Northern Ireland Management of

Infection Guidelines for Primary

and Community Care 2016
For Review 2018

For the most up-to

NI Management dateGuidelines
of Infection version for
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2 NI Management of Infection Guidelines for Primary and Community Care 2016

Contents

Aims, Important Notes and Useful Information........................... 5

Upper Respiratory Tract Infections.............................................. 8

Symptoms of Respiratory Tract Infections................................ 12

Lower Respiratory Tract Infections............................................ 13

Influenza........................................................................................ 16

Genito Urinary Tract Infections................................................... 23

Gastro-Intestinal Infections......................................................... 31

Skin & Soft Tissue Infections...................................................... 33

Viral Skin Infections..................................................................... 40

Eye Infections............................................................................... 41

Dental Infections in General Practice......................................... 42

Meningitis..................................................................................... 44

NI Management of Infection Guidelines for Primary and Community Care 2016 3

Aims, Important Notes and Useful
Information

Aims
• To provide a consistent Northern Ireland wide approach to empirical
management of common bacterial infections in primary care.

• To promote the safe, effective and economic use of antibiotics.

• To minimise the emergence of bacterial resistance in the community.

Important Prescribing Notes

1. These guidelines are based on national guidance, clinical evidence and
local expert opinion and are designed to support individual practitioners in
making appropriate prescribing decisions.

2. These guidelines are for empirical treatment of infection; a patient’s

treatment may be subject to change or else discontinued upon the
availability of microbiology test results.

3. As these guidelines are empiric they do not override local prescribing

decisions to address local circumstances e.g. where microbiologists are
aware of an emerging pattern of resistance, they can issue guidance
to local prescribers on the current most appropriate antibiotic for that
infection.

4. Do not accept telephone requests for antibiotics without speaking to the

patient and discourage these requests.

5. Limit telephone consultations for antibiotics to exceptional cases.

6. Prescribe an antibiotic ONLY when there is likely to be a clear clinical

benefit.

7. Do not prescribe antibiotics for viral sore throat or simple coughs and colds.

8. Consider alternative measures such as cough bottles, analgesics,

decongestants or delayed prescriptions.

4 NI Management of Infection Guidelines for Primary and Community Care 2016

 Remember that over-the-counter (OTC) cough and cold medicines should
not be used in children under 6 years of age.

9. Avoid the use of co-amoxiclav, quinolones and cephalosporins to reduce

the risk of MRSA & Clostridium difficile.

10. Prescribe antibiotics generically.

11. Avoid widespread use of topical antibiotics. Mupirocin must be reserved

for treatment of MRSA.

12. Where empirical therapy has failed or special circumstances exist,

advice can be obtained from your local microbiologist / infectious disease
specialist.

13. Some antibiotics must be avoided in pregnancy and breast-feeding.

When treating pregnant and breast-feeding mothers, please check the
suitability of the antibiotics recommended (consult BNF), and choose an
alternative where appropriate.

14. Where the weight of a child is available this should over-ride the age in
calculating doses.

• All doses are oral unless stated.

• All dosing regimens assume normal renal and hepatic function.

• For the purposes of these guidelines, adult doses may be used for
children over 12 years of age.

• The majority of liquid antibiotic bottles provide enough for 5 days

treatment.

NI Management of Infection Guidelines for Primary and Community Care 2016 5

Penicillins & Hypersensitivity
The most important side-effect of the penicillins is hypersensitivity which
causes rashes and anaphylaxis and can be fatal. Allergic reactions to
penicillins occur in 1–10% of exposed individuals; anaphylactic reactions
occur in less than 0.05% of treated patients.

The reasons why a patient believes they have a penicillin allergy, the history
of the perceived allergy and the nature of the allergy should be investigated.
It is important to distinguish between non-allergic adverse effects and true
allergic reactions.

Patients with a history of atopic allergy (e.g. asthma, eczema, hay fever) are
at a higher risk of anaphylactic reactions to penicillins. Patients who have
experienced a type I allergic reaction with penicillins (e.g. urticaria, laryngeal
oedema, bronchospasm, hypotension, angiodema) should not be prescribed
beta-lactam agents including penicillins, cephalosporins, carbapenems or
monobactams. Patients who are allergic to one penicillin will be allergic to all.

Patients with a history of immediate hypersensitivity to penicillins may also

react to the cephalosporins and other beta-lactam antibiotics. If a penicillin
(or another beta-lactam antibiotic) is essential in an individual with immediate
hypersensitivity to penicillin then specialist advice from microbiologist /
infectious disease specialist should be sought on hypersensitivity testing or
using a beta-lactam antibiotic with a different structure to the penicillin that
caused the hypersensitivity.

Individuals with a history of a minor rash or a rash that occurs more than 72
hours after penicillin administration, including widespread red macules or
papules (exanthema-like) or fixed drug eruption (localised inflamed skin),
are probably not allergic to penicillin and in these individuals a penicillin
should not be withheld unnecessarily for serious infections; the possibility of
an allergic reaction should, however, be borne in mind. Other beta-lactam
antibiotics (including cephalosporins) can be used in these patients.

Patients with perceived penicillin allergy may be treated with less effective and/
or more toxic antibiotics, leading to side-effects, antibiotic failure or resistance.
Obtain a reliable history and document exact nature in patient notes.

Refer people to a specialist drug allergy service if they have had:

• a suspected anaphylactic reaction or

• a severe nonimmediate cutaneous reaction (for example, drug

reaction with eosinophilia and systemic symptoms [DRESS],
Stevens–Johnson Syndrome, toxic epidermal necrolysis).
6 NI Management of Infection Guidelines for Primary and Community Care 2016
Appropriate use of antibiotics and preventing Clostridium
difficile
The use of broad-spectrum antibiotics such as cephalosporins, quinolones,
co-amoxiclav and clindamycin has been associated with the rise in
Clostridium difficile infection (CDI) observed in both primary and
secondary care.

CDI is one of the key unintended consequences of unnecessary and

inappropriate antibiotic prescribing. It leads to a significant increase in
morbidity, mortality and use of health-care resources.

To help prevent patients developing CDI, prescribers should:

• DO NOT prescribe unnecessary and/or inappropriate antibiotics

• Follow the NI Management of Infection Guidelines when prescribing

antibiotics empirically

• Always review empirical antibiotic treatment when the causative

pathogen is identified.

• Avoid prescribing the broad-spectrum antibiotics listed above

(especially in patients who are at increased risk of developing CDI,
including all patients aged 65 years and over, patients with co-
morbidities, patients with illnesses affecting their GI system)

• Avoid prescribing repeated courses of antibiotics to individual

patients unless there is a clear and evidenced requirement

There is increasing evidence that acid-suppressing medications, in particular

proton pump inhibitors (PPIs) may be a risk factor for CDI; consideration
should be given to stopping/reviewing the need for PPIs in patients with or at
high risk of CDI.

Patients diagnosed with CDI - discontinue any unnecessary antibiotic,

PPI treatment and any antimotility agents or laxatives

Patients with previous history of CDI - prescribers MUST ensure that

any antibiotic treatment is appropriate and absolutely necessary.

For treatment of CDI: see page 31

NI Management of Infection Guidelines for Primary and Community Care 2016 7

 Upper Respiratory Tract Infections
Throat Infection/ Pharyngitis/ Tonsillitis
The majority of sore throats are viral; most patients do not benefit from
antibiotics. Ensure adequate analgesia has been taken in all cases.
Patients with 3 or more of the following Centor Criteria are more likely
to benefit from antibiotics: fever, purulent tonsils, cervical adenopathy, or
absence of cough.

