GUIDELINES FOR ANTIMICROBIAL PRESCRIBING IN PRIMARY CARE IN IRELAND

April 2011 Version 2.2

Dr. Brian Carey, Consultant Microbiologist, Waterford Regional Hospital Ms. Marion Murphy, Research Pharmacist, University College Cork Professor Colin P. Bradley, Professor of General Practice, University College Cork Dr Rob Cunney, Consultant Microbiologist, Health Protection Surveillance Centre (HPSC) Dr. Stephen Byrne, Senior Lecturer, School of Pharmacy, University College Cork Dr. Nuala O Connor, Irish College of General Practitioners Dr. Anne Sheehan, Department of Public Health, Health Service Executive

On behalf of SARI Community Antibiotic Stewardship Expert Working Group

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

INTRODUCTION
Antimicrobial resistance is recognised as a significant threat to public health by compromising our ability to treat infections effectively. It is widely acknowledged that antibiotic resistance is driven by high rates of antibiotic prescribing. The continuing problem of antimicrobial resistance has prompted efforts to reduce unnecessary antibiotic use to maximise the lifespan of these valuable drugs and to strive to prevent a return to the pre-antibiotic era. It is estimated that 80% of all antibiotics consumed by patients are prescribed by general practitioners. It was established in 2008 that Ireland had relatively high rates of antibiotic prescribing compared to our European counterparts, and one of only three countries in Europe that community antibiotic consumption was continuing to increase, and in addition had relatively high levels of broad spectrum antibiotic use. - Source - ESAC

Penicillin non-susceptible Streptococcus pneumoniae (PNSP) is a marker organism and key indicator of antibiotic resistance in primary care. In Ireland, non-susceptibility rates to penicillin for this organism have increased from 10.3% in 2004 to 18.2% in 2010.* (See Europe map on page 3). Rates of quinolone resistance in E.Coli in Ireland has increased from 5.2% in 2002 to 23.6% in 2010.* Evidence-based antimicrobial guidelines are a key tool in efforts to improve antibiotic prescribing, reduce the progression of antibiotic resistance and optimise patient outcomes. These guidelines have been developed as part of the Strategy for the Control of Antimicrobial Resistance in Ireland (SARI) initiative which has been ongoing in Ireland since 2001.
Please send comments and queries to: Ms. Marion Murphy, Research Pharmacist, School of Pharmacy, University College Cork.

Tel: 021 4901690 Email: marion.murphy@ucc.ie

*provisional data in 2010 (European Antimicrobial Resistance Surveillance Network (EARS-Net))

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Distribution of Penicillin non-susceptible Streptococcus pneumoniae (PNSP) which is a marker for community resistance in Europe in 2009 (European Antimicrobial Resistance Surveillance Network (EARS-Net))

Aims to provide a simple, best guess approach to the treatment of common infections to promote the safe and effective use of antibiotics to minimise the emergence of bacterial resistance in the community Principles of Treatment 1. This guidance is based on the best available evidence but its application must be modified by professional judgement. 2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course 3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 4. Consider a no, or delayed, antibiotic strategy for acute sore throat, common cold, acute cough and acute sinusitis. 5. Limit prescribing over the telephone to exceptional cases. 6. Try to avoid over-use of broad spectrum antibiotics (eg co-amoxiclav, quinolones and cephalosporins) as this can increase risk of PNSP, Clostridium difficile, MRSA and resistant UTIs and also limit the future usefulness of these important agents. Consider use of narrow spectrum agents (e.g. penicillin, amoxicillin, flucloxacillin, trimethoprim) as outlined in these guidelines for specific indications where clinically appropriate. In particular, try to reserve use of cephalosporins and quinolones unless there is clear rationale (e.g. where guideline evidence recommends, true allergy with little alternative, specific indication for agent, and/or based on sensitivity results). 7. Note: Hospital antibiotic guidelines can differ from community guidelines as patients are generally systemically unwell when hospitalised and may require intravenous and/or broader spectrum agents due to possible recent exposure to antibiotics in the community and/or failed initial therapy and increased severity of illness. 8. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g. fusidic acid). 9. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high dose metronidazole (2g). Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus. 10. Clarithromycin has fewer side-effects than erythromycin. However, erythromycin is preferable to clarithromycin if patient is on warfarin. Clarithromycin has a greater potential for raising INR. Note, spectrum of activities of these drugs not identical. Exercise caution when considering concomitant administration of macrolides and statin therapy due to potential risk of rhabdomyolysis. 11. Where a best guess therapy has failed or special circumstances exist, seek microbiological advice.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS COMMENTS TREATMENT DOSE DURATION OF TX

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.APharyngitis / sore throat / tonsillitis 1. The majority of sore throats are viral; most patients do not benefit from antibiotics. Consider a delayed antibiotic strategy and explain soreness will take about 8 days to resolve. Patients with 3 of 4 centor criteria (history of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from antibiotics.A- Antibiotics only shorten duration of symptoms by 8 hours.A+ 2. Antibiotics to prevent Otitis media NNT 200,A+ Quinsy NNT >4000.B3. Penicillin for 7 days is more effective than 3 days.B+ Twice daily higher dose can also be used.AQDS may be more appropriate if severe.D 4. Phenoxymethylpenicillin suspension is available in two flavours; Calvepen (caramel) and Kopen (orange). Symptomatic relief Discomfort on swallowing lozenges containing benzocaine or flurbiprofen Sore, tickly throat demulcent pastilles Sucking a lozenze or pastille promotes saliva production which lubricates & soothes the throat. Main disadvantage; high sugar content though sugarfree preparations are available. Local analgesia- anti-inflammatory spray or mouthwash (e.g. benzydamine) Consider a no- or delayedantibiotic strategy.A+ If antibiotics deemed clinically indicated: first line (Adults) phenoxymethylpenicillin clarithromycin if allergic to penicillin first line (Children) phenoxymethylpenicillin suspension (250mg /5ml)

333-666 mg QDS 250-500 mg BD < 1 yr 62.5mg 1-5 yrs 125mg 6-12 yrs 250mg QDS < 2 yrs 125mg 2-8 yrs 250mg QDS < 1 yr 62.5mg 1-5 yrs 125mg 5-12yrs 250mg BD

10 days 5 days

7-10 days

erythromycin

OR clarithromycin if allergic to penicillin

5 days

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Otitis media (child doses) 1. Many are viral. Illness resolves over 4 days in 80% without antibiotics.A+ 2. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.A+ 3.Need to treat 20 children >2y and seven 6-24m old to get pain relief in one at 2-7 days.A+B+ 4. Children with otorrhoea, or <2years with bilateral acute otitis media, have greater benefit but are still eligible for delayed prescribing.A+ 5. Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, are less effective treatment. 6. Antibiotics to prevent mastoiditis NNT>4000.B second line co-amoxiclav < 1 yr max 68mg 1-6 yrs 156 mg 6-12 yrs 312 mg TDS Symptomatic relief Use NSAID or paracetamol.AConsider a no- or delayedantibiotic strategy.A+ If antibiotics deemed clinically indicated first line Amoxicillin erythromycin

