Cambridgeshire antibiotic guidelines updated

Updated: 31 July 2010 Next update due: 30 September 2010

Cambridgeshire Primary Care Trust Antimicrobial Treatment Guidelines
For Prescribing In Primary Care.
FORMULARY FIRST AND SECOND LINE CHOICES FOR COMMONLY PRESCRIBED DRUGS
(Both sections and individual entries are in alphabetical order)

The purpose of this document is to support the appropriate prescribing and use of antibiotics in Primary Care.

The top-line principles, in line with evidence based guidelines and PCT priorities, are to:

1) Promote the safe, effective and economic use of antibiotics. Antibiotics should be prescribed at the lowest effective dose and for the minimum
effective duration of treatment.
2) Reduce the amount of antibiotics prescribed to minimise the emergence of bacterial resistance in the community. GPs should consider
whether a course of antibiotics is necessary to ensure that the numbers of patients exposed to antibiotics falls.
3) Manage the prescribing of antibiotics to reduce levels of superbug infection, e.g. Clostridium difficile associated diarrhea (CDAD) and MRSA
infection.

Overall Principles and Aims of Treatment

• Antibiotic prescribing should only take place where consideration has been given to the origin of infection and where infection of viral origin
has been precluded where possible, e.g. viral sore throat, simple coughs and colds, viral conjunctivitis.
• Antibiotics should not be prescribed following telephone consultations unless the circumstances are exceptional.
• Where possible, antibiotics should be prescribed generically. The use of newer/more expensive antibiotics (e.g.fluoroquinolones and
cephalosporins) is inappropriate when well-established and less expensive antibiotics remain effective.
• The antibiotic chosen should be the narrowest spectrum for the identified condition.
• Topical antibiotic agents should be avoided, if possible.
These CPCT Antibiotic Guidelines for Primary Care, are a working document to support the NHS Cambridgeshire (formerly Cambridgeshire PCT) Formulary. Page 1 of 23
Comments are welcome and should be made to :Debbie Morrison, Principal Pharmacist CJPG, debbie.morrison@cambsphn.nhs.uk
Those antibiotics associated with increased risk for C.difficile infection are marked with the following symbol: ◄. Prescribers are encouraged to question the necessity to prescribe
these drugs before doing so.
It should be noted that the Clinical Knowledge Summaries, on which these guidelines are based, are updated regularly and while these guidelines are accurate at the date given on
Page 1 they may have been superseded. The Medicines Management Team will update the guidelines every three months.
Dosages are obtainable from the following link: BNF Antibiotics Dosages


Clostridium difficile Infections

1) Clostridium difficile: current evidence indicates that clindamycin and second or third generation cephalosporins, e.g. cefuroxime, cefixime,
cefotaxime, ceftriaxone) are significantly more likely to provoke C. dif associated diarrhoea (CDAD). Anecdotal evidence also incriminates
fluoroquinolones, first-generation cephalosporins (e.g. cefalexin) and co-amoxiclav. These antibiotics should be used sparingly especially in
the elderly, in patients in institutions with CDAD and in patients previously diagnosed and treated for CDAD.

2) A narrow spectrum antibiotic should be used or the prescriber should be guided by laboratory results.
As with all antibiotic prescribing, the minimum effective dose and duration of treatment should be prescribed.

3) There is evidence that the use of Proton Pump Inhibitors (PPIs) increases susceptibility to C dif. and Campylobacter infection. GPs should
ensure that all prescribing is within the recommendations of this guideline and that any prescribing is for the shortest appropriate treatment
period and at the lowest effective dose.

Antibiotics that are associated with C. difficile infection are highlighted in this document with the following symbol:◄ These should be
used with caution in those predisposed to infection with C.difficile such as the elderly and those receiving anti-cancer treatment,
particularly where there is a history of previous C.difficile infection and when cared for in units (e.g. nursing homes) with C.difficile positive
patients.