Those with confirmed Group A Streptococci infection should be treated for

10 days.

Consider antibiotics if history of valvular heart disease, marked systemic

upset, peritonsillar cellulitis or at increased risk from acute infection e.g.
immunocompromised or diabetic.

Adult Phenoxymethyl- 500mg QDS 10 days

1st line penicillin
Adult penicil- Clarithromycin 500mg BD 5 days
lin allergic /
2nd line
Child 1st line Phenoxymethyl- 1 month - < 62.5mg QDS 10 days
penicillin 1 year
1 - 6 years 125mg
6 - 12 years 250mg
Child Clarithromycin* < 8 kg 7.5mg/kg BD 5 days
penicillin 8 - 11 kg 62.5mg
allergic / 2nd
line 12 - 19 kg 125mg
20 - 29 kg 187.5mg
30 - 40 kg 250mg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for Children for dosing.

8 NI Management of Infection Guidelines for Primary and Community Care 2016

Peritonsillar Abscess
May require referral to secondary care for drainage

Croup
No antibiotic required. Mild cases can be managed in community. More
severe croup requires hospital admission and possibly steroids before
transfer. See BNF.

Otitis Media
Consider symptomatic treatment in the first instance including adequate
analgesia. Antibiotics are more likely to be of benefit for those under 6
months in age and those with bilateral infection.

Adult 1st line Amoxicillin 500mg TDS 5 days

Adult penicillin Clarithromycin 500mg BD 5 days
allergic / 2nd
line
Child 1st line Amoxicillin 1 month–1 125mg TDS 5 days
year
1–5 years 250mg
5–12 years 500mg
Child penicillin Clarithromycin* < 8 kg 7.5mg/kg BD 5 days
allergic / 2nd 8 - 11 kg 62.5mg
line
12 - 19 kg 125mg
20 - 29 kg 187.5mg
30 - 40 kg 250mg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.

NI Management of Infection Guidelines for Primary and Community Care 2016 9

Acute Otitis Externa
Systemic antibiotics are not usually required unless there are signs of
associated lymphadenitis or perichondritis.
An acetic acid 2% solution spray acts as an antibacterial and antifungal in the
external ear canal and is available as the proprietary preparation (Earcalm®)
for patients to purchase as a self-treatment. It may be of use in mild otitis
externa particularly where itch is a symptom but in severe cases an anti-
inflammatory with or without an anti-infective is required.
Debris in ear must be removed to allow topical medication to be absorbed
effectively; this may require referral for suction removal.
Advise patient to keep ears dry and not to insert any implements into the
ears. Prescribe analgesia as this may be a painful condition.
In recurrent infection cotton wool and Vaseline plugs may be used to keep ears
dry when washing or swimming as a preventative measure. Dispose after use.

Swab patient’s ear and refer to an emergency ENT clinic if:

• Persistent discharge or pain
• Diagnostic doubt as to condition of tympanic membrane
• Immunocompromised patient
• Poorly controlled diabetic patient
• Risk of malignant/necrotising otitis externa
• Patient does not respond to second-line treatment option
NEVER use any forms of drops, including consecutive courses from any source,
for more than 14 days as ototoxicity is cumulative and can be very rapid.

1st line: Otomize® Ear Spray 1 spray TDS 7 days

Adults & children

> 2 years
2nd line: Gentamicin 0.3% and 2 - 4 drops 3 – 4 times 7 days
Hydrocortisone 1% ear daily and at
If no response drops night
within 72 hours
to 1st line
therapy: Adults
& children >2
years

Fungal infection in otitis externa:

Clotrimazole 1% Solution, 2 - 3 drops, 2-3 times daily for at least 14 days
after disappearance of infection

10 NI Management of Infection Guidelines for Primary and Community Care 2016

Sinusitis
Antibiotics are not required for most people presenting with acute sinusitis.

Antibiotic use should be restricted to acute bacterial sinusitis. Adequate analgesia

should be taken in all cases. The following clinical presentations (any of 3) are
recommended for identifying adult patients with acute bacterial vs viral sinusitis:

1. Prolonged sign or symptom of acute sinusitis without

improvement (10 days+)

2. Severe symptoms for at least 3–4 consecutive days at the

beginning of illness, defined as pyrexia along with severe facial
pain and/or purulent discharge

3. “Double-sickening” i.e. worsening symptoms (fever, headache,

increased discharge) after initial 5-6 days of typically viral
symptoms

Red flag symptoms for sinusitis include:

• Unilateral signs (e.g. unilateral polyps or mass)

• Bleeding
• Diplopia or proptosis
• Orbital swelling or erythema
• Suspicion of intracranial complication
• Immunocompromised patient
Adult 1st line Amoxicillin 500mg – 1G TDS 7 days
(if severe)
Or Doxycycline 100mg BD 7 days
Adult 2 Line
nd
Clarithromycin 500mg BD 7 days
Child > 5 years Amoxicillin 500mg TDS 7 days
1st line
Child > 5 years Clarithromycin* 12 - 19 kg 125mg BD 7 days
penicillin
allergic /2nd
line 20 - 29 kg 187.5mg
30 - 40 kg 250mg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.

NI Management of Infection Guidelines for Primary and Community Care 2016 11

Symptoms of Respiratory Tract Infections

12 NI Management of Infection Guidelines for Primary and Community Care 2016

 Lower Respiratory Tract Infections
Non-Pneumonic Lower Respiratory Tract Infection
(‘Acute Bronchitis’)
Antibiotics are of little benefit in otherwise healthy adults with no co-
morbidities or systemic illness.

Symptom resolution can take up to 3 weeks.

Consider antibiotic use in >60 years or if underlying chest disease.

Adult 1st line Amoxicillin 500mg TDS 5 days

Adult penicillin Doxycycline 100mg BD 5 days
allergic /

2nd line
Or Clarithromycin 500mg BD 5 days
Child 1st line Amoxicillin 1 month – 125mg TDS 5 days
1 year
1–5 years 250mg
5–12 years 500mg
Child penicillin Clarithromycin* < 8 kg 7.5mg/kg BD 5 days
allergic/2nd line
8 - 11 kg 62.5mg
12 - 19 kg 125mg
20 - 29 kg 187.5mg
30 - 40 kg 250mg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.

NI Management of Infection Guidelines for Primary and Community Care 2016 13

 Infective Exacerbation of COPD
Antibiotics of unlikely benefit unless 2 or 3 of the following are increased:
breathlessness, sputum volume, sputum purulence

Adult 1st line: Amoxicillin 500mg-1G TDS 5 days

Higher dose (1G) recommended for adults with risk factors for antibiotic
resistant organism:

• Co-morbid disease

• Severe COPD

• Frequent exacerbations

• Antibiotics in last 3 months

Adult 2nd line/ Doxycycline* 100mg BD 5 days

penicillin allergic Or Clarithromycin 500mg BD 5 days
Or

Previous
exposure to
amoxicillin

*Doxycycline preferred in treatment failure

14 NI Management of Infection Guidelines for Primary and Community Care 2016

Community Acquired Pneumonia
Start antibiotics immediately.

Review patients within 48 hours or earlier and if no response consider

admission or discuss with microbiologist / infectious disease specialist.

