Infectious diseases

Dr Alan Shortt

48 Handwashing

Bacteriology / microbiology

Antibiotic mechanisms

Antibiotic prescribing guidelines

Always check
allergies
pregnancy
breast feeding
interactions
Follow local guidelines and be aware of local resistance patterns, e.g. for UTIs.
Be consistent in your refusal of antibiotics for the treatment of simple upper respiratory infections.
Explain why they are not appropriate and back it up with written advice and OTC recommendations.
This may take longer than issuing a prescription but it pays dividends in the long run.
If necessary come to a compromise and issue a delayed prescription to be used should symptoms deteriorate within a specified time.

Antibiotics in children (infections)

Hacking-Medschool/paeds-antibiotics

Upper Respiratory Tract Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments
Tonsillitis Virus (75%)
Strep. pyogenes

Nil
Penicillin V
Clarithromycin if allergic to penicillin. Avoid amoxicillin or ampicillin. 10 days therapy required to prevent sequelae.

Epiglottitis/acute bacterial tracheitis ALTB
Haemophilus influenzae
Staph. aureus Ceftriaxone (for epiglottitis) add flucloxacillin iv for
other patients
Acute otitis media Strep. pneumoniae
Haemophilus influenzae Amoxicillin
Mastoiditis As above but wider spectrum of causes Co-amoxiclav
Pertussis B. pertussis Clarithromycin(oral)
or erythromycin (iv)

Antibiotic resistance

Childrens antibiotic doses (infections)

hacking-medschool/abs-children

Paeds antibiotic doses
Amoxicillin
Clarithromycin
Trimethprim

Antibiotics children – more serious infections

Lower Respiratory Tract Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments

1. Pneumonia
Lobar pneumonia Strep. pneumoniae
Haemophilus influenzae
Staph. aureus (< 1 yr) Amoxicillin > 1 year
or co-amoxiclav
< 1 year
Atypical pneumonia Mycoplasma pneumoniae
and others

Erythromycin (iv) or clarithromycin (oral)

Post-operative aspiration/hospital acquired pneumonia
Strep. pneumoniae
Haemophilus influenzae
Staph, aureus
Anaerobes

Co-amoxiclav

Post-viral pneumonia Staph. aureus
Haemophilus influenzae Co-amoxiclav
2. Bronchitis/Bronchiolitis
Children < 1 year RSV Ribavirin If NPA positive and clinical criteria apply, only on Consultants’ instructions (see Bronchiolitis Protocol 1994)

Exacerbation of cystic fibrosis (bronchiectasis)
Pseudomonas aeruginosa
Staph. aureus

Ceftazidime plus gentamicin
Then treat as per culture

Urinary Tract Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments
Cystitis (no fever, not systemically unwell)
Acute cystitis E. coli Trimethoprim Then treat as per culture. NB recurring UTI requires prophylaxis as does first attack for children < 1 year (see protocol for Management of UTI in Children)
Pyelonephritis E. coli Ceftriaxone Then appropriate oral therapy as per culture.

Central Nervous System
Clinical conditions Pathogen(s) Antibiotic(s) Comments
1. Meningitis
Birth – 6 weeks Group B Streptococcus
E. coli (Listeria monocytogenes) Ceftriaxone plus
amoxicillin Then treat as per culture. See also protocol for Management of Meningitis, 1993. Cefotaxime is available as an alternative
Older children

Meningococcus
Haemophilus influenzae
Strep. pneumoniae
Ceftriaxone Treat for 7-10 days. Cefotaxime is an alternative. See also Meningitis Research Foundation “Early Management of Meningococcal Disease in Children” 4th edition at www.meningitis.org
Shunt infection Staph. epidermidis Intrathecal* vancomycin 5-10mg daily plus oral
rifampicin Seek specialist advice. May require removal of shunt.
Contact neurosurgeons.
* All intrathecals must be made in the pharmacy
2. Encephalitis H.simplex High dose IV aciclovir
3. Brain abscess Anaerobes
Streptococci and others Ceftriaxone
plus metronidazole Contact neurosurgeon

Urinary Tract Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments
Cystitis (no fever, not systemically unwell)
Acute cystitis E. coli Trimethoprim Then treat as per culture. NB recurring UTI requires prophylaxis as does first attack for children < 1 year (see protocol for Management of UTI in Children)
Pyelonephritis E. coli Ceftriaxone Then appropriate oral therapy as per culture.

Septicaemia
Clinical conditions Pathogen(s) Antibiotic(s) Comments
1. Central IV catheter in situ
(e.g. Parenteral nutrition) Staph. epidermidis
Staph. aureus Ceftriaxone
plus teicoplanin
2. Focus undiagnosed Ceftriaxone
3. Infective endocarditis Viridans streptococci High dose benzylpenicillin IV plus gentamicin Then treat as per culture
Staphylococci High dose flucloxacillin plus gentamicin Then treat as per culture
4. Neonatal sepsis E.coli
Group B streptococci Benzylpenicillin iv
plus gentamicin Then treat as per culture
5. Immunocompromised Tazocin
plus gentamicin Then treat as per culture as protocol

Abdominal Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments
1. Gastroenteritis
Treat only if proven infection and after discussion with Consultant
Seek specialist advice
Giardiasis Giardia lamblia Metronidazole
2. Peritonitis
Perforation of viscus Bowel flora Gentamicin plus
metronidazole plus
co-amoxiclav
CAPD associated Staphylococci
Coliforms
Pseudomonas aeruginosa Netilmicin plus
vancomycin Intraperitoneal administration (add to dialysis fluid). Use alternative aminoglycoside if netilmicin not available. Contact specialist for advice.
3. Post-operative wound infection Staph. aureus Flucloxacillin
4. Oral thrush Candida albicans
Immunocompromised Fluconazole
Newborn Nystatin liquid or miconazole gel Treat mother’s nipples with miconazole gel, if breastfeeding