40 mg/kg/day in 3 divided doses

(Maximum 1g TDS)

< 2 yrs 125mg 2-8 yrs 250mg QDS < 1 yr 62.5mg 1-5 yrs 125mg 5-12yrs 250mg BD

5 days

OR clarithromycin if allergic to penicillin

ILLNESS
Acute Sinusitis

COMMENTS
1. Many are viral. Symptomatic benefit of antibiotics is small. 2. 80% resolve in 14 days without antibiotics and they only offer marginal benefit after 7 days (NNT 15).A+ 3. Reserve for severeB+ or symptoms (>10 days). 4. Cochrane review concludes that amoxicillin and phenoxymethylpenicillin have similar efficacy to the other recommended antibiotics. 5. In persistent infection use an agent with antianaerobic activity e.g. co-amoxiclav.B+ Symptomatic relief Use NSAID or paracetamolB+ Systemic decongestants: pseudoephredrine Improve air circulation & mucus drainage Saline preparations for local irrigation (e.g. nasal rinses, sprays, drops) Topical decongestants: oxymetazoline, xylometazoline Suitable for most patient groups (hypertensive, diabetes, pregnant women post first trimester) Topical route should not be used >7 days due to rebound congestion

TREATMENT
Consider a no or delayed antibiotic strategyA+ If antibiotics deemed clinically indicated: amoxicillinA+ OR doxycycline OR clarithromycin if allergic to penicillin second line: co-amoxiclav

DOSE

DURATION OF TX

500 mg TDS 200 mg stat/100 mg OD 250-500mg BD

7-10 days

625 mg TDS

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS
COMMENTS TREATMENT DOSE DURATION OF TX

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 have poor activity against pneumococci. However, they do have use in PROVEN pseudomonal infections. Moxifloxacin and Levofloxacin has some anti-Gram-positive activity but should not be needed as first line treatment.
Acute cough, bronchitis (in otherwise healthy adults & children) In primary care, antibiotics have marginal benefits in otherwise healthy adults.A+ Patient leaflets can reduce antibiotic use.B+ Symptomatic relief

Cough expectorants: guaifenesin Mucolytic agent: carbocisteine Cough suppressants: dextromethorphan Codeine containing products should be used with care due to dependence potential

Consider no antibiotics where possible.A+ If antibiotics deemed clinically indicated: amoxicillin OR doxycycline 500 mg TDS 200 mg stat/100 mg OD 5 days

Acute exacerbation of COPD

30% viral, 30-50% bacterial, rest undetermined. Use antibiotics if increased dyspnoea and increased purulence of sputum volume.B+ In penicillin allergy use clarithromycin if doxycycline contraindicated.

amoxicillin OR doxycycline OR clarithromycin

500 mg TDS 200 mg stat/100 mg OD 250 500 mg BD 625 mg TDS 500 mg - 1g TDS 500 mg BD 200 mg stat/100 mg OD Up to 10 days 5 days

Communityacquired pneumonia treatment in the community (Adults)

If clinical failure to first line antibiotics, previous amoxicillin exposure <3 month, or severe symptoms (also consider hospital referral). Start antibiotics immediately.B- If no response in 48 hours consider admission or add a macrolide first line or a tetracyclineC to cover Mycoplasma infection (rare in over 65s). Assess using the CRB-65 score (Confusion, Respiratory rate 30/min, BP 90/90, Age 65) Score 0: suitable for home treatment; Score 1-2: consider hospital referral; Score 3-4: urgent hospital admission. Consider adding macrolide if CRB=1 and suitable for home treatment (HPA guidance). In severely ill give parenteral benzylpenicillin before admission C and seek risk factors for Legionella and Staph.aureus infection.D

co-amoxiclav amoxicillin OR clarithromycin doxycycline

Up to 10 days

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS
COMMENTS TREATMENT
At risk groups: Pregnant women 14 weeks- 6 weeks after giving birth Anyone aged >6 months and < 65 years who has: Long-term lung, cardiac, kidney, liver or neurological disease Immunosuppression Haemoglobinopathies Diabetes Severely obese (BMI40) Adults: doxycycline OR co-amoxiclav OR clarithromycin Children: co-amoxiclav

DOSE

DURATION OF TX

Influenza

Following a recent increase in the level of seasonal influenza including H1N1 (2009) (Swine flu) circulating in Ireland, the HPSC has issued guidance on influenza including guidance on the use of antiviral drugs for the management of patients with influenza like illness who are at high risk of developing complications from flu. Comprehensive guidance can be found on the HPSC website: http://www.hpsc.ie/hpsc/AZ/Respiratory/Influenza/SeasonalInfluenza/ (Please make sure to refresh any webpage you visit so that you are seeing the most up-to-date version) Treatment with antivirals is advised for patients who are particularly ill and for at risk groups. Check HPSC for use in children & in pregnancy. This guidance has been prepared by the Health Protection Surveillance Centre, Departments of Public Health and members of the Pandemic Influenza Expert Group.

1st line: Oseltamivir Adult-75mg bd 75mg od 2nd line: Zanamivir See BNF for dosage

5 days (treatment) 10 days (chemoprophylaxis)

Consult following documents for clinical guidance: Pneumonic and non-pneumonic post influenza LRTI managed in the community Adults & Children Interim Algorithm for the primary care: Management of persons with influenza, for use when flu is circulating. Clinical management of patients with influenza like illness during an influenza pandemic. Management of secondary bacterial infections in adults and children.

