GUIDELINES FOR THE MANAGEMENT OF COMMUNITY ACQUIRED INFECTIONS

November 2008

Bolton Primary Care Trust

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Status (version 2.0)

Date: October 2008

Document Control Document Ref No. Title of document CGMM03 Guidelines for the Management of Community Acquired Infections Original authors: Dr Joseph & Dr Khan Andrew White Updated by: Helen Clarke Kay Gibson Samim Patel Susan Cook Head of Medicines Management Assistant Director of Nursing Clinical Effectiveness Pharmacist Antibiotic Pharmacist, Royal Bolton Hospital Medicines Management Final See full list of references on page 12 Clinical Standards Board November 2008 30th September 2010 Trust wide / Internet Trust wide / Internet? Yes

Authors name

Authors job title

Dept / Service Doc. Status Based on Signed off by Original Publication Date Last Reviewed Next review date Distribution

Has an Equality & Diversity Impact Assessment been completed? Consultation History
Version V 1.0 V 1.1 V 2.0 Date October 05 July 08 November 08

Consultation Approved Clinical Care Group Sent to PCT GPs, Pharmacists nurses and Royal Bolton Hospital Microbiologists and antibacterial pharmacist Approved Clinical Standards Board

NHS Bolton is the name used to refer to Bolton Primary Care Trust. The legal identity of the organisation remains unchanged.

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Contents

Aims Principles of Treatment Further Advice Quick reference guide to common community infections

4 4 4

Full Guidelines for the Management of Community Acquired Infections

Upper respiratory Tract Infections Lower respiratory Tract Infections Meningitis Oral Infections Urinary Tract Infections Genital Tract Infections Gastro-Intestinal Tract Infections Skin/Soft Tissue Infections Treatment Algorithm for Clostridium Difficile Infection (CDI)

5 5 6 6 7 7 8 9

11

References

12

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Guidelines for the Management of Community Acquired Infections

AIMS OF THIS GUIDELINE To minimise the emergence of bacterial resistance in the community To promote the safe, effective and economic use of antibiotics To provide a simple, evidence based approach to the treatment of common infections PRINCIPLES OF TREATMENT 1. This guidance is based on local sensitivity data as well as evidence-based guidance from PHLS/HPA, SMAC, NHS Knowledge, Map of Medicine and appropriate UK national guidance. However, its application should be modified by professional judgement. 2. Prescribe an antibiotic only when there is likely to be a clear clinical benefit. 3. Use simple generic antibiotics first whenever possible. 4. The use of new and more expensive antibiotics (e.g. quinolones and cephalosporins) is inappropriate when standard and less expensive antibiotics remain effective. 5. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations) resistance is a problem. 6. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, 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. 7. All antibiotics have the potential to cause C.Difficile infection, particularly in the over-65 age group. Reduction in overall prescribing of antibiotics, reduction in the duration of courses of treatment and reduction in the prescribing of cephalosporins and quinolones in particular, will all help to reduce the incidence of C.Difficile. REMEMBER STANDING MEDICAL ADVISORY COMMITTEE 4 THINGS YOU CAN DO NO prescribing of antibiotics for simple coughs and colds NO prescribing of antibiotics for viral sore throats Uncomplicated cystitis in otherwise fit women limit course to 3 days Only prescribe over telephone in exceptional cases

FURTHER ADVICE
Where a best guess therapy has failed or special circumstances exist, microbiological advice can be obtained from The Consultant Microbiologist Rizwan Khan and Azhar Iqbal, Royal Bolton Hospital on 01204 390416

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNFC for further information on paediatric doses.

Quick reference guide to common community infections

(R) Sinusitis The adult with sinusitis-like symptoms in primary care does not need immediate antibiotics. In proven acute sinusitis 3 days of antibiotic therapy are as effective as 10. (R) Bacterial Sore Throat Sore throats should not be treated with antibiotics, unless there is good evidence that they are caused by Streptococcus pyogenes. (G) Infective exacerbation of COPD The BTS guidelines suggest treatment when two of the following exist: Increased breathlessness Increased sputum volume Purulent sputum (A) Acute urinary tract Infection Red (R) - Antibiotic unlikely to benefit in most cases Amber (A)- Antibiotic may be benefit some cases Green (G) - Antibiotic likely to benefit (R) Acute otitis media

Antibiotics are probably unnecessary in AOM. Reassurance, time and adequate pain relief are required. If antibiotics are prescribed, then the course should be limited to 3 days. (R) Acute bronchitis in otherwise healthy adults Most infections are mild and antibiotics are of no proven benefit.