Skin, Soft Tissue and Bone Infection
Clinical conditions Pathogen(s) Antibiotic(s) Comments
Impetigo erysipelas Staph. aureus
Strep. pyogenes Flucloxacillin Co-amoxiclav if child will not tolerate flucloxacillin
Umbilical flare in neonate Staph. aureus Flucloxacillin Adjust on basis of culture results
Fungal infection Nappy rash Candida albicans Nystatin or
miconazole Oral plus topical therapy

Viral infection
Primary Herpes simplex gingivostomatitis
Aciclovir iv If unwell enough to warrant hospital admission
Chickenpox Varicella zoster High dose iv
aciclovir If haemorrhagic chickenpox, eczematous patient, extensive infection with severe upset, or babies < 1 month old if within 24 hours of rash appearing. Also in immunocompromised (see use of zoster immune globulin in contacts)
Paronychia Staph. aureus Flucloxacillin
Infected burn wound Staph. aureus
Strep.pyogenes Flucloxacillin iv
Initially, then use oral therapy as per culture. Consider antipseudomonal cover. Seek specialist advice if no improvement
Septic arthritis/acute osteomyelitis Staph. aureus
Haemophilus influenzae
Streptococci Ceftriaxone iv
plus flucloxacillin iv Then treat for 2 weeks with oral follow-on therapy as per culture
Contact orthopaedic surgeon

Eye Infections
Clinical conditions Pathogen(s) Antibiotic(s) Comments
1. Conjunctivitis
Neonatal

Staph. aureus
Topical chloramphenicol
Chlamydia Oral clarithromycin
for at least 2 weeks Seek specialist advice
Other children Staph. aureus Topical chloramphenicol
2. Orbital cellulitis Staph. aureus
Strep. pyogenes Ceftriaxone iv plus
flucloxacillin iv initially
then oral co-amoxiclav

Empiric Treatment in the Immunocompromised (HIV incl)
Clinical conditions Pathogen(s) Antibiotic(s) Comments
NB. Treatment changed as per culture results
1. Fever / septicaemia in
neutropenic patient Gram-negative organisms
including Pseudomonas Tazocin plus gentamicin (1st line). Refer to specialist team
2. Pneumocystis
Infection in HIV children Pneumocystis carinii

High dose co-trimoxazole plus methylprednisolone (seek specialist advice)
3. Meningitis See relevant section Seek specialist advice
4. Respiratory tract infection See relevant section
5. Chickenpox Varicella zoster Give susceptible contact single dose IM Varicella zoster immune globulin (VZIG) as soon as possible but within 10 days of exposure. Further dose required if second exposure after 3 weeks. High dose iv aciclovir required for patients who develop chickenpox (click here). Seek specialist advice.
6. Fungal Infection Candida Asp Nystatin/fluconazole for prophylaxis. Invasive infection liposomal amphotericin. Post Bone Marrow Transplant itraconazole prophylaxis. Seek specialist advice.\\\

Antibiotic Prophylaxis Selection Page

IN GENERAL SURGERY

Usually abdominal surgery (e.g. emergency appendicectomy)
Co-amoxiclav 30mg/kg (as amoxicillin) slow IV bolus injection, with further dose (except in neonates) if prolonged surgery beyond 1-2 hours or if penicillin hypersensitivity.

Gentamicin 4mg/kg IV bolus + metronidazole 15mg/kg IV infusion (both single dose)

Orthopaedic surgery
Cefuroxime 30mg/kg slow IV bolus then further 15mg/kg dose (except in neonates) after 2 hours if surgery prolonged beyond this period.

Endoscopic urological surgery
Gentamicin 4mg/kg IV bolus single dose.

Other surgery: seek specialist advice

NB. Prophylaxis should be given at induction by the IV route.

Note: The use of antibiotic sprays or the application of antibiotic solutions to surgical wounds is not recommendedPATIENTS WITH CSF LEAK

Head trauma and compound skull fractures with or without CSF leak

Cefuroxime 30mg/kg IV bolus injection

MENINGITIS PROPHYLAXIS

NB: Inform Consultant in Public Health Medicine (CPHM) with responsibility for the control of infectious disease, at the earliest opportunity. Do not wait for laboratory confirmation. Time is of the essence in contact tracing. In particular, where the clinical suspicion is of Meningococcal meningitis/septicaemia, telephone CPHM and discuss.

NB: Treatment of the index case with rifampicin prior to discharge is unnecessary where ceftriaxone was used in the treatment of infection.

(A) Meningococcal Infection

Establish a list of close (kissing) household contacts. Give chemoprophylaxis as outlined below. Caution is required with pregnancy, breastfeeding, children under the age of three months and any person with severe hepatic impairment. The CPHM can advise.
12 years and over Rifampicin 600mg orally, twice daily for 2 days
1-12 years Rifampicin 10mg/kg orally, twice daily for 2 days
under 1 year Rifampicin 5mg/kg orally, twice daily for 2 days

Patients taking rifampicin should be advised that it stains body secretions. The urine may turn yellow/orange in colour and soft contact lenses may be similarly discoloured. Also, rifampicin is a potent liver enzyme inducer which, theoretically at least, may enhance the metabolism of oestrogens contained in the combined oral contraceptive. Women taking the pill should be warned that additional precautions are required during their current cycle. In the case of pregnant women, ceftriaxone should be given in a dose of 250mg IM stat. The index case should be treated with rifampicin prior to discharge to eliminate carriage but only if ceftriaxone was not used in the treatment of infection.

