BNF - Chapter 5 - Infection - (Part 1) Flashcards
What is an amoeba infection?
Amebiasis (am-uh-BYE-eh-sis) is an infection of the intestines with a parasite called Entamoeba histolytica (E. histolytica).
The parasite is an amoeba (uh-MEE-buh), a single-celled organism. People can get this parasite by eating or drinking something that’s contaminated with it.
Which antiprotozoal can be used for treatment of amoebic infection?
Mepacrine hydrochloride
Before selecting an antibacterial what three factors must the clinician consider?
- The patient
- The known or likely causative organism
- The risk of bacterial resistance with repeated courses
What factors related to the patient must be considered when selecting an antibacterial?
- history of allergy
- renal and hepatic function
- susceptibility to infection (i.e. whether immunocompromised)
- Ability to tolerate drugs by mouth
- severity of illness
- risk of complications
- ethnic origin
- age
- other medications
- if female (pregnant, breast-feeding or taking an oral contraceptive)
In patients receiving antibacterial prophylaxis who require acute treatment of bacterial infection what must be noted about the drug of choice?
an antibacterial from a different class should be used.
can viral infections be treated with antibacterials?
No
Can antibacterial be used to treat secondary bacterial infections?
antibacterials may be used to treat secondary bacterial infection (e.g. bacterial pneumonia secondary to influenza);
Is a narrow-spectrum antibacterial preferred over broad-spectrum?
Generally, narrow-spectrum antibacterials are preferred to broad-spectrum antibacterials unless there is a clear clinical indication (e.g. life-threatening sepsis);
What does the route of administration of an antibacterial often depend on?
The severity of the infection.
What route of administration of antibacterial do life threatening infections require?
Intravenous therapy
Antibacterials that are well absorbed may be given by mouth even for some serious infections.
Can intramuscular administration of antibacterial be used in children?
Whenever possible, painful intramuscular injections should be avoided in children;
What must the prescription for an antibacterial specify in terms of duration?
The prescription for an antibacterial should specify the duration of treatment or the date when treatment is to be reviewed.
Within how many hours should you review intravenous antibacterials?
within 48 hours and consider stepping down to oral antibacterials where possible.
Should patients identified as being at high risk of severe illness or death due to suspected sepsis be given a narrow or broad spectrum sepsis?
Should be given a broad spectrum antibacterial at the maximum recommended dose without delay (ideally within one hour)
In management of sepsis - patients at high risk should be monitored continuously if possible, and no less than every …. minutes?
No less than every 30 minutes
In England and Wales, registered medical practitioners must notify the proper officer at their local council or local health protection team of any patient(s) suspected of suffering from which diseases?
Anthrax Botulism Brucellosis Cholera COVID-19 Diarrhoea (infectious bloody) Diphtheria Encephalitis (acute) Food poisoning Haemolytic uraemic syndrome (HUS) Haemorrhagic fever (viral) Hepatitis (acute infectious) Legionnaires’ disease Leprosy Malaria Measles Meningitis (acute) Meningococcal septicaemia Mumps Paratyphoid fever Plague Poliomyelitis (acute) Rabies Rubella Severe acute respiratory syndrome (SARS) Scarlet fever Smallpox Streptococcal disease (Group A, invasive) Tetanus Tuberculosis Typhoid fever Typhus Whooping cough Yellow fever
What is Rheumatic fever?
Rheumatic fever (acute rheumatic fever) is a disease that can affect the heart, joints, brain, and skin. Rheumatic fever can develop if strep throat and scarlet fever infections are not treated properly. Early diagnosis of these infections and treatment with antibiotics are key to preventing rheumatic fever.
What are the antibacterials of choice for prophylaxis of rheumatic fever?
Phenoxymethylpenicillin or sulfadiazine.
What is meant by invasive group A streptococcal infection?
Some group A strep infections cause invasive disease. Invasive disease means that germs invade parts of the body that are normally free from germs.
What are the antibacterials of choice for prophylaxis of invasive group A streptococcal infection - prevention of secondary cases?
Phenoxymethylpenicillin.
Patients who are penicillin allergic, either erythromycin or azithromycin [unlicensed indication].
What are the antibacterials of choice for secondary prevention of meningococcal meningitis: prevention of secondary cases?
- Ciprofloxacin or
- Rifampicin or
- i/m ceftriaxone (unlicensed)
with haemophilius influenzae type b (Hib), the index case has a small, but significant risk of secondary Hib infection, particularly within how many months of the first episode?
- Within 6 months of the first episode
What does antibacterial prophylaxis of Hib aim to do?
Antibacterial prophylaxis aims to reduce the risk of secondary disease in the index case and among close contacts by eliminating asymptomatic pharyngeal carriage of Hib.
how many cases of Hib within how many days is considered as an outbreak for a pre-school or primary school setting?
2 or more cases of invasive Hib disease within 120 days
For all eligible contacts, antibacterial prophylaxis should be offered up to how many weeks after illness onset in the index case?
offered up to 4 weeks after illness onset in the index case
What are the drug of choice for antibacterial prophylaxis for Haemophilus influenzae type b infection: prevention of secondary disease?
First line:
Rifampicin;
Alternative if rifampicin unsuitable: ceftriaxone [unlicensed] (based on limited evidence), or oral ciprofloxacin [unlicensed] or azithromycin [unlicensed] (however effectiveness in healthy individuals has not been determined)
What are the drug of choice for prevention of secondary cases of diphtheria in non-immune patients?