100 mg OD 625mg TDS 500mg BD < 1 yr max 68mg 1-6 yrs 156 mg 6-12 yrs 312 mg TDS < 1 yr 62.5mg 1-5 yrs 125mg 5-12yrs 250mg BD

7 10 days

OR clarithromycin (if penicillin allergic)

MENINGITIS
Suspected meningococcal disease Transfer all patients to hospital immediately. Administer benzylpenicillin prior to admission, unless history of anaphylaxis,B- NOT allergy. Ideally IV but IM if a vein cannot be found. Prevention of secondary case of meningitis: Only prescribe following advice from Public Health Doctor. IV or IM benzylpenicillin Adults and children 10 yr and over: 1200 mg Children 1 - 9 yr: 600 mg Children <1 yr: 300 mg

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS
COMMENTS TREATMENT DOSE DURATION OF TX

URINARY TRACT INFECTIONS 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%
Information on local antibiotic resistance rates in urinary pathogens is particularly important as patterns can vary substantially across the country. trimethoprimB+ OR nitrofurantoinA200 mg BD 50-100 mg QDS 3 daysB+ 7 days in men

of women and 10% of men and is not associated with increased morbidity. B+ In the presence of a catheter, antibiotics will not eradicate bacteriuria; only treat if systemically unwell Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI.B
Uncomplicated UTI ie no fever or flank pain Use urine dipstick to exclude UTI -ve nitrite and leucocyte 95% negative predictive value. Note: Choice of empirical therapy should be goverened by local resistance rates where available. Patterns can vary substantially across the country For first presentations, low risk of resistant organisms in uncomplicated UTI consider narrow-spectrum antibiotics that concentrate in the bladder such as trimethoprim or nitrofurantoin in the first instance. There is less relapse with trimethoprim than cephalosporins. Community multi-resistant E. coli with Extended-spectrum Beta-lactamase enzymes are increasing so perform culture in all treatment failures. ESBLs are multi-resistant but remain sensitive to nitrofurantoin. Nitrofurantoin should be avoided in renal impairment due to inadequate urine concentrations. UTI in pregnancy Send MSU for culture. Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to cause problems to the foetus.B+Avoid trimethoprim if low folate status or taking folate antagonist (e.g. antiepileptic or proguanil). Refer to local resistance patterns for empiric therapy where available and refer to MSU results. Refer children <3 months to specialist. Send MSU in all for culture & susceptibility. If 3 years, use positive nitrite to start antibiotics. Refer children post UTI for imaging.

Consider the following agents also for empiric therapy where appropriate - based on local resistance rates. cephalexin, co-amoxiclav (For uncomplicated UTI reserve quinolones for resistant infections with limited option and confirmed by results of culture and sensitivity). amoxicillin OR cephalexin second line nitrofurantoin OR trimethoprim trimethoprim OR nitrofurantoin OR cefalexin If susceptible, amoxicillin, coamoxiclav co-amoxiclav 250 mg TDS 500 mg BD 50 mg 100 mg QDS 200 mg BD 3mth-12 years 4mg/kg BD (max 200mg) 750micrograms/kg QDS 12.5mg/kg BD 7 days

Children

Lower UTI 3 days

Upper UTI

< 1 yr max 68mg 1-6 yrs 156 mg 6-12 yrs 312 mg TDS 500 mg BD 500/125 mg TDS 200 mg BD

Upper UTI 7-10 days 7 daysA14 days 14 days

Acute pyelonephritis

Send MSU for culture. RCT shows 7 days ciprofloxacin was as good as 14 days co-trimoxazole.AIf no response within 24 hours admit.

ciprofloxacinAOR co-amoxiclav If susceptible, trimethoprim

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Recurrent UTI women 3/yr Post-coital prophylaxis or standby antibiotic B+ Nightly: reduces UTIs but side effects (antibiotics). nitrofurantoin OR trimethoprim 50 mg 100 mg Stat post-coital (off-label)OR OD at night

10

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS GASTRO-INTESTINAL TRACT INFECTIONS
Eradication of Helicobacter pylori Eradication is beneficial in DU, GU and low grade MALTOMA, but NOT in GORD. A In NUD, 8% of patients benefit. Triple treatment attains >85% eradication.A+ Do not use clarithromycin or metronidazole if used in the past year for any infection. A+ DU/GU: Retest for helicobacter if symptomatic NUD: Do not retest, treat as functional dyspepsia. In treatment failure consider endoscopy for culture & susceptibility.C Use 14d BD PPI PLUS 2 antibiotics. Consider adding bismuth salt. first lineA+ PPI PLUS clarithromycin AND metronidazole (MZ) OR amoxicillin (AM) Alternative regimens PPI OR ranitidine bismuth citrate PLUS 2 antibiotics: amoxicillin clarithromycinA+ metronidazole
A+

11

COMMENTS

TREATMENT

DOSE

DURATION OF TX

Managing symptomatic relapse

250 mg BD with MZ 500mg BD with AM 400 mg BD 1g BD

All for 7 daysA 14 days in relapse or maltoma

BD 400 mg BD 1 g BD 500 mg BD 400 mg BD

Infectious diarrhoea Clostridium difficile

Antibiotic therapy not indicated unless patient systemically unwell or post-antibiotic, suggesting Clostridium difficile. Stop unnecessary antibiotics and/or PPIs to re-establish normal flora. 70% respond to metronidazole in 5 days; 94% in 14 days. Severe if T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis. Consult HPSC website for guidance document: Surveillance , Diagnosis & Management of Clostridium difficile-associated disease in Ireland (2008) 1st/2nd episodes metronidazole 3rd episode/severe vancomycin 400mg oral TDS 125mg oral QDS 10-14 days

Travellers diarrhoea

Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 750 mg single dose) to people travelling to remote areas and for people in whom an episode of infective diarrhoea could be dangerous. mebendazole in all >6 mths or piperazine/senna sachet 100 mg 3 mths- 1yr 2.5ml 1-6 yrs 5mls >6yrs 1 sachet stat stat, repeat after 2 weeks

Threadworms

Treat household contacts. Advise morning shower/baths and hand hygiene. Use piperazine in children under 6 months.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS COMMENTS TREATMENT DOSE DURATION OF TX

12

GENITAL TRACT INFECTIONS Note: STI clinics may also known as STD,GUM & GUIDE clinics
Vaginal candidiasis Bacterial vaginosis All topical and oral azoles give 80-95% cure.AIn pregnancy avoid oral azole..B A 7 day course of oral metronidazole is slightly more effective than 2 g stat.A+ Avoid 2g stat dose in pregnancy & breastfeeding. Topical treatment gives similar cure ratesA+ but is more expensive. clotrimazole 10% OR clotrimazole OR fluconazole metronidazoleA+ OR metronidazole 0.75% vag gelA+ OR clindamycin 2% creamA+ Chlamydia trachomatis Treat contacts and consider referral to STI clinic if indicated. In pregnancy or breastfeeding: azithromycin can be used but is off label. If erythromycin or amoxicillin is used, retest after 5 weeks, as less effective. azithromycinA+ OR doxycyclineA+ OR erythromycin AOR amoxicillinA+ Trichomoniasis Refer to STI clinic. Treat partners simultaneously. In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure). clotrimazole Pelvic Inflammatory Disease (PID) Acute prostatitis Essential to test for N. gonorrhoea (as increasing antibiotic resistance) and chlamydia. Microbiological and clinical cure are greater with ofloxacin than with doxycycline. A+ Refer contacts to STI clinic. metronidazole + ofloxacinB OR metronidazole + doxycyclineB ciprofloxacin OR ofloxacinC OR trimethoprimC metronidazoleA5 g vaginal cream 500 mg pessary 150 mg orally 400 mg BD 5 g applicatorful at night 5 g applicatorful at night 1 g stat 100 mg BD 500 mg BD or 500 mg QDS 500 mg TDS 400 mg BD or 2 g in single dose 100 mg pessary 400 mg BD 400 mg BD 14 days 400 mg BD 100 mg BD 500 mg BD 200 mg BD 200 mg BD 28 days stat

