1. Bedfordshire Antimicrobial Prescribing Guidelines 2008

2. Managing Common Infections in Primary Care
Bedfordshire Antimicrobial Prescribing Guidelines 2008

3. QUIZ!

4. QUIZ (True/ False) 1. Clostridium Difficile
Is present in gut of one quarter of > 65 yr olds
Lies dormant without causing symptoms
Multiplies rapidly when normal gut flora disturbed, producing toxins causing illness
Is usually spread on the hands of health workers
can form spores which can survive for long periods in the environment
Can be eliminated from the hands by alcohol hand gel
Can be controlled partly by reducing use of broad spectrum antibiotics

5. QUIZ
2. Antibiotic sensitivities Rank the following antibiotics in terms of % sensitivity (high to low – Bedford lab)
E. Coli UTI: co-amoxiclav, trimethoprim, nitrofurantoin
Strep pneumoniae middle ear discharge: Erythromycin, Doxycycline, Penicillin V

6. QUIZ: 3. Sore Throat
List 5 indications for admitting a patient with a sore throat
TRUE OR FALSE:
Throat swabs should be routinely taken
Antibiotics prevent suppurative complications
Antibiotics should be given to patients on immunosuppressive chemotherapy
Antibiotics prevent the development of rheumatic fever and acute glomerulonephritis

7. QUIZ: 4. Sore Throat (cont)
The following patients should usually be prescribed antibiotics for sore throat by the GP:
Recurrent tonsillitis
With an increased risk of severe infection (e.g. diabetes or immunocompromised).
Who are at risk of immunosuppression (e.g. on disease-modifying anti-rheumatic drugs [DMARDs], carbimazole).
With a history of valvular heart disease.
With a history of rheumatic fever.
With peritonsillar abscess

8. 5. OTITIS MEDIA True/False
70% resolve within 3 days without antibiotics
Analgesics are the mainstay of treatment
For most patients frequency of side effects of antibiotics are similar to frequency of benefit
Antibiotics more likely to help the following groups:
above 6 months of age
systemically unwell
Purulent discharge

9. 6. OTITIS MEDIA True/False
If a delayed prescription is offered, instructions should be to use if not improved after 48 hours
Amoxicillin for 7 days is first line if antibiotics are used
Preferred second line treatment (if recurrent) includes cefalosporins
Trimethoprim is also a second line option

10. 7. Acute Sinusitis True/False
Reserve antibiotics for cases persisting more than 5 days in adults and 7 days in children
Plain sinus x ray is useful in establishing a diagnosis
Intranasal decongestants may have a short term benefit

11. 8. Treatment Duration How Long should antibiotics be used for:
Otitis Media
Uncomplicated pneumonia
Acute Sinusitis
Tonsillitis
Acute exacerbation of COPD
Uncomplicated lower UTI
Complicated UTI
Prostatitis
Epididymo-orchitis

12. 9. Treatment Choice Name 1st and 2nd choice antibiotics for:
Otitis Media
Uncomplicated pneumonia
Acute Sinusitis
Tonsillitis
Acute exacerbation of COPD
Uncomplicated lower UTI
Complicated UTI
Prostatitis
Epididymo-orchitis

13. 10. Pelvic Inflammatory Disease
TRUE/ FALSE
A chlamydial swab of the cervix and HVS should be taken prior to treatment
Should be treated before results of swabs if unwell, using broad spectrum combination
Specify broad spectrum regime – name of antibiotics, dose, durations

14. 11. Impetigo TRUE/ FALSE Topical therapy is preferred
Bactroban is preferred choice of topical therapies
Should be treated for 5 days if oral antibiotics are used
Is caused by staphylococcus aureus or streptococcus pyogenes

15. 12. Cellulitis TRUE/ FALSE
Often involves both Staphylococcus aureus and streptococcus pyogenes
Should be treated for 10 days
Name 3 possible treatment regimes (oral)