Admit children < 3 months old or if vomiting or severely ill.

CRB-65 score is useful to assess severity in adults. Score 1 point for:

• Increased Confusion,

• Respiration rate 30 breaths per minute or more.

• Blood pressure systolic <90mmHg or diastolic ≤60mmHg

• Age 65 years or more.

Score 0 - suitable for home treatment

Score 1 - consider hospital assessment or admission

Score 2 - hospital assessment or admission

Score 3-4 - urgent hospital admission

CRB-65 score is not an absolute and clinical judgment should be used; in

particular if systemically unwell consider sepsis.

NI Management of Infection Guidelines for Primary and Community Care 2016 15

 Community Acquired Pneumonia (continued)
Adult CRB-65 = 0 Amoxicillin 500mg TDS 5 days
Adult CRB-65 = 0 Clarithromycin 500mg BD 5 days
or Doxycycline 100mg BD 5 days
PENICILLIN
ALLERGIC
Adult CRB-65 = 1 Amoxicillin 500mg-1G TDS 7 – 10
and AT HOME days

Amoxicillin PLUS Prescribe

7 days
Clarithromycin in first
instance
OR and extend
to 10 days
Amoxicillin at review if
initially and necessary
consider adding +/- 500mg BD
Clarithromycin Clarithromycin
after 48 hours if
no improvement
Adult CRB-65 = 1 Doxycycline 100mg BD 7–10 days
and AT HOME
Prescribe
PENICILLIN 7 days
ALLERGIC in first
instance
OR 500mg BD and extend
to 10 days
Clarithromycin at review if
necessary
Child Amoxicillin 1 month - 125mg TDS 7 days
1 year
1- 5 years 250mg
5 - 12 years 500mg
Child Clarithromycin* < 8 kg 7.5mg/kg BD 7 days
8 - 11 kg 62.5mg
PENICILLIN
ALLERGIC 12 - 19 kg 125mg
20 - 29 kg 187.5mg
30 - 40 kg 250mg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.
16 NI Management of Infection Guidelines for Primary and Community Care 2016
 Influenza
Influenza vaccination
Annual vaccination is essential for all those at risk of influenza.

For further information on influenza vaccination - refer to the “Green Book”

and annual DHSSPS/ Chief Medical Officer circulars.

http://immunisation.dh.gov.uk/green-book-chapters/

Using anti-viral medication

The Chief Medical Officer at DHSSPSNI will inform GP practices when
national surveillance systems indicate that influenza is circulating in the
community. In this situation it is appropriate to prescribe anti-viral medication
for the treatment or prophylaxis of influenza.

Treatment:

• Treat ‘at risk’ patients that present with an influenza-like illness and
can start treatment within 48 hours of onset of symptoms.

• ‘At risk’ patients include: pregnant women, patients aged over 65

years, patients aged under 65 years who are at risk of developing
medical complications from influenza and patients with one of
the following conditions: diabetes mellitus, immunosuppression,
chronic respiratory disease including asthma and COPD, chronic
heart disease, chronic renal disease, chronic liver disease, chronic
neurological disease or BMI>40

• Previously healthy people, excluding pregnant women, should only

be prescribed treatment if the patient is considered at serious risk of
developing serious complications from influenza.

• Further information available at: www.nice.org.uk/Guidance/TA168

NI Management of Infection Guidelines for Primary and Community Care 2016 17

 Prophylaxis:

• Vaccination against influenza is the first-line intervention to prevent

influenza and its complications. The use of anti-viral medication
should not detract from efforts to ensure that all eligible people
receive vaccination.

• Post-exposure prophylaxis is recommended for people ‘at risk’ if

they have been exposed to an influenza-like illness, are able to
begin prophylaxis within the recommended time scale for individual
drugs (48 hours for oseltamivir or 36 hours for zanamivir) of contact
with the index case and have not been protected by vaccination

• At risk people include risk groups mentioned above

• Exposure to an influenza-like illness is defined as a close contact

with a person in the same household or residential setting who has
had recent symptoms of influenza

• Further information available at: www.nice.org.uk/Guidance/TA158

Suspected or confirmed outbreaks:

• Suspected or confirmed outbreaks in settings with people at risk

should be reported to the Public Health Agency. Such settings
include special schools and nursing and residential care homes.

• Treat symptomatic ‘at risk’ patients as in the previous section

• ‘At risk’ people that have been exposed within this setting should
be given anti-viral medication for post-exposure prophylaxis,
whether they are vaccinated or not

18 NI Management of Infection Guidelines for Primary and Community Care 2016

Choice of antiviral
Antivirals are recommended for ‘at risk’ individuals only. For otherwise healthy
individuals antivirals are not recommended (except in pregnant women).
For empiric treatment/prophylaxis the choice of antiviral is dependent on the
predominant strain circulating, the immune status of patient and the severity
of influenza. Complicated influenza should be referred to secondary care for
appropriate treatment.
Uncomplicated influenza: fever, coryza, generalised symptoms (headache,
malaise, myalgia, arthralgia) and sometimes gastrointestinal symptoms, but
no features of complicated influenza.
Complicated influenza: requiring hospital admission and/or with symptoms
and signs of lower respiratory tract infection (hypoxaemia, dyspnoea,
lung infiltrate), central nervous system involvement and/or a significant
exacerbation of underlying medical condition.
The following guidance summarises the current Public Health England (PHE)
recommendations for the antiviral treatment and prophylaxis of influenza:
www.gov.uk/government/publications/influenza-treatment-and-prophylaxis-
using-anti-viral-agents
A) Dominant influenza strain circulating has lower risk of oseltamivir
resistance e.g. H3N2
Uncomplicated influenza:
• Oseltamivir PO suitable in all cases as treatment/prophylaxis except when
resistance in the individual case is confirmed /suspected (see below)
Complicated influenza: Refer to secondary care
B) Dominant influenza strain circulating has higher risk of oseltamivir
resistance e.g. H1N1
Uncomplicated influenza:
• Oseltamivir PO should be used as first line treatment/prophylaxis for all
‘At risk’ Groups other than severely immunosuppressed except when
resistance in individual cases is confirmed /suspected (see below)
• Zanamivir INH should be used as first line for severely
immunosuppressed individuals >5years old requiring treatment/
post-exposure prophylaxis.
• If unable to administer zanamivir INH and in children under 5 years
with severe immunosuppression use oseltamivir PO and clinically
review treatment response due to increased risk of developing
resistance in this group.
Complicated influenza: Refer to Secondary Care
NI Management of Infection Guidelines for Primary and Community Care 2016 19
C) Suspected or confirmed oseltamivir resistant influenza (i.e. in the
patient, or in source individual in post-exposure prophylaxis)

• Zanamivir INH should be used in all cases requiring treatment/post-

exposure prophylaxis except in children under 5.

• For children under 5years and individuals unable to administer

zanamivir by inhaler, nebulised aqueous zanamivir should be used
after individual risk assessment and discussion with specialist. This is
unlicensed and available on a named patient basis only.