Note: Ciprofloxacin is also known to clear the organism from the throat. The dosage is 500mg orally stat. This is for adults only. Ciprofloxacin is not licensed for use in children under 12 years.

(B) Haemophilus influenzae B meningitis

Give prophylaxis to household members only when there is a child aged 3 years or under in the same household as the index case.

Treat all household members except pregnant or breastfeeding women, any person with severe hepatic impairment and children under 3 months.
12 years and over Rifampicin 600mg orally, once daily for 4 days
3 months – 12 years Rifampicin 20mg/kg (max 600mg) orally, once daily for 4 days

@@@Antibiotic guidelines RTI

Note: Low doses of penicillins are more likely to select out resistance^1, Do *not* use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms.
Acute cough, bronchitisCKS NICE 69	Antibiotic little benefit if no co-morbiditySymptom resolution can take 3 weeks.Consider 7-14 day delayed antibiotic with symptomatic advice/leaflet	amoxicillinor doxycycline	500 mg TDS200 mg stat/100 mg OD	5 days5 days
Acuteexacerbation of COPDNICE 12 Gold	Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 m	amoxicillinordoxycyclineclarithromycinIf resistance risk factors:co-amoxiclav	500 mg TDS200 mg stat/100 mg OD500 mg BD625 mg TDS	5 days5 days5 days5 days
Community-acquired pneumonia -treatment in the communityBTS 2009 Guideline	Use CRB65 score to help guide and review:Each scores 1: Confusion (AMT<8);Respiratory rate >30/min; Age >65;BP systolic <90 or diastolic ? 60;Score 0: suitable for home treatment;Score 1-2: hospital assessment or admissionScore 3-4: urgent hospital admissionGive immediate IM benzylpenicillin or amoxicillin 1G po ^Dif delayed admission/life threateningMycoplasma infection is rare in over 65s	IF CRB65=0: amoxicillinor clarithromycin or doxycycline	500 mg TDS500 mg BD200 mg stat/100 mg OD	7 days7 days7 days
		If CRB65=1 & AT HOME amoxicillin AND clarithromycin or doxycycline alone	500 mg TDS500 mg BD200 mg stat/100 mg OD	7-10 days7-10 days

Antibiotic guidelines URTI/ENT

Summary of Antibiotic Treatments in Adults MIMS

UPPER RESPIRATORY TRACT INFECTIONS¹
Influenza Influenza	Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not recommended. Treat ‘at risk’ patients, when influenza is circulating in the community and within 48 hours of onset or in a care home where influenza is likely. At risk: pregnant (including up to two weeks post partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Use 5 days treatment with oseltamivir 75 mg bd or if there is resistance to oseltamivir use 5 days zanamivir 10 mg BD (2 inhalations by diskhaler). For prophylaxis, see NICE. (NICE Influenza). Patients under 13 years see HPA Influenza link.
Acute Sore Throat CKS	Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours If Centor score 3 or 4: (Lymphadenopathy; No Cough; Fever; Tonsillar Exudate)consider 2 or 3-day delayed or immediate antibiotics Antibiotics to prevent Quinsy NNT >4000 Antibiotics to prevent Otitis media NNT 200	phenoxymethylpenicillin^5B- Penicillin Allergy:clarithromycin	500 mg QDS1G BD(QDS when severe)250-500mg BD	10 days5 days
Acute Otitis Media	Optimise analgesia and target antibiotics OM resolves in 60% in 24 h without antibiotics, which only reduce pain at 2 days (NNT15) and do not prevent deafness Consider 2 or 3-day delayedor immediate antibiotics for pain relief if: <2 yearsAND bilateral AOM (NNT4) or bulging membrane & ? 4 marked symptoms All ages with otorrhoea NNT3 Abx to prevent Mastoiditis NNT >4000^9B-	amoxicillin Penicillin Allergy:erythromycin	Child doses 40mg/kg/day in 3 doses (max. 3g daily) < 2yrs 125mg QDS 2-8yrs 250mg QDS 8-18yrs 250-500mg QDS	5 days5 days
Acute Otitis Externa CKS	First use aural toilet (if available) & analgesiaCure rates similar at 7 days for topical acetic acid or antibiotic +/- steroid If cellulitis or disease extending outside ear canal, start oral antibiotics and refer	First Line:acetic acid 2%Second Line:neomycin sulphate with corticosteroid^3A-,4D	1 spray TDS3 drops TDS	7 days7 days min to 14 days max^1A+
Acute Rhinosinusitis	Avoid antibiotics as 80% resolve in 14 days without, and they only offer marginal benefit after 7 days NNT15Use adequate analgesiaConsider 7-day delayed or immediate antibioticwhen purulent nasal discharge NNT8 In persistent infection use an agent with anti-anaerobic activity eg. co-amoxiclav	amoxicillinor doxycycline or phenoxymethylpenicillin For persistent symptoms:co-amoxiclav	500mg TDS1g if severe 200mg stat/100mg OD500mg QDS625mg TDS	7 days7 days7 days7 days

