Section 5: Wolverhampton City Primary Care Trust

Management of Infection

Link to Guidance for Secondary Care

Primary Care Antibiotic Patient Information Leaflet (available in 11 languages)

OTHER ANTI-INFECTIVES

BNF 5.1.7

Rifaximin for preventing episodes of overt hepatic encephalopathy. For initiation by CONSULTANT GASTROENTEROLOGIST only, then suitable for primary care prescribing NICE TA337 

BNF 5.3.3.2

Valganciclovir - hospital only. For initiation and maintenance prescribing by specialists only.

Elbasvir–grazoprevir for treating chronic hepatitis C NICE TA413 

Sofosbuvir–velpatasvir for treating chronic hepatitis C NICE TA430 

BNF 5.4.1

Pyrimethamine - hospital only

Section PRIMARY CARE GUIDANCE

A

Introduction

B

Clostridium difficile reduction strategy

C

Upper Respiratory Tract infections

D

Lower Respiratory Tract infections

E

Meningitis

F

Urinary Tract Infections

G

Gastro-intestinal Tract Infections

H

Genital Tract Infections

I

Skin Infections

J

Eye Infections

K

Dental Infections

 

A- Introduction

Aims

Principles of treatment

  1. This guidance is based on the best available evidence but professional judgement should be used and patients should be involved in the decision.
  2. A dose and duration of treatment for adults is usually suggested, but may need modfication for age, weight and renal function. In severe or recurrent cases consider a larger dose or a longer course.
  3. Lower thresholds for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek advice.
  4. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  5. Consider a no, or delayed, antibiotic strategy for acute or self-limiting upper respiratory tract infections
  6. Limit prescribing over the telephone to exceptional cases.
  7. 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 risk of Clostridium difficile, MRSA and resistant UTIs.
  8. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations e.g. fusidic acid).
  9. In pregnancy, AVOID tetracyclines, amonoglycosides, quinolones, high dose metronidazole (2g). Short-term use of nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus. Trimethoprim also unlikely to cause problems unless poor dietary folate intake or taking another folate antagonist such as antiepileptic.
  10. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily and generic tablets are similar costs. In children, erythromycin may be preferable as clarithromycin syrup is twice the cost.
  11. Where a "best guess" therapy has failed or special circumstances exist, microbiological advice can be obtained from the on-call microbiologist at New Cross Hospital, Wolverhampton - 01902 307999 ext: 8249. Out of hours contact via the New Cross Hospital switchboard.

 

B - Clostridium difficile reduction strategy

In an effort to reduce the incidence of Clostridium difficile-assocatied diarrhoea (CDAD) please note that some antibacterials are more likely to generate the problem than others. The antimicrobials in this guidance have been ranked according to risk. Please consider this when prescribing, and use a lower risk antimicrobial where appropriate.

High risk Medium risk Low risk
  • ciprofloxacin
  • ofloxacin
  • cefixime
  • cefuroxime axetil
  • cefalexin
  • low dose clindamycin (<600mg QDS)
  • moxifloxacin
  • co-amoxiclav
  • erythromycin
  • azithromycin
  • clarithromycin
  • high-dose clindamycin (>600mg QDS)
  • phenoxymethylpenicillin
  • amoxicillin
  • flucloxacillin
  • trimethoprim
  • nitrofurantoin
  • metronidazole
  • vancomycin
  • rifampicin
  • fusidic acid
  • oxytetracycline
  • doxycycline

C - Upper Respiratory Tract infections

Upper Respiratory Tract Infections - management in primary care

D - Lower Respiratory Tract infections

Lower Respiratory Tract Infections - management in primary care

E- Meningitis

NICE fever guidelines NICE CG47

Meningitis - management in primary care

Prevention of secondary case of meningitis: Only prescribe following advice from on-call Public Health contact via. New Cross Switch board Tel 01902 307999

F- Urinary Tract Infections

Urinary Tract Infections - management in primary care

Give TARGET UTI leaflet.

G- Gastro-intestinal Tract Infections

Gastro-intestinal tract infections - management in primary care

H- Genital Tract Infections

Contact UKTIS for information on foetal risks if patient is pregnant.

Genital tract infections - management in primary care

I- Skin Infections 

Skin infections - management in primary care

J- Eye Infections  

Management of eye infections in primary care

K- Dental Infections

Derived from the Scottish Dental Clinical Effectiveness Programme 2016 SDCEP Guidelines

ILLNESS COMMENTS DRUG ADULT DOSE
☺ = childrens' dose
DURATION OF TREATMENT
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 patient's dentist, who should have an answer-phone message with details of how to access treatment out of hours, or NHS Direct on 0845 4657
Mucosal ulceration and inflammation (simple gingivitis)
  • Temporary pain and swelling relief can be attained with saline mouthwash
  • Use antiseptic mouthwash: If more severe & pain limits oral hygiene to treat or prevent secondary infection
  • The primary cause for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes simplex infection, oral cancer) needs to be evaluated and treated.
Simple saline mouthwash Half tsp salt dissolved in glass warm water

Always spit out after use

Use until lesions resolve or less pain allows oral hygiene

Chlorhexidine 0.12-0.2% (Do not use within 30mins of toothpaste) Rines mouth for 1 minute BD with 5ml diluted with 5-10ml water
Hydrogen peroxide 6% (spit out after use) Rinse mouth for 2 mins TDS with 15ml diluted in half-glass warm water
Acute necrotising ulcerative gingivitis Commence metronidazole and refer to dentist for scaling and oral hygiene advice
Use in combination with antiseptic mouthwash if pain limits oral hygiene

Metronidazole

Chlorhexidine or hydrogen peroxide

400mg TDS

see above dosing in mucosal ulceration

3 days

Until oral hygiene possible

Pericoronitis Refer to dentist for irrigation and debridement. If persistent swelling or systemic symptoms use metronidazole.

Metronidazole

Amoxicillin

400mg TDS

500mg TDS

3 days

3 days

Use antiseptic mouthwash if pain and trismus limit oral hygiene Chlorhexidine or hydrogen peroxide see above dosing in mucosal ulceration Until oral hygiene possible
Dental abscess
  • Regular analgesia should be first optiomn until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscesses are not appropriate; repeated antibiotics alone, without drainage are ineffective in preventing spread of infection.
  • Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications.
  • Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction, Ludwigs angina. Refer urgently for admission to protect the airway, achieve surgical drainage and IV antibiotics.
  • The empirical use of cephalosporins, co-amoxiclav, clarithromycin and clindamycin do not offer any advantage for most dental patients and should only be used if no response to first line drugs when referral is the preferred option.

If pus drain by incision, tooth extraction or via root canal. Send pus for microbiology.

True penicillin allergy: use clarithromycin or clindamycin if severe.

If spreading infection (lymph node involvement, or systemic signs i.e. fever or malaise) ADD metronidazole

Amoxicillin

or

phenoxymethylpenicillin

500mg TDS (doubled in severe infection)

500mg-1g QDS

Up to 5 days, review at 3 day

True penicillin allergy: Clarithromycin

Severe infection add:
Metronidazole or if allergy Clindamycin

500mg BD

 

400mg TDS
600mg QDS

Up to 5 days, review at 3 days

5 days
5 days