Erythromycin (or another macrolide e.g. azithromycin or clarithromycin).
Treat for further 10 days if nasopharyngeal swabs positive after first 7 days treatment.
What is pertussis?
Pertussis, also known as whooping cough, is a highly contagious respiratory disease. It is caused by the bacterium Bordetella pertussis. Pertussis is known for uncontrollable, violent coughing which often makes it hard to breathe.
What is the antibacterial of choice for prophylaxis of pertussis?
Clarithromycin (or azithromycin or erythromycin).
Which antibacterial prophylaxis choices are used for operation on stomach or oesophagus?
Single dose of i/v gentamicin or i/v cefuroxime or i/v co-amoxiclav (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
How long before the operational procedure on stomach or oesophagus should the prophylactic antibiotic be given?
Intravenous antibacterial prophylaxis should be given up to 30 minutes before the procedure.
What if the patient is at high risk of meticillin-resistant staphyloccous aureus in prophylaxis of operations on stomach or oesophagus?
Add i/v teicoplanin (or vancomycin) if high risk of meticillin-resistant Staphylococcus aureus
What about prophylaxis of antibacterial of open biliary surgery?
Single dose of i/v cefuroxime + i/v metronidazole or i/v gentamicin + i/v metronidazole or i/v co-amoxiclav alone (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
Where i/v metronidazole is suggested, it may alternatively be given by suppository but to allow adequate absorption, it should be given 2 hours before surgery.
Which antibacterial prophylaxis is used in joint replacement including hip and knee?
Single dose of i/v cefuroxime alone or i/v flucloxacillin + i/v gentamicin (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
Which antibacterial prophylaxis is used in closed fractures?
Single dose of i/v cefuroxime or i/v flucloxacillin (additional intra-operative or postoperative doses may be given for prolonged procedures or if there is major blood loss).
Which antibacterial prophylaxis is used in high lower-limb amputation?
Use i/v co-amoxiclav alone or i/v cefuroxime + i/v metronidazole.
Intravenous antibacterial prophylaxis should be given up to 30 minutes before the procedure.
Continue antibacterial prophylaxis for at least 2 doses after procedure (max. duration of prophylaxis 5 days). If history of allergy to penicillin or to cephalosporins, or if high risk of meticillin-resistant Staphylococcus aureus, use i/v teicoplanin (or vancomycin) + i/v gentamicin + i/v metronidazole.
For the termination of pregnancy which antibacterial is used as prophylaxis?
Metronidazole single dose
What is endocarditis?
Endocarditis is a rare and potentially fatal infection of the inner lining of the heart (the endocardium).
It’s most commonly caused by bacteria entering the blood and travelling to the heart.
Is chlorhexidine mouthwash recommended for the prevention of infective endocarditis in at risk patients undergoing dental procedures?
No
Antibacterial prophylaxis is not routinely recommended for the prevention of infective endocarditis in patients undergoing which procedures?
dental;
upper and lower respiratory tract (including ear, nose, and throat procedures and bronchoscopy);
genito-urinary tract (including urological, gynaecological, and obstetric procedures);
upper and lower gastro-intestinal tract.
Patients at risk of infective endocarditis should be advised to do what?
advised to maintain good oral hygiene;
told how to recognise signs of infective endocarditis, and advised when to seek expert advice.
Do patients with prosthetic joint implants (including total hip replacements) require antibiotic prophylaxis for dental treatment?
No
What is the definition of septicemia?
Septicemia, or sepsis, is the clinical name for blood poisoning by bacteria. It is the body’s most extreme response to an infection. Sepsis that progresses to septic shock has a death rate as high as 50%, depending on the type of organism involved. Sepsis is a medical emergency and needs urgent medical treatment.
What is the antibacterial drug treatment for community acquired septicaemia?
A broad-spectrum antipseudomonal penicillin (e.g. piperacillin with tazobactam, ticarcillin with clavulanic acid) or a broad-spectrum cephalosporin (e.g. cefuroxime)
- If meticillin-resistant Staphylococcus aureus suspected, add vancomycin (or teicoplanin).
- If anaerobic infection suspected, add metronidazole to broad-spectrum cephalosporin.
- If other resistant micro-organisms suspected, use a more broad-spectrum beta-lactam antibacterial (e.g. meropenem).
What is the antibacterial of choice for hospital-acquired septicaemia?
A broad-spectrum antipseudomonal beta-lactam antibacterial (e.g. piperacillin with tazobactam, ticarcillin with clavulanic acid, ceftazidime, imipenem with cilastatin, or meropenem)
If meticillin-resistant Staphylococcus aureus suspected, add vancomycin (or teicoplanin).
If anaerobic infection suspected, add metronidazole to broad-spectrum cephalosporin
What is the treatment for septicaemia related to vascular catheter?
Vancomycin (or teicoplanin)
- If Gram-negative sepsis suspected, especially in the immunocompromised, add a broad-spectrum antipseudomonal beta-lactam.
- Consider removing vascular catheter, particularly if infection caused by Staphylococcus aureus, pseudomonas, or Candida species
What is the treatment for meningococcal septicaemia?
If meningococcal disease suspected, a single dose of benzylpenicillin sodium should be given before urgent transfer to hospital, so long as this does not delay the transfer; cefotaxime may be an alternative in penicillin allergy; chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or to cephalosporins.
