Indication Comment Drug Dose Duration Acute Otitis media Many infections are caused by viruses. Optimise analgesia Avoid antibiotics as 60% are better in 24 hours without: they only reduce pain at 2 days (NNT15) and do not prevent deafness Consider 2 or 3-day-delayed or immediate antibiotics if: < 2yrs with bilateral AOM (NNT4) or bulging membrane and ≥ 4 marked symptoms All ages with otorrhoea (NNT3) Antibiotics to prevent Mastoiditis NNT >4000 First choice No antibiotics - “Wait and see” recommended for 72 hrs Alternative Choice Amoxicillin If allergic to Penicillin: Clarithromycin Alternative in children <12yrs Erythromycin suspension Neonate 7- 28 days: 30 mg/kg tds 1 month – 1 year: 125mg tds 1-5 years: 250mg tds >5 yrs: 500mg tds Adult &child >12 yrs: 500mg bd Children <12yrs: Dose dependent on age and body weight. See 1 mth - 1yr: qds 2-7 yrs qds 8-12 yrs 250 -500mg qds 5 days 5 days 5 days 5 days Indication Comment Drug Dose Duration Otitis externa – acute Remove or treat any precipitating or aggravating factors. Exclude an underlying chronic OM before treating Use analgesia and toilet first line Avoid ear drops containing an aminoglycoside if the tympanic membrane is perforated Cure similar at 7 days for topical acetic acid or antibiotic +/- steroid First choice Aural toilet Mild Acetic acid 2% Alternative choices 1 spray tds 7 days
Treat with 1% azole cream Widespread Infection/Topical Treatment Ineffective/Immunocompromised Patient Use oral fluconazole for 2 and then review response to treatment as follows: Infection completely resolved - stop treatment. Infection improved but not completely resolved, continue treatment for a further 2 Poor response or no improvement seek specialist advice. 1% cream - use lotion if treating paronychia If oral therapy indicated (see left) Fluconazole 1-2 daily 50mg od 1 week or in case of paronychia until swelling goes 2 then review (see left) Indication Comment Drug Dose Duration Pityriasis versicolor Scratching the surface of the lesion should demonstrate mild scaling If initial therapy fails, verify that the treatment regimen has been followed adequately. Consider a second topical therapy before considering systemic treatment. Topical or oral corticosteroids should not be used as they may exacerbate the condition and cause skin atrophy. If pityriasis versicolor is extensive or if topical treatment is ineffective: Confirm the diagnosis by taking skin samples for microscopy. Consider referral to dermatologist or specialist, particularly if 12 years of age Consider an oral antifungal treatment First Choice Ketoconazole 2% shampoo Second choice Selenium sulphide 2.5% shampoo (unlicensed indication) Small areas Clotrimazole 1% cream If oral therapy indicated (see left) Choice Itraconazole Second Choice Fluconazole once daily once daily 2-3 times daily od 50mg od 5 days 7 days 2-3wks 7 days 2-4wks
5. EYE INFECTIONS Indication Comment Drug Dose Duration Conjunctivitis Most bacterial conjunctivitis is self-limiting. infections may be associated with other upper respiratory tract symptoms Mild may not need treatment; treat if moderate or severe or not resolving in days. Consider taking appropriate swabs before initiating treatment, including separate swabs for Chlamydia if indicated (see below). Pseudomonal infection requires Gentamicin. Suggest referral as risk of severe progressive infection. Corneal ulcers Refer urgently to the eye Department – do not treat with topical antibiotics as this can interfere with subsequent microbiological investigation Neonatal Neisseria gonorrhoea causes conjunctivitis in the first few days of life and Chlamydia trachomatis at around 5-14 days. Urgently refer to Paediatrics; all infants in the first 28 days of life with conjunctivitis, for same day assessment and management of their conjunctivitis. NB. A simple sticky eye (when are no signs of conjunctival inflammation) does not usually require specialist assessment. Contact lens associated infections Acanthamoeba spp is a of corneal ulcer primarily in contact lens wearers For contact lens wearers with keratitis, the contact lens should be sent for culture in a sample of contact lens fluid. Urgently refer to eye specialist Chlamydia trachomatis C. trachomatis can acute follicular conjunctivitis in adults (usually associated with sexually transmitted genital infection) and neonates Use specific Chlamydia swabs i.e. urethral or vaginal, and ensure the conjunctiva is swabbed not the discharge from the eye. Refer patient to local eye and STD clinics immediately Herpes simplex virus Refer immediately to eye casualty First choice: Topical Chloramphenicol Alternative choices: Fusidic acid (Fucithalmic®) eye drops - only for organisms particularly S. aureus or Topical Gentamicin (if pseudomonas) drops: 1 drop for 2 days then 4 hourly (whilst awake) and ointment: at night If ointment used alone then 3-4 times daily Apply twice each day drops: 1 drop (if severe); qds when controlled For 48 hours after resolution For 48 hours after resolution
If penicillin allergic or ESBL risk contact microbiologist to discuss treatment options Acute prostatitis Acute prostatitis is caused by urinary tract pathogens Send MSU for culture and start antibiotics 4-weeks treatment is recommended to reduce the risk of chronic prostatitis Following recovery, investigation to exclude an underlying structural abnormality is advised Chronic prostatitis refer to Urology Quinolones are more effective, as they have greater penetration into the prostate, but there is a higher risk of adverse effects e.g. C.difficile. There is poorer evidence for trimethoprim but it can be used in patients allergic to or unable to take ciprofloxacin (e.g. seizures). First Choice Ciprofloxacin Alternative Choice Trimethoprim bd 200mg bd 28 days 28 days
12. DENTAL INFECTIONS Indication Comment Drug Dose Duration Dental infections This section of the guidance should only be used for the management of acute oral conditions pending referral to dentist. If possible advice should be sought from the patient’s dentist. Mucosal ulceration and inflammation (simple gingivitis) Temporary pain and swelling relief can be attained with saline mouthwash Use antiseptic mouthwash if more severe & pain limits oral hygiene. Can also be used to or prevent secondary infection. The primary for mucosal ulceration or inflammation (aphthous ulcers, oral lichen planus, herpes simplex infection, oral cancer) needs to be evaluated and treated. Simple saline mouthwash Chlorhexidine 0.12-0.2% (Do not use within 30 mins of toothpaste) ½ tsp salt dissolved in glass warm water Rinse mouth for one minute BD with 5 ml diluted with 5-10 ml water. Always spit out after use. Use until lesions resolve or less pain allows oral hygiene Dental abscess Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscess are not appropriate. Repeated antibiotics alone, without drainage are ineffective in preventing spread of infection. Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of complications. Refer urgently for admission severe odontogenic infections such as cellulitis plus signs of sepsis, difficulty in swallowing, impending airway obstruction, Ludwigs angina. Amoxicillin Or Phenoxymethylpenicillin True penicillin allergy Clarithromycin Severe Infection or Spreading infection (lymph node involvement or systemic signs i.e. fever or malaise) Add Metronidazole TDS to 1g QDS 500mg BD 400mg TDS 5 days 5 days 5 days 5 days