Dosages: The current guidance for GPs is for the dosage guidance in the BNF to be used. The link is given here and at the bottom of each
page: BNF Antibiotics Dosages

It is the intention of Cambridgeshire PCT to audit for compliance against the antibiotics formulary to support judicious prescribing of antibiotics and
SHA and PCT objectives. This will be carried out by the Medicines Management Team who will be able to give help and support to practices and
prescribers in achieving this.

Cambridgeshire PCT would like to acknowledge the help of Hugo Ludlam, Consultant Medical Microbiologist and other members of his team at CUHFT, in the
production of these guidelines.


ANTIMICROBIAL TREATMENT GUIDELINES FOR PRESCRIBING IN PRIMARY CARE.
FORMULARY FIRST AND SECOND LINE CHOICES FOR COMMONLY PRESCRIBED DRUGS
(Both sections and individual entries are in alphabetical order)
5. Infections
Infection 1st Line 2nd Line Duration of Rationale/ Additional Information for Treatment
Formulary Formulary Treatment
Choice Choice (Days)
Dental
Dental Amoxicillin 5 Mild – empirical (Strep, anaerobic streps, bacteroides spp (but
infections rarely penicillin resistant))
Metronidazole 5 Moderate/severe/recurrent :
(organisms as above but note possibility of penicillin-resistance)
In penicillin allergy: 5
Erythromycin Dental abscess - CKS link – treat for five days
Ear , Nose and Throat
Acute Otitis If antibiotics are For acute attacks where there are no systemic features:
Media indicated: paracetamol or ibuprofen for pain
Amoxicillin 5 For acute attacks with systemic features: treat systemically.
BNF recommends for children: Acute attacks with no systemic
In penicillin allergy: features may be treated systemically after 72 hours if still
Erythromycin symptomatic or earlier if there is deterioration or no
improvement.
Azithromycin 3 Clinical Knowledge Summary
Sore throat Question necessity Penicillin 10 Usually viral and may not require antibiotic treatment.
(Pharyngitis) for treatment as Antibiotics only generally shorten duration of symptoms by
frequently viral in In penicillin allergy: 10 approximately 8 hours
origin. Treatment Erythromycin There may be overlap between viral and streptococcal
with paracetamol or infections.
ibuprofen may be More severe symptoms (history of fever, purulent tonsils,
appropriate. cervical adenopathy, absence of cough) or patients with a
history of otitis media may benefit more from antibiotics.
Clinical Knowledge Summary


Acute Where symptoms 7 Many attacks are viral in origin and symptomatic benefit of
Sinusitis have persisted for 7 antibiotics is small (69% resolve without antibiotics, 15% resolve
days or more: or with antibiotics).
are severe or
deteriorating Initial therapy may include nasal decongestants or intranasal
rapidly: corticosteroids, e.g. beconase

Amoxicillin (7 days) In penicillin allergy :
Azithromycin (3
days)

In penicillin allergy :
Clarithromycin or 7
Doxycycline. Erythromycin for Clinical Knowledge Summary
Erythromycin pregnant woemen.
Eye

Ocular Refer to secondary - - Herpes simplex – 1,2 virus
Herpes care clinicians On suspicion - refer immediately to eye casualty –
corticosteroids should not be used in undiagnosed red eye.

Acanthamoeba spp is a cause of corneal ulcer primarily in
contact lens wearers - refer urgently.

For contact lens wearers with keratitis, the contact lens should
be sent for culture in a sample of contact lens fluid.