(A) Community acquired chest infection Treat empirically for seven days if there is no improvement obtain sputum sample for analysis. If symptoms worsen refer to hospital. Medicines Management

Limiting the prescription of antibiotics for uncomplicated cystitis in otherwise healthy women to 3 days reduces the selection pressure for resistance. Guidelines for the Management
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Guidelines for the Management of Community Acquired Infections

ILLNESS COMMENTS DRUG DOSE DURATION OF Tx UPPER RESPIRATORY TRACT INFECTIONS: Consider delayed antibiotic prescriptions.AInfluenza Pharyngitis / sore throat / tonsillitis Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults the use of antivirals is not recommended. See current guideline on use of antivirals during an influenza epidemic on PCT website. The majority of sore throats are viral; most patients do not benefit from antibiotics. Laryngitis is always viral antibiotics have no role 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.AAntibiotics only shorten duration of symptoms by 8 hours.A+ You need to treat 30 children or 145 adults to prevent one A+ B+ case of otitis media. Seven days treatment gives less relapse than three days. Evidence indicates that 500 mg BD-QDS 7-10 days First line phenoxymethylpenicillin 500 mg QDS for 7 Phenoxymethylpenicillin days is more effective than 3 days.B+ AIf allergic to penicillin Twice daily higher dose can also be used. Erythromycin 500 mg QDS 5-10 days QDS 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.AAUse NSAIDs or paracetamol. Antibiotics do not reduce pain in first 24 hours, subsequent attacks or deafness.A+ Need to treat 20 children >2y and seven 624m old to get pain relief in one at 2-7 days.A+B+ Treat children <2 yrs with fever and/or discharge or 3 previous episodes of AOM. First line Amoxicillin <2 yrs : 125 mg TDS 2-10 yrs : 250 mg TDS 1.1.1 >10 yrs : 500 mg TDS <2 yrs 125 mg QDS 2-8 yrs 250 mg QDS >9 yrs 250-500mg QDS < 1year 0.25mL/kg of 125/31mg TDS 1-6yrs 125/31mg TDS 6-12yrs 250/62mg TDS 12-18yrs 250/125 TDS Doses may be doubled in severe infections. Chronic Otitis Media Acute Otitis externa Send swab and treat bacteria according to the culture results Topical treatment is usually effective. Use short courses to avoid secondary fungal infection. Oral antibiotics are indicated if systemically unwell or spreading of infection First line Otosporin ear drops First line Flucloxacillin If allergic to penicillin Erythromycin 3 drops into the ear TDS-QDS 500 mg QDS 250 mg QDS or 500mg BD 7 days 3-7 days* 3-7 days* 3-7 days* 3-7 days* 3-7 days*

Acute Otitis media (child doses)

If allergic to penicillin Erythromycin

Second line Co-amoxiclav

5 days

5 days 5 days

Sinusitis acute or chronic

Many are viral. First line First line treatment should be Amoxicillin A+ 500 mg TDS 3-7 days* decongestants and/or analgesics If allergic to penicillin Symptomatic benefit of antibiotics is Erythromycin 500 mg QDS 3-7 days* small - 69% resolve without antibiotics; A+ and 84% resolve with antibiotics. Second line Reserve for severeB+ or persistent Doxycycline 200mg stat/100mg OD 7 days symptoms (>10 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

Acute bronchitis Systematic reviews indicate antibiotics have marginal benefits in otherwise healthy adults.A+ B+ Patient leaflets can reduce antibiotic use. First line Amoxicillin If allergic to penicillin Erythromycin 500 mg TDS 500 mg QDS Second line Doxycycline Acute exacerbation of COPD Antibiotics not indicated in absence of purulent/mucopurulent sputum.B+ Most valuable if increased dyspnoea and increased purulent sputum or increase in First line Amoxicillin If allergic to penicillin Erythromycin 200 mg stat/100 mg OD 500 mg TDS 500mg QDS 5 days 5 days 5 days 7 days 7 days

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sputum volume.B+ If clinical failure to first line antibiotics Communityacquired pneumonia treatment in the community

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Second line (community) Doxycycline In RBH Clarithromycin First line Amoxicillin If no clinical response after 2 days add in Clarithromycin If true allergy to penicillin: Clarithromycin oral During Influenza epidemic Add Flucloxacillin Second line Levofloxacin First line Amoxicillin

Date: October 2008

200 mg stat/100 mg OD 500mg BD 500 mg - 1g TDS 500mg BD 500mg BD 1g QDS 500mg OD 1-12 mths 125mg TDS 1-5yrs 250mg TDS 5-18 yrs 500mg TDS 1-24 mths125mg QDS 2 - 8yrs 250mg QDS - 18 yrs 250 - 500mg QDS Doses may be doubled in severe infections. 7 days 7 days 7 days 7 days 7 days 7 days 7 days 7 - 10 days

Use CRB-65 score (Refer to app A ) to aid assessment of severity Start antibiotics immediately.B- If no response after 48 hours consider admission or add C clarithromycin first line or a tetracycline to cover Mycoplasma infection. Mycoplasma is rare in over 65s. In severely ill give parenteral benzylpenicillin 1.2g before admissionC and seek risk factors for Legionella and D Staph. aureus infection.

Community acquired pneumoniatreatment of children in the community.

Use CKS risk assessment to aid assessment of severity. Start antibiotics immediately. If a child deteriorates on treatment or does not improve after 48hrs, review and refer for hospital assessment. For child <5yrs amoxicillin is first choice. For child >5yrs amoxicillin or erythromycin if known Mycoplasma outbreak. Refer to BNFC for more information

if allergic to penicillin Erythromycin

7 10 days

Note: Avoid tetracyclines in pregnancy or children. Low doses of penicillins are more likely to select out
resistance. Ciprofloxacin has 30-40 % resistance to pneumococci in Bolton. However, quinolones do have use in PROVEN pseudomonal infections.