Antibiotic guidelines GIT

Summary of Antibiotic Treatments in Adults MIMS

GASTRO-INTESTINAL TRACT INFECTIONS
Eradication of Helicobacter pylori NICE HPA QRG CKSSymptomatic relapse	Eradication is beneficial in known DU, GU or low grade MALToma For NUD, the NNT is 14 for symptom relief Consider test and treat in persistent uninvestigated dyspepsia Do not offer eradication for GORD Do not use clarithromycin or metronidazole if used in the past year for any infection DU/GU relapse: retest for H. pylori using breath or stool test OR consider endoscopy for culture & susceptibility NUD: Do not retest, offer PPI or H₂RA	First line PPI (use cheapest) PLUSclarithromycin (C)ANDmetronidazole (MTZ)oramoxicillin (AM)Second line PPI PLUS bismuthate (De-nol tab^®)PLUS 2 unused antibiotics:amoxicillin metronidazole tetracycline	BD250 mg BD with MTZ500mg BD with AM400 mg BD1g BDBD120 mg QDS1 g BD400 mg TDS500 mg QDS	All for 7 days ^1,9A+ Relapse ^10C or MALToma ^1C 14 days
Infectious diarrhoea CKS	Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection.Antibiotic therapy not indicated unless systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin 250–500 mg BD for 5–7 days if treated early
*Clostridium difficile*DH & HPA	Stop unnecessary antibiotics and/or PPIs 70% respond to MTZ in 5days; 92% in 14days Treat ribotype 027 with vancomycinAdmit if severe: T >38.5; WCC >15, rising creatinine or signs/symptoms of severe colitis^1C	1^st/2^nd episodesmetronidazole (MTZ) 3^rd episode/severe/type 027 oral vancomycin	400 or 500 mg TDS125mg QDS	10-14 days 10 -14 days
Traveller’s diarrhoea CKS	Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers’ diarrhoea If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private Rx) If quinolone resistance high (eg south Asia): consider bismuth subsalicylate (Pepto Bismol) 2 tablets QDS as prophylaxis or for 2 days treatment
ThreadwormsCKS	Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower) PLUS wash sleepwear, bed linen, dust, and vacuum on day one	>6 months: mebendazole (off-label if <2yrs)3-6 mths: piperazine+senna< 3mths: 6 wks hygiene	100 mg 2.5ml spoonful	statstat, repeat after 2 weeks

@@@Antibiotic guidelines eyes

Summary of Antibiotic Treatments MIMS

EYE INFECTIONS
ConjunctivitisCKS	Treat if severe, as most viral or self-limiting.Bacterial conjunctivitis is usually unilateral and also self-limiting it is characterised by red eye with mucopurulent, not watery, discharge; 65% resolve on placebo by day five Fusidic acid has less Gram-negative activity	If severe: chloramphenicol 0.5% drop and 1% ointment Second line:fusidic acid 1% gel	2 hourly for 2 days then 4 hourly (whilst awake)at nightBD	All for 48 hours after resolution

@@@Antibiotic guidelines UTI

Summary of Antibiotic Treatments in Adults MIMS

URINARY TRACT INFECTIONS
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI
UTI inmen & women(no fever or flank pain)HPA QRG SIGN CKS, CKS	Women with severe symptoms: treat Women with mild/ ? 2 symptoms: use dipstick to guide treatment. Nitrite & blood/leucocytes has 92% positive predictive value ; -ve nitrite, leucocytes, and blood has a 76% NPV Men: send pre-treatment MSU OR if symptoms mild/non-specific, use –ve nitrite and leucocytes to exclude UTI	trimethoprim or nitrofurantointo	200mg BD100mg m/r BD		Women all ages 3 days Men 7 days
		Second line: perform culture in all treatment failures Amoxicillin resistance is common; only use if susceptible Community multi-resistant Extended-spectrum Beta-lactamase E. coli are increasing: consider nitrofurantoin (or fosfomycin 3g stat in women plus 2^nd 3g dose in men 3 days later), on advice of microbiologist
UTI in pregnancy HPA QRG CKS	Send MSU for culture & sensitivity and start empirical antibiotics Short-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus Avoid trimethoprim if low folate status or on folate antagonist (eg antiepileptic or proguanil)	First line: nitrofurantoinif susceptible, amoxicillinSecond line: trimethoprim Third line: cefalexin		100 mg m/r BD500 mg TDS200 mg BD (off-label)Give folic acid if first trimester500 mg BD	All for 7 days
UTI in childrenHPA QRG CKS NICE	Child <3 mths: refer urgently for assessment Child ? 3 months: use positive nitrite to start antibioticsSend pre-treatment MSU for all. Imaging: only refer if child <6 months, recurrent or atypical UTI	Lower UTI: trimethoprimor nitrofurantoin if susceptible, amoxicillinSecond line: cefalexinUpper UTI: co-amoxiclavSecond line: cefixime		See BNF for dosage	Lower UTI 3 days Upper UTI 7?10 days
Acute pyelonephritisCKS	If admission not needed, send MSU for culture & sensitivities and start antibiotics If no response within 24 hours, admit	ciprofloxacin or co-amoxiclav		500 mg BD500/125 mg TDS	7 days 14 days
Recurrent UTI in women? 3 UTIs/year	Post-coital prophylaxis or standby antibiotic Nightly: reduces UTIs but adverse effects	nitrofurantoin or trimethoprim		50–100 mg100 mg	Post coital stat (off-label) ProphylaxisOD at night

