Empirical guidance on the management of infection in primary care in adults
Empirical Guidance on the Management of Infection in Primary Care in adults
♦To provide a simple, best guess approach to the treatment of common infections. ♦To minimise the emergence of bacterial resistance in
the community ♦
To promote the safe, effective and economic use of antibiotics
Principles of treatment
1. This guidance is based on the best available evidence but professional judgment should be used and patients should be involved in the
2. Antibiotics should be reviewed based on culture results. 3. A dose and duration of treatment for adults is suggested but may need modification for age, weight, height and renal function, always check
for hypersensitivity history. In severe or recurrent or complicated cases send samples for microbiology and consider a larger dose or longer course. All treatments are oral or topical unless specified. Please refer to BNF for further dosing and interaction information.
4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 5. There is a lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice. 6. Consider a no, or delayed, antibiotic strategy for acute sore throat, common cold, acute cough and acute sinusitis. 7. Limit prescribing over the telephone to exceptional cases 8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow
spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile
, MRSA, ESBLs and other resistant organisms.
9. Avoid widespread use of topical antibiotics (especially those agents available as systemic preparations (eg fusidic acid) 10. Please refer to BNF for update on antibiotics in pregnancy and in breast feeding, take specimens to guide treatment , AVOID tetracycline’s,
quinolones or high dose metronidazole (2g) unless specialist advice.
11. Where a "best guess" therapy has failed or special circumstances exist, microbiological advice can be obtained on 01908 243106/3404 12. Penicillin allergy: please take proper history and distinguish between anaphylaxis, just rash and intolerance. Important to inform patients
and include in any letter to other healthcare workers.
Upper Respiratory Tract Infections: Consider delayed antibiotic Prescriptions and Patient Information Leaflet
Annual vaccination is essential for all those at risk of influenza.
For otherwise healthy adults, the use of antivirals is not
recommended. Treat "at risk" patients only when influenza is circulating in the community, within 48 hours of start of symptoms. At risk: pregnant (including up to two weeks post partum), those 65 years or over, chronic respiratory disease including asthma & COPD, significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Patients over 13 years use oseltamivir 75mg oral capsule BD unless pregnant or there is resistance to oseltamivir, then use zanamivir 10mg (2 inhalations by diskhaler) and seek advice. For patients 13 years and under – seek further advice from the HPA Antivirals may be used for post-exposure prophylaxis during localized outbreaks in at risk people living in long-term residential or nursing homes on advice from the HPA/local microbiologist. (see NICE Influenza http://guidance.nice.org.uk/TA158)
Majority of sore throats are viral; Avoid antibiotics as 90% resolve in 7 days without and pain is only reduced by 16
Patients with 3 or 4 centor criteria (Hx of fever, purulent tonsils, cervical adenopathy, absence of cough) have a 40%
chance of Group A Beta Haemolytic Streptococci (GABHS) infection and wil benefit more from antibiotics, for these patients,
consider offering a 2 or 3 day delayed prescription or immediate prescription NICE Clinical guideline 69
You need to treat 200 patients to prevent one case of otitis media or over 4000 patients to prevent one case of quinsy
Peterson et al. BMJ
:982-4. Spinks A et al. Cochrane Database of systematic reviews
2006 Treatment for 10 days with penicillin. Under treatment
500mg QDS or 1g BD
may lead to treatment failure or increased bacterial
resistance. Amoxicillin should be avoided due to high risk
Use ibuprofen or paracetamol to optimal effect.
Illness resolves in 66% in 24 hours and antibiotics
have no effect.
Antibiotics do not reduce pain in first 24
hours, subsequent attacks, perforation or deafness.
Consider 2 or 3 day delayed or immediate antibiotic if:
<2 years AND bilateral AOM (NNT4) or bulging
You need to treat >4000 patients to prevent 1 case of
mastoiditis Thompson et al Pediatrics
First use aural toilet (if available) and analgesia.