Oseltamivir and Zanamivir Doses

Oseltamivir Doses (all PO) Treatment Post-exposure
prophylaxis
Adults (13 years+) 75mg BD x 5 days OD x 10 days
Under 1 year: 3 mg/kg
1-12 years and <15kg 30mg
1-12 years and >15-23kg 45mg
1-12 years and >23kg-40kg 60mg
1-12 years and >40kg 75mg

Zanamivir Doses (Inhaler) Treatment Post-exposure

prophylaxis
(see notes above on when to use
Zanamivir)
Adults & child 5 years and over 10mg BD x 5 days OD x 10 days

Up to 10 days
in confirmed/
suspected
oseltamivir
resistance
Under 5 years Not licensed/not suitable, see text on managing

Oseltamivir should be commenced within 48 hours and zanamivir within

36 hours of onset or last contact in case of post-exposure prophylaxis.
Commencing beyond these times is an off-label use and clinical judgement
should be exercised; seek specialist advice in post-exposure prophylaxis.

20 NI Management of Infection Guidelines for Primary and Community Care 2016

Oseltamivir oral suspension: for use in infants under 1 year only
Oseltamivir oral suspension should be used only for children under the age
of one. Children > 1 year and adults with swallowing difficulties, and those
receiving nasogastric oseltamivir, should use capsules which are opened and
mixed into an appropriate sugary liquid.

The capsule can be opened and the powder contents stirred into one
teaspoonful of chocolate or fudge dessert syrup or one teaspoon-full (5mL)
of undiluted concentrated blackcurrant drink such as Ribena®. Despite the
wording on Ribena® products saying they are unsuitable for children under 3
years, if the small amount means children accept their doses of Tamiflu® then
Ribena® can be used (ref: NHS Direct Fact Sheet on Oseltamivir Nov 2011)

NI Management of Infection Guidelines for Primary and Community Care 2016 21

 Genito Urinary Tract Infections
Uncomplicated Urinary Tract Infection (UTI) Adults
Symptoms of UTI include dysuria, frequency, suprapubic tenderness,
urgency, polyuria, haematuria, fever ≥ 38°C. Prescribe empirical antibiotic
treatment if symptoms are severe or ≥ 3 symptoms of UTI and NO vaginal
discharge/irritation. Some patients may also have non-specific symptoms of
infection such as abdominal pain, alteration of behaviour, delirium (confusion)
or loss of diabetes control

Female Under 65: Acute uncomplicated UTI in women <65 years often
resolves in a few days without treatment. Consider chlamydia in sexually
active young women. Do not routinely culture urine unless suspected
pyelonephritis, failed antibiotic treatment or persistent symptoms, recurrent
UTI, abnormalities of genitourinary tract, renal impairment.

Male Under 65: Send a pre-treatment MSU OR if symptoms are mild/

non-specific, use negative nitrite and leucocytes to exclude UTI. Consider
differential diagnosis e.g. prostatitis, or chlamydia in sexually active young
men with urinary tract symptoms.

Male & Female Over 65 years:

Do not treat asymptomatic bacteriuria, as it is very common, but is not

associated with increased morbidity. Treating does not reduce mortality or
prevent symptomatic episodes, but increases the chance of side effects &
antibiotic resistance.

Urine culture in over 65s: Only send urine for culture if two or more signs
of infection, especially dysuria, fever > 38°C or new incontinence.

Dipstick tests in Over 65s:

• Dipsticks should NOT be used to diagnose UTI in older people,

as diagnosis in this group should be made on the basis of urinary
symptoms and signs of sepsis identified as part of a full clinical
assessment.

• Do NOT send urine for culture if an older patient with no symptoms or

other signs of a UTI produces a positive leucocyte or nitrate dipstick
reaction as part of the overall examination process.

22 NI Management of Infection Guidelines for Primary and Community Care 2016

 Trimethoprim 200mg BD Females: 3 days

or Males: 7 days
Nitrofurantoin* 50mg QDS or 100mg M/R BD Females: 3 days

or Males: 7 days
Pivmecillinam 400mg stat then TDS Females: 3 days
200mg
(contraindicated in peni- Males: 7 days
cillin hypersensitivity)

*Nitrofurantoin can be considered first line if GFR over 45ml/min and

there are risk factors for resistance including: care home resident, recurrent
UTI, hospitalisation >7d in last 6 mths, unresolving urinary symptoms,
recent travel outside Northern Europe or Australasia, previous known
resistance to trimethoprim, quinolones or cephalosporins. If GFR is 30-45ml/
min use nitrofurantoin only if resistance & no alternative; otherwise it is
contraindicated in this group.

A dose reduction of nitrofurantoin or trimethoprim may be required in renal

impairment.

Acute Pyelonephritis
For clinical management including admission criteria see NICE
Clinical Knowledge Summary: Pyelonephritis – acute (search online
for: NICE CKS Pyelonephritis).

If admission not needed, send MSU for culture and sensitivities and start
antibiotics.

Admit to hospital: Rarely, patients with acute pyelonephritis present with

sepsis, multiple organ system dysfunction, shock, and/or acute renal
failure.

If no response within 24 hours, admit.

Ciprofloxacin 500mg BD 7 days

Co-amoxiclav 625mg TID 14 days
If lab report shows sensitive:

Trimethoprim 200mg BD 14 days

NI Management of Infection Guidelines for Primary and Community Care 2016 23

 DIAGNOSIS AND MANAGEMENT OF SUSPECTED UTI IN OLDER PEOPLE >65 YEARS OLD

Decision aid to guide management of residents reported to G.P. / OOHs with suspected UTI by a nursing /
residential home
Confirm that resident has had temperature > 37.9◦C / < 36◦C on two occasions during a 12 hour period (at least
30 minutes apart.
Confirm that the resident does not have any non-urinary symptoms of infection and that they have two / more
of the following:

Does patient/resident have two or more of

following?
UTI unlikely but advise care
1. Shaking chills (Rigors)
home to continue to monitor
2. New onset / increased confusion / agitation
3. Pain in flank (side of body) or suprapubic (above the resident’s symptoms for 72
pubic bone) or new lower central back pain. hours (4 hourly temperature
NO
4. Visible blood in urine recordings & continuous
5. Urinary catheter insitu observation for signs &

6. New onset of / increase in incontinence of urine symptoms of infection) & report
7. Pain when passing urine
any deterioration.
8. Urgent need to pass urine
9. Having to pass urine more often than normal

MANAGEMENT NOTES
YES Diagnosis of UTI is based on clinical
assessment not laboratory testing as the
presence of bacteria in the urine alone
UTI likely
without signs of infection (asymptomatic
Check that care home has sent urine sample for culture bacteriuria) does not indicate a UTI.
& sensitivity (C&S) & decide whether or not to treat • The frequency of asymptomatic bacteriuria
empirically or wait for culture & sensitivity results See increases with age and is common among
management notes Care Home residents
• Dipstick urinalysis should not be used to
Advise care home to push fluids (if not on restricted help diagnose UTI in residents > 65 years of
fluid intake) & report any deterioration in resident. age.
When results of urine sample are available check if • Antibiotic therapy should not be initiated
prior to receipt of C&S results (unless
resident is still symptomatic and treat in accordance
medical status is deteriorating rapidly).
with NI Management of Infection Guidelines for
Primary and Community Care • If required, selection of an antibiotic before
C&S results are available should be based
If urinary catheter is in place consider the need to on NI Management of Infection Guidelines
for Primary and Community Care
instruct home to remove it versus the need for catheter
to stay in place.

Adapted from SIGN 88: Management of suspected bacterial urinary tract infection in adults July 2006 (updated July 2012) adapted by
Health protection Team, Public Health Agency (Northern Ireland), November (2015).