MENINGITIS
Suspected meningococc al 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. IV or IM benzylpenicillin Adults and children 10 yr and over: 1200 mg Children 1 - 9 yr: 600 mg Children <1 yr: 300 mg Adults and children 12yr and over :1g Children under 12yr: 50mg/kg. Prevention of secondary case of meningitis STAT dose then transfer to hospital for further treatment

if allergic to penicillin IV or IM cefotaxime

Only prescribe following advice from the Gtr Manchester Health Protection Unit tel. 0161 786 6710

ORAL INFECTIONS
Gingivitis Severe acute Gingivitis For most cases Chlorhexidine mouthwash is sufficient. Oral systemic treatment may be required in severe cases. Chlorhexidine 0.2% mothwash First line Amoxicillin If allergic to penicillin Metronidazole 10ml BD 7 days

500mg TDS 400 mg TDS

5 days 5 days

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URINARY TRACT INFECTIONS Note: Amoxicillin resistance is over 40% for E. Coli in Bolton, 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 or pyelonephritis likely.
Uncomplicate d UTI in females and males ie no fever or flank pain Recurrent UTI 3/yr in sexually active women UTI in pregnancy Use urine dipstick to exclude UTI. Perform culture and susceptibility only in treatment failure First line trimethoprim Second line nitrofurantoin Post coital prophylaxis can be as effective as prophylaxis taken nightly. First line Nitrofurantoin or trimethoprim First line Cefalexin Second line Nitrofurantoin 200mg BD Females: 3 days Males: 7 days 3 days

50-100mg BD

50 mg 100 mg 500mg BD 50-100mg QDS

Stat post coital or od at night 7 days 7 days-refer to Urologist or Obs/Gynae

UTI in infant younger than 3 months Acute Pyelonephriti s/Upper UTI in infants and children over 3 months of age Cystitis or Lower UTI in infants and children 3 months or older

Suggest MSU for susceptibility testing. Short-term use of trimethoprim or nitrofurantoin in pregnancy is unlikely to B+ cause problems to the foetus. Post test should be done. Call Microbiologist if further guidance is required Immediately refer to a Paediatric Specialist Treat with parenteral antibiotics in line with Feverish illness in Children NICE Guideline CG47 Immediately refer to a Paediatric Specialist

Acute pyelonephritis in adults

Treat with oral antibiotics for 3 days The parents or carers should be advised to bring the infant or child for reassessment if the infant or child is still unwell after 24-48 hours. If an alternative diagnosis is not made, a urine sample should be sent for culture to identify the presence of bacteria and determine antibiotic sensitivity if urine culture has not already been carried out. A recent RCT showed 7 days ciprofloxacin Awas as good as 14 days co-trimoxazole. If no response within 24-48 hours admit.

First line Trimethoprim or Cefalexin

See BNFC for dosage

3 days

First line CiprofloxacinAor Co-amoxiclav If susceptible, Trimethoprim

500 mg BD 500/125 mg TDS 200 mg BD

7 days 14 days 14 days

A-

GENITAL TRACT INFECTIONS UK NATIONAL GUIDELINES

Vaginal candidiasis All topical and oral azoles give 80-95% Acure. In pregnancy avoid oral azole.B A 7 day course of oral metronidazole is A+ slightly more effective than 2 g stat. Avoid 2g stat dose in pregnancy. Topical treatment gives similar cure ratesA+ but is more expensive. Clotrimazole 10% or Clotrimazole or Fluconazole A+ Metronidazole or Metronidazole 0.75% vag gelA+ or Clindamycin 2% A+ cream 5 g vaginal cream 500 mg pessary 150 mg orally 400 mg BD 5 g applicatorful at night 5 g applicatorful at night stat stat stat 7 days 5 days 7 days

Bacterial vaginosis

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Chlamydia trachomatis Chlamydia quick reference guide Trichomoniasi s

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First line A+ azithromycin or DoxycyclineA+ In pregnancy AErythromycin MetronidazoleAClotrimazole 100 mg pessary Metronidazole + OfloxacinB or Metronidazole + B Doxycycline 400 mg BD 400 mg BD 400 mg BD 100 mg BD 500mg BD 1 g stat 100 mg BD 500 mg BD or 500 mg QDS

Date: October 2008

1 hr before or 2 hrs after food 7 days 14 days 7 days 5-7 days 6 days 14 days 14 days 14 days 14 days

Tetracyclines are contra-indicated in pregnancy. Erythromycin and ciprofloxacin are less efficacious than doxycycline. Treat partners Refer contacts to GUM clinic Treat partners simultaneously. In pregnancy avoid 2g single dose metronidazole. Topical clotrimazole gives symptomatic relief (not cure). 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 GUM clinic

400 mg BD or 2 g in single dose

Pelvic Inflammatory Disease (PID)

If pregnant substitute doxycycline /quinolone with erythromycin and refer

First line Ciprofloxacin Second line Trimethoprim Add in doxycycline if patient under 35 years old

Acute prostatitis

4 weeks treatment may prevent chronic infection. Quinolones are most effective.