Gastro-intestinal
Diverticulitis Co-amoxiclav ◄ At least 7 Awaiting comments from gastroenterologist
days

Eradication of Formulary PPI + 7 Where patients are HP negative do not retest unless there is
Helicobacter Amoxicillin + strong clinical need – treat as functional dyspepsia with low
pylori Clarithromycin dose PPI or H2A for one month then reassess before continuing
Or therapy (reassess dose for maintenance therapy)
For HP +ve Formulary PPI +
result Metronidazole + Do not use the clarithromycin/metronidazole regimen if either
Clarithromycin (eradication failure) drug used for infection in the past year.
Formulary PPI + 14 days
Tripotassium treatment for In the case of treatment failure following TWO treatment
dicitratobismuthate relapse and regimens consider endoscopy for culture and susceptibility.
+ tetracycline + maltoma NICE
metronidazole
Gastro- Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1 to 2 days and can lead to antibiotic
enteritis resistance.
Check travel, food, hospitalisation and antibiotic history (C. difficile is increasing).
Initiate treatment if the patient is systemically unwell. Fluid replacement is essential.
Please send stool specimens from suspected cases of food poisoning and post antibiotic use and notify the Health Protection
Unit (via the statutory ‘Notification of Infectious Disease or Food Poisoning’ form faxed to 01480 398684) on clinical
suspicion or after seeking advice from a Public Health Doctor.
Infective Erythromycin Ciprofloxacin ◄ 7 Antibiotic treatment for campylobacteriosis is only indicated if
diarrhoea (confirmed the patient has severe symptoms, dysentery or is
Campylobacteriosis immunocompromised.
only)

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Infection 1 Line 2 Line Duration of Rationale/ Additional Information for Treatment
Infective Metronidazole C.diff assoc Ciprofloxacin ◄ may occasionally be required for those who are
diarrhoea (antibiotic related diarrhoea 10- at high risk (such as the elderly and those receiving anti-cancer
(cont’d) inc. C.difficile 14 days treatment), particularly where there is a history of previous
assoc. diarrhoea, C.difficile infection and when cared for in units (e.g. nursing
amoebic dysentery Giardiasis 5 homes with C.difficile positive patients), or who present with
and giardiasis) days dysentery.

Amoebic
dysentery 5 – CKS - Infective diarrhoea
10 days

Ciprofloxacin ◄ Stat dose or
(Traveller’s 3 days
diarrhoea)
Threadworm Mebendazole Piperazine Stat Piperazine can be given second line and for children aged 3 to 6
(for adults and months.
children over 6m)
Household contacts should be treated.
Only retreat after
14 days if Advise on morning shower/baths and on hand hygiene.
infestation persists
Dose of If an anthelmintic is contraindicated (e.g. first trimester of
Piperazine, pregnancy, children aged less than 3 months) or if the individual
where used, does not wish to take an anthelmintic, advise physical removal
should be of eggs, combined with hygiene measures for 6 weeks
repeated after
2 weeks

Threadworm -CKS link


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Genital Tract - BASHH
Clotrimazole 10% Oral fluconazole Stat.
Vaginal All topical and oral azoles give 80-95% cure.
OR Miconazole
candidiasis
Clotrimazole
In pregnancy avoid oral azole.

Bacterial Metronidazole - Stat or 7 days A 7 day course of oral metronidazole is slightly more effective
vaginosis OR than 2g stat.
Metronidazole - 5
0.75% vaginal gel Avoid 2g stat dose in pregnancy.
Clindamycin 2% 7 Topical treatment gives similar cure rates but is more
cream expensive.
Candidal Topical Until 2-3 days An irritant balanitis is more common than infective
Balanitis clotrimazole 1% after clinical
cure Diagnosis of candidal balanitis is probably more common than
bacterial (e.g strep, anaerobes) and should be made on clinical
Oral fluconazole Single dose grounds whilst awaiting culture results.
(adults and children
over 16 only), if
Advise to avoid contact with any potential skin irritants (e.g.
candidal balanitis
has not cleared soap). Keeping area clean by bathing twice daily with a weak
after 7 days or is saline solution while symptoms persist.
severe.
Gardnerella Oral metronidazole 7 Children should be treated using topical anti-fungals.
associated
balanitis If symptoms not improving by 7 days, a sub-preputial swab
should be taken for culture, (to exclude or confirm infection type)
A mild topical steroid cream may settle inflammation for irritant
balanitis


