbinafine/itracpnazole.

Scalp – oral therapy indicated

• Topical terbinafine BD, for 1-2 weeks for 1-2 weeks after healing (total 4-6 weeks), or

• Topical imidazole BD, for 1-2 weeks for 1-2 weeks after healing (total 4-6 weeks)

• Athlete’s foot only – topical indecanoates: Mycota BD, for 1-2 weeks for 1-2 weeks after healing (total 4-6 weeks)

Dermatophyte infection – nail

Take nail clippings. Start treatment only if infection confirmed.

• First line: terbinafine 250mg OD, for 6 – 12 weeks (fingers), 3 – 6 months (toes)

• Second line: itraconazole 200mg BD for 7 days monthly (phased treatment): fingers – 2 courses; toes – 3 courses

• Third line (limited evidence of effectiveness) amorolfine 5% nail lacquer, 1-2 weekly for 6 months (fingers), 12 months (toes)

Varicella zoster (chicken pox), Herpes zoster (shingles)

Pregnant or immunocompromised seek urgent specialist advice

Chicken pox: IF onset of rash 14 years or severe pain or dense/oral rash or secondary household case or steroids or smoker, consider aciclovir

Shingles: treat if >50 years and within 72 hours of onset of rash (post herpetic neuralgia rare if >50 years) or if active ophthalmic or Ramsey Hunt or eczema

IF indicated:

• Aciclovir 800mg 5 times a day, for 7 days

• Second line (for shingles) if compliance a problem – ten times the cost: valaciclovir 1g TDS for 7 days, or famciclovir 500mg TDS or 750mg BD, for 7 days.

Herpes simplex (cold sores)

Resolve after 7-10 days without treatment. Topical antivirals applied prodromally (i.e. before lesion appears) reduce duration by <24 hours.

EYE INFECTIONS

Conjunctivitis

Treat if severe – most viral or self-limiting

Bacterial conjunctivitis usually unilateral and also self-limiting; characterised by mucopurulent (not watery) discharge

If severe:

• Choramphenicol 0.5% drop and 1% ointment, 2 hourly for 2 days then 4 hourly (during waking hours) for 48 hours after resolution

• Second line: fusidic acid 1% gel BD, for 48 hours after resolution.

References

1. Public Health England. Implementing the UK Five Year Antimicrobial Resistance Strategy 2013-2018.

2. Public Health England. https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care