28 days 500 mg BD 200mg BD 100mg BD 28 days 28 days

Note: Refer patients with STDs, including trichomoniasis, to Sexual health for contact tracing. GASTRO-INTESTINAL TRACT INFECTIONS
Gastroenteriti s Fluid replacement essential. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 daysB+ and can cause resistance.B+ Initiate treatment, on advice of microbiologist, if the patient is systemically unwell. Please notify suspected cases of food poisoning to, and seek advice on exclusion of patients from, Environmental Services on 01204 336562 Send stool samples in these cases. Limit prescription of antibacterial to be carried abroad and taken if illness develops (ciprofloxacin 500 mg single dose) to people travelling to remote areas and for people in whom an episode of infective diarrhoea could be dangerous. Antibiotic use is the major risk factordiscontinue causative antibiotic. In most cases the symptoms will subside and the normal bowel flora will re-emerge For further details see the Guidelines for the Management of C.Difficile on the PCT website www.bolton.nhs.uk/yourpct/foi/foi_policies_InfectionControl.asp Treat household contacts. Advise morning shower/baths and hand hygiene. Use piperazine in children under 2. Metronidazole In serious cases oral metronidazole is usually effective in treating symptoms and must be continued for 10 days. First line Mebendazole (for over 2 years of age) or Piperazine sachet (for under 2 years of age) 400mg TDS See FLOW CHART attached on page 11 10 days

Travellers diarrhoea Clostridium Difficile diarrhoea

Threadworms

100mg

Stat, repeat after 2 weeks if reinfection occurs stat, repeat after 2 weeks if reinfection occurs 3 days repeat monthly for 3 months if reinfection risk.

From sachet 3-12 mths 2.5ml spoon 1-6 yrs 5ml spoon

Roundworms

Increasingly an issue as more patients travel abroad.

First line Mebendazole (for over 2 years of age) or Piperazine sachet (for under 2 years of age)

100mg BD dose as for threadworms above

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ILLNESS

COMMENTS

DRUG

DOSE

DURATION OF Tx
7 days

SKIN / SOFT TISSUE INFECTIONS

Impetigo First line treatment is oral therapy As resistance and sensitivity reactions are increasing, reserve topical antibiotics for very localised lesions. Reserve Mupirocin for MRSA. First line Flucloxacillin Adults (over 12 years) Oral 500 mg QDS Childrens Doses 1 month-2yrs 125mg/5ml, 2.5-5ml QDS 2 to 5yrs 125mg/5ml, 5ml QDS 5 to 12 yrs 250mg/5ml, 5ml QDS

Eczema Cellulitis

Adult (over 12 years) 500 mg, QDS Childrens Doses Age 1 month-2 years 125mg/5mls 5ml QDS Age 2 years-12years 250mg/5ml 5ml QDS Routinely adding topical antibiotic to steroid in eczema does not improve response. If allergic to penicillin Erythromycin In mild cellulitis flucloxacillin maybe used as single drug treatment. Always add amoxicillin if severe or rapid deterioration. If febrile and ill, admit for IV treatment First line Flucloxacillin add in Amoxicillin Second line Clindamycin(hosp prescribing only) 500 mg QDS 500 mg QDS

7 days

7 14 days 7 14 days

300mg QDS

7-14 days

If allergic to penicillin 500 mg QDS 7 14 days Erythromycin Bacteria will always be present. Antibiotics do not improve healing.A+ Culture swabs and antibiotics are only indicated if there is evidence of clinical cellulitis; increased pain; enlarging ulcer or pyrexia Leg ulcers Review antibiotics after culture results. Refer for specialist opinion if severe infection Refer to tissue viability if severe infection. First line Flucloxacillin First line Co-amoxiclav If allergic to penicillin Ciprofloxacin and Clindamycin (group A Strep and Staph.) First line animal & human prophylaxis and treatment BCo-amoxiclav If allergic to penicillin 500mg QDS 500mg/125 mg TDS 500mg BD 300mg QDS Adults (over 12 yrs): 375mg TDS Children 1-6 yrs Coamoxiclav125/31 TDS 6-12 yrs Coamoxiclav 250/62 TDS Adults (over 12 yrs) 200-400 mg TDS 100 mg BD Children Age 1 month-2 years Metronidazole 200mg/5ml 7.5mg/kg bodyweight (max 400mg) TDS Erythromycin 125mg/5ml 5ml QDS Age 2 years-12 years Metronidazole 200mg/5ml 7.5mg/kg bodyweight (max 400mg) TDS Erythromycin 250mg/5ml 5ml QDS 7 days 7 days 7 days 7-10 days and review

Diabetic Foot Infection

Animal bite

Human bite

Surgical wound cleanliness 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

Adults
Metronidazole PLUS Doxycycline

7 days

Children:
Metronidazole PLUS Erythromycin

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Conjunctivitis

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First line Chloramphenicol 0.5% drops + 1% ointment Second line Fusidic acid First line Permethrin A+ Second line Malathion First line Malathion PermethrinA+ Second line A+ Permethrin (pubic lice only) Early stage 1-2 nails Amorolfine 5% nail lacquer More severe infections TerbinafineAItraconazole

Date: October 2008

2 hrly reducing to QDS after 48hrs at night 1% gel BD 2 applications one week apart

Most bacterial infections are selflimiting (64% resolve on placeboA+). They are usually unilateral with yellow-white mucopurulent discharge. Fusidic acid has less Gram-negative activity N.B.Consider Chlamydia infection in resistant neonatal infections Treat whole body including scalp, face, ears and under nails. Treat household contacts. A metal comb should be used to remove lice and nits. This may take several days, despite successful treatment. Malathion alcoholic solutions should NOT be prescribed to those with eczema or asthma. Aqueous soln would be more appropriate. Take nail clippings: Start therapy only if infection is confirmed by laboratory. Care. Idiosyncratic liver reactions can occur rarely with terbinafine.