16. 13. Dermatophyte infections - tinea capitis
TRUE/ FALSE
Scalp scraping and hair root should be sent for fungal culture
Topical imidazole creams are ineffective
Should be referred to a dermatologist
Oral Griseofulvin is recommended

17. 14. Dermatophyte infections - tinea corporis/ cruris/ pedis
TRUE/ FALSE
Skin scrapings should be routinely sent for fungal culture
Topical imidazole creams are effective
Should all be referred to a dermatologist
Topical treatments should be continued for 1-2 weeks after clinical cure

18. 15. Dermatophyte infections: fungal nail infections
TRUE/ FALSE
Nail clippings should be routinely sent for fungal culture
Treat only positive nail clippings
Should not be treated if only symptoms are cosmetic appearance
For toe nail infections treatment is usually needed for 3 months

19. 16. Antivirals SHINGLES – TRUE/ FALSE Oral antiviral are indicated in:
Healthy 50 year old man presenting within 24 hrs of appearance of rash on trunk
24 year old with ophthalmic shingles rash for 48 hrs
80 year old presenting with chest wall shingles after 96 hours

20. ANSWERS

21. QUIZ (True/ False) 1. Clostridium Difficile
Is present in gut of one quarter of > 65 yr olds FALSE (1/3 of over 65 yr olds)
Lies dormant without causing symptoms TRUE
Multiplies rapidly when normal gut flora disturbed, producing toxins causing illness TRUE
Is usually spread on the hands of health workers TRUE
can form spores which can survive for long periods in the environment TRUE
Can be eliminated from the hands by alcohol hand gel FALSE
Can be controlled partly by reducing use of broad spectrum antibiotics TRUE

22. Consequences of high community prescribing
MRSA: Staphylococcus aureus (SA) is a bacterium found on the skin of around 30% of the general population at any time causing no apparent ill effect. This is known as colonisation. SA infections of the skin may cause pimples or boils. However, inside the body, it can cause serious infections such as pneumonia, organ failure and death.
MRSA (Methicillin-resistant SA) is a form of SA that is resistant to commonly used antibiotics. Individuals can be colonised with SA or MRSA and are carriers of the organisms, possibly passing them on to others through physical contact.
Clostridium difficile (C.Diff):C.diff (Clostridium difficile) is a bacterium found in the gut of around a third of people aged 65 and over. It lies dormant causing no ill effect until the normal flora of the gut is disturbed (e.g. through taking antibiotics), when it can multiply and produce toxins. It then causes severe explosive diarrhoea. Spread may then occur via the hands of healthcare workers, or from contaminated objects or contaminated food. C.diff can form spores which can survive for long periods in the environment and be dispersed through the air.

23. Return to disease areas

24. Strep pneumoniae middle ear discharge: Erythromycin & Penicillin V 96%
2. Rank the following antibiotics in terms of % sensitivity (high to low – Bedford lab)
E. Coli UTI:
nitrofurantoin 96%
co-amoxiclav 94%
Trimethoprim 73%
Strep pneumoniae middle ear discharge:
Erythromycin & Penicillin V 96%
Doxycycline 90%

25. QUIZ: 3. Sore Throat
5 indications for admitting a patient with a sore throat:
Stridor/ suspected epiglottitis/ upper airways obstruction
Suppurative complications – quinsy/ peri-tonsillar abscess
Suspected Kawasaki disease
Suspected diphtheria
Suspected Stevens-Johnson syndrome
Suspected Yersinial pharyngitis
Profoundly unwell/ severely dehydrated
Throat swabs should be routinely taken FALSE
Antibiotics prevent suppurative complications FALSE
Antibiotics should be given to patients on immunosuppressive chemotherapy TRUE
Antibiotics prevent the development of rheumatic fever and acute glomerulonephritis FALSE