Cure rates similar at 7 days for topical acetic acid or
antibiotic +/- steroid, therefore use as second line therapy if Neomycin sulphate
Oral antibiotics are not as effective and should only be
given if cellulitis or disease extending outside ear canal,
then start oral antibiotics for cellulitis or
Many are viral, optimize analgesia.
80% resolve in 14
days without antibiotics and they only offer marginal benefit
after 7 days (NNT15). Consider 7 day delayed or
immediate antibiotics if purulent nasal discharge (NNT8),
fever>38, maxillary toothache or raised ESR.
Anaerobes are more common in persistent rhinosinusitis,
therefore in chronic infection, use an agent with anti-
Lower Respiratory Tract Infections
Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones (ciprofloxacin
and ofloxacin) should not be used 1st line as they have poor activity against pneumococci. Reserve all quinolones including
levofloxacin for PROVEN resistant organisms. Bronchiectasis infective exacerbations: please see Map of Medicine.
Antibiotics have marginal benefits in healthy adults.
Reserve use for patients with co-morbidities, consider 7-14
day delayed antibiotic (from symptom onset) with advice,
i.e. patient leaflet, and explain symptom resolution can take Doxycycline
3 weeks. Consider immediate antibiotics if >80 years and
one of: hospitalization in last year, oral steroids, diabetic, congestive heart failure OR >65 with two of above.
Small but significant benefit to antibiotic use. Use promptly
if increased dyspnoea and increased purulent sputum
If clinical failure to 1st line antibiotics or resistance factors
eg: severe COPD, frequent exacerbations, 1st line
antibiotics in last 3 months, co-morbid disease
Use CRB65 score to help guide therapy. Each scores 1:
espiratory rate >30/min;
P systolic <90 or diastolic ≤ 60;
(age over 65)
Score 1-2: hospital assessment or admission
Score 3-4: URGENT hospital admission
(Mycoplasma is rare in over 65's and epidemics occur
every 4 years). Add Flucloxacillin for 14-21 days for
suspected infection with staphylococci (in influenza or
Urinary Tract Infections
Note: People >65 years: do not treat asymptomatic bacteriuria; it occurs in 25% of women and 10% of men and is not associated with
increased morbidity. In the presence of a catheter, antibiotics will not eradicate bacteriuria and treatment may cause harm; only treat if
systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter changes unless history of catheter –change associated UTII/
sepsis. Amoxicillin should not be used empirically as resistance is over 50% locally.
In women with severe or with 3 or more symptoms treat. In
UTI in women
women with mild or 2 or less symptoms, use urine dipstick
to exclude UTI. (-ve nitrite, leucocyte and blood gives 76%
negative predictive value.) In women <65, cloudy urine, or
+ve dipstick (nitrite with
either blood or leucocytes has
92% positive predictive value), indicates treatment.
2nd Line depends on susceptibility of organism isolated.
Multi-resistant bacteria producing ESBLs are increasing, perform
UTI in men:
Consider prostatitis if recurrent UTI or if febrile UTI. Always
urine cultures in treatment failures. Pivmecillinam/Mecillinam may
send PRE-TREATMENT MSUs for all men. If symptoms
be recommended if no history of penicillin allergy. Avoid
are mild/non-specific use negative nitrite and leucocytes to
cephalosporins and quinolones, especially in the over 60s.
If necessary seek advice from the Microbiology Laboratory.
Cranberry products, post coital or stand by antibiotics may
reduce recurrence. Nightly prophylaxis is effective, but
increases adverse effects and resistance. Cranberry
Please see local guidance, breakthrough acute UTIs may
indicate change in therapy according to culture results.