http://www.biomedcentral.com/1471-2296/12/108

@@@Antibiotic guidelines STIs

Antibiotic Treatments MIMS

GENITAL TRACT INFECTIONS

STI screening	People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to GUM service. Risk factors: < 25y, no condom use, recent (<12mth)/frequent change of partner, symptomatic partner
*Chlamydia trachomatis*SIGN, BASHH HPA, CKS	Opportunistically screen all aged 15-25yrs Treat partners and refer to GUM service Pregnancyor breastfeeding: azithromycin is the most effective optionDue to lower cure rate in pregnancy, test for cure 6 weeks after treatment	azithromycin or doxycycline Pregnant or breastfeeding:azithromycinor erythromycinor amoxicillin	1 g100 mg BD1g (off-label use)500 mg QDS500 mg TDS	stat ^4A+7 days ^4A+stat ^5A+7 days ^5A+7 days ^5A+
Vaginal candidiasisBASHH HPA, CKS	All topical and oral azoles give 75% cureIn pregnancy: avoid oral azole and use intravaginal treatment for 7 days	clotrimazole or oral fluconazole clotrimazole or miconazole 2% cream	500 mg pess or 10%cream150 mg orally100 mg pessary at night5 g intravaginally BD	statstat6 nights ^5C7 days
Bacterial vaginosisBASHH HPA, CKS	Oral metronidazole (MTZ) is as effective as topical treatment but is cheaper.Less relapse with 7 day than 2g stat at 4 wks Pregnant/breastfeeding: avoid 2g stat Treating partners does not reduce relapse	oral MTZ or MTZ 0.75% vag gelor clindamycin 2% crm	400 mg BDor2 g5 g applicatorful at night5 g applicatorful at night	7 daysstat5 nights7 nights
TrichomoniasisBASHH HPA, CKS	Treat partners and refer to GUM service In pregnancy or breastfeeding: avoid 2g single dose MTZ. Consider clotrimazole for symptom relief (not cure) if MTZ declined	metronidazole (MTZ)clotrimazole	400 mg BDor 2 g100 mg pessary at night	5-7 daysstat 6 nights
Pelvic Inflammatory Disease RCOG BASHH, CKS	Refer woman & contacts to GUM service Always culture for gonorrhoea & chlamydia 28% of gonorrhoea isolates now resistant to quinolonesIf gonorrhoea likely (partner has it, severe symptoms, sex abroad) use ceftriaxone regimen or refer to GUM.	metronidazole PLUSofloxacin If high risk of GCCeftriaxonePLUSMetronidazole PLUSdoxycycline	400 mg BD400 mg BD500 mg IM400 mg BD100 mg BD	14 days14 daysStat14 days14 days
Acute prostatitisBASHH, CKS	Send MSU for culture and start antibiotics 4-wk course may prevent chronic prostatitis Quinolones achieve higher prostate levels	ciprofloxacin or ofloxacin2^nd line: trimethoprim	500 mg BD200 mg BD200 mg BD	28 days 28 days 28 days

Antibiotic guidelines skin infections

Summary of Antibiotic Treatments in Adults MIMS

SKIN INFECTIONS
ImpetigoCKS	For extensive, severe, or bullous impetigo, use oral antibiotics Reserve topical antibiotics for very localised lesions to reduce the risk of resistance Reserve mupirocin for MRSA	oral flucloxacillin ^2CIf penicillin allergic: oral clarithromycin topical fusidic acid *MRSA only* mupirocin		500 mg QDS250-500 mg BDTDSTDS		7 days7 days5 days5 days
EczemaCKS	If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing In eczema with visible signs of infection, use treatment as in impetigo ^2C
CellulitisCKS	If patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone If river or sea water exposure, discuss with microbiologist.If febrile and ill, admit for IV treatment Stop clindamycin if diarrhoea occurs.	flucloxacillin If penicillin allergic:clarithromycin or clindamycin facial: co-amoxiclav		500 mg QDS500 mg BD300–450 mg QDS500/125 mg TDS		All for 7 days.If slow responsecontinue for a further 7 days
Leg ulcersHPA QRG CKS	Ulcers always colonized. Antibiotics do not improve healing unless active infection^1A+ If active infection, send pre-treatment swab ^3CReview antibiotics after culture results.	Active infection if cellulitis/increased pain/pyrexia/purulent exudate/odour
Leg ulcersHPA QRG CKS		If active infection:flucloxacillinor clarithromycin		500 mg QDS500 mg BD		As for cellulitis
MRSA	For MRSA screening and suppression, see HPA MRSA quick reference guide.
	For active MRSA infection:Use antibiotic sensitivities to guide treatment.If severe infection or no response to monotherapy after 24-48 hours, seek advice from microbiologist on combination therapy.		If active infection, MRSA confirmed by lab results, infection not severe and admission not required ^1,2B+:
			If active infection confirmeddoxycycline alone ORclindamycin alone		100 mg BD300–450 mg QDS	Both for 7 days If diarrhoea, stop
PVL S. aureusHPA QRG	Panton-Valentine Leukocidin (PVL) is a toxin produced by 2% of S. aureus. Can rarely cause severe invasive infections in healthy people. Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport; poor hygiene
BitesCKS Human: Cat or dog:	Thorough irrigation is important Assess risk of tetanus, HIV, hepatitis B&CAntibiotic prophylaxis is advised Assess risk of tetanus and rabies ^2CGive prophylaxis if ³cat bite/puncture wound; bite to hand, foot, face, joint, tendon, ligament; immunocompromised/diabetic/asplenic/cirrhotic	Prophylaxis or treatment: co-amoxiclavIf penicillin allergic:metronidazole PLUS doxycycline (cat/dog/man)or metronidazole PLUS clarithromycin (human bite) AND review at 24&48hrs		375-625 mg TDS 200-400 mg TDS100 mg BD 200-400 mg TDS250-500 mg BD		All for 7 days ^4,5,6C
ScabiesCKS	Treat all home & sexual contacts within 24h Treat whole body from ear/chin downwards and under nails. If under 2/elderly, also face/scalp	permethrin If allergy:malathion		5% cream0.5% aqueous liquid		2 applications 1 week apart ^1C
Fungal infection – skinCKS body & groin CKS foot CKS scalp	Terbinafine is fungicidal , so treatment time shorter than with fungistatic imidazolesIf candida possible, use imidazole If intractable: send skin scrapings If infection confirmed, use oral terbinafine/itraconazole ^3B+ Scalp: discuss with specialist	Topical terbinafine or topical imidazole or (athlete’s foot only): topical undecanoates (Mycota®)		BDBDBD		1-2 weeks ^4A+for 1-2 wks after healing(i.e. 4-6wks) ^4A+
Fungal infection –fingernail or toenailCKS	Take nail clippings: start therapy only if infection is confirmed by laboratory Terbinafine is more effective than azoles Liver reactions rare with oral antifungals If candida or non-dermatophyte infection confirmed, use oral itraconazole For children, seek specialist advice	*Superficial only* amorolfine 5% nail lacquer ^5B-First line: terbinafine ^6A+Second line: itraconazole ^6A+		1-2x/weekly fingerstoes250 mg OD fingerstoes200 mg BDfingerstoes		6 months12 months6 – 12 weeks3 – 6 months7 days monthly2 courses3 courses
Varicella zoster/chicken poxCKSHerpes zoster/shinglesCKS	Pregnant/immunocompromised/neonate: seek urgent specialist advice Chicken pox:IF started <24h of rash & >14y or severe pain or dense/oral rash or 2^ohousehold case or steroids or smoker consider aciclovirShingles: treat if >50 yrsand within 72 hrs of rash(PHN rare if <50yrs); or if active ophthalmic or Ramsey Hunt or eczema.	If indicated: aciclovir Second line for shingles if compliance a problem, as ten times cost valaciclovir or famciclovir		800 mg five times a day 1 g TDS 250 mg TDS		7 days 7 days ¹7 days ^11B+
Cold sores	Cold sores resolve after 7–10d without treatment. Topical antivirals applied prodromally reduce duration by 12-24hrs