7 days 5 days

7 days 1 hr before or 2 hrs after food 7 days 14 days 7 days 7 days 5 days

6 days

4 weeks treatment may prevent chronic infection. Quinolones are more effective, as they have greater penetration into prostate.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS COMMENTS TREATMENT DOSE DURATION OF TX

13

SKIN / SOFT TISSUE INFECTIONS

Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of Staphylococcus aureus and is associated with persistent recurrent pustules and carbuncles or cellulitis. Send swabs for culture in these clinical scenarios. On rare occasions it causes more severe invasive infections, even in otherwise fit people. Risk factors include: nursing homes, contact sports, sharing equipment, poor hygiene and eczema.
Acne vulgaris Topical treatment first line e.g. benzoyl peroxide gel, retinoid or topical antibiotic. Avoid using topical and oral antibiotics concurrently. However, topical benzoyl peroxide gel with oral antibiotic reduces risk of antibiotic resistance. doxycycline OR lymecycline OR erythromycin (OR trimethoprim in tetracycline resistance) first line flucloxacillin or clarithromycin fusidic acid mupirocin (MRSA only) Eczema Cellulitis 100mg OD 408mg OD 500mg BD 300mg BD Review in 3 months, but may take 46 months

Impetigo

Systematic review indicates topical and oral treatment produces similar results.A+ As resistance is increasing reserve topical antibiotics for very localised lesions.C or D Reserve Mupirocin for MRSA.

Oral 500 mg QDS Oral 500 mg BD Topically TDS Topically TDS

7 days

5 days

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. If patient afebrile and healthy other than cellulitis flucloxacillin may be used as single drug treatment. If water exposure, discuss with microbiologist. If febrile and ill, admit for IV treatment In facial cellulitis use co-amoxiclavC Flucloxacillin If penicillin allergic: clarithromycin* alone OR clindamycin co-amoxiclav 500 mg QDS

500 mg BD 450mg QDS 500/125 mg TDS

7 14 days

Leg ulcers

Antibiotics do not improve healing unless active infection.A+ Culture swabs and antibiotics are only indicated if there is evidence of clinical cellulitis; increased pain; enlarging ulcer or pyrexia. Review antibiotics after culture results. Refer for specialist opinion if severe infection. Flucloxacillin OR clarithromycin 500 mg QDS 500mg BD 7 days and review

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

ILLNESS
Animal bite

14

COMMENTS
Surgical toilet most important. Assess tetanus and rabies risk. Antibiotic prophylaxis advised for puncture wound; bite involving hand, foot, face, joint, tendon, ligament; immunocompromised, diabetics, elderly, asplenic. Antibiotic prophylaxis advised. Assess HIV/hepatitis B & C risk.

TREATMENT
First line animal & human prophylaxis and treatment co-amoxiclavBIf penicillin allergic: metronidazole PLUS doxycycline OR clarithromycin (human) If severe:B+ chloramphenicol 0.5% drops PLUS 1% ointment fusidic acid

DOSE

DURATION OF TX

Human bite

375-625 mg TDS 7 days 200-400 mg TDS 100 mg BD 250-500 mg BD 2 hrly reducing to QDS when infection controlled & at night

Conjunctivitis

Most bacterial infections are self-limiting (64% resolve on placeboA+). They are usually unilateral with yellow-white mucopurulent discharge. Fusidic acid has less Gram-negative activity.

All for 48 hours after resolution

1% gel BD 5% cream 0.5% aqueous liquid 1-2x/weekly fingers toes 250 mg OD fingers toes fingers toes 2 applications one week apart

Scabies

Treat whole body including scalp, face, neck, ears, under nails (BNF recommendations; manufacturers recommend to exclude head and neck). All members of the affected household should be treated simultaneously. Take nail clippings: Start therapy if infection is confirmed by laboratory. 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 For children seek advice.

Dermatophyte infection of the proximal fingernail or toenail

permethrinA+ If allergy: Malathion 5% amorolfine nail lacquerB- (for superficial) terbinafineASecond line: itraconazole Topical 1% terbinafine A+ Topical undecenoic acid or 1% azoleA+

6 months 12 months 6 12 weeks 3 6 months 7 days monthly (2 courses) 7 days monthly (3 courses) 1 weekA+ 4 6 weeksA+

200 mg BD OD - BD 1-2x/daily

Dermatophyte infection of the skin

Take skin scrapings for culture if not localised. Treatment: 1 week terbinafine as effective as 4 weeks azole.AIf intractable consider oral itraconazole. Discuss scalp infections with specialist.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Varicella zoster/ Chicken pox & Herpes zoster/ shingles If pregnant/immunocompromised seek advice. 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.AShingles: Always treat if active ophthalmic, and Ramsey Hunt or eczema. aciclovir Second line if a compliance problem valaciclovir or famciclovir 800 mg 5x/day

15

1 g TDS 750 mg OD

7 days

Non-ophthalmic shingles: Treat >50 yrs if <72h of onset of rash, as post-herpetic neuralgia rare in <50 yrs but occurs in 20% >50 yrsA+.

Disclaimer: Whilst every effort has been made to ensure the accuracy of the information and material contained in this document, errors or omissions may occur in the content. We acknowledge that new evidence may emerge that may overtake some of these recommendations. The document will be reviewed and revised as and when appropriate. Prescribers should ensure that the correct drug and dose is prescribed, as is appropriate for each individual patient. References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and the drug data sheets (available on www.medicines.ie). Clinical guidelines are guidelines only and the interpretation and application of the guidelines remains the responsibility of the individual clinician. Please send comments and queries to; Marion Murphy, Research Pharmacist, School of Pharmacy, University College Cork. Tel: 021 4901690 Email: marion.murphy@ucc.ie
The following references were used when developing these guidelines: This guidance was initially developed in 1999 by practitioners in South Devon, England, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The guidance has been modified for use in Ireland. Grading of guidance recommendations The strength of each recommendation is qualified by a letter in parenthesis. Study design Recommendation grade A+

Good recent systematic review of studies

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF/BNFC/MIMS/Product SPC for further information (Refer to page 26 for guidance on dosing in children). Letters indicate strength of evidence range from A+ (systematic review) to D (informal opinion).

