Infection treatment

Question 1

Treatment of cellulitis

Answer 1

Oral or IV:
[1] Flucloxacillin
Pen allergy: clarithromycin, oral erythromycin (preg) or oral doxy

If infection near nose or eyes:
[1] Co-amoxiclav
Pen allergy: clarithromycin WITH metronidazole

Severe infection, oral or IV:
Co-amoxiclav, clindamycin, IV cefuroxime or IV ceftriaxone (ambulatory care only)
MRSA suspected: Add IV vancomycin/teicoplanin/linezolid (if teic and vanc can’t be used)

Question 2

Treatment of animal/human bite

Answer 2

Oral:
[1] co-amoxiclav
Pen allergy - doxycycline WITH metronidazole

IV:
First line - co-amoxiclav
Pen allergy - cefuroxime or cetriaxone WITH metronidazole

Symptomatic: 5 days (treatment)

Non-symptomatic: 3 days (prophylaxis)

Question 3

Treatment of endocarditis

Answer 3

Amoxicillin +/- low dose gentamicin
+ Vancomycin if MRSA suspected/pen allergy

Flucloxacillin in staphylococci
Benzylpenicillin in streptococci

Question 4

Treatment of bacterial meningitis

Answer 4

Benzylpenicillin (IV or IM)

• Child <1 year 300mg
• Child 1-9: 600mg
• Adult/child 10+: 1.2g

Pen allergic - cefotaxime (or Chloramphenicol in immediate anaphylaxis reaction to penicillins)

Dexamethasone as adjuvant

Question 5

Treatment of osteomyelitis

Answer 5

6 weeks for each treatment
[1] Flucloxacillin

If penicillin allergic: Clindamycin

If MRSA suspected: Vancomycin/Teicoplanin

Consider adding fusidic acid or rifampicin for initial 2 weeks (for all options)

Question 6

Treatment for community acquired pneumonia (low, med and high severity)

Answer 6

5 days’ treatment duration for all

Low severity:
[1] Amoxicillin 500mg TDS
[2] Doxycycline, Clarithromycin or Erythromycin in pregnancy

Moderate severity:
[1] Amoxicillin (If atypicals suspected, add clarithromycin/erythromycin )
[2] Doxycycline, Clarithromycin or Erythromycin in pregnancy

High severity (oral or IV):
[1] Co-amoxiclav + clarithromycin/erythromycin
If penicillin allergic: Levofloxacin

Question 7

What makes HAP early onset

Answer 7

Less than five days after admission to hospital

Question 8

Treatment for early and late onset hospital acquired pneumonia?

Answer 8

Oral (if non-severe):
[1] Co-amoxiclav 500/125mg TDS
[2 - adult] Doxycycline or Cefalexin or Co-trimoxazole (unlicensed) or Levofloxacin (unlicensed)
[2 - children] Clarithromycin

IV (severe or high risk of resistance):
Piperacillin with tazobactam, Ceftazidime (+/- avibactam), ceftriaxone, levofloxacin (unlicensed) or meropenem

MRSA suspected: Add Vancomycin/Teicoplanin/Linezolid

Pseudomonas suspected: Add Aminoglycoside (Gentamicin, Amikacin)

Question 9

Treatment for infective exacerbation of COPD

increased sputum/change in colour and SoB

Answer 9

Amoxicillin 500mg TDS OR
Doxycycline 200mg on day 1 then 100mg OD OR
Clarithromycin 500mg BD

For 5 days

(Avoid Clarithromycin if already taking Azithromycin prophylactically)

Question 10

Pylenophritis (Upper UTI)

Answer 10

[1] Cefalexin 500mg BD - TDS for 7-10 days OR Ciprofloxacin (Cefalexin if pregnant)
If sensitivity known: co-amoxiclav or trimethoprim

IV (if severe or unable to swallow)

• Amikacin, gentamicin, ceftriazone, cefuroxime, ciprofloxacin
• Cefuroxime if pregnant

Question 11

What is the treatment for meningococcal meningitis?

Answer 11

[1] Benzylpenicillin
[2] Cefotaxime
[3] Chloramphenicol for 7 days

Question 12

What is the treatment for pneumococcal meningitis?

Answer 12

[1] Cefotaxime (OR ceftriaxone)

• If pen sensitive: replace with Benzylpenicillin
• If resistant: vancomycin/rifampicin

For 14 days

Consider adding dexamethasone (started no later than 14 hours after staring antibiotic)

Question 13

What is the treatment for meningitis caused by haemophilus influenza?

Answer 13

[1] Cefotaxime (OR ceftriaxone)

For 10 days

Consider adding dexamethasone

Question 14

What is the treatment for meningitis caused by listeria?