All for 48 hours after resolution

Scabies

5% cream 0.5% solution 1% lotion 0.5% soln

Head lice/ pubic lice

Dermatophyte infection of the proximal fingernail or toenail For children seek specialist advice Dermatophyte infection of the skin Herpes zoster/ Chicken pox & Varicella zoster/ shingles

1-2x/weekly 250 mg OD 200 mg BD

fingers toes fingers toes fingers toes

6 months 9-12 months 6 12 weeks 3 6 months 7 days monthly 2 courses 7 days monthly 3 courses 1 week
A+

Further advice in dermatology guidelines

Pulsed itraconazole monthly is recommended for infections with yeasts C and non-dermatophyte moulds. Take skin scrapings for culture. Treatment: 1 week terbinafine is as effective as 4 weeks azole. ADiscuss scalp infections with dermatologist Chicken pox: Clinical value of antivirals minimal unless immunocompromised, severe pain, on steroids, secondary household case AND treatment started <24h of onset of rash.AShingles: Treatment indicated if: ophthalmic or predictors of post-herpetic A+ A+ neuralgia: >60 y , severe pain, severe B+ skin rash, prolonged prodomal pain AND <72h of onset of rash. If pregnant seek advice.

First line A+ Terbinafine topical 1% Second line Clotrimazole1% A+ First line Aciclovir or Valaciclovir

OD - BD TDS 800 mg 5x/day 1 g TDS Child doses see BNFC

4 6 weeks 7 days 7 days

A+

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Treatment algorithm for clostridium difficile infection (CDI) CD Toxin positive diarrhoea
(1st episode)

Assess and isolate patient Rehydrate and correct electrolyte disturbances Review Antibiotics and PPIs/H2RAs. Discontinue if possible. Commence stool chart Stop any laxatives. Avoid anti-peristaltic agents (e.g. codeine, loperamide) as these will increase risk of developing severe CDI

Assess severity of disease

Mild to moderate disease 4 8 liquid stools per day Temp 37.5 38.5 C Abdominal pain (None severe) WCC 20 x 109/L CRP 150mg/L Albumin 25g/L

Severe disease Patient on ICU and/or 2 or more of the following: > 8 liquid stools per day Temp 38.6 C Signs/symptoms of peritonism (Generalised tenderness, distended abdomen, abnormal abdominal x-ray) Albumin < 25g/L WCC > 20 x 109/L CRP > 150mg/L

Metronidazole oral 400mg TDS for 10 days

Vancomycin oral 125mg QDS for 10 days

Failure to respond after 4 7 days or worsening of symptoms

Failure to respond after 4 7 days or worsening of symptoms

Vancomycin oral 250mg - 500mg QDS for 10 days

Failure to respond after 4 7 days or worsening of symptoms Contact Microbiologist for advice
References
Full references are available on the pct website at www.bolton.nhs.uk/your-career/clinical-and-professional/treatment-guidelines.asp

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References
The following references were used when developing these guidelines: This guidance was initially developed by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users, and information from systematic reviews as they have been published. It was further modified in August 2007 following review by the Department of Health MRSA/HCAI Improvement Team. It has been adopted by Bolton Primary care trust. Grading of guidance recommendations The strength of each recommendation is qualified by a letter in parenthesis. Study design Good recent systematic review of studies 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 Recommendation grade A+ AB+ BC D

General resources BNF (No 56, September 2008), at www.bnf.org BNFC 2008, at www.bnfc.org Clinical Knowledge Summaries (CKS) web at www.cks.library.nhs.uk/. HPA Primary Care Guidance at www.hpa.org.uk/webw/HPAweb&Page&HPAwebAutoListName/Page/1197637041219 Plymouth Management of Infection Guidelines project LRTI and URTI. SMAC report - The path of least resistance (1998),at www.advisorybodies.doh.gov.uk/smac1.htm SDHCT Medical Directorate guidelines + GU medicine guidelines,

Original Authors
Andrew White, Head of Medicines Management, Bolton PCT Dr Leela Joseph, Consultant Microbiologist, Royal Bolton Hospital

Updated by
Helen Clarke, Assistant Director of Nursing/DIPC Kay Gibson, Clinical Effectiveness Pharmacist, Bolton PCT Samim Patel, Antibiotic Pharmacist, Royal Bolton Hospital Susan Cook, Prescribing Support Pharmacist, Bolton PCT

Reviewers
William Newsholme, DoH HCAI Improvement Team Anthony Robinson, PCT Pharmacist Dr Bob Walker, GP Dr Colin Mercer, GP Steve Wilson, District Nursing Team Leader, Bolton PCT

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Document Ref No CGMM03 UPPER RESPIRATORY TRACT INFECTIONS Influenza

Status (version 2.0)

Date: October 2008

http://www.hpa.org.uk/infections/topics_az/influenza/flu.htm Oseltamir for influenza. Drug & Therapeutic Bulletin 2002;40:89-91. (Review of benefits of oseltamir in influenza) Turner D, Wailoo A, Nicholson K et al. Systematic review and economic decision modelling for the prevention and treatment of influenza A and B. University of Leicester 2002.