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

One or more rigorous studies, not combined One or more prospective studies One or more retrospective studies Formal combination of expert opinion Informal opinion, other information AB+ BC D

16

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UPPER RESPIRATORY TRACT INFECTIONS

17

Pharyngitis/sore throat/tonsillitis Centor RM, Whitherspoon JM Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decision Making 1981;1:239-46. Scoring system for sore throats. Spinks A, Glasziou PP, Del Mar C. Antibiotics for sore throat. Cochrane Database of systematic reviews 2006, Issue 4.Art. No CD000023.DOI:10.1002/14651858.CD000023.pub3. Altamimi S, Khali A, Khalaiwa KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database of systematic reviews 2009, Issue 1. Art No.: CD004872. DOI: 10/1002/14651858.CD004872.pub2. Del Mar C. Sore throats and antibiotics: Applying evidence on small effects is hard; variations are probably inevitable. Brit Med J 2000;320:130-1. Editorial covering treatment. Del Mar C & Glasziou P. Sore Throat. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:516-17. Lan AJ, Colford JM, Colford JMJ. The impact of dosing frequency on the efficacy of 10 day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analysis. Pediatr 2000;105(2):E19. Meta-analysis showed BD and QDS dose equivalent. McIsaac WJ, Goel V, Slaughter PM, Parsons GW, Woolnough KV, Weir PT, Ennet JR. Reconsidering sore throats. Part 2: Alternative approach and practical office tool. Can Fam Physician 1997;43:495-500. Review of scoring system that supports Centor. Petersen, I.Johnson, A. M.Islam, A.Duckworth, G.Livermore, D. M.Hayward, A. C. (2007). "Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database." BMJ 335(7627): 982. Zwart Sjoerd, Sachs APE, Ruijs G, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. Brit Med J 2000;320:150-4. RCT showing 7 days penicillin V at 500 mg was better than 3 days in terms of time of symptom resolution, bacterial resolution and relapse. Also confirms validity of Centor criteria. Otitis media Damoiseaux RAMJ, Van Balen FAM, Hoes AW, Verhiej TJM, de Melker RA. Primary care-based randomised, double blind trial of amoxicillin versus placebo for acute otitis media in children aged under 2 years. Brit Med J 2000;320:350-4. Del Mar C, Glasziou P, Hayem M. Are antibiotics indicated as initial treatment for children with acute otitis media? A meta-analysis. Brit Med J 1997;314:1526-9. Search date 1966 to August 1994; primary sources Medline, current contents. Froom J, Culpepper L, Jacobs M, de Melker RA, Green LA, Van Buchem L, Grob P, Heeren T. Antimicrobials for acute otitis media? A review from the International Primary Care Network. Brit M J 1997;315:98-102. Glasziou IP, Del Mar CB, Sanders SC, Hayem M. Antibiotics for acute otitis media in children (Cochrane Review). In: The Cochrane Library 2006. Issue 4. Chichester, UK: John Wiley & Sons, Ltd http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000219/pdf_fs.html Accessed 20.04.11.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Kozyrskyj AL, Hildes Ripstein GF, Longstaffe SE, et al. Short-course antibiotics for acute otitis media. Cochrane Database Syst Rev 2000;(2):CD001095. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J. Pragmatic randomised controlled trial of two prescribing strategies for childhood acute otitis media. BMJ 2001;322:336-42. Little P. Gould C, Moore M, Warner G, Dunleavey J. Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ 2002;325:22-26. Thompson PL, Gilbert RE, Long PF, Saxena S, Sharland M, Wong IC. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United Kingdom general practice research database. Pediatrics 2009;123(2):424-30.

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Rovers MM, Glasziou P, Appelman CL, Burke P, McCormick DP, Damoiseaux RA, Gaboury I, Little P, Hoes AW. Antibiotics for acute otitis media: a meta-analysis with individual patient data. Lancet 2006;368:1429-35. Shows that patients with otorrhoea, or children <2 years with bilateral acute otitis media benefited more from antibiotics (NNT 3 and 4 respectively). Rovers MM, Glasziou P, Appleman CL, Burke P, McCormick DP, Damoiseaux RA, Little P, Le Saux N, Hoes AW. Predictors of pain and/or fever at 3 to 7 days for children with acute otitis media not treated initially with antibiotics: a meta-analysis of individual patient data. Pediatrics 2007;119(3):579-85 Rhinosinusitis de Ferranti SD, Lonnidis JPA, Lau J, Anniger WV, Barza M. Are amoxicillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. Brit Med J 1998;317:632-7. Search date May 1998; primary sources Medline 1966 May 1998; manual search of Excerpta Medica: recent abstracts for Interscience Conference on Antimicrobial Agents & Chemotherapy 19931997 and references of all trails review articles and special issues for additional studies. Ah-See KW, Evans AS. Sinusitis and its management. BMJ 2007:334:358-61 Hansen JG, Schmidt H, Grinsted P. Randomised, double blind, placebo controlled trial of Penicillin V in the treatment of acute maxillary sinusitis in adults in general practice. Scan J Prim Health Care 2000;18:44-47. Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomised trials. British Journal of Clinical Pharmacology2009;67(2):161-71. Thomas M, Yawn B, Price D, Lund V, Mullol J, Fokkens W. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 a summary. Primary Care Respiratory Journal2008;17(2):79-89. Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams Jr JW, Mkel M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000243. DOI: 10.1002/14651858.CD000243.pub2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000243/frame.html Accessed 20.04.11 Young J, De Sutter A, Merenstein D, van Essen GA, Kaiser L, Varonen H, Williamson I, Bucher HC. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371:908-914.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Hansen JG, Hojbjerg T, Rosborg J. Symptoms and signs in culture proven acute maxillary sinusitis in general practice population. APMIS 2009;117(10):724-9.

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LOWER RESPIRATORY TRACT INFECTIONS

Woodhead M, Blasi F, Ewig S, Huchon G, Leven M, Ortqvist A, Schabert T, Torres A, can der Jeijden G, Werheij TJM. Guidelines for the management of adult lower respiratory tract infection. Eur Respir J 2005;26:1138-80. http://www.erj.ersjournals.com/contents-by-date.0.shtml Accessed 20.04.11. Acute bronchitis Fahey T, Smucny J, Becker L, Glazier R. Antibiotics for acute bronchitis. In: The Cochrane Library, 2006, Issue 4. Chichester, UK: John Wiley & Sons, Ltd http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000245/pdf_fs.html Accessed 20.04.11. Studies in primary care showed antibiotics reduced symptoms of cough and feeling ill by less than one day in an illness lasting several weeks in total. Wark P. Bronchitis (acute). In: Clinical Evidence. London. BMJ Publishing Group. 2008;07:1508-1534 Francis N et al. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ, 2009;339:2885 Chronic cough due to acute bronchitis. Chest. 2006;129:95S-103S. Treatment of cough available in Clinical Knowledge Summaries website: http://www.cks.nhs.uk/chest_infections_adult/management/scenario_acute_bronchitis Accessed 20.04.11 COPD Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Int Med 1987;106:196-204. Calverley PMA, Walker P. Chronic obstructive pulmonary disease. Lancet 2003;362:1053-61. Excellent review on pathophysiology and management of COPD. Little detailed information on antibiotic treatment. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. Management of exacerbations. Updated December 2009 Chronic obstructive pulmonary disease. Management of COPD in adults in primary and secondary care. NICE Clinical Guideline 12 February 2004. http://guidance.nice.org.uk/CG101 Accessed 20.04.11 Community-acquired pneumonia BTS guidelines for the management of community-acquired pneumonia in adults. Thorax 2009;64(Suppl III):III 1-55.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Loeb M. Community-acquired pneumonia. In: Clinical Evidence. London BMJ Publishing Group. 2008;07:1503-1516.