26. QUIZ: 4. Sore Throat (cont)
The following patients should usually be prescribed antibiotics for sore throat by the GP:
Recurrent tonsillitis FALSE
With an increased risk of severe infection (e.g. diabetes or immunocompromised). TRUE
Who are at risk of immunosuppression (e.g. on disease-modifying anti-rheumatic drugs [DMARDs], carbimazole). TRUE
With a history of valvular heart disease. TRUE
With a history of rheumatic fever. TRUE
With peritonsillar abscess FALSE (ADMIT)

27. 5. OTITIS MEDIA True/False
70% resolve within 3 days without antibiotics FALSE – (80%)
Analgesics are the mainstay of treatment TRUE
For most patients frequency of side effects of antibiotics are similar to frequency of benefit TRUE
Antibiotics more likely to help the following groups:
above 6 months of age FALSE
systemically unwell TRUE
Purulent discharge TRUE

28. 6. OTITIS MEDIA True/False
If a delayed prescription is offered, instructions should be to use if not improved after 48 hours FALSE (72 hours)
Amoxicillin for 7 days is first line if antibiotics are used FALSE (5 DAYS)
Preferred second line treatment (if recurrent) includes cefalosporins FALSE
Trimethoprim is also a second line option FALSE – CO-AMOXICLAV/ ERYTHROMYCIN/ CLARITHROMYCIN

29. Patient Decision Aids

30. Patient Decision Aids

31. 7. Acute Sinusitis True/False
Reserve antibiotics for cases persisting more than 5 days in adults and 7 days in children FALSE (7 days adults 10 days children)
Plain sinus x ray is useful in establishing a diagnosis FALSE
Intranasal decongestants may have a short term benefit TRUE

32. 8. Treatment Duration How Long should antibiotics be used for:
Otitis Media ZERO OR 5 DAYS
Uncomplicated pneumonia 7 DAYS
Acute Sinusitis ZERO OR 5 DAYS
Tonsillitis ZERO OR 10 DAYS
Acute exacerbation of COPD 5 DAYS
Uncomplicated lower UTI ZERO OR 3 DAYS
Complicated UTI 7 DAYS
Prostatitis 28 DAYS
Epididymo-orchitis 14 DAYS

33. 9. Treatment Choice 1st and 2nd choice
Otitis Media Amoxicillin, Erythromycin (Clarithromycin) (or None)
Uncomplicated pneumonia Amoxicillin, Erythromycin (Clarithromycin)
Acute Sinusitis Amoxicillin, Amoxicillin, Erythromycin (Clarithromycin) (or None)
Tonsillitis Penicillin V, Amoxicillin, Amoxicillin, Erythromycin (Clarithromycin) or None
Acute exacerbation of COPD co-amoxiclav, doxycycline
Uncomplicated lower UTI trimethoprim, nitrofurantoin MR
Complicated UTI nitrofurantoin MR, co-amoxiclav
Prostatitis Ofloxacin, doxycycline
Epididymo-orchitis doxycycline + cefixine, ofloxacin

34. 10. Pelvic Inflammatory Disease TRUE/ FALSE
A chlamydial swab of the cervix and HVS should be taken prior to treatment FALSE (also take cervical bacterial swab)
Should be treated before results of swabs if unwell, using broad spectrum combination TRUE
Specify broad spectrum regime – name of antibiotics, dose, durations:
Cefixime 400mg one dose + doxycycline 100mg bd 14 days + metronidazole 400mg bd 14 days

35. 11. Impetigo TRUE/ FALSE Topical therapy is preferred FALSE
Bactroban is preferred choice of topical therapies FALSE (fusidate 5 days small lesions only)
Should be treated for 5 days if oral antibiotics are used FALSE 7 days
Is caused by staphylococcus aureus or streptococcus pyogenes FALSE only staph