Only treat if symptomatic, send urine for culture as per local
Send MSU for culture and start empirical antibiotics. Short
term use of Nitrofurantoin in pregnancy is unlikely to cause
problems to the foetus. Avoid Trimethoprim in 1st trimester,
Or Trimethoprim (not 200mg BD (off label)
low folate status or taking folate antagonist (e.g.
antiepileptic or proguanil). And avoid Nitrofurantoin at term
– may produce neonatal haemolysis. If pregnant or
penicillin allergy, please state on request form. Cefalexin
use is not contra-indicated in pregnancy; however there is
a small risk of C difficile
May require a test of cure 7 days after completion of
Refer all children <3months old on basis of positive nitrite
to specialist immediately for IV antibiotics
In all children 3 months or over, send MSU for culture and
susceptibility, use positive nitrite to start antibiotics. Only
refer children for subsequent imaging if <6 months old, or
: Consider referral to paediatric
Consider admission, send MSU for culture and sensitivities Ciprofloxacin
and start antibiotics. Review culture results immediately
and change antibiotics appropriately. If no response within
Send MSU for culture and start antibiotics. 4 weeks
treatment may prevent chronic infection. Quinolones are
more effective due to greater penetration into prostate.
Genital Tract Infections – Contact UKTIS for information on foetal risks if patient is pregnant 0844 8920909
Note: Refer patients with risk factors for STIs (<25 years, no condom use, recent (<12 month) or frequent change of sexual partner, previous
STI, symptomatic partner) to REACH sexual health services 0300 3038273 or Brook 0808 8021234 for screening and advice.
All topical and oral azoles give 75% cure.
In pregnancy, avoid oral azole, use intravaginal product
A 7 day course of oral metronidazole is slightly more
effective than 2g stat. Avoid 2g stat dose in pregnancy and
Topical treatment gives similar cure rates but is more
expensive. Treating partners does not reduce relapse.
Treat patient & refer to Sexual Health for follow up and
In pregnancy or breastfeeding, azithromycin is most
effective, but use is “off-label”. Tetracyclines are
contraindicated in pregnancy. Due to lower cure rate in
pregnancy, test for cure 6 weeks after treatment.
Could be due to STD infections or enteric pathogens.
Appropriate samples need to be taken –MSU, samples for
Chlamydia & Gonococcus if appropriate.
Refer to sexual health if due to STDs or under 35 years of
Send MSU for culture and start antibiotics. 4 weeks
treatment may prevent chronic infection. Quinolones are
more effective due to greater penetration into prostate.
Refer to Sexual Health. Treat partners simultaneously.
In pregnancy or breastfeeding, avoid 2g single dose
metronidazole. Topical clotrimazole gives symptomatic
relief (not cure), consider if metronidazole declined.
Essential to test for N. gonorrhoea (increasing antibiotic
resistance), chlamydia and other organisms. Refer patient
to Sexual Health for follow up and contact tracing.
If severe disease or if high risk of gonorrhoea eg partner has it, sex abroad, severe symptoms, multiple partners refer for IM Ceftriaxone.
Uncomplicated infection only, for complicated cases seek
Consider co-infection with Chlamydia & Gonococcus
Patients need to be referred to Sexual Health for full STD screen and follow up.
Skin / Soft Tissue Infections
Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staph. Aureus
(positive in MRSA & MSSA). It is associated with persistent
recurrent pustules and carbuncles or cellulitis. Send swabs for bacterial culture with request for PVL detection in these clinical scenarios. On
rare occasions it causes severe invasive infections, even in fit people. Risk factors include: close contact environments, contact sport, sharing
equipment, poor hygiene, travel and compromised skin integrity. MRSA
Contact CHS Infection Control Team for advice on decolonization strategy. If active infection confirmed by laboratory, use
sensitivities to guide treatment. If severe infection or no response to appropriate monotherapy from sensitivities after 48 hours,
For extensive, severe or bullous impetigo use oral
As resistance is increasing reserve topical antibiotics for
very localised lesions. Reserve mupirocin for confirmed
Mupirocin MRSA only
Using antibiotics or adding them to steroids in eczema encourages resistance and does not improve healing unless there are visible signs of infection. In infected eczema use treatment as in impetigo. See local Guidance on Infected Eczema.
If patient afebrile and healthy other than cellulitis,
flucloxacillin may be used as single drug treatment. If
wound has been exposed to non-chlorinated water, (river,
lake or sea) discuss with microbiologist.
If febrile and ill, admit for IV treatment.