@@@Antibiotic guidelines CNS

Antibiotic Treatments MIMS

Suspected Bacterial Meningitis(NICE fever guidelines)

Transfer all patients to hospital immediately.

If time before admission, give IV benzylpenicillin or cefotaxime unless hypersensitive ie history of difficulty breathing, collapse, loss of consciousness, or rash

IV or IM benzylpenicillin
or
IV or IM cefotaxime

Age 10+ years: 1.2 g
Children 1 – 9 yr: 600 mg
Children <1 yr: 300 mg
Age 12+ years: 1 gramChild < 12 yrs: 50mg/kg

(give IM if vein cannot be found)

Prevention of secondary case of meningitis: Only prescribe following advice from Public Health Doctor

Central Nervous System
Clinical conditions Pathogen(s) Antibiotic(s) Comments
1. Meningitis
Birth – 6 weeks Group B Streptococcus
E. coli (Listeria monocytogenes)
Ceftriaxone plus amoxicillin Then treat as per culture. See also protocol for Management of Meningitis, 1993. Cefotaxime is available as an alternative
Older children

Meningococcus
Haemophilus influenzae
Strep. pneumoniae
Ceftriaxone Treat for 7-10 days. Cefotaxime is an alternative. See also Meningitis Research Foundation “Early Management of Meningococcal Disease in Children” 4th edition at www.meningitis.org
Shunt infection Staph. epidermidis Intrathecal* vancomycin 5-10mg daily plus oral
rifampicin Seek specialist advice. May require removal of shunt.
Contact neurosurgeons.
* All intrathecals must be made in the pharmacy
2. Encephalitis H.simplex High dose IV aciclovir
3. Brain abscess Anaerobes
Streptococci and others Ceftriaxone
plus metronidazole Contact neurosurgeon

@@@ Antibiotic guidelines septicaemia

Summary of Antibiotic Treatments in Adults MIMS

Clinical conditions Pathogen(s) Antibiotic(s) Comments
1. Central IV catheter in situ (e.g. Parenteral nutrition) Staph. epidermidis
Staph. aureus Ceftriaxone plus teicoplanin
2. Focus undiagnosed Ceftriaxone
3. Infective endocarditis Viridans streptococci High dose benzylpenicillin IV plus gentamicin Then treat as per culture
Staphylococci High dose flucloxacillin plus gentamicin Then treat as per culture
4. Neonatal sepsis E.coli Group B streptococci Benzylpenicillin iv plus gentamicin Then treat as per culture
5. Immunocompromised Tazocin plus gentamicin Then treat as per culture as protocol

Healthcare associated infections HCAI

MRSA
C difficile

Clostridium difficile (HAI)

250textbooks/clostridium-difficile

MRSA (HAI)

MRSA clearance
prontoderm -available FP 10.
octenisan wash
Mucoporicin nasal cream tds 3g
Prontoderm
Current Salford guidelines high risk – recurrent attendees invasive devices recurrent/resistant wounds

Childhood Infectious Diseases

Childhood infectious diseases Skinsight

Incubation Infectivity Exclusion from School

Childhood Infectious Diseases Exclusion
Measles	6-19 days	From 4 days before onset of rash	5 days after rash appear	Refer neonates non-immune pregnant or immunocompromised contacts
Mumps	15-24 days	6 days b4 symptoms	4-5 days	none
Chickenpox	11-20 days	From 1 day before until 5 days from onset of rash	Refer neonates, non-immune pregnant or	5 days after rash appear
Conjunctivitis	3-29 days	While discharge present	none	none
Impetigo	Unknown	While purulent lesions persist	Until lesions crusted, or 48 h after Rx begun
D&V	1 hour-14 days	While diarrhoea or vomiting Until 24 h after last D&V		(48 h under 5s) lasts(depending on cause)
Glandular fever	33-49 days	While symptomatic	Until well	none
Head lice	7-10 days	As long as lice/live eggs present	Until child and family have been treated	none
Hand, foot & Mouth	3-5 days	Up to 7 days	1 week or until ulcers healed	none