24 NI Management of Infection Guidelines for Primary and Community Care 2016

Catheter associated UTI
Antibiotics will not eradicate asymptomatic bacteriuria; only treat if
systemically unwell or pyelonephritis likely

• Do not treat asymptomatic bacteriuria in those with indwelling

catheters, as bacteriuria is very common

• Treating with antibiotics does not reduce mortality or prevent

symptomatic episodes, but increases side effects & antibiotic
resistance

• Only treat if patient is systemically unwell or pyelonephritis is likely

• Only send urine for culture in catheterised patients if features of

systemic infection. Continuing antibiotic therapy for urinary tract
infection should be based on reported culture and sensitivity results.
A seven day course of antibiotics is recommended in symptomatic
patients and then review progress

However, always:

 Exclude other sources of infection.

 Check that the catheter drains correctly and is not blocked.

 Consider need for continued catheterisation. There should always

be an appropriate indication for the use of urinary catheters and
they should only be in place for as long as needed.

 Catheter should normally be changed before/when starting antibiotic

treatment. Allow patient to remain without catheter for as long as
possible between removal of catheter and insertion of new catheter.

Do not offer prophylactic antibiotics routinely when changing catheters

in patients with long- term indwelling urinary catheters. Consider antibiotic
prophylaxis for patients who have a history of symptomatic urinary tract
infection after catheter change or patients who experience trauma during
catheterisation.

Further information available at: http://guidance.nice.org.uk/CG139

NI Management of Infection Guidelines for Primary and Community Care 2016 25

Pregnant Women- General
Treatment Choices when sensitivities are known in order of
preference are:
1) Amoxicillin (do not use emperically, only use if susceptible)
2) Nitrofurantoin
3) Trimethoprim (off-label)
4) Cefalexin
Cautions:
Nitrofurantoin – do not use at term / use with caution in third trimester.
Trimethoprim – avoid in first trimester or if patient has low folate status or is
on folate antagonist e.g. antiepileptic medication.

Pregnant Women- Asymptomatic UTI

1. Dipstick diagnosis is not appropriate for diagnosing
asymptomatic bacteriuria in pregancy

2. Only treat following TWO MSU results with same organism and treat
as per sensitivities

Pregnant Women- Symptomatic UTI

1. Send pre-treatment MSU for culture and sensitivity testing – indicate
on laboratory request form that sample is from pregnant patient.

2. Commence empirical treatment with cefalexin, then deescalate

treatment from cefalexin if appropriate when laboratory results are
available.
First Line: Cefalexin 500mg BD 7 days
Penicillin allergic Nitrofurantoin 50mg QDS or 100mg M/R BD 7 days
Or
Trimethoprim 200mg BD 7 Days
(off-label)

26 NI Management of Infection Guidelines for Primary and Community Care 2016

Recurrent Urinary Tract Infections in Women( ≥ 3 UTIs/ year)
Recurrent UTI - a repeated UTI, which may be due to relapse or
reinfection.

• Relapse is recurrent UTI with the same strain of organism. Relapse

is the likely cause if infection recurs within a short period (for
example within 2 weeks) after treatment.

• Reinfection is recurrent UTI with a different strain or species of

organism. Reinfection is the likely cause if UTI recurs more than 2
weeks after treatment.

Diagnosis of recurrent UTI should be based on detection of a urinary

pathogen on culture of the urine and on clinical judgement - the number
of recurrences regarded as clinically significant depends on the risks of
infection and the impact on the patient.

The patient should be counselled at an early stage that antibiotic prophylaxis

is not usually a life-long treatment. Antibiotics are given in this way to allow
a period of bladder healing which makes UTI much less likely. There is no
evidence they have any additional benefit beyond 6-12 months treatment
therefore the treatment should be discontinued ideally after 6 months.

For post-menopausal women with no obvious risk factors, consider referral

to urology for further investigations, particularly if recurrent UTI is a recent
problem

For further information and algorithms see: www.scottishmedicines.org.uk/

files/sapg/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf

Trimethoprim 100mg Nocte Prophylactic use at night -

take before going to bed,
or after emptying bladder.
Nitrofurantoin 50 - 100mg Nocte
Maximum treatment -
6 months, then review.

NI Management of Infection Guidelines for Primary and Community Care 2016 27

Urinary Tract Infection Children
Send pre-treatment MSU.

Child <3 months: refer urgently for assessment.

Child ≥ 3 months: use positive nitrite to start antibiotics. Imaging: refer only if
child <6 months, recurrent or atypical UTI.

Atypical UTI includes:

• seriously ill (for more information refer to Feverish illness in children
[NICE clinical guideline 47])
• poor urine flow • raised creatinine
• abdominal or bladder mass • septicaemia
• failure to respond to treatment with suitable antibiotics within 48 hours
• infection with non-E.coli organisms.

Recurrent UTI:
• two or more episodes of UTI with acute pyelonephritis/upper urinary
tract infection, or
• one episode of UTI with acute pyelonephritis/upper urinary tract
infection plus one or more episode of UTI with cystitis/lower urinary
tract infection, or

• three or more episodes of UTI with cystitis/lower urinary tract infection.

See NICE Guidelines CG54 for management of proven UTI in children

http://www.nice.org.uk/CG54 (or as updated)

Where infection suspected, prompt antibacterial treatment minimises renal

scarring. Treat initially with trimethoprim then on basis of sensitivity.

Trimethoprim Child 6 weeks – 12 4mg/kg BD Lower UTI:

years (maximum 200mg) 3 days
Weight unknown: Upper UTI:
7 days
6 weeks – 6 25mg
months
6 months – 6 50mg
years
6 – 12 years 100mg

28 NI Management of Infection Guidelines for Primary and Community Care 2016

 Sexually Transmitted Infections (STIs)
For suspected STIs, refer patients to local genitourinary clinic.
Further information on STIs available at: www.bashh.org/guidelines
Candidiasis (vulvo-vaginal infection)
Advise patient to consider self-referral to the community pharmacy
minor ailments scheme should they experience this condition in the
future. Further information available at: www.hscbusiness.hscni.net/
services/2055.htm

Clotrimazole* 500mg pessary or 10% Stat

intravaginal cream

plus BD/TID for up to two weeks

clotrimazole 1% cream

or Fluconazole 150mg Stat

*Clotrimazole damages latex condoms and diaphragms- counselling required.

Chlamydia
Provide initial treatment, then refer onwards to local genitourinary clinic.

Azithromycin - 1st line treatment choice for all females and heterosexual
males. Doxycycline - consider 1st line for men who have sex with men.

Azithromycin*   1G Stat  
Or 
Doxycycline 100mg  BD 7 days

*Azithromycin is effective in pregnancy but off-label (doxycycline is

contraindicated in pregnancy/breast feeding)

NI Management of Infection Guidelines for Primary and Community Care 2016 29

 Pelvic Inflammatory Disease
Provide initial treatment as below and refer woman and contacts to GUM
service. Always test for gonorrhoea and chlamydia. Appropriate analgesia
should be provided.

Ofloxacin and moxifloxacin should be avoided in patients who are at high

risk of gonococcal PID (e.g. when the patient’s partner has gonorrhoea,
in clinically severe disease, following sexual contact abroad) because
of increasing quinolone resistance in the UK - refer such cases directly
to GUM for appropriate susceptibility testing, resistance monitoring and
treatment.

