Primary Care Antimicrobial Guidelines
On 16 January 2019 the South West Yorkshire Area Prescribing Committee approved local use of the new NICE/PHE managing common infections guidance.
This supersedes our local primary care guideline. As NICE/PHE have not completed all sections yet, we will continue to use local guidelines for those sections.
These guidelines should be used in conjunction with professional judgement and involving patients in management decisions.
NICE/PHE – introduction to guidelines and further information on illnesses such as upper and lower respiratory conditions, UTIs, prostatitis, pyelonephritis. Within the summary tables some minor text has been added for clarifications in the Chlamydia, Conjunctivitis and Bites sections. NICE have included a summary for the Bronchiectasis guidance and have included an alternative dosing option for Nitrofurantoin.
In July 2019 updates were made to the content in the summary by adding acute exacerbation of bronchiectasis as well as updates to the contents for UTIs, meningitis, Chlamydia, bites and conjunctivitis.
NICE/PHE table – managing common infections (whole guideline)
NICE surgical site infections: prevention and treatment (NG125)
Urinary tract infection: diagnostic tools for primary care – This quick reference tool for primary care describes when to send for urine cultures and when to consider a UTI in adults >65 years, women < 65 years and in children. The flowchart for adults > 65 has been updated to reflect NICE guidance on managing catheter-associated UTIs.
|Subject||Information or link||APC Date
(n) = New
(a) = Amendment
|Azithromycin||Azithromycin guidance||1st May 2019 (n)
31st July 2019 (a)
|Conjunctivitis||Public Health England does not recommend an exclusion period from school, nursery or childminders except if an outbreak or cluster of cases occurs|
|Diverticulitis – acute||Diverticulitis|
|Leg ulcers||If non healing:|
Seek advice from Tissue Viability Nurse (TVN) for specialised wound management dressings.
The current wound formulary contains contact details for TVNs - it can be found in the wound care formulary
|Prevention of a secondary case of invasive meningococcal, haemophilus influenzae or Group A streptococcal disease||Refer to the West Yorkshire health protection team:|
0113 386 0300 or out of hours 0114 304 9843
|Prevention of secondary case of meningitis||Only prescribe if advised to by local health protection specialist/consultant.|
Contact Public Health England on 0113 386 0300. Out of hours call 0114 304 9843 and ask for public health on-call
|Salmonella||Most cases are mild and self-limiting. Seek advice from a microbiologist if treatment considered|
|Surgical site infections treatment options||Surgical site infections|
Microbiological advice can be obtained from the duty Microbiologist via switchboard
Calderdale and Huddersfield NHS Foundation Trust
Calderdale Royal Hospital: 01422 357171 or Huddersfield Royal Infirmary: 01484 342000
Mid Yorkshire Hospitals NHS Trust: 0844 8118110
Bradford Teaching Hospitals NHS Foundation Trust: 01274 542200
Airedale NHS Foundation Trust: 01535 652511
Outpatient parenteral antimicrobial therapy (OPAT)
OPAT is a method for delivering intravenous antimicrobials in the community or outpatient setting as an alternative to inpatient care. It is useful for patients who require parenteral therapy for moderate to severe infections but are otherwise well enough to be at home. The benefits of OPAT include admission avoidance and reduced length of stay in hospital. This means there is an increase in inpatient capacity, significant cost savings compared with inpatient care, reduction in the risk of healthcare-associated infection and improved patient choice.
Contact your local acute Trust for further information.
Antimicrobial allergy e.g. penicillin
- Obtain an accurate allergy status from the patient. If they say they are allergic, ask them what happened to them when they took penicillin?
- Ensure that all patients’ allergies and adverse side effects are documented fully.
- Always check the allergy status of the patient before prescribing, dispensing or administering a medicine.
- Be alert to the fact that the name of a medicine itself may not indicate 100% of the time that the medicine is a penicillin or related to a penicillin.