Rashes and fever

Really Sick People Must Take No Exercise
Rubella day 1
Scarletina day 2
smallPox day 3
Measles day 4
Typhoid fever day 5
(none) day 6
Exercise day 7

Measles

Measles
caused by	RNA paranyxovirus
incubation	1-2 w
infectivity	4d before – 4 d after appearance of rash highly contagious
spread	Contact and droplet spread
rash	dark red blotchy (macular/maculopapular) rash behind ears spreading to face and trunkFine white koplick spots on buccal mucosa precede the skin rash skin may flake off as rash fades
symptoms	fever coryza malaise cough for 4 days + red ENT
diagnosis	blood or saliva test
complications
vaccination	MMR

What are the long-term effects of measles?
These include: ear infections, with risk of hearing loss, pneumonia or
bronchitis, croup, diarrhoea, and encephalitis (inflammation of the brain). A
severe late development is a condition called sub-acute sclerosing pan
encephalitis (SSPE). The risk of getting this is greatest in people infected at a
young age (under two years of age). The virus remains in the brain tissue
causing chronic infection which becomes evident around 8 years after initial
infection. Death invariably follows.
Diagnosis is by . In the past most people with a measles-like rash actually had measles. However since widespread vaccination genuine measles is very rare. It is now more likely that those with a measles-like rash have Parvovirus B19, or another viral illness.

Spread by respiratory droplets or by direct contact with the saliva of a case.

(i) Cough is a characteristic feature and often associated with signs in chest
(ii) If temperature not settling within a few days of the rash appearing suspect secondary infection

Complications
1. Otitis media (commonest)
2. Chest infection (but cough part of illness)
3. Conjunctivitis
4. Febrile convulsions with fever
5. Gastroenteritis
6. Laryngeal stridor
7. Encephalitis in 1:1 000. Many years after an attack a risk of subacute sclerosing panencephalitis

Mumps

Mumps @ HPA

Mumps
caused by
incubation	12-28 days
infectivity	3 days prior to the swelling until 7 days after it resolves
symptoms	mild prodromal symptoms prior to swelling of salivary glands. Parotid glands nearly always affected, sometimes unilaterally and may also affect submandibular glands
spread	saliva or droplet spread
disgnosis	salivary sample kit
complications	Aseptic meningitis common but usually mild and manageable at home. Orchitis, rare before puberty, usually unilateral and rarely, if ever, causes infertility. Oophoritis, pancreatitis and encephalitis all very rare complicationsin women, check for possible pregnancy
treatment
vaccination	MMR

Moping with mumps

Meningism
Orchitis/oorporitis
Parotitis/pancreatitis/paramyxovirus
Encephalitis

Rubella German measles

Rubella
caused by
incubation	14-21 days
infectivity	7 days prior to rash until 5 days after
spread	Contact and droplet spread
rash	pink macular rash appears on face first, spreading rapidly over trunk and lasting 2-3 days at the most. Rash may be absent
symptoms	Arthralgia may occur in adolescents and adults. Other complications (thrombocytopenia and encephalitis) extremely rare
diagnosis	If patient is pregnant and there is suggestion of a contact with rubella, do serial blood tests to detect a recent infection
complications
vaccination	MMR

Chickenpox varicella zoster virus

chickenpox
caused by	varicella zoster virus
incubation	11-21 days
infectivity	2 days before rash develops until 7 days after the last crop
spread	Contact and droplet spread
rash	Rash appears as first sign of illness, appearing in crops mainly on the trunk. Lesions go through macular, papular, vesicular and pustular stages before drying to form scabs. Often lesions in the mouth
symptoms	mild fever and malaise itching and pain
complications

vaccination	available but not currently routine in UK

Beware infection in neonates, pregnancy, and immunocompromised.
In people with a compromised immune response and in newborns, an infection with the varicella-zoster virus
Pregnant women who develop chickenpox are at risk of having a baby with congenital foetal varicella syndrome.Maternal infection up to 1 week before and 1 week after delivery is also a problem it can result in severe chickenpox infection in the neonate. The pregnant woman herself is at risk of complications, especially pneumonitis.
Prophylaxis Varicella-zoster immunoglobulin is recommended in some individuals following contact, refer to “Immunisation Against Infectious Disease”.

Chickenpox in adults

Varicella In Adults @ Patient UK

Aciclovir 800mg five times daily or valaciclovir 1g three times daily for seven days should be prescribed to those adults and adolescents (over 12 years) who present to general practitioners within 24 hours of the onset of the chickenpox rash If the patient has respiratory symptoms (particularly smokers) they may be referred to infectious diseases for exclusion of pneumonitis. All patients, especially smokers, should be monitored by their general practitioner to ensure that they do not develop complications. If complications do develop, refer to hospital.

Shingles

After primary varicella infection, the virus remains present in the dorsal root ganglia for life. It can become active again later giving rise to an attack of shingles.

