Prescribing Pathways

Question 1

What is the treatment plan for human and animal bites

Answer 1

First line: co-amoxiclav broad spectrum

If can’t use co-amoxiclav because of penicillin allergy

Second line: doxycycline (broad spectrum) and metronidazole (anaerobic infections)

Prophylaxis: 3 days
Treatment: 5 days

Question 2

What is the treatment plan for tick bites (Lyme disease)

Answer 2

First line: Doxycycline (100mg BD) treatment is for 21 days

Second line: amoxicillin (100mg 3x a day) treatment for 21 days

Question 3

What is the treatment pathway for human or animal scratches

Answer 3

Flucloxacillin

Question 4

What is the treatment pathway for diabetic foot infection- mild less than 2cm

Answer 4

Flucloxacillin

Penicillin allergy: clarithromycin/ erythromycin / doxycycline

Question 5

What is the treatment plan for diabetic foot infection- moderate/ severe (abscess, osteomyelitis)

Answer 5

Flucloxacillin or co-amoxiclav +/- gentamicin

Penicillin allergy: co-trimoxazole +/- gentamicin

Question 6

What is the treatment pathway for cellulitis

Answer 6

First line: Flucloxacillin

Penicillin allergy or if Flucloxacillin is unsuitable
clarithromycin or erythromycin (in pregnancy)
Doxycycline
Co-amoxiclav

Question 7

What is the treatment pathway if cellulitis is near the eyes or the nose

Answer 7

Co-amoxiclav
Penicillin allergy: clarithromycin and metronidazole

Question 8

What is the treatment plan for community acquired pneumonia

Answer 8

Low severity
First line: amoxicillin
Second line: doxycycline or clarithromycin (erythromycin in pregnancy)

Moderate severity
First line: amoxicillin and clarithromycin (erythromycin in pregnancy)
Second line doxycycline or clarithromycin

High severity
First line: co-amoxiclav and clarithromycin (erythromycin in pregnancy
Second line levofloxacin

Question 9

What is the treatment plan for diarrhoea

Answer 9

If you have confirmed c.diffe (10 day treatment)
1st line: vancomycin
Second line: fidaxomicin
Life threatening: vancomycin and iv metronidazole

Travellers diarrhoea
Standby: azithromycin
Prophylaxis/ treatment: bismuth subsalicylate

Ciprofloxacin can be used as a prophylaxis but not routinely recommended

Question 10

What is the treatment pathway for otitis media

Answer 10

First line: amoxicillin
Second line (worsening symptoms despite 2-3 days treatment: co-amoxiclav
Penicillin allergy: clarithromycin (erythromycin in pregnancy)

Question 11

What is the treatment pathway for otitis externa

Answer 11

First line: topical acetic acid 2%
Second line: topical neomycin sulphate with corticosteroid
If systemic treatment needed: Flucloxacillin

Question 12

What is the treatment pathway for h.pylori

Answer 12

Triple therapy:
PPI: Omeprazole, esomeprazole etc
Might not be prescribed if on clopidogrel would be prescribed lansoprazole instead
+
Two of the following antibiotics:
amoxicillin (100mg BD) OR
Metronidazole 400mg BD) OR
Clarithromycin (500mg BD)

Amoxicillin tends to be included in triple therapy unless patient has penicillin allergy

Diagnosed with urea (13c) breath test
Shouldn’t be performed within 2 weeks of taking PPIs
Shouldn’t be performed within 4 weeks of taking antibiotics

Question 13

What should you take into consideration when taking Omeprazole

Answer 13

Give Omeprazole 1-2 a day depending on the risk of the patient developing ulcers due to being on other medications such as ssris, older blood thinners

Question 14

What is the treatment pathway for hospital acquired pneumonia

Answer 14

Non severe:
First line: co-amoxiclav for both adults and children
Second line (adults): doxycycline or cefalexin or co-trimoxazole or levofloxacin
Second line (children): clarithromycin

Question 15

Why wouldn’t our use doxycycline in children

Answer 15

Discolouration of teeth’s in children
Avoid tetracyclines in children aged 12 and below

Question 16

What is the prescribing pathway for impetigo

Answer 16

Localise non-bulbous
First line: hydrogen peroxide 1%
Second line: fusidic acid (mupirocin 2% if fusidic acid resistance is suspected )

Wide spread non-bulbous
First line: fusidic acid (mupirocin 2% if fusidic acid resistance is suspected )

Bulbous or patients who are systemically unwell
First line: Flucloxacillin
Second line: clarithromycin (erythromycin in pregnancy)

Question 17

What is the treatment pathway for lower UTI

Answer 17

Treatment in men:
First line: nitrofurantoin or trimethoprim

Treatment in non-pregnant women first choice
First line: nitrofurantoin or trimethoprim
Second line: pivmecillinam or fosfomycin

Treatment in pregnant women
First line nitrofurantoin
Second line: cefalexin or amoxicillin

Question 18

When should nitrofurantoin be used

Answer 18

Should only be used for eGFR is > or equal to 45ml/min

Question 19

What is the length of time for lower UTIs

Answer 19

Men: 7 days
Pregnancy: 7 days
Uncomplicated: 3 days
Catheter associated: 7 days

Question 20

Why wouldn’t you give trimethoprim in pregnancy

Answer 20

Teratogenic
Or methotrexate as antifolate
Phenytoin as antifolate

Question 21

What is the treatment pathway for strep throat and Scarlett fever

Answer 21

Both infections are part of the streptococcus bacteria family

First line: phenoxymethylpenicillin
Second line: clarithromycin or erythromycin (in pregnancy)

Scarlett fever:
Flu like symptoms, high temperature, swollen neck glands
A red rash with small raised bumps, rough feeling like sandpaper
White coating on tongue

Question 22

What are the treatment pathways of other infections

Answer 22

Acne vulgaris: adapalene, clindamycin, benzoyl peroxide and lymecycline (acne side)

Bacterial vaginosis and trichomoniasis: metrondiazole

Clamydia: doxycycline

Conjunctivitis and blepharitis: chloramphenicol not for under 2 or pregnant can’t be sold otc

Dental abscess: amoxicillin or metrondiazole

Gonorrhoea: ceftriaxone or ciprofloxacin

Meningitis: benzylpenicillin

Scabies: permethrin- give advice of apply all over the body from neck down

Sinusitis: phenoxymethylpenicillin ( if penicillin allergy- doxycycline )

Threadworms: mebendazole not for pregnant women and under 2

Question 23

What are the most common pathogens

Answer 23

Community acquired pneumonia : streptococcus pneumoniae

UTI: escherichia coli

Thrush: Candida albicans

Cellulitis: staphylococcus aureus

Meningitis: streptococcus pneumoniae