To eliminate nasopharyngeal carriage, ciprofloxacin, or rifampicin, or ceftriaxone may be used.
What is the treatment (antibacterial) for initial ‘blind’ therapy?
Native valve endocarditis, amoxicillin (or ampicillin)
Consider adding low-dose gentamicin
If penicillin-allergic, or if meticillin-resistant Staphylococcus aureus suspected, or if severe sepsis, use vancomycin + low-dose gentamicin
If severe sepsis with risk factors for Gram-negative infection, use vancomycin + meropenem
If prosthetic valve endocarditis, vancomycin + rifampicin + low-dose gentamicin
What is the antibacterial of choice for endocarditis (native valve) caused by staphylococci?
Flucloxacillin:
Suggested duration of treatment 4 weeks (at least 6 weeks if secondary lung abscess or osteomyelitis also present)
If penicillin-allergic or if meticillin-resistant Staphylococcus aureus, vancomycin + rifampicin
Suggested duration of treatment 4 weeks (at least 6 weeks if secondary lung absecess or osteomyelitis also present)
What is the antibacterial of choice for endocarditis caused by fully-sensitive streptococci?
Benzylpenicillin sodium
Suggested duration of treatment 4–6 weeks (6 weeks for prosthetic valve endocarditis)
If penicillin-allergic, vancomycin (or teicoplanin) + low-dose gentamicin
Suggested duration of treatment 4–6 weeks (stop gentamicin after 2 weeks)
If meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) suspected should benzylpenicillin sodium be given before transfer to hospital?
Yes so long as this does not delay the transfer.
If meningococcal disease is suspected but patient has penicillin allergy meaning first line benzylpenicillin sodium is not suitable, what alternative can be given?
Cefotaxime
What if both benzylpenicillin and cefotaxime are not suitable?
chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or to cephalosporins.
In particularly in adults if pneumococcal meningitis in hospital what other drug should be considered as adjunct treatment?
In hospital, consider adjunctive treatment with dexamethasone (particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial; avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or in meningitis following surgery.
In hospital for treatment of meningitis if aetiology is unknown then which drugs are adminstered?
Suggested duration of treatment at least 10 days
Adult and child 3 months–50 years,
- cefotaxime (or ceftriaxone
Adult over 50 years - cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin
(Over 50 years old - add amoxicillin or ampicillin)
What is the treatment for meningitis caused by meningococci?
Benzylpenicillin sodium or cefotaxime (or ceftriaxone)
(Suggested duration of treatment 7 days)
If history of immediate hypersensitivity reaction to penicillin or to cephalosporins, chloramphenicol
Suggested duration of treatment 7 days.
What is the treatment of meningitis caused by pneuomococci?
Cefotaxime (or ceftriaxone)
Consider adjunctive treatment with dexamethasone, preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial (may reduce penetration of vancomycin into cerebrospinal fluid).
If micro-organism penicillin-sensitive, replace cefotaxime with benzylpenicillin sodium.
If micro-organism highly penicillin- and cephalosporin-resistant, add vancomycin and if necessary rifampicin.
Suggested duration of antibacterial treatment 14 days
What is the treatment of Meningitis caused by Haemophilus influenzae?
Cefotaxime (or ceftriaxone)
Consider adjunctive treatment with dexamethasone, preferably starting before or with first dose of antibacterial, but no later than 12 hours after starting antibacterial.
Suggested duration of antibacterial treatment 10 days.
For H. influenzae type b give rifampicin for 4 days before hospital discharge to those under 10 years of age or to those in contact with vulnerable household contacts
What is the treatment of meningitis caused by listeria?
Amoxicillin (or ampicillin) + gentamicin
Suggested duration of treatment 21 days.
Consider stopping gentamicin after 7 days.
If history of immediate hypersensitivity reaction to penicillin, co-trimoxazole
Suggested duration of treatment 21 days.
What diabetic foot infection defined as?
as any type of skin, soft tissue or bone infection below the ankle in patients with diabetes.
It includes cellulitis, paronychia, abscesses, myositis, tendonitis, necrotising fasciitis, osteomyelitis, and septic arthritis
What id diabetic foot infection clinically defined by the presence of?
It is defined clinically by the presence of at least 2 of the following: local swelling or induration, erythema (type of rash caused by injured or inflamed blood capillaries), local tenderness or pain, local warmth, or purulent discharge.
What is the treatment for mild diabetic foot infection?
Oral first line - Flucloxacillin
- Alternative in penicillin allergy or flucloxacillin unsuitable: clarithromycin, doxycycline, or erythromycin (in pregnancy)
What is oteomyelitis?
Osteomyelitis is an infection that usually causes pain in the long bones in the legs.
What is the antibacterial treatment for moderate to severe diabetic foot infection?
Oral or Intravenous first line:
Flucloxacillinwith or without intravenous gentamicin and/or metronidazole, or co-amoxiclav with or without intravenous gentamicin, or intravenous ceftriaxone with metronidazole.
Alternative in penicillin allergy: co-trimoxazole [unlicensed] with or without intravenous gentamicin and/or metronidazole.
Additional antibacterial choices if Pseudomonas aeruginosa suspected or confirmed: intravenous piperacillin with tazobactam, or clindamycin with ciprofloxacin and/or intravenous gentamicin.
If meticillin-resistant Staphylococcus aureus (MRSA) confirmed or suspected add intravenous vancomycin, or intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
Other antibacterials may be appropriate based on microbiological results and specialist advice.