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Levy, M. L., I. Le Jeune, et al. (2010). "Primary care summary of the British Thoracic Society Guidelines for the management of community acquired pneumonia in adults: 2009 update." Primary Care Respiratory Journal 19(1): 21-27. MENINGITIS NICE. Bacterial meningitis and meningococcal septicaemia. National Collaborating Centre for Womens and Childrens health 2009. http://guidance.nice.org.uk/CG102/Guidance Accessed 20.04.11. SIGN. Management of invasive meningococcal disease in children and young people. Scottish Intercollegiate Guidelines Network. 2008 http://www.sign.ac.uk/guidelines/fulltext/102/index.html Accessed 20.04.11.

INFLUENZA

Health Protection Surveillance Centre (HPSC) See http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/ Accessed 21.04.11 Infection prevention and control for patients presenting to Emergency Departments or GP practices with signs and symptoms of influenza-like illness (ILI) http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/AdviceforGPshospitalcliniciansandpharmacists/ Accessed 21.04.11. Vaccination Information (vH1N1) http://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/Vaccination/ Accessed 21.04.11. Management of secondary bacterial infections in adults and children http://www.hpsc.ie/hpsc/AZ/Respiratory/Influenza/PandemicInfluenza/Guidance/PandemicInfluenzaPreparednessforIreland/File,3261,en.pdf Accessed 21.04.11.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

URINARY TRACT INFECTIONS Elderly Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Int Med 1994:827-33. Nicholl LE. Urinary tract infection. In: Infection Management for Geriatrics in Long-term Care Facilities. Eds Yoshikawa TT, Ouslander JG. Marcel Dekker. New York. 2002:173-95.

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Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1110. Uncomplicated UTI Christiaens TCM, Meyere M De, Vershcraegen G. Peersman W, Heytens S. Maeseneer JM De. Randomised controlled trial of nitrofurantoin versus placebo in the treatment of uncomplicated urinary tract infection in adult women. Brit J Gen Pract 2002;52:729-34. Davey PG, Steinke D. MacDonald TM, Phillips G, Sullivien F. Not so simple cystitis: How should prescribers be supported to make informed decisions about the increasing prevalence of infections caused by drug resistant bacteria? Brit J Gen Pract 2000;50:143-46. Dobbs FF & Fleming DM. A simple scoring system for evaluating symptoms, history and urine dipstick testing in the diagnosis of urinary tract infections. J Roy Col Gen Pract 1987;37:100-4. Gossius G Vorland L. The treatment of acute dysuria-frequency syndrome in adult women: double blind randomized comparison of three day versus ten day trimethoprim therapy. Curr Ther Res 1985;37(1):34-42. Falagas, M.E., Kotsantis, I.K., Vouloumanou, E.K. and Rafailidis, P.I. Antibiotics versus placebo in the treatment of women with uncomplicated cystitis: a meta-analysis of randomized controlled trials. Journal of Infection 2009;58(2):91-102. Hiscoke C, Yoxall H, Greig D, Lightfoot NF. Validation of a method for the rapid diagnosis of urinary tract infection suitable for use in general practice. Brit J Gen Pract 1990;40:403-5. Hummers-Pradier E. Kocken MM. Urinary tract infections in adult general practice patients. Brit J Gen Pract 2002;52:752-61. Livermore D, & Woodford N. Laboratory detection of bacteria with extended-spectrum beta-lactamases. CDR Weekly 2004;14 No. 27. Little P, Turner S, Rumsby K., Warner G, Moore M, Lowes JA, Smith H, Hawke C, Turner D, Leydon GM, Arscott A, Mullee M. Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study. Health Technology Assessment 2009;13(19):1-96. McCarty JM, Richard G, Huck W, Tucker RM, Toxiello RL, Shan M, Heyd A, Echols RM. A randomised trial of short-course ciprofloxacin, ofloxacin or trimethoprim/sulfamethoxazole for the treatment of acute urinary tract infection in women. Am J Med 1999;106:292-9.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Naber KG, Schito G, Botto H, Palou J, Mazzei T. Surveillance study in Europe and Brazil on clinical aspects and Antimicrobial Resistance epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. European Urology 2008;54:1164-1175. Milo G, Katchman EA, Paul M, Christiaens T, Baerheim A, Leibovici L. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Review. The Cochrane Library 2006, Issue 2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004682/pdf_fs.html Accessed 21.04.11. Review showing there is no difference in outcome between 3 day, 5 day or 10 day antibiotic treatment course for uncomplicated UTI. Spencer RC, Moseley DJ, Greensmith MJ. Nitrofurantoin modified release versus trimethoprim or co-trimoxazole in the treatment of uncomplicated urinary tract infection in general practice. J Antimicrob Chemother 1994;33(Suppl A):121-9. UTI in pregnancy UKTIS. The treatment of infections in pregnancy. The UK Teratology Information Service. 2008. (Tel: 0844 892 0909, www.toxbase.org)

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Trimethoprim: : trimethoprim is a folate antagonist. Folate supplementation during the first trimester reduces the risk of neural tube defects in offspring of pregnant women treated with trimethoprim. In women with normal folate status, who are well nourished, trimethoprim is unlikely to cause folate deficiency. However, it should not be used by women with established folate deficiency or low dietary folate intake, or by women taking other folate antagonists (e.g. antiepileptic drugs or proguanil). Nitrofurantoin: : significant placental transfer of nitrofurantoin does not occur. Nitrofurantoin has not been associated with an increased risk of congenital malformations. Nitrofurantoin has been associated with haemolysis in people with glucose-6-phosphate dyhydrogenase (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. Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1110. Children Hodson EM, Willis NS, Craig JC. Antibiotics for acute pyelonephritis. Cochrane Database of Systematic Reviews 2007. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003772/frame.html Accessed 20.04.11. National collaborating centre for womens and childrens health. NICE Clinical guideline. Urinary tract infection in children. Diagnosis, treatment and long-term management. http://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdf Accessed 21.04.11) Comprehensive guidance with summaries and flow charts. Acute pyelonephritis Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, Reuning-Scherer J and Church DA. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis in women. A randomized trial. JAMA 2000;283:1583-90. Evidence for 7 days ciprofloxacin. Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1110.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Recurrent UTI in non-pregnant women Albert X, Huertas I, Pereir I, Sanflix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database of Systematic Reviews 2004, Issue 3, Art No. CD001209. DOI: 10.1002/14651858.CD001209.pub2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001209/frame.html This is an excellent review of prophylaxis. It shows that it is very effective (NNT2). However 30% do not comply. Benefit lost as soon as prophylaxis stops and prophylaxis after intercourse is as effective as daily prophylaxis.