STOP IF DIARRHOEA
In facial cellulitis only, use co-amoxiclav to cover
from buccal microbes.
Bacteria will always be present. Antibiotics do not improve healing unless active infection.
Send properly taken culture
to empirical therapy. Antibiotics are only indicated if there is evidence of clinical cellulitis; increased pain;
enlarging ulcer, purulent exudate, foul odour or pyrexia. Treat as cellulitis above, refer to tissue viability team.
Review antibiotics after culture results
Refer for specialist opinion if severe infection
Surgical toilet most important. Assess tetanus and rabies
risk. Antibiotic prophylaxis advised for: cat bite/ puncture
wound; bite involving hand, foot, face, joint, tendon,
ligament, or in immunocompromised, diabetic, elderly,
asplenic or cirrhotic patients. Macrolides are not
If penicillin allergic:
recommended for animal bites because they do not
adequately cover pasturella. Seek specialist advice for
children under the age of 12 years (doxycycline
Thorough irrigation is important. Antibiotic prophylaxis
advised. Assess HIV/Hepatitis B&C and tetanus risk.
Treat whole body from ear/chin down and under nails. If
under 2/elderly, also include scalp, face and ears. Treat all
household and sexual contacts within 24 hours.
Dermatophyte Take nail clippings: start therapy ONLY if infection is
confirmed by laboratory, (only 50% cases of nail dystrophy
are fungal). Seek specialist advice in children. Use 5%
amorolfine nail lacquer for superficial infection.
Idiosyncratic liver reactions occur rarely with terbinafine. It
seek specialist Itraconazole is also active against yeasts eg candida and
Terbinafine is fungicidal, therefore shorter treatment time
Dermatophyte than with a fungistatic imidazole. If candida possible, use
infection of the imidazole. If intractable: send skin scrapings. If infection
confirmed, use oral terbinafine/itraconazole. Discuss scalp
infections with specialist. Community Dermatology
Pregnant / immunocompromised / neonate seek URGENT
specialist advice for VZIG and antiviral treatment.
: If >14yrs, immunocompromised, or severe
pain, or dense/oral rash, or secondary household case, or
on steroids or smoker, consider aciclovir if treatment
Always treat if ophthalmic
for shingles if compliance is a
– treat if >50 yrs old AND <72
hours of onset of rash, (as post-herpetic neuralgia rare in
<50 yrs), or Ramsey Hunt or eczema associated.
Chickenpox direct contacts –
If pregnant /
immunocompromised / neonate seek advice urgently.
Local link for varicella zoster gammaglobulin (VZIG) use:
Cold sores resolve after 7-10 days without treatment. Topical antivirals applied prodromally reduce duration by 12-24 hours.
Gastro-Intestinal Tract Infections
Drugs fully absorbed (fluconazole, ketoconazole
Antifungal agents absorbed from the gastrointestinal tract
and itraconazole), however only fluconazole on the formulary
prevent oral candidiasis in patients receiving treatment for
for unrestricted use. Drugs partially absorbed (miconazole and
clotrimazole) are effective compared with placebo or no
treatment. See BNF for licensed dosage
Beneficial in DU, GU and low grade MALTOMA but not in
GORD. In NUD, NNT is 14 for symptom relief.
PPI full dose Plus
Consider test and treat in persistent uninvestigated
dyspepsia. Do not offer eradication for GORD. Do not use
clarithromycin or metronidazole if used in past year for any
PPI full dose PLUS
Retest for Helicobacter using breath or stool test,
or consider endoscopy for culture and sensitivity.
: Do not retest, treat as functional dyspepsia with PPI
Send stool samples for cultures. Consider E coli 0157 in previously healthy children/adults with acute painful or bloody
diarrhoea and refer if clinically indicated. Antibiotic therapy not indicated unless patient systemically unwell
/immunocompromised or antibiotic associated colitis, suggestive of Clostridium difficile
(see below) infection. If campylobacter suspected (eg undercooked meat and abdominal pain), consider oral Erythromycin 250-500mg QDS for 5-7 days if indicated
Send stool samples in suspected C difficile
suspected/confirmed CDI stop unnecessary antibiotics
and/or PPIs to re-establish normal flora. Do not use
antiperistaltics due to risk of toxic megacolon. Review and
discontinue any constipating i.e. opioid component of
current analgesia/antitussives if possible.