What does otitis mean?
inflammation of the ear - inflammation is usually due to an infection
What is the difference between otitis externa and otitis media?
Otitis externa means that the inflammation is confined to the external part of the ear canal and does not go further than the eardrum.
(Otitis Media), is an infection of the middle ear.
Which organisms can cause otitis externa?
Otitis externa is inflammation of the external ear canal; it can be triggered by a bacterial infection caused by Pseudomonas aeruginosa or Staphylococcus aureus.
Oral antibacterials are rarely indicated but if they are required, consider seeking specialist advice.
What is the choice of antibacterial therapy for otitis externa?
No penicillin allergy -
Flucloxacillin
Penicillin allergy or intolerance -
Clarithromycin (or azithromycin or erythromycin)
If pseudomonas suspected -
Ciprofloxacin (or an aminoglycoside)
Which is seen commonly in children - otitis externa or media?
Otitis media
What is the choice of antibacterial therapy in children for otitis media?
No penicillin allergy
First line: amoxicillin.
Second line (worsening symptoms despite 2 to 3 days of antibacterial treatment): co-amoxiclav.
Penicillin allergy or intolerance First line: clarithromycin or erythromycin. Second line (worsening symptoms despite 2 to 3 days of antibacterial treatment): consult local microbiologist.
Does gastro-enteritis require antibiotic treatment?
Frequently self-limiting and may not be bacterial.
Antibacterial not usually indicated
Does campylobacter enteritis require antibiotic treatment?
Frequently self-limiting; treat if immunocompromised or if severe infection.
Clarithromycin (or azithromycin or erythromycin)
Alternative, ciprofloxacin
Strains with decreased sensitivity to ciprofloxacin isolated frequently
What is diverticulitis, acute?
Acute diverticulitis is a condition where diverticula (small pouches protruding from the walls of the large intestine) suddenly become inflamed or infected.
Which patients should be treated for acute diverticulitis?
For patients with acute diverticulitis who are systemically well, consider a watchful waiting and a no antibacterial prescribing strategy. Advise patients to re-present if symptoms persist or worsen.
For patients who are systemically unwell, immunosuppressed, or have significant comorbidities, an antibacterial prescribing strategy should be offered.
What is the choice of antibiotic therapy for acute diverticulitis?
Patients unable to take oral treatment should be referred to hospital.
Suspected or confirmed uncomplicated acute diverticulitis
Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: cefalexin (caution in penicillin allergy) with metronidazole, or trimethoprim with metronidazole, or ciprofloxacin (only if switching from intravenous route with specialist advice) with metronidazole.
Suspected or confirmed complicated acute diverticulitis
Intravenous first line:
Co-amoxiclav, or cefuroxime with metronidazole, or amoxicillin with gentamicin and metronidazole.
Alternative in penicillin and cephalosporins allergy: ciprofloxacin with metronidazole.
For alternative antibacterials consult local microbiologist.
Are all patients with salmonella treated with antibiotics?
Treat invasive or severe infection. Do not treat less severe infection unless there is a risk of developing invasive infection (e.g. immunocompromised patients, those with haemoglobinopathy, or children under 6 months of age).
Which antibiotics are used in salmonella?
Ciprofloxacin or cefotaxime
What is the antibiotic therapy for typhoid fever?
Cefotaxime (or ceftriaxone)
azithromycin may be an alternative in mild or moderate disease caused by multiple-antibacterial-resistant organisms
In which patients is C.difficile most common in?
in patients who are currently taking or have recently taken antibacterials.
Which antibiotics have been associated with causing C.difficile infection?
Clindamycin, cephalosporins (especially third and fourth generation), fluoroquinolones, and broad-spectrum penicillins have been frequently associated with C. difficile infection.
Other than antibiotics, what are other risk factors of C.difficile?
Other risk factors for C. difficile infection include current use of acid suppressing drugs (such as proton pump inhibitors), age over 65 years, prolonged hospitalisation, underlying comorbidity, exposure to other people with the infection, and previous history of C. difficile infection(s).
Are antibacterial recommended for preventing C.difficile?
No
How long may diarrhoea symptom associated with C.difficile infection take to resolve while on antibiotics?
1-2 weeks
What is the treatment of first episode of mild, moderate or severe C.difficile infection?
Oral first line:
Vancomycin.
Oral second line:
Fidaxomicin.
If first and second line antibacterials are ineffective: seek specialist advice.
What is the treatment for further episode of C.difficile infection?
Oral first line for infection within 12 weeks of symptom resolution (relapse):
Fidaxomicin.
Oral first line for infection more than 12 weeks after symptom resolution (recurrence):
Vancomycin or fidaxomicin.
For life threatening C-Difficile what may be offered?
pecialist may offer oral vancomycin with intravenous metronidazole
Which drugs would you use in biliary-tract infections?
- Ciprofloxacin or gentamicin or cephalosporin
What is peritonitis?
Peritonitis is a redness and swelling (inflammation) of the tissue that lines your belly or abdomen. This tissue is called the peritoneum. It can be a serious, deadly disease.
Which drugs are offered for peitonitis?
A cephalosporin + metronidazole or gentamicin + metronidazole or gentamicin + clindamycin or piperacillin with tazobactam alone
What is the antibiotic of choice for bacterial vaginosis?