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Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1110.

GASTRO-INTESTINAL TRACT INFECTIONS

Eradication of Helicobacter pylori Bazzdi F. Pozzato P. Rokkas T. Helicobacter pylori: the challenge in therapy. Helicobacter 2002;7 (Suppl 1):43-49. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096. de Boer WA, Tytgat GNJ. Treatment of Helicobacter pylori infection. Brit Med J 2000;320:31-4. Delaney B, Moayyedi P, Forman D. Helicobacter pylori infection. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:184-188 Moayyedi P, Soo S, Deeks JJ, Delaney B, Harris A, Innes M, Oakes R, Wilson S, Roalfe A, Bennett C, Forman D. Eradication of Helicobacter pylori for non-ulcer dyspepsia. The Cochrane library 2006. Issue 2 http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002096/frame.html Accessed 19.04.11 NICE dyspepsia guidance. August 2004. Evidence indicates once daily PPI plus metronidazole 400mg BD + clarithromycin 250mg BD is as effective as using BD PPI or 500mg clarithromycin. This regimen is cheaper than using BD PPI or higher dose clarithromycin. http://www.nice.org.uk/pdf/CG017fullguideline.pdf Accessed 20.04.11 Luther J, Higgins PDR, Schoenfield PS, Moayyedi P, Vakil N, Chey WD. Empiric quadruple vs. triple therapy for primary treatment of Helicobacter pylori infection: systematic review and metaanalysis of efficacy and tolerability. Am J Gastroenterol 2010;105:65-73. Clostridium difficile Linsky A, Gupta K, Lawler EV, Fonda JR, Hermos JA. Proton pump inhibitors and risk for recurrent Clostridium difficile infection. Arch Intern Med 2010;170:772-778. Belmares J, Gerding DN, Parada JP, Miskevics S, Weaver F, Johnson S. Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system. J Infect 2007;55:495501. Of 83% of patients who dont respond to 5 days metronidazole, 30% do respond by 14 days.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

HPSC Surveillance, Diagnosis and Management of Clostridium difficile - associated disease in Ireland (2008) http://www.hpsc.ie/hpsc/AZ/Gastroenteric/Clostridiumdifficile/Publications/File,2936,en.pdf Accessed 21.04.11 Gastroenteritis de Bruyn G. Diarrhoea in adults (acute). In: Clinical Evidence. London. BMJ Publishing Group 2006;15:1031-48. Summarises evidence for a single dose or 3 days of ciprofloxacin in treatment of travellers diarrhoea.

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Farthing M, Feldman R, Finch R, Fox R, Leen C, Mandal B, Moss P, Nathwani D, Nye F, Percival A, Read R, Ritchie L, Todd WT, Wood M. J of Infect 1996;33:143-52. The management of infective gastroenteritis in adults. A consensus statement by an expert panel convened by the British Society for the Study of Infection. Goodman LJ, Trenholme GM, Kaplan RL el al. Empiric antimicrobial therapy of domestically acquired acute diarrhoea in urban adults. Arch Intern Med 1990;150:541-6. Travellers diarrhoea Dupont HL. Systematic review: prevention of travellers diarrhoea. Aliment Pharmacol Ther 2008;27:741-51. Spira AM. Travel Medicine 1: Preparing the traveller. Lancet 2003;361:1368-81. Summarises treatment of travellers diarrhoea in a simple table. Dupont HL. Systematic review: prevention of travellers diarrhoea. Aliment Pharmacol Ther 2008;27:741-51. Threadworm CKS (2007) Threadworm. Clinical Knowledge Summaries. http://www.cks.nhs.uk/search?&page=1&q=threadworm&site=0 Accessed 21.04.11.

GENITAL TRACT INFECTIONS

Vaginal Candidiasis Nurbhai M, Grimshaw J, Watson M, Bond CM, Mollison JA, Ludbrook A. Oral versus intravaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush). Cochrane Database of Systematic Reviews 2007, Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002845/frame.html Accessed 21.04.11. UKTIS. Use of fluconazole in pregnancy. The UK Teratology Information Service. 2008. (Tel: 0844 892 0909, www.toxbase.org) Data on the outcomes of over 1,700 pregnancies exposed to low-dose fluconazole (150 mg stat) show no increased incidence of spontaneous abortions, malformations, or patterns of defects. However, there may be an increased risk of malformations associated with high-dose chronic therapy (>400 mg/day). First-line treatment of candidal infection in pregnancy should be with an imidazole. However, fluconazole (150mg stat) may be a suitable second-line treatment if clotrimazole is ineffective.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Young GL, Jewell D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000225/frame.html Accessed 20.04.11. Bacterial vaginosis Joesoef MR, Schmid GP, Hillier SL. Bacterial vaginosis: review of treatment options and potential clinical implications for therapy. Clin Infect Dis 1999;28(suppl 1):S57-S65. McDonald HM, Brocklehurst P, Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database of Systematic Reviews 2007, Issue 1. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000262/frame.html Accessed 20.04.11. Joesoef MR & Schmid G. Bacterial vaginosis. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:533-35.

