Principles of antibacterial treatment

The Formulary Primary Care Infections Guidance aims to provide a simple, effective, economical and empirical approach to the treatment of common infections, and to minimise the emergence of bacterial resistance in the community.

Advice is based on the Public Health England: Primary care guidance, diagnosing and managing infections, adapted with local specialists.

Professional judgement should be used in the management of infections and patients should be involved in the decision.

Non-prescription / delayed prescription forms to help reduce inappropriate antibiotic prescribing are available from a number of websites (see notes below), an example can be found here.

Principles of treatment

Prescribe an antibiotic only when there is likely to be a clear clinical benefit.

It is important to initiate antibiotics as soon as possible in severe infection.

The formulary gives dose and duration of treatment for adults; these may need modification for age, weight and renal function. Children's doses are provided for some infections. In severe or recurrent cases consider a larger dose or longer course. Please refer to the BNF for further dosing, cautions and interaction information if needed and please check for hypersensitivity.

The GFR supplied by local laboratories relates to an estimated value for 70kg males. In patients with a BMI less than 18kg/m 2 or greater than 40kg/m2, the true creatinine clearance may be very different and in such instances consider using the Cockcroft-Gault calculation for a better estimate of creatinine clearance www.nuh.nhs.uk.

Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and seek specialist advice.

Do not prescribe an antibiotic for sore throat, simple coughs and colds. Consider a no, or back-up / delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections, and mild UTI symptoms. Simple cystitis in young women will often resolve within 72 hours, consider delayed antibiotic prescription in such instances. Patient information leaflets that support a no prescription or delayed prescription strategy are available from a number of websites, an example can be found here.

Limit prescribing over the telephone to exceptional cases.

Use simple generic antibiotics first line whenever possible. Avoid broad spectrum antibiotics, for example co-amoxiclav, quinolones and cephalosporins, when standard less expensive antibiotics remain effective, as broad spectrum antibiotics increase the risk of Clostridium difficile, MRSA and resistant UTIs

Allergic reactions to penicillins occur in 1-10% of patients. Those with a history of severe allergy, for example, immediate hypersensitivity to penicillins, including urticarial rash and Stevens-Johnson syndrome, may also react to cephalosporins and other beta-lactam antibiotics therefore in severe allergy these should also be avoided

Avoid widespread use of topical antibiotics, especially those agents also available as systemic preparations e.g. fusidic acid

In pregnancy avoid tetracyclines, aminoglycosides, quinolones and high dose metronidazole (2g) unless benefit outweighs risk. See Urinary tract infections for advice on managing UTI in pregnancy. Avoid trimethoprim if woman has low folate status or is taking a folate antagonist e.g. antiepileptic drug or proguanil and discuss use with a Microbiologist

Where a 'best guess' therapy has failed or special circumstances exist, including the suspicion/confirmation of MRSA, ESBLs and Clostridium difficile infection, microbiological advice should be obtained from:

  • 01803 654990 for Torbay and South Devon or
  • 01752 430010 for Plymouth and bleep on call microbiologist if OOH or urgent advice is sought

NICE have issued best practice advice on the care of children with feverish illness ( NICE CG160: Fever in under 5s: assessment and initial management) (August 2017)

Sepsis - information for patients

Women taking combined hormonal contraceptives: Additional precautions are not required to maintain contraceptive efficacy when using antibiotics that are not enzyme inducers (e.g. not rifampicin-like drugs) for 3 weeks or less, unless diarrhoea and vomiting occur. See the latest version of the BNF for full details.

 

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