70% respond to metronidazole in 5 days; 92% in 14 days.
Severe if temp>38.5, WCC>15, rising creatinine or
signs/symptoms of severe colitis, need hospital admission.
Ensure patient is adequately re-hydrated. Cases who
relapse may require tapering dose of antibiotic – discuss
with Consultant Microbiologist and CHS IPC Team
Only consider standby for people travelling to remote areas and for people in whom an episode of infective diarrhoea could be
dangerous. If appropriate a PRIVATE prescription for Ciprofloxacin 500mg BD for 3 days can be supplied. In areas of high
ciprofloxacin resistance (Asia), consider prophylactic bismuth subsalicylate (Pepto Bismol) 2 tablets QDS or for 2 days as treatment, this can be brought OTC. Patients developing diarrhoea should be advised to see a local doctor if no improvement or symptoms get worsen’’
Treat household contacts at the same time.
On day 1: wash sleepwear, bed linen, vacuum and dust
Advise morning shower/baths, hand hygiene and wearing
Patient <3 months, extra hygiene precautions for 6 weeks.
Transfer all patients to hospital immediately
. If time
before admission, and non-blanching rash, administer
Adult & child 10 yrs & over -
benzylpenicillin or cefotaxime, unless definite history of
anaphylaxis, NOT intolerance/allergy. Ideally IV but IM if
Age 12+ years -1g Child<12 years - 50mg/kg
Prevention of secondary case of meningitis:
Only prescribe following advice from local Health Protection Unit (0845 2799879) (9am-5pm)
Out of hours contact the on-call Public Health doctor via MKHFT switchboard on (01908) 660033
Most bacterial infections are self-limiting (65% resolve
on placebo by day 5
). Treat if severe, symptoms usually
start unilaterally with red eye and yellow-white
0.5% drops plus
Fusidic acid has less Gram-negative activity
DENTAL INFECTIONS – derived from the Scottish Dental Clinical Effectiveness Programme
This guidance is not designed to be a definitive guide to oral conditions. It is for GPs for the management of acute oral conditions pending being
seen by a dentist or specialist. GPs should not routinely be involved in dental treatment, if possible, advice should be sought from the patient’s
dentist, who should have an answer-phone message with details of how to access treatment out-of-hours, or call 111
Temporary pain and swelling relief can be
If more severe & pain limits oral hygiene to
The primary cause for mucosal ulceration or
inflammation (aphthous ulcers, oral lichen
cancer) needs to be evaluated and treated.
Commence metronidazole and refer to dentist Metronidazole
Use in combination with antiseptic mouthwash peroxide
Refer to dentist for irrigation & debridement.
If persistent swelling or systemic symptoms
Use antiseptic mouthwash if pain and trismus
Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics
for abscess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing spread of
Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications.
odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway
obstruction, Ludwig’s angina. Refer urgently for admission to protect airway, achieve surgical drainage and IV antibiotics
drain by incision, tooth extraction or via
If spreading infection
involvement, or systemic signs i.e. fever or
Metronidazole or if allergy
Based on Guidance issued by the Health Protection Agency, 2001 comprehensively reviewed October 2012.
Amended for local use by Naomi Fleming, Antibiotic Pharmacist contact 01908 243082, & Dr L Ragunathan, Consultant
Microbiologist, MKHFT. First Issued: October 2000. Last Review: December 2012-March 2013. Review Date: March 2015.
ADDIS ABABA UNIVERSITY Framework Document Reforming Academic Governance February 2011 I. Introduction In the academic arena, the reform process at AAU has now reached a stage where the following have been successfully accomplished: 1. Definition of the university-wide structure for academic administration 2. Establishment of all academic units and university-wide academic o
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