Oral metronidazole
Suggested duration of treatment 5–7 days (or high-dose metronidazole as a single dose)
Alternatively, topical metronidazole for 5 days or topical clindamycin for 7 days
What are the antibiotic choices for treating chlamydia infections and duration of each?
Azithromycin (as a single dose)
or
Doxycycline for 7 days
Alternatively,
Erythromycin for 14 days
When is treatment for gonorrhoea recommended?
Treatment is only recommended for those presenting within 14 days of exposure, or those presenting 14 days after exposure with a positive test.
For gonorrhoea, how long should sexual intercourse be avoided while getting treated?
Sexual intercourse should be avoided until 7 days after patients and their partner(s) have completed treatment.
What are the drug choices for gonorrhoea (uncomplicated)?
First line:
If antimicrobial susceptibility unknown: intramuscular ceftriaxone.
If micro-organism is sensitive to ciprofloxacin: oral ciprofloxacin.
Alternatives due to allergy, needle phobia or contra-indications:
Intramuscular gentamicin plus oral azithromycin.
If parenteral administration is not possible: oral cefixime [unlicensed] plus oral azithromycin.
In non-pharyngeal infections: intramuscular spectinomycin [unlicensed] plus oral azithromycin.
If unable to take standard therapy: oral azithromycin.
What is the treatment choice for pelvic inflammatory disease?
Doxycycline + metronidazole + single-dose of i/m ceftriaxone
or
ofloxacin + metronidazole
Suggested duration of treatment 14 days (except i/m ceftriaxone).
What is the recommended antibiotic treatment for early syphilis (infection of less than 2 years)?
Benzathine benzylpenicillin
Suggested duration of treatment single-dose (repeat dose after 7 days for women in the third trimester of pregnancy)
Alternatively, doxycycline or erythromycin
Suggested duration of treatment 14 days
What is the recommended antibiotic treatment for late latent syphilis (Asymptomatic infection of more than 2 years)?
Benzathine benzylpenicillin
Suggested duration of treatment once weekly for 2 weeks
Alternatively, doxycycline
Suggested duration of treatment 28 days
What antibiotic is recommended for asymptomatic contacts of patients with infectious syphyllis?
Doxycycline
Suggested duration of treatment 14 days
What is the antibiotic drug treatment for osteomyelitis?
Flucloxacillin
Consider adding fusidic acid or rifampicin for initial 2 weeks.
Suggested duration of treatment 6 weeks for acute infection
If penicillin-allergic, clindamycin
Consider adding fusidic acid or rifampicin for initial 2 weeks.
Suggested duration of treatment 6 weeks for acute infection
If meticillin-resistantStaphylococcus aureussuspected, vancomycin (or teicoplanin)
Consider adding fusidic acid or rifampicin for initial 2 weeks.
Suggested duration of treatment 6 weeks for acute infection
Which antibiotics are recommended for septic arthritis?
Flucloxacillin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If penicillin-allergic, clindamycin
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If meticillin-resistantStaphylococcus aureussuspected, vancomycin (or teicoplanin)
Suggested duration of treatment 4–6 weeks (longer if infection complicated).
If gonococcal arthritis or Gram-negative infection suspected, cefotaxime (or ceftriaxone)
Suggested duration of treatment 4–6 weeks (longer if infection complicated; treat gonococcal infection for 2 weeks).
What is the causative organism for sinusitis (acute)?
Acute sinusitis is generally triggered by a viral infection, although occasionally it may become complicated by a bacterial infection caused by Streptococcus pneumoniae, Haemophylus influenzae, Moraxella catharrhalis, or Staphylococcus aureus.
What is the antibiotic treatment for sinusitis for someone with no penicillin allergy?
No penicillin allergy
First line:
Non-life threatening symptoms: phenoxymethylpenicillin.
Systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications: co-amoxiclav.
Second line (worsening symptoms despite 2 or 3 days of antibiotic treatment):
Non-life threatening symptoms: co-amoxiclav.
Systemically very unwell, signs and symptoms of a more serious illness or at high-risk of complications: consult local microbiologist.
What is the antibiotic treatment for sinusitis for someone with a penicillin allergy or intolerance?
First line: doxycycline or clarithromycin (erythromycin in pregnancy).
Second line (worsening symptoms despite 2 or 3 days of antibiotic treatment): consult local microbiologist.
If the oral infection fails to respond to antibacterial treatment within 48 hours what should you do about the antibacterial?
The antibiotic should be changed, preferably on the basis of bacteriological investigation.
Which combination may sometimes be helpful for the treatment of severe oral infections or oral infections that have not responded to initial antibacterial treatment?
- Combination of a penicillin (or a macrolide) with metronidazole
Which penicillin is effective for dentoalveolar abscess?
Phenoxymethylpenicillin
Which is better absorbed - amoxicillin or phenoxymethylpenicillin?
Amoxicillin however it may encourage emergence of resistant organisms
Are phenoxymethylpenicillin or amoxicillin effective against bacteria that produce beta-lactamases?
No they are not effective
Which antibiotic can be used and is active against beta-lactamase-producing bacteria that are resistant to amoxicillin?
Co-amoxiclav is active against beta-lactamase-producing bacteria that are resistant to amoxicillin
Out of the three (doxycycline, tetracycline or oxytetracyline) which has a longer duration of action?
Doxycycline
Which antibiotics are recommended in bronchiectasis (non-cystic fibrosis)?
The recommended total duration of treatment is 7–14 days.