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Acute Oral amoxicillin 7 An infective complication of an underlying dermatosis should
streptococcal In penicillin also be considered.
balanitis sensitivity:
Erythromycin/ Balanitis - CKS link
clarithromycin

Chlamydia Azithromycin - Stat Tetracyclines are contra-indicated in pregnancy.
trachomatis
7
Doxycycline Erythromycin is less efficacious than doxycycline.
OR
Erythromycin (for 14 Treat partners and refer contacts of positive patients to CPCT
pregnancy) Chlamydia screening service, Tel 01480 398787
cambridgeshirecso@nhs.net
Trichomo- Tinidazole 7 Refer to GUM. Treat partners simultaneously
Metronidazole
niasis Or
Second course of In pregnancy avoid 2g single dose metronidazole.
Topical Metronidazole
clotrimazole Topical clotrimazole gives symptomatic relief but no cure.

Pelvic Ceftriaxone I/M ◄ Metronidazole + 14 Test for N. gonorrhoea (as increasing antibiotic resistance) and
Inflammatory (single dose) Ofloxacin ◄ chlamydia.
Disease + Metronidazole Microbiological and clinical cure are greater with ofloxacin than
(PID) +Doxycycline with doxycycline.
Refer contacts to GUM clinic


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Meningitis
Suspected Benzyl penicillin Chloramphenicol if Administer antibiotic prior to hospital admission.
meningio- history of
coccal In penicillin allergy: anaphylaxis with
disease Cefotaxime ◄ penicillin or cephs

Respiratory
Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. The quinolones
ciprofloxacin (◄) and ofloxacin (◄) have poor activity against pneumococci, however, they do have use in PROVEN pseudomonal
infections
Acute Doxycycline (only where 7 30% of cases are viral in origin, 30-50% bacterial, remainder
Exacerbation tetracyclines undetermined. Antibiotics are not indicated in the absence of
of COPD contraindicated) purulent/mucopurulent sputum.

Co-amoxiclav In the event of treatment failure the second line drug should be
considered, and a sputum specimen sent for analysis.
(If penicillin
intolerant, consult Co-amoxiclav is only recommended where doxycycline is
microbiologist for inappropriate or ineffective, as it may predispose patient to c
advice) difficile infection. Other antibiotics should only be used on
microbiological advice due to resistance of some organisms
locally.

Thorax, CKS, NICE

Acute Amoxicillin Doxycycline 5 Antibiotics are not indicated in people who are otherwise well.
Bronchitis Explain why antibiotics are not necessary, giving written
In Penicillin allergy: Clarithromycin information if necessary.
Erythromycin or
Clarithromycin Clinical Knowledge Summary


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Acute Amoxicillin Doxycycline 7 If no response at 48 hours consider addition of erythromycin,
Community oxytetracycline or doxycycline.
Acquired In Penicillin allergy: In Penicillin allergy:
Pneumonia Erythromycin or Clarithromycin BTS pdf, BTS,
Clarithromycin IDSA -
http://www.thoracic.org/sections/publications/statements/pages/
mtpi/idsaats-cap.html
Seasonal Annual vaccination - Yearly In otherwise healthy adults, antivirals are not recommended -
Influenza for at risk patients only when influenza is circulating in the community, within 48
hours of onset. At risk: 65 years or over, chronic respiratory
When flu disease (including COPD and asthma) significant cardiovascular
circulating, disease (not hypertension), immunocompromised, diabetes
antivirals may be mellitus, chronic renal disease and chronic liver disease.
prescribed as per
local advice

For swine flu (H1N1) please follow the latest Department of Health/ Health Protection Agency advice

Skin and Soft Tssue
Acne Oxytetracycline / Erythromycin if At least 3 Propionibacterium acnes
Moderate to Tetracycline tetracyclines not months The tetracyclines should not be used in pregnancy, during
severe 500mg bd tolerated breastfeeding, or in children under 12 years of age, as they are
500mg bd deposited in the teeth and bones of the unborn or developing
child.
Lymecycline
408mg od Women of childbearing age should use effective contraception
(note that tetracyclines may cause oral contraceptives to fail
during the first few weeks of treatment).