Metronidazole PLUS 400mg BD 14 days

Ofloxacin 400mg BD

Bacterial Vaginosis
ADULT WOMEN:
Metronidazole  400mg BD 7 days

Or Metronidazole Gel 5gm applicatorful Nocte 5 nights

0.75%

Or Clindamycin 2% 5gm applicatorful Nocte 7 nights

intravaginal cream*

*Clindamycin cream damages latex condoms and diaphragms- counselling required.

Post Partum Endometritis

If uterine tenderness or signs of sepsis refer to hospital urgently.
ADULT WOMEN:
1st Line Amoxicillin 1G TDS 5-7 days

PLUS 400mg TDS

Metronidazole
2nd Line Clindamycin 450mg QDS 5-7 days

30 NI Management of Infection Guidelines for Primary and Community Care 2016

 Gastro-Intestinal Infections
Clostridium difficile Infection (CDI)

Prevention of CDI- see Appropriate use of antibiotics and preventing

Clostridium difficile < cross ref to page number needed>

Clinical diagnosis of Clostridium difficile Infection

Patients with diarrhoea (profuse +/- blood), particularly patients aged >65
years of age who are currently on antibiotic treatment or recent antibiotic
treatment in the preceeding 3 months should have a stool sample sent to
laboratory for Clostridium difficile testing.

CDI is a toxin mediated disease. Not all patients with Clostridium difficile
have toxin detected in their stool samples, therefore the testing process for
Clostridium difficile is now a two/ three stage test to increase sensitivity of
detection for Clostridium difficile:

• Glutamate dehydrogenase (GDH) test. Detects antigen of both

toxigenic and non-toxigenic Clostridium difficile

• Polymerase Chain Reaction (PCR) test. Detects presence of Toxin

gene

• Clostridium difficile toxin test. Detects presence of Toxin

Patients diagnosed with CDI:

• Review the need for any currently prescribed antibiotic and

discontinue if possible.

• Stop any PPI treatment if possible.

• Do not prescribe antimotility agents or laxatives.

• Prescribers MUST ensure that any future antibiotic treatment is

appropriate and absolutely necessary.

NI Management of Infection Guidelines for Primary and Community Care 2016 31

 Interpretation of results
+ GDH positive and/or PCR positive Clostridium difficile Infection most
likely to be present and may require
+ Toxin Positive treatment
(PPV=91.4%)
+ GDH positive and/or PCR positive Clostridium difficile could be present
(confirmed present if PCR positive).
- Toxin Negative
Potential for Clostridium difficile
excretion and transmission. Clinical
assessment required to diagnose
infection and treatment
- GDH negative Clostridium difficile Infection very
unlikely. Patient could have other
- Toxin negative potential pathogens
(NPV 98.9%)

Queries regarding interpretation of CDI test results should be referred to

the local Consultant Microbiologist

Adult – severe CDI

Signs of severe disease include: Temperature > 38.5°C, WCC > 15 x 109/l,
rising serum creatinine, pain/tenderness and signs of severe colitis.

Any patient severely unwell with CDI- discuss case with local Consultant
Microbiologist / Infectious Diseases and consider urgent referral to hospital

Adult – mild CDI

Patient is symptomatic but does not meet any of the criteria for severe
CDI and may be managed at home depending on co-morbidity and social
circumstances.

See Interpretation of results table above for differentiation between

active infection, colonisation/carriage and unlikely CDI cases. Only active
infection or symptomatic colonisation/carriage should be considered for
treatment with antibiotics

Metronidazole 400mg TDS 10 – 14 days

32 NI Management of Infection Guidelines for Primary and Community Care 2016

 Skin & Soft Tissue Infections

Acne & Folliculitis

Adult 1st line Benzoyl Peroxide 2.5% gel BD Review after
topical therapy increasing to 5% 2 months
  if tolerated  

Adult topical A topical retinoid e.g. Adapalene or Tretinoin

if benzoyl or Isotretinoin may be used as an alternative.
peroxide not Benzoyl peroxide or other abrasive cleansers
tolerated may cause peeling which should be given time
to subside before using a topical retinoid.
 
Adult 1st Oxytetracycline  500mg BD Review in 3
line systemic   months, full
therapy Rx may take
  6 - 12 months
Adult 1st Or  500mg BD
line systemic Tetracycline  
therapy
  Or  408mg OD
Lymecycline  

Adult 2nd Erythromycin 500mg BD

line systemic  
therapy
  Or  100mg OD
  Doxycycline  

Adult 3rd Refer to

line systemic dermatology
therapy

NI Management of Infection Guidelines for Primary and Community Care 2016 33

Abscesses / Boils
1st line: Boils don’t usually respond to antibiotics. Treat with drainage
as soon as possible.

Antibiotics should only be used as an interim measure until drainage

takes place. Following drainage the continuing need for antibiotics
should be reassessed.

Risk factors for MRSA Skin & Soft Tissue Infection: Previous MRSA
infection or colonisation, frequent readmission to healthcare facilities, recent
inpatient/resident at hospital or care facility with known or likely high MRSA
prevalence.

Adult Flucloxacillin 1G QDS Initial

course 7
days all
Adult Clarithromycin 500mg BD
antibiotics
penicillin Extend to
allergic 14 days
on review
Adult Doxycycline 100mg BD if slow to
with MRSA respond
risk factors

Child Flucloxacillin 1 month – 62.5 - 125mg QDS

  2 years

2 - 10 years 125 - 250mg

10 – 12 250 - 500mg
years
Child Clarithromycin* < 8 kg 7.5mg/kg BD
penicillin  
allergic 8 - 11 kg 62.5mg

12 - 19 kg 125mg

20 - 29 kg 187.5mg

30 - 40 kg 250mg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.

34 NI Management of Infection Guidelines for Primary and Community Care 2016

Cellulitis / Impetigo
Serious or deteriorating cellulitis is an emergency and will need referral for IV
antibiotics.
Bacteria are always present in leg ulcers, antibiotics do not improve healing.
Use antibiotics only if cellulitis, increasing pain, enlarging ulcer or pyrexia.
Contact microbiologist / infectious disease specialist if river or sea water
exposure.
In recurrent or persistent cellulitis assess patient for tinea pedis and treat as
per Athlete’s Foot if necessary.
Risk factors for MRSA Skin & Soft Tissue Infection: Previous MRSA
infection or colonisation, frequent readmission to healthcare facilities, recent
inpatient/resident at hospital or care facility with known or likely high MRSA
prevalence
Adult 1st line Flucloxacillin 500mg - 1G QDS Initial course
7 days all
Adult penicillin Clarithromycin 500mg BD antibiotics
allergic / 2nd line Extend to
Adult Doxycycline 100mg BD 14 days on
with MRSA risk review if slow
factors to respond

Child 1st line Flucloxacillin 1 month 62.5 - QDS

    – 2 years 125mg

2 - 10 125 -
years 250mg
10 - 12 250 -
years 500mg
Child penicillin Clarithromycin* < 8 kg 7.5 mg/ BD
allergic / 2nd line   kg
  8 - 11 kg 62.5mg

12 - 19 125mg
kg
20 - 29 187.5mg
kg
30 - 40 250mg
kg

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.

NI Management of Infection Guidelines for Primary and Community Care 2016 35

 Bites – Human
Surgical toilet is most important; assess risk of tetanus, HIV, hepatitis B&C.