Treatment should be guided by the most recent sputum culture and susceptibility results when available.
Oral first line:
Amoxicillin, clarithromycin, or doxycycline.
Alternative if at high risk of treatment failure (repeated courses of antibacterials, previous culture with resistant or atypical bacteria, or high risk of complications): co-amoxiclav, or levofloxacin.
Intravenous first line (severely unwell or unable to take oral treatment):
Co-amoxiclav, piperacillin with tazobactam, or levofloxacin.
For COPD acute exacerbations - what should be taken into account when considering antibiotic treatment?
Many exacerbations are not caused by bacterial infections, but instead can be triggered by other factors such as smoking or viral infections.
Consider antibacterial treatment taking into account:
The severity of symptoms, sputum colour changes and increases in volume and thickness;
The need for hospital admission;
Previous exacerbations and hospital admission history, and risk of developing complications.
What is the treatment options for COPD acute exarcerbations?
The recommended total duration of treatment is 5 days.
Oral first line:
Amoxicillin, clarithromycin, or doxycycline.
Alternative if at high risk of treatment failure (repeated courses of antibacterials, previous culture with resistant or atypical bacteria, or high risk of complications): co-amoxiclav, or levofloxacin.
Oral second line (if no improvement after at least 2 to 3 days):
Use a first line antibacterial from a different class to the antibacterial used previously.
Alternative if at high risk of treatment failure: co-amoxiclav, levofloxacin, or co-trimoxazole (only when sensitivities are available and there is good reason to use co-trimoxazole over single antibacterials).
Intravenous first line (severely unwell or unable to take oral treatment):
Amoxicillin, co-amoxiclav, clarithromycin, co-trimoxazole, or piperacillin with tazobactam.
Acute cough is usually self limiting and often resolves within how many weeks?
3-4 weeks without antibacterials
Which patients with an acute cough be offered antibacterials?
Patients with an acute cough who are systemically very unwell should be offered immediate antibacterial treatment.
Which patients are at a higher risk of complications if they present with an acute cough?
Patients with a pre-existing co-morbidity, young children who were born prematurely, and patients aged over 65 years of age and the presence of certain criteria (hospitalisation in the previous year, type 1 or 2 diabetes, history of congestive heart failure, or currently taking oral corticosteroids)
What is the choice of antibacterial therapy for acute cough?
The recommended duration of oral treatment is 5 days.
First line
Doxycycline.
Alternative first line choices: amoxicillin, clarithromycin, or erythromycin.
Choice during pregnancy:
Amoxicillin or erythromycin.
Which organ does pneumonia affect?
Lungs
What are the symptoms of pneumonia?
cough, chest pain, dyspnoea, and fever.
For community acquired pneumonia treatment within how many hours of diagnosis should antibacterial treatment be started?
As soon as possible within 4 hours
within 1 hour if the patient has suspected sepsis and meets any of the high risk criteria for this
In patients with moderate or high-severity community acquired pneumonia - what should be obtained?
obtain blood and sputum cultures and consider performing pneumococcal and legionella urinary antigen tests.
Which tools are used to assess community-acquired pneumonia?
CRB65 or CURB65
What is the antibiotic drug choice in community acquired pneumonia?
Low severity
Oral first line:
Amoxicillin.
Alternative in penicillin allergy or amoxicillin unsuitable (e.g. atypical pathogens suspected): clarithromycin, doxycycline, or erythromycin (in pregnancy).
Moderate severity
Oral first line:
Amoxicillin.
If atypical pathogens suspected: amoxicillin with clarithromycin or erythromycin (in pregnancy).
Alternative in penicillin allergy: clarithromycin, or doxycycline.
High severity
Oral or Intravenous first line:
Co-amoxiclav with clarithromycin or oral erythromycin (in pregnancy).
Alternative in penicillin allergy: levofloxacin (consult local microbiologist if fluoroquinolone not appropriate).
For hospital acquired pneumonia - within how many hours of hospital hours if symptoms show should you follow recommendations for patients with community acquired pneumonia?
Within 48 hours
What factors cause a higher risk of resistance in hospital-acquired pneumonia?
Higher risk of resistance includes signs or symptoms starting more than 5 days after hospital admission, relevant comorbidity, recent use of broad-spectrum antibacterials, colonisation with multidrug-resistant bacteria, and recent contact with a health or social care setting before the current admission.
For Hospital acquired pneumonia - for non severe signs or symptoms and not at higher risk of resistance which antibiotics are recommended?
Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable (based on specialist microbiological advice and local resistance data): doxycycline, cefalexin (caution in penicillin allergy), co-trimoxazole [unlicensed], or levofloxacin [unlicensed] (only if switching from intravenous levofloxacin under specialist advice).
For Hospital acquired pneumonia - for severe signs or symptoms or at a higher risk of resistance - which antibiotics are recommended?
ntravenous first line:
Piperacillin with tazobactam, ceftazidime, ceftazidime with avibactam, ceftriaxone, cefuroxime, levofloxacin [unlicensed], or meropenem.
If meticillin-resistant Staphylococcus aureus confirmed or suspected add vancomycin, or teicoplanin, or linezolid (under specialist advice only if vancomycin cannot be used)
Does impetigo (a bacterial infection of the skin) affect all age groups?
Yes but it is more common in young children.
What are the two main clinical forms of impetigo?
Non-bullous impetigo (most common)
Bullous impetigo
What is the difference between non-bullous and bullous impetigo?