Acne vulgaris - CKS link


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Balanitis – see under Genital Tract

Bites Doxycycline + In penicillin allergy: 7 Antibiotic prophylaxis (antibiotics and duration as for treatment
(Cat, Dog, Metronidazole Metronidazole + (CKS)) advised for puncture wounds; bites involving hand, foot,
Human) (Animal) doxycycline face, joint, tendon, ligament in immunocompromised, diabetic,
(animal) elderly and asplenic patients
Erythromycin And
Antibiotic prophylaxis (antibiotics and duration as for treatment
Metronidazole Metronidazole +
(CKS)) advised for all human bites.
(Human) Erythromycin
(human) Human bites should be reviewed after 24 and 48 hours.
Co-amoxiclav ◄ Assess HIV/hepatitis B & C risk, tetanus and rabies.
(Human/animal) Clinical Knowledge Summary

Breast Flucloxacillin - 7
Abscess Erythromycin

Cellulitis – Flucloxacillin 7 If the patient is afebrile and healthy other than cellulitis, treat as
minimal or indicated.
minor trauma Co-amoxiclav ◄ in
facial cellulitis For diabetic patients or patients where the infected area has
been exposed to fresh water – ciprofloxacin◄ should be added
In penicillin allergy: to the primary treatment.
Erythromycin
Where the infected area has been exposed to salt water –
doxycycline shoud be added.


(See also Appendix B).


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Chicken Pox Aciclovir - 7 days If pregnant seek advice (see link).
800mg 5x/day
Clinical value of antivirals minimal unless immunocompromised,
severe pain, on steroids, secondary household case AND
Child doses – see treatment started less than 24 hours from onset of rash.
BNF / RCPCH
Medicines for If patients develop life-threatening complications (encephalitis,
Children pneumonia or CNS deterioration) send them immediately to
hospital for IV aciclovir treatment. Immunocompromised patients
with severe chickenpox must always be given IV aciclovir.

It is recommended that immunocompromised patients who
come into contact with chicken pox should be given Varicella-
Zoster immunoglobulin (VZIG)
Chickenpox - CKS link

Cold sores Aciclovir topical 5 days Herpes simplex virus
Topical aciclovir must be started, five times a day, as soon as
symptoms begin to be of any benefit, otherwise paracetamol or
ibuprofen can be used for pain and pyrexia.

Herpes Simplex (oral) - CKS link

Conjunctivitis Chloramphenicol Fusidic acid Until 48 hours Many infections are viral in origin
0.5% drops after
Most bacterial infections are self-limiting (64% resolve on
OR resolution
placebo). They are usually unilateral with yellow-white
Chloramphenicol mucopurulent discharge.
1% ointment Fusidic acid has less Gram-negative activity.



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Dermatophyte Amorolfine nail Once or twice Treatment should only be considered if the patient has poor or
-
infection of lacquer 5% (for a week: diminished circulation (diabetes, imunocompromised or
the proximal superficial Fingers, 6m peripheral vascular disease) and can/will comply with a long
fingernail or infections) Toes, 12m course of treatment.
toenail
Fingers:
6 – 12 weeks Take nail clippings: Start therapy only if infection is confirmed by
Oral Terbinafine mycological examination.
Toes:
(generic only) 3 – 6 months
Idiosyncratic liver reactions occur rarely with terbinafine.
Fingers: 7 For infections with yeasts and non-dermatophyte moulds use
days monthly itraconazole. Itraconazole can also be used for dermatophytes.
Oral Itraconazole – 2 courses
(pulsed) For children seek advice
Toes 7 days
monthly – 3
courses Clinical Knowledge Summary