Patients with a history of anaphylaxis, urticaria or rash immediately after penicillin administration are at risk of immediate hypersensitivity to penicillins. These individuals should not normally receive a penicillin, a cephalosporin, carbapenem (e.g. imipenem, meropenem, ertapenem), or another β-lactam antibiotic.
Signs and symptoms of immediate hypersensitivity include dyspnoea, swelling, rash and urticaria.
Individuals with a history of a minor rash (i.e. non-confluent restricted to a small area of the body), or a rash that occurs more than 72 hours after penicillin administration have a mild allergy and can be prescribed other β-lactam antibiotics like cephalosporins.
Drug intolerance (e.g. gastrointestinal symptoms, feeling faint) is not an indication to avoid β-lactam antibiotics.
This study used primary care data from 2013-2015. The most common reasons for antibiotics being prescribed were acute cough and bronchitis, acute sore throat, AOM and acute sinusitis. Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for > 2/3 of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. The median number of days beyond the guideline recommendation was 2 (5th-95th centile 2-3 days) for acute cough and bronchitis, 2 (2-8) days for acute otitis media, and 3 (1-7) days for acute sinusitis.
There is also a NICE commentary for further information.
Use of antibiotics in pregnancy
Refer to the BNF and UK Teratology Information Service http://www.uktis.org or phone 0344 8920909.
Fluoroquinolones – disabling and potentially permanent side effects leading to restrictions of fluoroquinolone antibiotics
On 15 November 2018, the European Medicines Agency (EMA) finalised a review of serious, disabling and potentially permanent side effects with fluoroquinolone antibiotics given by mouth, injection or inhalation.
Restrictions on fluoroquinolones include:
avoid in patients who have previously had serious adverse effects with a fluoroquinolone or quinolone antibiotic.
– discontinue fluoroquinolone treatment at the first sign of tendon pain or inflammation and patients should be advised to stop treatment with a fluoroquinolone and speak with the doctor in case of symptoms of neuropathy such as pain, burning, tingling, numbness or weakness so as to prevent development of potentially irreversible condition
-use with special caution in the elderly, patients with renal impairment and those who have had an organ transplantation as these patients are at increased risk of tendon injury.
-avoid concomitant treatment with a fluoroquinolone and a corticosteroid.
Further details are available from MHRA
In addition, systemic and inhaled fluoroquinolones may be associated with a small increased risk of aortic aneurysm and dissection, particularly in older patients. Further details from the MHRA.
The Faculty of General Dental Practice (FGDP(UK)) and British Dental Association have published an updated version of their antimicrobial prescribing self-audit tool for dentists.
The move coincides with the launch of the government’s five-year action plan and 20-year vision for antimicrobial resistance. The tool is intended to help the dental profession play its part by further reducing inappropriate antibiotic prescribing.
Tools to support the system to consistently manage and remove urinary catheters.
The urinary catheter tools have been developed collaboratively with national experts to support providers in delivering consistent evidence based catheter care. The use of the tools needs to be supported by strong leadership and education.
Leaflets and forms
A range of leaflets for patients are available from the Royal College of General Practitioners TARGET Antibiotics Toolkit page.
One can be used during consultations with women who are experiencing non-complicated urinary tract infections, when the clinician feels that the patient does not require an antibiotic prescription.
The leaflet is available in different languages from the TARGET website.
FOR CARE HOME STAFF: Form (currently under review) to be completed and fax to GP if an older resident has a suspected urinary tract infection:
For hospital patients and visitors
Public Health England has produced a patient information leaflet about an uncommon fungus called Candida auris.
CCGs are continuing to work with healthcare professionals, patients and the public to reduce inappropriate prescribing of antibiotics. In addition, from 1 April 2017 we will be working to reduce gram negative blood stream infections (BSI) across the whole health economy and reduce inappropriate antibiotic prescribing for urinary tract infections (UTI) in primary care.
From 1 April 2019, hospitals are now working on improving lower urinary tract infection prescribing in older people; antibiotic prophylaxis for elective colorectal surgery; in addition to reducing total antibiotic consumption.