Non-bullous impetigo is characterised by thin-walled vesicles or pustules that rupture quickly, forming a golden-brown crust, while bullous impetigo is characterised by the presence of fluid-filled vesicles and blisters that rupture, leaving a thin, flat, yellow-brown crust.
What is the first line treatment for localised non-bullous impetigo for someone who is not systemically unwell or at high risk of complications?
- Hydrogen peroxide 1% cream
- If unsuitable (e.g. impetigo is around the eyes), offer a topical antibacterial
In widespread non-bullous impetigo in patients who are not systemically unwell or at high risk of complications, what is used for the treatment?
offer a topical or oral antibacterial.
In patients with non-bullous impetigo who are systemically unwell or at high risk of complications and in all patients with bullous impetigo, what is offered?
- Offer an oral antibacterial
For impetigo, is a combination treatment of oral and topical antibacterial recommended?
No
What is the choice of antibacterial therapy for impetigo?
Topical first line if hydrogen peroxide unsuitable or ineffective:
- fusidic acid
Alternative if fusidic acid resistance suspected or confirmed:
- Mupirocin (bactroban)
Oral first line:
Flucloxacillin.
Alternative if penicillin allergy or flucloxacillin unsuitable: clarithromycin or erythromycin (in pregnancy).
Cellulitis and erysipelas are infections of which part of the tissues?
Of the subcutaneous tissues, which usually result from the contamination of a break in the skin
Are lesions more superficial in cellulitis or erysipelas?
In erysipelas and have well-defined and raised margin
What are the first choice antibiotics for Cellulitis or erysipelas
Flucloxacillin.
Alternative in penicillin allergy or flucloxacillin unsuitable: clarithromycin, oral erythromycin (in pregnancy), or oral doxycycline.
Oral or Intravenous first line if infection near the eyes or nose:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: clarithromycin with metronidazole.
What are the alternative choice antibiotics for severe cellulitis or erysipelas infection?
Oral or Intravenous:
Co-amoxiclav, clindamycin, intravenous cefuroxime, or intravenous ceftriaxone (ambulatory care only).
If meticillin-resistant Staphylococcus aureus confirmed or suspected, add intravenous vancomycin, intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
For ambulatory care, and in MRSA confirmed or suspected infections, other antibacterials may be appropriate based on microbiological results and specialist advice.
In which patients who have had cellulitis or erysipelas may prophylactic antibiotics be considered?
For patients who have been treated in hospital, or under specialist advice, for at least 2 separate episodes of cellulitis or erysipelas in the previous 12 months, a trial of antibacterial prophylaxis may be considered by a specialist.
What if cellulitis or erysipelas returns even when on prophylactic antibiotics?
If cellulitis or erysipelas recurs, stop or change the prophylactic antibacterial to an alternative once the acute infection has been treated.
Where do leg ulcers usually develop?
On the lower leg - between the shin and the ankle
how long do leg ulcers take to heal?
Take more than 4-6 weeks to heal
What are the signs and symptoms of an infected leg ulcer?
- redness (may be less visible on darker skin tones)
- swelling spreading beyond the ulcer
- localised warmth
- Increased pain
- fever
Is taking a sample for microbiological testing at initial presentation with a leg ulcer recommended?
No even if the ulcer is infected
What is the antiobiotic of choice for leg ulcer in non-severely unwell patients?
Oral first line:
Flucloxacillin.
Alternative in penicillin allergy or flucloxacillin unsuitable: doxycycline, clarithromycin, or erythromycin (in pregnancy).
Oral second line (guided by microbiological results when available):
Co-amoxiclav.
Alternative in penicillin allergy: co-trimoxazole [unlicensed].
What is the anitibiotic of choice for leg ulcer in severely unwell patients?
Oral or Intravenous first line (guided by microbiological results if available):
Intravenous flucloxacillin with or without intravenous gentamicin and/or metronidazole, or intravenous co-amoxiclav with or without intravenous gentamicin.
Alternative in penicillin allergy: intravenous co-trimoxazole [unlicensed] with or without intravenous gentamicin and/or metronidazole.
Oral or Intravenous second line (guided by microbiological results when available or following specialist advice):
Intravenous piperacillin with tazobactam, or intravenous ceftriaxone with or without metronidazole.
Which antibacterials can be added if MRSA infection suspected or confirmed?
Oral or Intravenous (in addition to antibacterials listed above):
Intravenous vancomycin, intravenous teicoplanin, or linezolid (specialist use only if vancomycin or teicoplanin cannot be used).
Which patients with insect bites and stings should be considered for referral?
Consider referral or seeking specialist advice for patients with fever or persistent lesions after an insect bite or sting from outside the UK, as this may indicate a more serious illness such as rickettsial infection or malaria.
Patients with a human or animal bite should be assessed for what?
their risk of tetanus, rabies, or a blood-borne viral infection (such as HIV, and hepatitis B and C), and should be managed accordingly.
In which conditions would you offer antibacterial prophylaxis for an uninfected bite?
ffer antibacterial prophylaxis to patients with a:
cat or human bite that has broken the skin and drawn blood; or
dog or other traditional pet bite (excluding cat bites) that has broken the skin and drawn blood if it:
has penetrated bone, joint, tendon or vascular structures;
is deep, a puncture or crush wound, or has caused significant tissue damage; or
is visibly contaminated (for example if there is dirt or a tooth in the wound).
