prescribing pathways

Question 1

Bites

Answer 1

Human and animal bites:
- 1st line co-amoxiclav
- 2nd line doxycycline + metronidazole

doxy covers broad
metronidazole covers anaerobic

prophylaxis 3 days
treatment 5 days

tick bites (lyme disease): prophylaxis
1st line doxycycline 100mg BD
2nd line amoxicillin 1000mg TDS
treatment 21 days

Question 2

diabetic foot infection

Answer 2

mild (less than 2cm):
flucloxacillin
penicillin allergy: clarithromycin/erythromycin/doxycycline

moderate/severe (abscess/osteomyelitis)
flucloxacillin or co-amoxiclav +/- gentamicin
pen allergy: co-trimoxazole +/- gentamicin

Question 3

cellulitis

Answer 3

1st line flucloxacillin
pen allergy or if fluc unsuitable
clarithromycin or erytho in pregnancy
doxcycline
co-amoxiclav

if infection near eyes or nose:
co-amoxiclav
pen allergy: clarithromycin + metronidazole

Question 4

CAP

Answer 4

low severity:
1st line amoxicillin
2nd line doxy or clari/erythro

moderate severity:
1st line amoxicillin or amox + clari/erythro if atypical pathogens suspected

2nd line doxy or clari

high severity:
1st line co-amoxiclav + clari/erytho

2nd line levofloxacin

Question 5

diarrhoea

Answer 5

clostridium difficile (10 day treatment):
1st line vancomycin
2nd line fidaxomicin
life-threatening - vancomycin + IV metronidazole

traveller’s diarrhoea:
standby azithromycin

prophylaxis/treatment bismuth subsalicylate

Question 6

ear infections

Answer 6

otitis media - inner ear - hard to apply topical - systemic treatment needed:
1st line - amoxicillin

2nd line - worsening symptoms despite 2-3 days treatment - co-amoxiclav (upgrade, harder to break down)

penicillin allergy - clarithromycin (erythro in pregnancy)

otitis externa (outer ear):
1st line - topical acetic acid 2%

2nd line - topical neomycin sulphate + corticosteroid (hydrocortisone)

if systemic needed - flucloxacillin
- if pseudomonas suspected - ciprofloxacin

Question 7

H.pylori

Answer 7

diagnosed with urea 13c breath test - however if previously treated with ppi or antibioitics
- wait 2 weeks for ppi
- wait 4 weeks for antibiotic

if positive test - confirms H.pylori:
- go for triple therapy
- PPI + 2 antibiotics: amoxicillin 1000mg BD + metronidazole 400mg BD or clarithromycin 500mg BD

amoxicillin usually 1st line unless penicillin allergy then give metro + clari

Question 8

HAP

Answer 8

non severe:
1st line (adults + children)
co-amoxiclav

2nd line (adults) - doxycycline or cefalexin or co-trimaxazole or levofloxacin

2nd line (children) - clarithromycin

avoid tetracycylines in <12: discolouration of teeth, affects bone deposit

Question 9

impetigo

Answer 9

localised non-bullous:
1st line - hydrogen peroxide 1%

2nd line - fusidic acid (mupirocin 2% if fusidic acid resistance suspected)

widespread non-bullous:
1st line - fusidic acid (mupirocin 2% if fusidic acid resistance suspected)

bullous or systemically unwell pts:
1st line - flucloxacillin

2nd line - clarithromycin (erythro in pregnancy)

Question 10

lower UTI

Answer 10

men:
1st line - nitrofurantoin or trimethoprim

non-pregnant women:
1st line - nitrofurantoin or trimethoprim

2nd line - pivmecillinam or fosfomycin

pregnant women:
1st line - nitrofurantoin
2nd line - cefalexin or amoxicillin

don’t give trimethoprim in pregnant as teratogenic + antifolate

duration:
men - 7 days
pregnant women - 7 days
catheter associated - 7 days
uncomplicated (women) - 3 days

nitrofurantoin only given if eGFR >45ml/min

Question 11

strep throat and scarlett fever

Answer 11

both part of steptococcus bacteria family

1st line - phenoxymethylpenicillin

2nd line - clari or erthro in pregnancy

scarlett fever:
- flu-like symptoms, hot temp, swollen neck glands
- rash with raised red bumps, rough like sandpaper
- white coating on tongue

Question 12

other infections

Answer 12

acne - adapalene, clindamycin, benzoyl peroxide, lymecycline

bacterial vaginosis and trichomoniasis - metronidazole as anaerobic pathogens

chlamydia - doxycycline

conjunctivitis and blepharitis - chloramphenicol (can’t give <2, pregnant)

dental abscess - amoxicillin or metronidazole or phenoxymethylpenicillin

gonorrhea - ceftriaxone or ciprofloxacin

meningitis - benzylpenicillin

scabies - permethrin - apply all over body neck down

sinusitis - phenoxymethylpenicillin (doxy in pen allergy)

threadworm - mebendazole (can’t give <2, pregnant)

Question 13

most common pathogens

Answer 13

CAP - streptococcus pneumoniae

meningitis - streptococcus penumoniae

cellulitis - staphylococcus aures

UTI - e coli

thrush - candida albicans