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
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Management of Infection Guidance for Primary Care in Ireland
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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
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).
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).
6
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
Symptomatic relief
Use NSAID or paracetamol.A-
Consider a no- or delayed-
antibiotic strategy.A+
If antibiotics deemed
clinically indicated
first line
Amoxicillin
erythromycin
OR clarithromycin
if allergic to penicillin
second line
co-amoxiclav
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
< 1 yr max 68mg
1-6 yrs 156 mg
6-12 yrs 312 mg
TDS
5 days
ILLNESS COMMENTS
TREATMENT DOSE DURATION
OF TX
Acute Sinusitis
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 anti-
anaerobic 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
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).
NNoottee:: 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.
If clinical failure to first line antibiotics, previous amoxicillin exposure <3 month,
or severe symptoms (also consider hospital referral).
amoxicillin
OR doxycycline
OR clarithromycin
co-amoxiclav
500 mg TDS
200 mg stat/100 mg OD
250 – 500 mg BD
625 mg TDS
5 days
Community-
acquired
pneumonia
treatment in the
community
(Adults)
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 admissionC and seek risk
factors for Legionella and Staph.aureus infection.D
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).
8
ILLNESS
COMMENTS TREATMENT DOSE DURATION
OF TX
Influenza
Pneumonic and
non-pneumonic
post –influenza
LRTI managed
in the
community
Adults &
Children
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/A-
Z/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.
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 (BMI≥40)
1st line:
Oseltamivir
Adult-75mg bd
75mg od
2nd line:
Zanamivir
See BNF for
dosage
5 days (treatment)
10 days (chemo-
prophylaxis)
Consult following documents for clinical guidance:
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.
Adults:
doxycycline
OR co-amoxiclav
OR clarithromycin
Children:
co-amoxiclav
OR clarithromycin (if
penicillin allergic)
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
MMEENNIINNGGIITTIISS
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
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).
9
ILLNESS COMMENTS TREATMENT DOSE DURATION OF TX
UURRIINNAARRYY TTRRAACCTT IINNFFEECCTTIIOONNSS
NNoottee::. 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.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 EExxtteennddeedd--ssppeeccttrruumm BBeettaa--llaaccttaammaassee
eennzzyymmeess 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.
Information on local antibiotic resistance rates in urinary pathogens is particularly
important as patterns can vary substantially across the country.
trimethoprimB+
OR nitrofurantoinA-
200 mg BD
50-100 mg QDS
3 daysB+
7 days in men
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).
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.
amoxicillin
OR cephalexin
second line
nitrofurantoin
OR trimethoprim
250 mg TDS
500 mg BD
50 mg – 100 mg QDS
200 mg BD
7 days
Children 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.
Upper UTI
trimethoprim
OR nitrofurantoin
OR cefalexin
If susceptible,
amoxicillin, co-
amoxiclav
co-amoxiclav
3mth-12 years
4mg/kg BD (max 200mg)
750micrograms/kg QDS
12.5mg/kg BD
< 1 yr max 68mg
1-6 yrs 156 mg
6-12 yrs 312 mg TDS
Lower UTI
3 days
Upper UTI
7-10 days
Acute
pyelonephritis
Send MSU for culture. RCT shows 7 days ciprofloxacin was as good as 14 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).
10
Recurrent UTI
women ≥ 3/yr
Post-coital prophylaxis or standby antibiotic B+
Nightly: reduces UTIs but side effects (antibiotics).
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).
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 regimensA+
PPI OR
ranitidine bismuth citrate
PLUS 2 antibiotics:
amoxicillin
clarithromycinA+
metronidazole
250 mg BD with MZ
500mg BD with AM
400 mg BD
1g BD
BD
400 mg BD
1 g BD
500 mg BD
400 mg BD
All for 7 daysA
14 days in relapse
or maltoma
Infectious diarrhoea Antibiotic therapy not indicated unless patient systemically unwell or post-antibiotic, suggesting Clostridium difficile.
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
Traveller‟s 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.
Threadworms
Treat household contacts. Advise morning shower/baths and hand hygiene.
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).
12
ILLNESS COMMENTS TREATMENT DOSE DURATION
OF TX
GGEENNIITTAALL TTRRAACCTT IINNFFEECCTTIIOONNSS
NNoottee:: STI clinics may also known as STD,GUM & GUIDE clinics
Vaginal
candidiasis
All topical and oral azoles give 80-95% cure.A-
In pregnancy avoid oral azole..B
clotrimazole 10%
OR clotrimazole
OR fluconazole
5 g vaginal cream
500 mg pessary
150 mg orally
stat
Bacterial
vaginosis
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.
metronidazoleA+
OR metronidazole
0.75% vag gelA+
OR clindamycin 2% creamA+
400 mg BD
5 g applicatorful at
night
5 g applicatorful at
night
7 days
5 days
7 days
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 A-
OR amoxicillinA+
1 g stat
100 mg BD
500 mg BD
or 500 mg QDS
500 mg TDS
1 hr before or
2 hrs after food
7 days
14 days
7 days
7 days
Trichomoniasis Refer to STI clinic. Treat partners simultaneously.
In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure).
metronidazoleA-
clotrimazole
400 mg BD
or 2 g in single dose
100 mg pessary
5 days
6 days
Pelvic
Inflammatory
Disease
(PID)
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
400 mg BD
400 mg BD
400 mg BD
100 mg BD
14 days
Acute
prostatitis
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).
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)
100mg OD
408mg OD
500mg BD
300mg BD
Review in 3 months, but may take 4-
6 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.
first line -
flucloxacillin
or clarithromycin
fusidic acid
mupirocin (MRSA
only)
Oral 500 mg QDS
Oral 500 mg BD
Topically TDS
Topically TDS
7 days
5 days
Eczema
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.
Cellulitis 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
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).
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).
15
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.A-
Shingles: Always treat if active ophthalmic, and Ramsey Hunt or eczema.
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+
.
aciclovir
Second line if a
compliance problem
valaciclovir
or
famciclovir
800 mg 5x/day
1 g TDS
750 mg OD
7 days
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.
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.
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Otitis media
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Rhinosinusitis
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Polyps 2007 – a summary. Primary Care Respiratory Journal2008;17(2):79-89.
Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, Liira H, Williams Jr JW, Mäkelä M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:
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
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.
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
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.
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.
Loeb M. Community-acquired pneumonia. In: Clinical Evidence. London BMJ Publishing Group. 2008;07:1503-1516.
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 Women’s and Children’s 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)
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.
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: 1-
110.
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.
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)
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: 1-
110.
Children
Hodson EM, Willis NS, Craig JC. Antibiotics for acute pyelonephritis. Cochrane Database of Systematic Reviews 2007.
National collaborating centre for women‟s and children‟s 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: 1-
Albert X, Huertas I, Pereiró I, Sanfélix 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.
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: 1-
110.
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.
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
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 meta-
analysis 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;55:495-
501. Of 83% of patients who don’t respond to 5 days metronidazole, 30% do respond by 14 days.
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
traveller’s diarrhoea.
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.
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).
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.
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.
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/clinical-
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
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.
Denton M, O‟Connell 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.
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
O‟Meara S, Al-Khurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews. 2010. Issue 1.
Medeiros I, Saconat H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). In: The Cochrane Library, 2006 Issue 4. Chichester. John Wiley & Sons Ltd.
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.
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
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.
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
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.
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
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.