Antibiotic prophylaxis advised for all human bites.

Review at 24 and 48 hours.

Adult 1st line Co-amoxiclav 625mg TDS 7 days

Adult penicillin Metronidazole 400mg TDS 7 days

allergic / 2nd line PLUS      
  Doxycycline 100mg BD

Child 1st line Co-amoxiclav 1 month – 0.25mL/kg TDS 7 days

    1year of 125/31    
suspension

1 - 6 years 5mL of
125/31
suspension
6 - 12 years 5mL of
250/62
suspension
Child penicillin Clarithromycin* < 8 kg 7.5mg/kg BD 7 days
allergic/ 2nd line  
    8 - 11 kg 62.5mg
PLUS
12 - 19 kg 125mg

20 - 29 kg 187.5mg

30 - 40 kg 250mg

Metronidazole 1–2 7.5mg/kg BD 7 days

months
2 months – 7.5mg/kg TDS
12 years (Max 400mg)

*Erythromycin suspension may be used as an alternative to clarithromycin

suspension, as its taste may be more acceptable to children. See BNF/BNF
for children for dosing.

36 NI Management of Infection Guidelines for Primary and Community Care 2016

 Bites – Animal
Surgical toilet is most important. Assess tetanus and rabies risk.

Antibiotic prophylaxis advised for puncture wounds and bites involving hand,
foot, face, joint, tendon, ligament; immunocompromised, diabetic, elderly,
cirrhotic or asplenic patients, presence of prosthetic valve or prosthetic joint.

Note: Clarithromycin does not work for animal bites.

Review at 24 and 48 hours.

Adult 1st Co-amoxiclav 625mg TDS 7 days

line
Adult Metronidazole 400mg TDS 7 days
penicillin PLUS      
allergic
/2nd line  Doxycycline 100mg BD

Child 1st Co-amoxiclav 1 month – 0.25mL/kg TDS 7 days

line   1 year of 125/31    
  suspension

1–6 5mL of
years 125/31
suspension

6 – 12 5mL of
years 250/62
suspension

Child Where a child, who has been bitten by an animal, is genuinely

penicillin penicillin allergic (see Penicillins & Hypersensitivity page 7), and
allergic requires antibiotic prophylaxis - consult your local microbiologist/
/2nd line infectious disease specialist for advice. Clarithromycin does not work
  for animal bites.

NI Management of Infection Guidelines for Primary and Community Care 2016 37

 Athlete’s Foot (Tinea Pedis)
Advise patient to consider self-referral to the community pharmacy
minor ailments scheme should they experience this condition in the
future. Further information available at: www.hscbusiness.hscni.net/
services/2055.htm
Adult and Child Clotrimazole 1% Cream 20g BD - Use for 2 weeks
    TDS after area has
healed

Miconazole 2% Cream 30g BD Continue for 10

  days after area
has healed

Fungal Nail Infections (Onychomycosis)

Send nail clippings to laboratory for testing: start therapy only if infection is
confirmed by laboratory. Use terbinafine first line, but if candida or non-
dermatophyte infection confirmed, use oral itraconazole.

Self-care alone may be appropriate for people who are not concerned
by the infected nail or who wish to avoid the possible adverse effects
of drug treatment. Consider drug treatment if the patient has diabetes,
vascular disease or a connective tissue disorder (because of a higher
risk for secondary bacterial infections and cellulitis), or is severely
immunocompromised.

Topical treatment is inferior to systemic therapy and should only be

considered for mild or superficial infection of nails or where systemic therapy
is contraindicated e.g. liver or renal impairment. Topical treatments such as
medicated nail paint or lacquers are available to purchase over the counter.

For children, seek specialist advice

Adults – Terbinafine 250mg Daily 6 – 12 weeks (finger nails)
1st line 3 – 6 months (toe nails)
Adults – Itraconazole* 200mg BD 7 day course (‘pulse’),
2nd line subsequent courses
repeated after 21 days:
2 courses (finger nails)
3 courses (toe nails)

*Itraconazole should be used in caution in those at increased risk of heart

failure (including risk due to other medication); it should not be used for
treating fungal nail infections in patients with ventricular dysfunction or a
history of heart failure. See current BNF for full details.

38 NI Management of Infection Guidelines for Primary and Community Care 2016

 Fungal Skin Infections:
Patients with fungal skin infections in the groin area may obtain advice
and treatment via the community pharmacy minor ailment scheme. Advise
patient to consider self-referral to the scheme should they experience this
condition in the future. Further information available at: www.hscbusiness.
hscni.net/services/2055.htm

Adults Terbinafine 1% cream BD 1 - 2 weeks

Adults if candida Miconazole 2% cream BD 2 weeks (Con-

possible     tinue for 1 - 2
weeks after area
has healed)

Adults – systemic Terbinafine 250mg Daily 4 weeks

treatment for
intractable
conditions only
(skin scrapings sent
to laboratory and
infection confirmed)

Children Miconazole 2% cream BD 2 weeks (Con-

tinue for 1 - 2
weeks after area
has healed)

NI Management of Infection Guidelines for Primary and Community Care 2016 39

 Viral Skin Infections
Shingles
Offer non-immunocompromised patients appropriate analgesia and local
skincare advice to prevent secondary bacterial infection.

Treat:
• If patient is over 50 years of age and within 72 hours of rash
• Active ophthalmic shingles
• Ramsey Hunt Syndrome
• Eczema

Seek urgent specialist advice: for management of high-risk patients

following significant exposure to shingles or chicken pox. Post-exposure
management is to protect individuals at high-risk of suffering severe
varicella and those who may transmit infection to those at high- risk. High-
risk patients include:

• Pregnant women
• Immunocompromised patients
• Neonates

For further information on varicella vaccination and post-exposure

management – refer to the

“Green Book”:

http://immunisation.dh.gov.uk/green-book-chapters/chapter-34/

Adults 1st Aciclovir 800mg Five times a day 7 days

line

Adults Valaciclovir 1G TDS 7 days

2nd line

40 NI Management of Infection Guidelines for Primary and Community Care 2016

 Eye Infections
Conjunctivitis
1st line: Treat only if severe, as most are viral or self-limiting.

Bacterial conjunctivitis is usually unilateral and also self-limiting – it is

characterised by red eye with mucopurulent, not watery, discharge.

Ointment stays in the eye longer and therefore is a good night-time

treatment option, however due to blurring of vision, drops may be more
acceptable to some patients during day.

Adults & children Chloramphenicol Use every 3 Use for 48 hours after
>1month - if severe  0.5% drops and/or hours resolution
1% ointment
 
or Fusidic acid 1% BD
gel

NI Management of Infection Guidelines for Primary and Community Care 2016 41

 Dental Infections in General Practice
Dental Infections Presenting in General Practice
GPs should not routinely be involved in dental treatment. Dental infections
should be assessed by a qualified dental practitioner as soon as possible.

An antibiotic prescription is a temporary measure which should only be

provided when clinically indicated and by someone who feels competent to
assess the problem.