Answer 14

• Amoxicillin [or ampicillin] + gentamicin

- Co-trimoxazole [ if pen allergic]

Question 15

Symptoms suggestive of meningitis

Answer 15

stiff neck, non-blanching rash, fever, sensitivity to light

Question 16

Treatment for diabetic foot infection

Answer 16

Mild infection (less than 2cm)
[1] Flucloxacillin
If pen allergy: clarithromycin, doxycycline or erythromycin in pregnancy

Moderate/severe infection (abscess, osteomyelitis)
[1] Flucloxacillin or Co-amoxiclav +/- Gentamicin
Penicillin allergy: Co-trimoxazole +/- Gentamicin

min. 7 days treatment and up to 6 weeks for osteomyelitis.
IV treatment - at least 48 hours

Question 17

Treatment for diabetic foot infection

Answer 17

MILD INFECTION (LESS THAN 2CM):
[1] Flucloxacillin 500mg to 1g QDS for 7 days
If pen allergy: clarithromycin, doxycycline or erythromycin in pregnancy

MODERATE/SEVERE INFECTION (ABSCESS, OSTEOMYELITIS):
[1] Flucloxacillin or Co-amoxiclav +/- Gentamicin
Penicilllin allergy: Co-trimoxazole +/- Gentamicin

Min. 7 days treatment and up to 6 weeks for osteomyelitis.
IV treatment - at least 48 hours

Question 18

Treatment for H. pylori

Answer 18

PPI + Amoxicillin 1000mg BD + Metronidazole 400mg BD OR Clarithromycin 500mg BD

For 7 days

Amoxicillin tends to be included in triple therapy unless patient has a penicillin allergy (then it’s PPI + Metronidazole + Clarithromycin)

Question 19

Talk me through treatment of UTI’s in pregnancy?

Answer 19

[1] Nitrofurantoin
[2] Cefalexin or Amoxicillin

Nitrofurantoin: okay to use but avoid at term (after 36 weeks), if eGFR <45 and if have asthma/COPD

Trimethoprim: Teratogenic risk in first trimester as it is a folate antagonist

Cefalexin: a cephalosporin, these are safe in pregnancy

Cranberry juice or other cranberry products are not recommended as no evidence to support their use

Question 20

Treatment for lower urinary tract infections

Answer 20

Non-pregnant women (3 days):
[1] Nitrofurantoin or Trimethoprim
[2] Pivmecillinam, fosfomycin

Pregnancy (7 days):
[1] Nitrofurantoin
[2] Cefalexin or Amoxicillin

Men (7 days):
[1] Nitrofurantoin or Trimethoprim

Catheter associated (7 days):

If no upper UTI symptoms:
[1] Nitrofurantoin, Amoxicillin (if susceptible culture) or Trimethoprim (low resistance)
[2] Pivmecillinam

If upper UTI symptoms:
[1] Cefalexin, ciprofloxacin, co-amoxiclav (if culture susciptible), trimethoprim

Severe or unable to take oral:
- Amikacin, ceftriaxone, cipro, cefuroxime, gentamicin (or co-amoxiclav but only in combo)

Question 21

Co-amoxiclav usual dosing in pneumonia

Answer 21

500/125mg TDS (5 days total)

Question 22

Doxycycline usual dosing in pneumonia

Answer 22

200mg on day 1 then 100mg OD (5 days total)

Question 23

Macrolide usual dosing

Answer 23

Clarithromycin 500mg BD

Erythromycin 500mg QDS

Question 24

Treatment for sepsis

Answer 24

Consult local guidelines but typically empirical treatment:
- Broad-spectrum β-lactam (e.g. piperacillin/tazobactam, cefepime, meropenem) and antibiotic for MRSA coverage (e.g. vancomycin/teicoplanin)

Question 25

Treatment for diabetic foot infection (mild)

Answer 25

[1] Flucloxacillin 500 mg to 1 g four times a day for 7 days

Penicillin allergy:
- Clarithromycin 500 mg twice a day for 7 days2
- Doxycycline 200 mg on first day, then 100 mg once a day (can be increased to 200 mg daily) for 7 days

Alternative oral antibiotic for penicillin allergy in pregnancy:
Erythromycin 500 mg four times a day for 7 days

Question 26

Treatment for diabetic foot infection (moderate/severe)

Answer 26

In severe infection give IV for at least 48 hours (until stabilised).

Course length is based on clinical assessment: minimum 7 days and up to 6 weeks for osteomyelitis

• Flucloxacillin 1 g QDS orally or 1 to 2 g QDS IV
  +/- Gentamicin and/or Metronidazole 400 mg TDS orally or 500 mg TDS IV
• Co-amoxiclav 500/125 mg TDS orally or 1.2 g TDS IV
  +/-
  Gentamicin

Penicillin allergy:
* Co-trimoxazole 960 mg BD orally or IV (IV can be increased to 1.44 g twice a day)
+/-
Gentamicin and/or Metronidazole

• Ceftriaxone 2 g OD IV + Metronidazole

Additional antibiotic choices if Pseudomonas aeruginosa suspected or confirmed:
- Piperacillin with tazobactam 4.5 g three times a day IV (can be increased to 4.5 g four times a day)
- Clindamycin + Ciprofloxacin (consider safety issues11) +/- Gentamicin

Antibiotics to be added if MRSA infection suspected or confirmed (combination therapy with an antibiotic listed above :
- Vancomycin
- Teicoplanin
- Linezolid