Dermatophyte Topical 1% - 7 Take skin scrapings for culture.
infection of terbinafine
the skin Topical 1% azole 4 - 6 weeks
Treatment: 1 week terbinafine is as effective as 4 weeks of an
treatment
azole. -If intractable consider oral itraconazole. Discuss scalp
infections with specialist. Clinical Knowledge Summary

Eczema Not usually Oral flucloxacillin 7 Using antibiotics, or adding them to steroids, in eczema does
required not improve healing unless there are visible signs of infection.
Or in penicillin 7 Where there are visible signs of infection treat orally.
allergy: Topical antimicrobial/corticosteroid combinations have been
Erythromycin shown to be no more effective than topical corticosteroid alone
in treating either visibly infected or uninfected flare-ups.


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Erysipelas Penicillin V Erythromycin 7 - 10 days Only if diagnosis certain (beta-haem Strep A,B,C,G)
Genital Aciclovir Famciclovir 5 days Herpes simplex virus
herpes (for first episode &
acute recurrence) or
Oral antiviral treatment should be given to people presenting
5 days
within 5 days of the start of the episode, or while new lesions
Valaciclovir
are still forming. If new lesions are still appearing after 5 days
treatment – continue treatment.
Recurrent episodes of genital herpes are often mild and may be
managed by supportive measures alone.

Second line drug choices should only be considered where
there is recurrence and compliance may be an issue.
Genital Herpes - CKS link
Head Lice Hedrin Phenothrin or As recommended by the local Health Protection Unit (based on
malathion. Stafford Report and CKS).
Repeat after 7 Hedrin (dimeticone) unlikely to provoke resistance in head lice.
days. Where
Permethrin not recommended for head lice in BNF or CKS.
phenothrin or
malathion needed,
choose a product
with the longest
contact time (i.e.
not mousses or
shampoos).
Impetigo Minor – topical Topical Mupirocin 7 Topical antibiotics should only be used for very localised lesions
fusidic acid (should be to prevent resistance developing.
reserved for MRSA
Severe or or if fusidic acid has
extensive disease – been ineffective or 7
Oral Flucloxacillin not tolerated).
Erythromycin Clinical Knowledge Summary


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Insect bites or Oral Flucloxacillin Try alternative first 7 As recommended by CKS
stings (If allergic to line treatment
penicillin –
Erythromycin/
Clarithromycin 7
days)

Lacerations Co-amoxiclav◄ Erythromycin + 5 Only treat if at high risk of infection, i.e. where laceration may
Metronidazole be contaminated with soil, faeces, bodily fluids, or purulent
exudates.
5
In penicillin allergy Clarithromycin For clean lacerations flucloxacillin may be used or erythromycin
Erythromycin + +Metronidazole where there is penicillin allergy.
Metronidazole

Leg ulcers Flucloxacillin In penicillin allergy: 7 Antibiotics do not improve healing. Culture swabs and
Clarithromycin or antibiotics are only indicated if there is evidence of clinical
Erythromycin infection such as inflammation/redness/cellulitis; increased pain;
purulent exudate; rapid deterioration of ulcer or pyrexia.



As above As above 7 Refer for specialist opinion if severe infection.
Diabetic leg Co-amoxiclav ◄ or Cefradine ◄ may be considered by
ulcer specialist


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Paronychia Flucloxacillin 7 Empirical therapy
(Staph. Aureus, beta-haem Strep A, B, C, G)
In penicillin allergy: If there is no response to initial antibiotic, swab to confirm
In penicillin allergy: 7 infecting organism and treat according to sensitivities. Arrange
Erythromycin
Erythromycin + for incise and drain if fluctuant.
(or clarithromycin if
metronidazole If no pus and incision not possible, change to second line
erythromycin not
(or clarithromycin if antibiotic. In the event of treatment failure consider candidal
tolerated)
erythromycin not paronychia.
tolerated)
Co-amoxiclav ◄ only for treatment failures and where patients
show no sensitivities.
Paronychia – CKS link