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. Del Mar C & Glasziou P. Antibiotics for the symptoms and complications of sore throat. In: The Cochrane Library, Issue 2. 1998 Oxford: Update Software. Search date 1998; primary sources Index Medicus 1945-65. Medline 1966 to 1997; Cochrane Library 1997 Issue 4; hand search of reference lists of relevant articles. 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. Del Mar C & Glasziou P. Upper respiratory tract infections. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:1701-11. 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. 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. CKS Guidance @ http://www.cks.library.nhs.uk/sore_throat_acute Swart 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. Scottish Intercollegiate Guidelines Network. Management of sore throat and indications for tonsillectomy. 1999. http://www.show.scot.nhs.uk/sign/index.html.

Otitis media
Dagan R, Klugman KP, Craig WA. Baquero F. Evidence to support the rationale that bacterial eradication in respiratory tract infection is an important aim of antimicrobial therapy. J Antimicrob Chemother 2001;47:129-140. (Discusses penetration of antibiotics in OM) Damoiseaux RAMJ, Van Balen FAM, Hoes AW, de Melker RA. Antibiotic treatment of acute otitis media in children under two years of age: evidence based? Brit J Gen Pract 1998;48:1861-4. Damoiseaux RAMJ, Van Balen FAM, Hoes AW, Verhiej TJM, de Melker RA. Primary care-based randomised, double blind trial of amoxycillin 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. Kozyrskj AL, Hildes Ristein E, Longstaffe SEA, Wincott JL, Sitar DS, Klassen TP et al. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA 1998;279:1736-42. 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. ONeill P & Roberts R. Acute otitis media. In: Clinical Evidence. London. BMJ Publishing Group 2003;9:274-86.

Rhinosinusitis de Ferranti SD, Lonnidis JPA, Lau J, Anniger WV, Barza M. Are amoxycillin 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
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Medline 1966 May 1998; manual search of Excerpta Medica: recent abstracts for Interscience Conference on Antimicrobial Agents &
Chemotherapy 1993-1997 and references of all trails review articles and special issues for additional studies. Del Mar C & Glasziou P. Upper respiratory tract infections. In: Clinical Evidence. London. MBJ Publishing Group 2003;9:1701-11. Diagnosis and treatment of acute bacterial rhinosinusitis. Summary, Evidence Report/Technology Assessment: Number 9 March 1999. Agency for Health Care Policy & Research, Rockville MD. http://www.ahcpr.gov/clinic/epcsums/sinussum.htm Hansen JG, Schmidt H, Grinsted P. Randomised, double blind, placebo controlled trial of Penicillin V in the treatment of acute maxillary sinusisit in adults in general practice. Scan J Prim Health Care 2000;18:44-47. International Rhinosinusitis Advisory Board. Infectious rhinosinusitis in adults. Classification, aetiology and management. Ear Nose & Throat Journal 1997;76 (12 Suppl):1-22. CKS Guidance @ http://www.cks.library.nhs.uk/sinusitis Williams JW Jr, Aquilar C, Makela M, Cornell J, Hollman DR. Chiquette E, Simel DL. Antibiotics for acute maxillary sinusitis. In: Cochrane Library 1999. Oxford.Update software, search date October 1998; primary sources Medline and Embase.

LOWER RESPIRATORY TRACT INFECTIONS Acute bronchitis

Becker L, Glazier R, McIsaac W, Smucny J. Antibiotics for acute bronchitis. In: The Cochrane Library, Issue 2, 1998. Oxford: Update software, search date 1997; primary sources Medline 1966 to 1996; Embase 1974. Fahey T, Stocks N, Thomas T. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. Brit Med J 1998;316:906-10. Glasziou P, Del Mar C. Upper respiratory tract infections. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:1701-11 Macfarlane J, Holmes W, Gard P, Thornhill D. Macfarlane R. Reducing antibiotic use for acute bronchitis in primary care: blinded, randomised controlled trail of patient information leaflet. BMJ 2002;324:91-4. Treatment of cough available at CKS website: http://www.cks.library.nhs.uk/chest_infections_adult

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.

Community-acquired pneumonia
BTS guidelines for the management of community-acquired pneumonia in adults. Thorax 2001;56(Suppl 4):IV1-64. Hopstaken RM, Muris JWM, Knottnerus JA, Kester ADM, Rinkens PELM, Dinant GJ. Contributions of symptoms, signs, enthrocyte sedimentation rate and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection. Brit J Gen Pract 2003;53:358-364. Loeb M. Community-acquried pneumonia. In: Clinical Evidence. London BMJ Publishing Group. 2003;9:1664-75.

