Antibiotic Respir

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Treatment Tables
Aims
to provide a simple, best guess approach to the treatment of common infections to promote the safe, effective and economic use of antibiotics to minimise the emergence of bacterial resistance in the community to avoid destroying bowel flora (a vital defence mechanism)

Principles of Treatment
1. 2. 3. 4. 5. 6. This guidance is based on the best available evidence but its application must be modified by professional judgement Prescribe an antibiotic only when there is likely to be a clear clinical benefit. The benefit must be documented in the patient’s notes Do not prescribe an antibiotic for viral sore throat, simple coughs and colds Limit prescribing over the telephone to exceptional cases Use simple generic antibiotics first whenever possible for as short a time as possible The use of new and broad spectrum antibiotics (e.g. quinolones and cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective 7. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations such as Fucidin™) 8. In pregnancy AVOID tetracyclines, quinolones, and high dose metronidazole. Short-term use of trimethoprim (theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus 9. Clarithromycin is an acceptable alternative in those who are unable to tolerate erythromycin because of side effects 10. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from North East Essex 01206 747474 or Mid-Essex Switchboard on 0844 822 0002 and ask for the duty Microbiologist or Dr. Teare 07770736427

ILLNESS

COMMENTS

DRUG

DOSE

DURATION OF Tx

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.AInfluenza Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals are not recommended. Treat ‘at risk’ patients, only when influenza is circulating in the community, within 48 hours of onset. At risk: 65 years or over, chronic respiratory disease (including COPD and asthma), significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic renal disease, poultry workers. Use oseltamivir 75 mg oral capsule 12hrly (patients over 13 years), (for OD prophylaxis see Influenza ) or zanamivir 10 mg (2 inhalations by diskhaler) 12hrly for 5 days.(see BNF for children’s doses)

Influenza

Pharyngitis / sore throat / tonsillitis Clinical Knowledge Summaries: Practical, reliable, evidence-based SIGN

The majority of sore throats are viral; most patients do not benefit from antibiotics. 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+ You need to treat 30 children or 145 adults to prevent one case of otitis media.A+ Seven days treatment gives less relapse than three days.B+ Recent evidence indicates that penicillin 500 mg 8hrly for 7 days is more effective than 3 days.B+ Twice daily higher dose can also be used.A- 6hrly may be more appropriate if severe.D Many are viral. Resolves in 80% without antibiotics.A+ Poor outcome unlikely if no vomiting or temp <38.5oC.A- Use NSAID or paracetamol.A- Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.A+ Need to treat 20 children >2y and seven 6-24m old to get pain relief in one at 2-7 days.A+B+ Haemophilus is an extracellular pathogen, thus macrolides, which concentrate intracellularly, have poor activity, erythromycin being ineffective. first line phenoxymethylpenicillin erythromycin if allergic to penicillin amoxicillin first line erythromycin if allergic to penicillin Azithromycin 2nd line if allergic to penicillins co-amoxiclav 2nd line 500 mg 12hrly-6hrly 500 mg 12hrly or 250 mg 6hrly (6hrly less side-effects) <2 yrs 125 mg 8hrly 2-10 yrs 250 mg 8hrly >10 yrs 500 mg 8hrly <2 yrs 125 mg 6hrly 2-8 yrs 250 mg 6hrly Other: 250-500 mg 6hrly 15-25kg 200 mg OD 26-35kg 300 mg OD 36-45kg 400 mg OD 1-6 yrs 156 mg 8hrly 6-12 yrs 312 mg 8hrly 7-10 days 5-10 days

Otitis media (child doses) Clinical Knowledge Summaries: Practical, reliable, evidence-based

3-7 days* 3-7 days* 3-7 days* 3-7 days* 3-7 days* 3-7 days* 3 days 3 days 3 days 3-7 days* 3-7 days*

Mid-Essex Antibiotic Guidelines June 2008 Revision date June 2010

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ILLNESS COMMENTS DRUG DOSE DURATION OF Tx

UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.ARhinosinusitis acute or chronic Clinical Knowledge Summaries: Practical, reliable, evidence-based Many are viral. Symptomatic benefit of antibiotics is small - 69% resolve without antibiotics; and 84% resolve with antibiotics.A+ Reserve for severeB+ or symptoms (>10 days). Cochrane review concludes that amoxicillin and phenoxymethylpenicillin have similar efficacy to the other recommended antibiotics. If failure to respond to first line antibiotics phenoxymethylpenicillin or amoxicillin or oxytetracycline or erythromycin or doxycycline co-amoxiclav or azithromycin 500 mg 6hrly 500 mg 8hrly 250 mg 6hrly 250 mg 6hrly/500mg 12hrly 200 mg stat/100 mg OD 625 mg 8hrly 500 mg OD 7-10 days 7-10 days 7-10 days 7-10 days 7-10 days 7-10 days 3 days

* Standing Medical Advisory Committee guidelines suggest 3 days. In otitis media, relapse rate is slightly higher at 10 days with a 3 day course but long-term outcomes are similar.A+.

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. Levofloxacin has some anti-Gram-positive activity but should not be needed as first line treatment.
Acute bronchitis Clinical Knowledge Summaries: Practical, reliable, evidence-based Acute exacerbation of COPD NICE Systematic reviews indicate antibiotics have marginal benefits in otherwise healthy adults.A+ Patient leaflets can reduce antibiotic use.B+ 30% viral, 30-50% bacterial, rest undetermined Antibiotics not indicated in absence of purulent/mucopurulent sputum.B+ Most valuable if increased dyspnoea and increased purulent sputum.B+ In penicillin allergy use erythromycin if tetracycline contraindicated If clinical failure to first line antibiotics Start antibiotics immediately.B- If no response in 48 hours consider admission or add azihromycin first line or a doxycyclineC to cover Mycoplasma infection (rare in over 65s) In severely ill give parenteral benzylpenicillin before admissionC and seek risk factors for Legionella and Staph. aureus infection.D amoxicillin or doxycycline 500 mg 8hrly 200 mg stat/100 mg OD 5 days 5 days

amoxicillin or doxycycline erythromycin (avoid if Haemophilus influenzae likely) co-amoxiclav Amoxicillin or azithromycin doxycycline

500 mg 8hrly 200 mg stat/100 mg OD 250 – 500 mg 6hrly

5-10 days 5-10 days 5-10 days

625 mg 8hrly 500 mg - 1g 8hrly 500mg OD 200 mg stat/100 mg OD

5-10 days Up to 10 days 3 days Up to 10 days

Community-acquired pneumonia treatment in the community BTS BTS pdf

Mid-Essex Antibiotic Guidelines June 2008 Revision date June 2010

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