Swab or scrape for mycological culture and treat only if positive
Until healed for candida albicans +/- mixed coliforms.
Candidal Topical (Treatment
Paroncychia Systemic treatment is only indicated in patients unresponsive to
clotrimazole lasting 3-6 topical treatment or where immunocompromised.
months may Candidal paronychia – CKS link
be required)


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Otitis externa: Topical In resistant cases: 7 days NB: cleaning essential
Mild betamethasone Otosporin Topical treatment is recommended unless systemically unwell,
+neomycin drops perforated eardrum or infection is spreading

Colistin/Polymixin (Otosporin) required if resistant to neomycin,
but this still contains neomycin – i.e. not suitable in neomycin
allergy

Empirical therapy and Staph. aureus
Beta-haem Strep A, C, G

If severe or Flucloxacillin In penicillin allergy: 7 days N.B. Pseudomonas aeruginosa not covered by flucloxacillin.
cellulitis or Erythromycin Seek specialist advice if spreading cellulitis outside ear canal, or
boil where Pseudomonas infection suspected
(immunocompromised, diabetic). Refer urgently if suspected
malignant otitis externa
If fungal Topical For 4 weeks
Infection clotrimazole
Fungi (dermatophytes, yeasts, moulds
Otitis externa – CKS link
Pubic lice Malathion aqueous As recommended by CKS
lotion or Permethrin
cream.
Repeat application
after 7 days.
Permethrin only
suitable in over-
18’s, and not for
those who are
pregnant or breast
feeding.


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2 applications Treat whole body including scalp, face, neck, ears, under nails.
Scabies Permethrin Malathion 0.5%
1 week apart (BNF guidance). Treat all household contacts.

NICE Guideline CG 54

Varicella Aciclovir [Valaciclovir] / 7 days Because of the higher risk of complications, it would seem
zoster / 800mg 5x/day [Famciclovir] sensible to give a course of antiviral treatment to a person
shingles [1g tds] presenting for the first time after 72 hours of the onset of the
[750mg 1x/day] rash if they have: ophthalmic or predicators of post-herpetic
neuralgia, are >60yrA+, severe painA+, severe skin rash,
prolonged prodromal painB+, or are immunosuppressed.
In pregnant women Valaciclovir can be given, because the
active ingredient aciclovir has been shown to be safe in
pregnancy

Shingles - CKS link


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Urinary Tract

Note:. Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>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; only treat if systemically unwell or pyelonephritis likely.

Uncompli- Trimethoprim Try an alternative 3 For patients with clinical signs of UTI treat empirically.There
cated lower Nitrofurantoin 1st line agent should be no fever or flank pain.
UTI/Cystitis in
To confirm presence of infection in patients with few clinical
women.
signs of UTI – use dipstick test for nitrite and leucocyte esterase
[LE] – only treat if both are positive.

Community multi-resistant E. coli with ESBLs (Extended
Spectrum Beta-Lactamases) are increasing so perform culture
in all treatment failures. ESBLs are multi-resistant but remain
sensitive to nitrofurantoin.
[There is less relapse with trimethoprim than cephalosporins.]