CKS Clinical knowledge summaries. Community acquired pneumonia BTS: Guidelines for the management of CAP in childhood. Thorax 2002; 57(suppl 1) Kabra SK, Lodha R, Pandey RM. Antibiotics for community acquired pneumonia in children. Cochrane database of systematic reviews 2006 Issue 3. BNFC 2007 MENINGITIS
Cartwright KAV, Strang J Gossain S, Begg N. Early treatment of meningococcal disease. Brit Med J 1992;305:774. Correla J & Hart CA. Meningococcal disease. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:879-89. Pre-admission benzylpenicillin for suspected meningococcal disease: other antibiotics not needed in the GP bag. CDR Weekly 15 February 2001. PHLS Meningococcal Infections Working Group & Public Health Medicine Environment Group. Control of meningococcal disease: guidance for consultants in communicable disease control. CDR Review 1995;5:R189-95. Guidelines for the Management Page 14 of 18 Medicines Management of Community Acquired Infections

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URINARY TRACT INFECTIONS Elderly

Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteruria 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.

Uncomplicated UTI
Charlton CAC, Crowther A, Davies JG, Dynes J, Howard MWA, Mann PG, Rye S. Three day and ten day chemotherapy for urinary tract infections in general practice. Brit Med J 1976;1:124-6. 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. Ellis R & Moseley DJ. A comparison of amoxycillin, co-trimoxazole, nitrofurantoin, macrocrystals and trimethoprim in the treatment of lower urinary tract infections. Management of UTIs. Ed. LH Harrison. 1990. Royal Society of Medicine Services International Congress & Symposium Series No. 154, publishers RSM Services Ltd. pp 45-52. 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. Guay DR. An update on the role of nitrofurans in the management of urinary tract infections. Drugs 2000;61:353-64. 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.

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/surfamethoxazole for the treatment of acute urinary tract infection in women. Am J Med 1999;106:292-9. MeReC Bulletin. UTI. August 1995. 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
Information from the National Teratology Information Service (Tel: 0191 230 2036, Fax: 0191 232 7692) states: Trimethoprim is a folate antagonist. In some women low folate levels have been associated with an increased risk of malformations. However, in women with normal folate status, who are well nourished, therapeutic use of trimethoprim for a short period is unlikely to induce folate deficiency. A number of retrospective reviews and case reports indicate that there is no increased risk of foetal toxicity following exposure to nitrofurantoin during pregnancy. Serious adverse reactions eg peripheral neuropathy, severe hepatic damage and pulmonary fibrosis are extremely rare. Nitrofurantoin can cause haemolysis in patients with G6PD deficiency. Foetal erythrocytes have little reduced glutathione and there is a theoretical possibility that haemolysis may occur. However, haemolytic disease of the new-born has not been reported following in utero exposure to nitrofurantoin.

Children
Larcombe J. Urinary tract infections in Children. In: Clinical Evidence. London. BMJ Publishing Group 2003;9:446-60.

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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-sulpha methoxazole (14 days) for acute uncomplicated pyelonephritis in women. A randomized trial. JAMA 2000;283:1583-90. Evidence for 7 days ciprofloxacin. Warren JW, Abrutyn E. Hebel JR et al Guidelines for antimicrobial treatment of uncomplicated bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999;29:745-58.

GENITAL TRACT INFECTIONS

Joesoef M & Schmid G. Bacterial vaginosis. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:1712-20. Low N & Cowan F. Genital chlamydial infection. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:1721-28. Ross JDC. Outpatient antibiotics for pelvic inflammatory disease. BMJ 2001;322:251-2. Sabbaj J, Hoagland VL, Cook T. Norfloxacin versus co-trimoxazole in the treatment of recurring urinary tract infections in men. Scand J Infect Dis 1986;Suppl 48:48-53. BASHH ( British Association for Sexual Health and HIV) These guidelines are fully comprehensive and extensively referenced. http://www.bashh.org Walker CK, Workowski KA, Washington AE, Soper DE, Sweet RL. Anaerobes in pelvic inflammatory disease: implications for the Centers for Disease Control and preventions guidelines for treatment of sexually transmitted diseases. Clin Infect Dis 1999;28:529-36.

GASTRO-INTESTINAL TRACT INFECTIONS Gastroenteritis

de Bruyn G. Diarrhoea. In: Clinical Evidence. London. BMJ Publishing Group200;9:767-75. 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. Gastroenteritis guidance on CKS: http://www.cks.library.nhs.uk/gastroenteritis 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
What to do about Travellers diarrhoea. Drugs & Therapeutic Bulletin 2002;40:36-38.