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Chlamydia trachomatis
SIGN. Management of genital Chlamydia trachomatis infection: a national clinical guideline. Scottish Intercollegiate Guidelines Network 2009. http://www.sign.ac.uk/guidelines/fulltext/109/index.html Accessed 20.04.11. Low N. Chlamydia (uncomplicated, genital) In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:536-38 Lau CY, Qureshi AK. Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomised controlled trials. Brocklehurst P, Rooney G. Interventions for treating genital Chlamydia trachomatis infection in pregnancy. Cochrane Database of Systematic Reviews 1998. Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000054/frame.html Accessed 20.04.11 Trichomoniasis Forna F, Gulmezoglu MU. Interventions for treating trichomoniasis in women. Cochrane Database of Systematic Reviews. 2003. Issue 2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000218/frame.html Accessed 20.04.11 Pelvic Inflammatory Disease RCOG. Management of Acute Pelvic Inflammatory Disease. Green Top Guideline No.32. Royal College of Obstetricians & Gynaecologists. 2008. http://www.rcog.org.uk/womens-health/clinicalguidance/acute-pelvic-inflammatory-disease-pid Accessed 20.04.11 Acute prostatitis BASHH. UK National Guidelines for the Management of Prostatitis. British Association for Sexual Health and HIV. 2008. http://www.bashh.org/guidelines Accessed 20.04.11

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

SKIN/SOFT TISSUE INFECTIONS

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Impetigo Koning S, Verhagen AP, van Suijlekom-Smit LWA, Morris AD, Butler C, van der Wouden JC. Interventions for impetigo. Cochrane Database of Systematic Reviews. 2003. Issue 2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003261/frame.html Accessed 20.04.11. Denton M, OConnell B, Bernard P, Jarlier V, Williams Z, Santerre Henriksen A. The EPISA study: antimicrobial susceptibility of Staphylococcus aureus causing primary or secondary skin and soft tissue infections in the community in France, the UK, and Ireland. J Antimicrob Chemother 2008;61:586-588. Eczema Birnie AJ, Bath-Hextall FJ, Ravenscroft JC, Williams HC. Interventions to reduce Staphylococcus aureus in the management of atopic eczema. Cochrane Database of Systematic Reviews. 2008. Issue 3. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003871/frame.html Accessed 20.04.11. National Collaborating Centre for Women's and Children's Health (2007) Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years (full NICE guideline). National Institute for Health and Clinical Excellence. www.nice.org.uk Accessed 20.04.11. Cellulitis Dilemmas when managing cellulitis. Drugs & Therapeutic Bulletin 2003;41:43-46. (Review of the management of cellulitis) Eron LJ, Lipsky BA, Low DE, Nathwani D, TiceAD, Volturo GA. Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother 2003;52 (Suppl S1):i3-17. Leg ulcer 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 Accessed 20.04.11. Jeffcoate WJ, Harding KG. Review: Diabetic foot ulcers. Lancet 2003;361:1545-51. Animal/human bites Anderson CR. Animal bites. Guidelines to current management. Postgraduate Medicine 1992;92:134-49. Goldstein EJC. Bites. In: Mandell GL, Bennett JE, Dolin R Eds. Principles and Practice of Infectious Diseases. Churchill Livingstone. 2000;2:3202-05.

MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE IN IRELAND APRIL 2011

Medeiros I, Saconat H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). In: The Cochrane Library, 2006 Issue 4. Chichester. John Wiley & Sons Ltd. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001738/pdf_fs.html Accessed 20.04.11 CKS. Bites human and animal. Clinical Knowledge Summaries. 2007. http://www.cks.nhs.uk/bites_human_and_animal Accessed 20.04.11. Clinical Knowledge Summaries: bites. Conjunctivitis Sheikh A and Hurwitz B. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane Database of Systematic Reviews 2006. Issue 2. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001211/frame.html Accessed 20.04.11 Rose PW, Harnden A, Brueggemann A, Perera R, Skeikh A, Crook D, Mant D. Chloramphenicol treatment for acute infective conjunctivitis in children in primary care: a randomised double-blind placebo-controlled trial. Lancet 2005;366:37-43.

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Reitveld RP, ter Riet G, Bindels PJ, Bink D, Sloos JH, van Weert HC. The treatment of acute infectious conjunctivitis with fusidic acid: a randomised controlled trial. Br J Gen Pract 2005;55:924-930. Scabies Strong M, Johnstone P. Interventions for treating scabies. Cochrane Database of Systematic Reviews. 2007. Issue 3 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000320/frame.html Accessed 20.04.11. Dermatophytes Crawford F and Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database of Systematic Reviews 2007. Issue 3. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001434/frame.html Accessed 20.04.11. Bell-Syer SEM, Hart R, Crawford F, Torgerson DJ, Tyrrell W, Russel I. Oral treatments for fungal infection of the foot. Cochrane Database of Systematic Reviews. 2002. Issue 2 www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003584/frame.html Accessed 20.04.11. Evans EGV & Sigurgeirsson B for the LION Study Group. Double blind randomised study of continuous terbinafine compared with intermittent itraconazole in treatment of toenail onychomycosis. Brit Med J 1999;318:1031-5. Chung CH, Young-Xu Y, Kurth T, Orav JE, Chan AK. The safety of oral antifungal treatments for superficial dermatophytosis and onychomycosis: a meta-analysis. Am J Med 2007;120:791-798. Chickenpox/shingles Klassen TP and Hartling L. Aciclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database of Systematic Reviews. 2005. Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002980/frame.html Accessed 20.04.11. Hope-Simpson RE. Postherpetic neuralgia. Brit J Gen Pract 1975;25:571-75. Study showing that incidence of post-herpetic neuralgia in a general practice population increases with age and is much more common in over 60 year olds.

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Johnson RW.Herpes zoster predicting and minimizing the impact of post-herpatic neuralgia. J Antimicrob Chemother 2001;47:Topic T11-8. Swingler G. Chicken Pox. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:267-79. Wareham D. Postherpetic neuralgia. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:306-8. Wood MJ, Kay R, Dworkin RH, Soong S-J, Whitley RJ. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: A meta-analysis of placebo-controlled trials. Clin Inf Dis 1996;22:341-7. Meta-analysis showing that oral acyclovir reduced post herpetic neuralgia pain. In patients over 50 years pain resolution occurred on average twice as fast.

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Prescribing for children
Weight and height The table below shows the mean values for weight and height by age; these values may be used to calculate doses in the absence of actual measurements. However, the childs actual weight and height might vary considerably from the values in the table and it is important to see the child to ensure that the value chosen is appropriate. In most cases the childs actual measurement should be obtained as soon as possible and the dose re-calculated. (Adapted from BNF for children 2006) Approximate conversions and units Age Weight Height kg 3.5 4.2 4.5 5.6 6.5 7.7 10 15 18 23 30 39 50 68 56 cm 50 55 57 59 62 67 76 94 108 120 132 148 163 173 163 lb 1 2 3 4 5 6 7 8 9 10 11 12 13 14 kg 0.45 0.91 1.36 1.81 2.27 2.72 3.18 3.63 4.08 4.54 4.99 5.44 5.90 6.35 stones 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 kg 6.35 12.70 19.05 25.40 31.75 38.10 44.45 50.80 57.15 63.50 69.85 76.20 82.55 88.90 95.25 ml 50 100 150 200 500 1000 fl oz 1.8 3.5 5.3 7.0 17.6 35.2

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Full-term neonate 1 month 2 months 3 months 4 months 6 months 1 year 3 years 5 years 7 years 10 years 12 years 14 years Adult male Adult female