Complicated Trimethoprim Nitrofurantoin 5 - 10 Send MSU for culture.
lower (if susceptible) Cefalexin ◄, Co-amoxiclav ◄ can be used following prior
UTI treatment failure
(See Appendix A for further treatment options)
http://www.cks.nhs.uk/uti_lower_women#191454001

Lower UTI in Trimethoprim Nitrofurantoin 7 Send MSU for culture.
men


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Lower UTI in Trimethoprim 7 Send MSU for culture.
pregnancy (First trimester:
teratogenic risk – In women with a low folate status (i.e. women with established
manufacturer folic acid deficiency or low dietary intake, or in those already
advises avoid) taking known folate antagonists), trimethoprim should be
avoided unless the woman is also taking a folate supplement
Nitrofurantoin In women with normal folate status, short-term use of
(Third trimester – trimethoprim is unlikely to induce folate deficiency. Note: women
may induce neo- who are pregnant, or at risk of pregnancy, should be taking folic
natal haemolysis if acid until week 12 of their pregnancy in order to prevent neural
used at term) tube defects in the foetus.
However, the BNF cautions against the use of trimethoprim in
Cefalexin ◄ the first trimester of pregnancy because the manufacturers
recommend that it not be used then. The manufacturer's
information leaflet also advises against the use of trimethoprim
for women who are pregnant or planning to become pregnant.

Nitrofurantoin should not be prescribed if the mother is glucose-
6-phosphate dehydrogenase (G6PD)-deficient. It can otherwise
be used during pregnancy, but should not be taken near term as
it can cause haemolysis in the foetus

During pregnancy, cefalexin◄ has not been shown to cause
harm to the foetus.
http://www.cks.library.nhs.uk/uti_lower_women/view_whole_topic



Lower UTI in Trimethoprim Nitrofurantoin 3 For children ≥ 3m and under 3 with signs and symptoms of UTI,
Children send MSU for culture and susceptibility. Treat with antibiotics.
The child should be taken for reassessment if they remain
unwell after 24 – 48 hours.

For chldren ≥ 3 years, use dipstick test – if both leukocyte/nitrite
+ve, treat with antibiotics otherwise send MSU for culture and
susceptibility and treat with antibiotics if appropriate.
Cefalexin ◄ can be considered for patients with prior treatment
failure.

For children < 3m, possible UTI should be referred to the care of
a paediatric specialist for treatment with parenteral antibiotics.
Clinical Knowledge Summary, NICE Guidance CG54

Recurrent UTI Trimethoprim Nitrofurantoin Post coital prophylaxis is as effective as prophylaxis taken
lower women nightly. Prophylactic doses
≥ 3/yr Cephalexin ◄ can be considered for patients with prior
treatment failure

May be needed for up to 6 months.



Prostatitis Acute – Trimethoprim 4 weeks 4 weeks treatment may prevent chronic infection.
(acute and Ciprofloxacin ◄
chronic) Ofloxacin ◄ Quinolones are more effective.
Aged <35 years - 4 weeks
Ciproflaxacin◄ +
Azithromycin
Chronic – Ofloxacin◄ 4 weeks
Trimethoprim Clinical Knowledge Summary
Ciprofloxacin◄
plus microbiology
advice
Acute Ciprofloxacin◄ - 7 Send MSU for culture.
pyelonephritis OR If no response within 24 hours admit
Co-amoxiclav ◄ 14 CKS - pyelonephritis acute
CKS = Clinical Knowledge Summaries, previously known as ‘Prodigy’

Appendix A - Recurrent Urinary Tract Infections

For recurrent infection where treatment failure has occurred despite optimal treatment with appropriate formulary antibiotics and where patient
compliance has been assessed, the following process should be followed to ensure a reduction in referrals to hospital:

1) For lower urinary tract infection resistant to all other oral antibiotics, consider fosfomycin trometamol (Monuril) sachets:
For uncomplicated infection, 1 x 3g sachet at night after emptying the bladder may be given (BNF 34).
For complicated infections, 1 x 3g sachet every other night, 3 times may be given (Pullukcu H et al. International Journal of
Antimicrobial Agents 2007; 29: 62-65). Complicated infections occur in the presence of a structural abnormality of the urinary tract, and
may be suspected in recurrent UTI.

Note local procedure for procurement: FP10 to be taken to Peterborough, Addenbrooke’s or Hinchingbrooke Hospital pharmacy


Cambridgeshire antibiotic guidelines updated

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