SKIN/SOFT TISSUE INFECTIONS Impetigo

Smethurst D & Macfarlane S. Atopic eczema. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:1785-1803. George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Brit J Gen Pract 2003;53:480-87. (No difference between topical mupirocin and fusidic acid, no significant difference between topical and oral). Livermore D. James D, Duckworth G, Stephens P. Fusidic acid use and resistance. Lancet 2002;360:806. MeReC Bulletin. Acne. November 1994. Mupirocin and fusidic acid resistance increasing in Staphylococcus aureus. N Zealand Public Health Report 1999;6:53. Shanson DC. Clinical relevance of resistance to fusidic acid in Staphylococcus aureus. J Antimicrob Chemother 1990;25(Suppl B):15-21. Waite DG, Collins PO, Rowsell B. Topical antibiotics in the treatment of superficial skin infections in general practice a comparison of mupirocin with sodium fusidate. J Infect 1989;18:221-9. Wilkinson JD. Fusidic acid in dermatology. Brit J Dermatol 1998;139:37-40.

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Dilemmas when managing cellulitis. Drugs & Therapeutic Bulletin 2003;41:43-46. (Review of the management of cellulitis)

Diabetic leg ulcer

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. Jones DA & Standbridge TN. A clinical trial using co-trimoxazole in an attempt to reduce wound infection rates in dog bite wounds. Postgraduate Medical J 1985;61:593-4. Medeiros I, Saconat H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). In: The Cochrane Library, Issue 2, 2001 Oxford: Update Software. CKS guidance. www.cks.library.nhs.uk/bites_human_and_animal Snook R. Dog bites man. Brit Med J 1982:284-93. Wiggins ME, Akelman E, Weiss A-PC. The management of dog bites and dog bite infections to the hand. Orthopaedics 1994;17:617-23.

Conjunctivitis
Smith J. Bacterial conjunctivitis. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:712-17.

Scabies
The management of scabies. Drug & Therapeutics Bulletin 2002;40:43-46.

Dermatophytes
Crawford F. Athletes foot and fungally infected toenails. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:1776-84. 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. Finlay AY. Skin and nail fungi almost beaten. Dont get confused by the evidence. Brit Med J 1999;319:71-2. Fuller LC, Child FJ, Midgley G, Higgins EM. Diagnosis and management of scalp ringworm. BMJ 2004;326:539-41. Getting rid of athletes foot. Drug & Therapeutics Bulletin 2002;40:53-54. Hart R, Bell-Syer SEM, Crawford F, Torgerson DJ, Young P, Russell I. Systematic review of topical treatments for fungal infections of the skin and nails of the feet. Brit Med J 1999;319:79-82. MeReC Bulletin. Fungal nail infections. 1997;8:45-8. Roberts DT. Systemic antifungals as a cause of liver damage. Prescribers Journal 1998;38:190-4.

Chickenpox/shingles
Balfour HH Jr, Rotbart HA, Feldman S, Dunkle LM. Feder HM Jr, Proker CG et al. Acyclovir treatment of varicella in otherwise healthy adolescents. J Paediatr 1992;120:627-33. Dunkle LM, Arvin AM, Whitley RJ, Rotbart HA, Feder HM, Feldman S et al. A controlled trial of acyclovir for chickenpox in normal children. N Engl J Med 1991;325:1539-44. 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. Johnson RW.Herpes zoster predicting and minimizing the impact of post-herpatic neuralgia. J Antimicrob Chemother 2001;47:Topic T11-8. McKendrick MW & Balfour HH Jr. Acyclovir for childhood chickenpox. Controversies in management. Brit Med J 1995;310:108-110. CKS Shingles & postherpetic neuralgia. April 2002. At www.cks.library.nhs.uk/shingles_postherpetic_pain Guidelines for the Management of Community Acquired Infections

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Ross AH. Modification of chickenpox in family contacts by administering gamma globulin. N Engl J Med 1962;267:369-76. Swingler G. Chicken Pox. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:755-62. Lancaster T, Wareham D, Yaphe J. Post herpetic neuralgia. In: Clinical Evidence. London. BMJ Publishing Group. 2003;9:890-900.

Appendix A-from British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Adults-2004 update. The CURB-65 score is a Severity Assessment Model which allows patients to be stratified into different mortality groups suitable for different management pathways. It is a 6-point score, one for each of Confusion, Urea > 7 mmol/l, Respiratory rate >= 30/min, low systolic (<90mmHg) or diastolic (<= 60mmHg) Blood pressure, Age >65 years. The CRB-65 score is a 5 point score excluding the urea, which may not be available at the time of assessment. Identifying those patients seen out of hospital, who can usually be safely treated at home or who require hospital referral Recommendations: Patients who have a CRB-65 score of 0 are at low risk of death and do not normally require hospitalisation for clinical reasons. Patients who have a CRB-65 score of 1 or2 are at increased risk of death and hospital referral and assessment should be considered, particularly with score 2. Patients who have a CRB-65 score of 3 or more are at high risk of death and require urgent hospital admission. Identifying those with severe Community Acquired Pneumonia (CAP) from those with non-severe CAP after initial hospital assessment Recommendations Patients who have a CURB-65 score of 3 or more are at high risk of death and should be managed as having severe pneumonia according to the recommendations outlined in sections 7.3-7.4 and 8.11 of the BTS 2001 Guidelines for CAP. Patients who have a CURBb score of 2 are at increased risk of death. They should be considered for short stay inpatient treatment or hospital supervised outpatient treatment. This decision is a matter of clinical judgement. Patients who have a CURB-65 score of 0 or 1 are at low risk of death. They can be treated as having non-severe pneumonia and may be suitable for home treatment.

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