In which conditions would you consider antibacterial prophylaxis for an uninfected bite?
Consider antibacterial prophylaxis in a patient with:
a cat bite that has broken the skin but not drawn blood and the wound could be deep; or
a human bite that has broken the skin but not drawn blood, or a dog or other traditional pet bite (excluding cat bites) that has broken the skin and drawn blood, if it:
involves a high-risk area (such as the hands, feet, face, genitals, skin overlying cartilaginous structures, or an area of poor circulation), or
is in an individual at risk of a serious wound infection because of a comorbidity (such as diabetes, immunosuppression, asplenia, or decompensated liver disease).
What are the choice of antibacterial for human/ animal bites?
Oral first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: doxycycline with metronidazole; seek specialist advice in pregnancy.
Intravenous first line:
Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: cefuroxime or ceftriaxone, with metronidazole; seek specialist advice if a cephalosporin is not appropriate.
What are some common secondary bacterial infections of common skin conditions?
eczema, psoriasis, scabies, and shingles
Are antibacterial recommended for chickenpox, psoriasis, scabies and shingles?
No - there is no evidence available for antibacterial use
What are the signs and symptoms of secondary bacterial infection of eczema?
weeping, pustules, crusts, no response to treatment, rapidly worsening eczema, fever, and malaise.
Even if weeping and crusts are present, not all eczema flares are caused by a bacterial infection.
What are the antibacterial of choice for secondary bacterial infection of eczema?
Topical first line:
Fusidic acid.
If fusidic acid unsuitable or ineffective: offer an oral antibacterial.
Oral first line:
Flucloxacillin.
Alternative if penicillin allergy or flucloxacillin unsuitable: clarithromycin or erythromycin (in pregnancy).
What is mastitis?
Mastitis is an inflammation of breast tissue that sometimes involves an infection. The inflammation results in breast pain, swelling, warmth and redness. You might also have fever and chills. Mastitis most commonly affects women who are breast-feeding (lactation mastitis).
When would you treat mastitis with antibacterials?
Treat if severe, if systemically unwell, if nipple fissure present, if symptoms do not improve after 12–24 hours of effective milk removal, or if culture indicates infection. Continue breast-feeding or expressing milk during treatment.
What are the drug treatment of choice for treating mastitis during breast-feeding?
Flucloxacillin
Suggested duration of treatment 10–14 days.
If penicillin-allergic, erythromycin
Suggested duration of treatment 10–14 days.
As a summary, what is endocarditis treated with?
Treated ‘blind’ with amoxicillin then gentamicin until the causative organism is identified
What is acute exacerbations of COPD or chronic bronchitis treated with?
Amoxicillin or a tetracycline (Doxycyline usually)
What is used to treat community acquired pneuomonia?
Amoxicillin + clarithromycin (if atypical pathogens present)
What is used to treat non severe hospital acquired pneumonia?
Co-amoxiclav
What are used to treated UTIs in general?
Trimethoprim or nitrofurantoin
What are chlamydia and gonorrhoea treated with?
Azithromycin
What is used for septicaemia?
PIPERACILLIN WITH TAZOBACTAM
What is used to treated gingivitis?
Metronidazole
What is otitis externa treated with?
Flucloxacillin
What is otitis media treated with?
Amoxicillin
What antibiotic is cellulitis treated with?
Flucloxacillin
Patients with Asplenia or Sickle-cell disease are prophylactically treated for Pneumococcal infection with which antibiotic?
Phenoxymethylpenicillin
Which antibiotics are used for the prophylaxis of meningococcal meningitis?
Ciprofloxacin or rifampicin
Is vancomycin an aminoglycoside or a glycopeptides antibiotic?
glycopeptide
Give examples of aminoglycoside antibiotics?
- Amikacin
- Gentamicin
- Neomycin sulfate
- Streptomycin
- tobramycin
Are all of the aminoglycoside antibiotics bacteriostatic or bactericidal?
Bactericidal
What activity do aminoglycosides have on gram positive and gram negative bacteria?
Are active against some gram-positive and many gram-negative organisms
Which aminoglycosides are also active against pseudomonas aeruginosa?
Amikacin, gentamicin and tobramycin
Which aminoglycoside is active against mycobacterium tuberculosis?
streptomycin is active against Mycobacterium tuberculosis and is now almost entirely reserved for tuberculosis.
Why must aminoglycosides be given by injection for systemic infections?
The aminoglycosides are not absorbed from the gut (although there is a risk of absorption in inflammatory bowel disease and liver failure) and must therefore be given by injection for systemic infections.
Which aminoglycoside is the drug of choice in the UK?
Gentamicin
Is gentamicin broad spectrum?
Yes
Is gentamicin active against anaerobes?
inactive against anaerobes and has poor activity against haemolytic streptococci and pneumococci.
When gentamicin is given in ‘blind’ therapy for undiagnosed serious infections which other drugs is it usually given with?
with a penicillin or metronidazole (or both)
What are the loading and maintenance doses of gentamicin calculated based on?
on the basis of the patient’s weight and renal function (e.g. using a nomogram); adjustments are then made according to serum-gentamicin concentrations. High doses are occasionally indicated for serious infections, especially in the neonate, in the patient with cystic fibrosis, or in the immunocompromised patient.
Whenever possible, treatment with gentamicin should not exceed how many days?
Should not exceed 7 days
Which is more stable to enzyme inactivation - Gentamicin or amikacin?
Gentamicin