Out-of-hours dental treatment is appropriate in the following situations:

severe swelling, intractable pain, bleeding, and trauma.
Information on the availability of out-of-hours dental services is detailed
below or alternatively may be accessed at:
www.hscboard.hscni.net/news/EmergencyDentalServices.html

Area Contact Details

Greater Belfast Area Relief of Dental Pain Service - Dental Out-patients
Department, Belfast City Hospital
Telephone number: (028) 9063 8486
Monday to Friday: Clinic opens at 7.00pm
Saturday, Sunday and Bank Holidays: Clinic
opens at 10.00am, 2.30pm and 7.00pm
(The first 15 patients to arrive at each clinic will be seen)
Northern Trust Area Relief of Dental Pain Clinic - Dalriada Urgent Care
Centre, Ballymena
Telephone number: 028 2566 3510
Monday to Friday: Clinic opens 6.30pm – 9.30pm
Saturday, Sunday and Bank Holidays: Clinic opens
9.30am – 12.30pm
Southern Trust Area Emergency Dental Clinic - Craigavon Area Hospital
Telephone number: 028 3861 2292
Monday to Friday: Clinic opens 7.00pm – 9.00pm
Saturday & Sunday: Clinic opens 10.00am – 12 noon
Western Trust Area Phone own dentist and details of local out-of-hours
arrangements will be available on the answering
machine.

*Information accurate at time of publication.

42 NI Management of Infection Guidelines for Primary and Community Care 2016

Dental Abscess requiring urgent treatment
Advise urgent dental consultation as dental abscess is treated in the
first instance by drainage and repeated courses of antibiotics are not
appropriate.

Antibiotics are only recommended if there are signs of severe infection,

systemic symptoms or high risk of complications. Otherwise regular
analgesia should be first option until a dentist can be seen.

In severe spreading infection (cellulitis, lymph node involvement or

swelling) or systemic involvement (pyrexia, malaise) a combination
of amoxicillin and metronidazole can be used and referral to hospital
considered.

If obstruction of the airways is possible, urgent referral to hospital is

required.

 Adult 1st line  Amoxicillin  500 mg  TDS 5 days

 Adult 2nd line Metronidazole 400mg TDS 5 days

Other dental conditions

Advise dental consultation for treatment of other dental infections including
acute necrotising gingivitis, pericoronitis and mucosal inflammation or
ulceration. See BNF for treatment information if necessary.

NI Management of Infection Guidelines for Primary and Community Care 2016 43

 Meningitis
Meningitis- immediate treatment
Transfer all patients to hospital immediately

Administer antibiotic STAT if hospital transfer will not be immediate but

urgent transfer to hospital should not be delayed in order to give the
parenteral antibiotics

Treatment should ideally be administered IV

1st Line: Benzylpenicillin IV/IM​

Child < 1 year 300mg
Child 1-9 years 600mg
Adult & child > 10 years 1.2g

Penicillin allergic: Cefotaxime IV/IM​

Do not use cefotaxime in patients with history of immediate hypersensitivity
reaction to penicillin

Adults 1G
Child Child (1 month-12 years) 50mg/kg
Where weight of a child is available, this should over-ride age in
calculating dose

Age Approx Weight Dose

1 month 9lbs or 4kg 200mg

3 months 13lbs / 6kg 300mg

6 months 18lbs / 8kg 400mg

12 months 22lbs / 10kg 500mg

3 years 2st5lbs / 15kg 750mg

6 years 3st2lbs / 20kg+ 1G

Note: There is no option readily available to GPs for use in patients with true
history of penicillin anaphylaxis (IV chloramphenicol is recommended by BNF
but is not available at time of publication in primary care). Urgent transfer to
hospital is the key priority, and this applies regardless of whether an antibiotic
can be administered or not.
44 NI Management of Infection Guidelines for Primary and Community Care 2016
 Meningitis- prevention of secondary cases
Only prescribe on advice from Public Health Doctor (Public Health Duty
Room Tel: 03005550119). Start prophylaxis ideally within 24 hours of
diagnosis of index case.

Chemoprophylaxis should be offered to close contacts of cases,

irrespective of vaccination status, in the following categories:

(a) Those who have had prolonged close contact with the case in a
household type setting during the seven days before onset of illness.

(b) Those who have had transient close contact with a case only if
they have been directly exposed to large particle droplets/secretions
from the respiratory tract of a case around the time of admission to
hospital

Ciprofloxacin Adult 500mg Stat

(preferred option Child 5-12 years 250mg Stat

including children
Child under 5yrs 30mg/kg up to Stat
and pregnancy)
maximum of 125
mg stat
Rifampicin Adult 600mg BD 2 days

(if ciprofloxacin Child 1-12 years 10mg/kg BD 2 days

contraindicated)
Infants under 12 5 mg/kg BD 2 days
months of age

Suitable doses of rifampicin in children based on average weight for age are:

0–2 months: 20 mg (1 ml*)

3–11 months: 40 mg (2 ml*)

1–2 years: 100 mg (5 ml*)

3–4 years: 150 mg (7.5 ml*)

5–6 years: 200 mg (10 ml*)

7–12 years: 300 mg (as capsule/or syrup)

* Rifampicin syrup contains 100 mg/5 ml

NI Management of Infection Guidelines for Primary and Community Care 2016 45

46 NI Management of Infection Guidelines for Primary and Community Care 2016
NI Management of Infection Guidelines for Primary and Community Care 2016 47
anagement of Infection Adults
ary Care 2016 Meningitis Adult:
Included in child chart
overleaf

Urinary Tract Infection (Adults First Line):

Trimethoprim or 200mg BD Females: 3 days

Males: 7 days
Nitrofurantoin* or 50mg QDS or 100mg M/R BD

Pivmecillinam 400mg stat then 200mg TDS

(contraindicated in
penicillin hypersensitivity)

*Nitrofurantoin can be considered first line if GFR over 45ml/min and there are risk factors for resistance
including: care home resident, recurrent UTI, hospitalisation >7d in last 6 mths, unresolving urinary
symptoms, recent travel outside Northern Europe or Australasia, previous known resistance to trimethoprim,
quinolones or cephalosporins. If GFR is 30-45ml/min use nitrofurantoin only if resistance and no alternative;
otherwise it is contraindicated in this group.

Skin and Soft Tissue Infections:

Condition First Line Treatment Second Line Treatment or

Penicillin Allergic

Abscesses / Boils Adult: Flucloxacillin 1G Adult: Clarithromycin

Boils don’t usually respond to
antibiotics - drainage is needed.
Antibiotics are an interim measure
and following drainage the
continuing need for antibiotics
should be reassessed.
QDS for 7 days initially; 500mg BD for 7 days
extend to 14 days at review initially; extend to 14
if slow to respond days at review if slow to
respond
MRSA risk: use doxycycline 100mg BD for 7 days then
extend to 14 days if need be

r Cellulitis / Impetigo Adult: Flucloxaciillin Adult: Clarithromycin

500mg-1G QDS for 7 days 500mg BD for 7 days
initially; extend to 14 days initially; extend to 14
at review if slow to days at review if slow to
respond respond

For the most up-to date version download thedoxycycline

MRSA risk: use ‘Microguide’
100mgApp on7 the
BD for days App
then
Store or Google Play (select Northern
extend Ireland
to 14 daysPrimary
if need beCare when prompted)

r Human Bites and Animal Adult: Co-amoxiclav 625mg Adult: Metronidazole

Bites TDS for 7 days 400mg TDS for 7 days
plus Doxycycline 100mg
BD for 7 days.

MicroGuide for MicroGuide for

iPhone iPodTouch Android

Health and Social

Care Board
48 NI Management of Infection Guidelines for Primary and Community Care 2016