36. 12. Cellulitis TRUE/ FALSE
Often involves both Staphylococcus aureus and streptococcus pyogenes TRUE
Should be treated for 10 days TRUE
Name 3 possible treatment regimes (oral):
Amoxicillin 500mg tds + Flucloxacillin 500mg qds 10 days
Co-fluampicil 1-2 caps qds 10 days
Erythromycin 500mg qds 10 days (or Clarithromycin 500mg bd)

37. 13. Dermatophyte infections - tinea capitis
TRUE/ FALSE
Scalp scraping and hair root should be sent for fungal culture TRUE
Topical imidazole creams are ineffective TRUE
Should be referred to a dermatologist TRUE
Oral Griseofulvin is recommended TRUE

38. 14. Dermatophyte infections - tinea corporis/ cruris/ pedis
TRUE/ FALSE
Skin scrapings should be routinely sent for fungal culture TRUE
Topical imidazole creams are effective TRUE
Should all be referred to a dermatologist FALSE
Topical treatments should be continued for 1-2 weeks after clinical cure TRUE

39. 15. Dermatophyte infections: fungal nail infections
TRUE/ FALSE
Nail clippings should be routinely sent for fungal culture TRUE
Treat only positive nail clippings TRUE
Should not be treated if only symptoms are cosmetic appearance TRUE
For toe nail infections treatment is usually needed for 3 months TRUE

40. 16. Antivirals SHINGLES – TRUE/ FALSE Oral antiviral are indicated in:
Healthy 50 year old man presenting within 24 hrs of appearance of rash on trunk FALSE
24 year old with ophthalmic shingles rash for 48 hrs TRUE
80 year old presenting with chest wall shingles after 96 hours FALSE

41. ANSWERS

42. Antibiotic Prescribing Figures

44. Resources myweb.tiscali.co.uk/bedpgme/AMG08.htm
Clinical Knowledge Summaries cks.library.nhs.uk
Local Antibiotic Guidelines & Other Resources myweb.tiscali.co.uk/bedpgme/Nurse%20Events/Antiobioticresources.htm
NICE Respiratory Tract Infections

45. Care pathway for respiratory tract infections (RTIs)
At the first face-to-face contact in primary care, including walk-in centres and emergency departments, offer a clinical assessment, including:
history (presenting symptoms, use of over-the-counter or self medication, previous medical history, relevant
risk factors, relevant comorbidities)
examination as needed to establish diagnosis.

46. Care pathway for respiratory tract infections (RTIs)
Address patients’ or parents’/carers’ concerns and expectations when agreeing the use of the three antibiotic strategies:
no prescribing
delayed prescribing
immediate prescribing

47. No Antibiotics
Agree a no antibiotic or delayed antibiotic prescribing strategy for patients with acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitis
No antibiotic prescribing Offer patients:
reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
a clinical review if the RTI worsens or becomes prolonged.

48. Delayed Antibiotics Delayed antibiotic prescribing Offer patients:
reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rash
advice about using the delayed prescription if symptoms do not settle or get significantly worse
advice about re-consulting if symptoms get significantly worse despite using the delayed prescription.
The delayed prescription with instructions can either be given to the patient or collected at a later date

49. Immediate prescribing
Consider an immediate prescribing strategy for:
children younger than 2 years with bilateral acute otitis media
children with otorrhoea who have acute otitis media
patients with acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria are present:
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
an absence of cough

50. Offer all patients
advice about the usual natural history of the illness and average total illness length:
– acute otitis media: 4 days
– acute sore throat/acute pharyngitis/acute
- tonsillitis: 1 week
common cold: 11/2 weeks
acute rhinosinusitis: 21/2 weeks
acute cough/acute bronchitis: 3 weeks
advice about managing symptoms including fever (particularly analgesics and antipyretics). For information about fever in children younger than 5 years, refer to ‘Feverish illness in children’

51. Time trends

52. Practice Variation (3 fold)

53. Cephalosporins

54. Quinolones

55. Variation in prescribing
There is a large variation in prescribing between practices
Why?
What differs?