Shingles post-herpetic neuralgia

Post-herpetic neuralgia Versatis plaster

Pertussis (Whooping Cough)

Whooping cough / pertussis
caused by	bordetella pertussis
incubation	7-10 days
infectivity	2 days prior to start of symptoms, until up to 5 weeks after the onset of the cough
spread	Contact and droplet spread
symptoms	Catarrhal stage precedes the paroxysmal stage. Cough is 1. Paroxysmal-spasms with possible cyanosis ending in a whoop 2. Often associated with vomiting 3. Persistent for weeks or months (the ‘100-day’ cough.) Infants may have no whoop but present as apnoeic/cyanotic spellsmay be vomitting, petechiae, low grade fever and episyaxis
complications	fits, hemiplegia encephalopathy bronchopneumonia
treatment	Symptomatic-tube feeding, oxygen, etc., in severe cases Early use of erythromycin for 14 days to patient and non-immune infant contacts may reduce infectivity of pertussis

vaccination	available but not currently routine in UK

Modified pertussis – in immunised patients may present with a milder ilness causing prolonged couh.

Fifth Disease

aka Slapped Cheek Disease Erythema Infectiosum Parvovirus B19

5th disease
caused by	human parvovirus B19 occurs in winter/spring epidemics every 3-5 years
incubation	4-14 days
infectivity	27-10 days
spread	airborne droplet infection
rash	Fine red macular rash on cheeks not around mouth. May later spread to trunk – extensor side of the arms and legs and on the buttocks.
symptoms	mild viraemia with coryza lasting 5days then rash malaise mild fever and arthralgia 1w later rash may recurr for some weeks later provoked by hot bath or sunlight
treatment	Symptomatic-tube feeding, oxygen, etc., in severe cases Early use of erythromycin for 14 days to patient and non-immune infant contacts may reduce infectivity of pertussis

pregnancy	May cause spontaneous abortion or intrauterine foetal death – keep patients away from pregnant women

Sixth Disease

Roseola PubMed Health

6th disease Roseola infantum exanthema subitum 3 day fever
caused by	herpesvirus type-6 (HHV-6) and 7
incubation	approx 14 days
infectivity	first five days of illness
spread	droplet and oral contact
rash andsymptoms	Harmless illness of young (1-3 years) children characterized by a high fever lasting approximately 3 days then appearance of fine pink macular rash on trunk and limbs with occipital postauricular and submandibular lymphadenopathy

Scarletina Scarlet Fever Gp A Strep Pyogenes

Scarletina Dermnet.nz

Scarletina
caused by	herpesvirus type-6 (HHV-6) and 7
incubation	1-5 days
infectivity	till 24 hours after abs started
spread	Droplet or contact
rash	2-5 days Fine diffuse blanching starts on face sparing lips (circumoral pallor) and spreads to trunk and limbs my be followed by desquamation in the second week
symptoms	Severe rapid onset exudative tonsilitis with fever malaise cervical lymphadenopathy furred tongue

Hand Foot and Mouth Disease Cocksackie A17

Mild illness fever malaise. Rash of grey vesicles in mouth fingers palms soles heels buttocks

Kawasaki Disease (infections)

Erisipelas

Food Poisoning

E coli

Salmonella (infections)

salmonella motile
shigela no flagella non motile

Enteric Fever

Shigellosis

Campylobacter

Campylobacter HPA

Norovirus winter vomiting virus

aka Norwalk virus

Listeria

Listeria @ HPA

Staphylococcal food poisoning

Bacillus cereus food poisoning

Bacillus cereus Todar’s Online textbook of bacteriology

BC HPA

Botulinism

More GIT pathogens causing D+V and other problems

D+V more GIT pathogens

Cryptosporidium

Amoebiasis

Giardiasis

Rotavirus

Yersinia enterocolitica

yersinia pestis = the Plague

Clostridium Difficile (infections)

ABs PPIs renal cops alcoholic liver disease – use local formulary first line – document reasons for deviation
Refaxamine ?

Glutamate Dehydogenose test (Read Code A3Ay2)
GDH positive C-diff toxin positive = infection
GDH positive toxin negative = carrier

vancomycin 125mg qds 10-14 days
monitor patient and inflammatory markers weekly

Caution re future use of ABs
Caution re use of PPIs.

Clostridium difficile in Salford July 2011
This is an update of the situation on Clostridium Difficile in Salford. As we all know this is an avoidable infection but we are continuing to see cases within the community and during the last weeks we have seen an increase in cases with 9 pre 72 hour/GP cases in June 2011. These are cases where the testing has been requested by the GP or within 72 hours of their admission to hospital and are therefore identified as ‘community cases’. We analyse every case and there are two recurring issues which are:
• Antibiotic prescribing and
• Prolonged use of proton pump inhibitors (PPIs).

We have also identified groups of patients who appear to be at higher risk of developing C-difficile and these include patients with:
• Chronic obstructive pulmonary disease,
• Acute kidney disease,
• Alcoholic liver disease
• Immuno-compromised patients.
We must all be aware of our responsibilities, prevention and treatment of this avoidable infection. There is a cost both in morbidity, mortality and financial to these cases.
It costs £7,000 per patient admitted to hospital with C-difficile and there is a potential saving of approximately £400,000.
We just want to remind you of the main points with regard to symptoms, signs, treatment and prevention and the role that you and your staff can play in preventing this disease.

What is C-difficile?
C-difficile is a bacterium that can be found in people’s intestines (their ‘digestive tract’ or ‘gut’). It is found in about 3% of adults and two-thirds of babies without causing any symptoms. C-difficile causes diarrhoea (mild to severe) and sometimes, life-threatening inflammation of the intestines. Other symptoms can include fever, loss of appetite, nausea and abdominal pain or tenderness. People who become infected with C-difficile are usually those who have taken antibiotics, and other medication that may alter the gut flora. It particularly affects the elderly and people whose immune systems are compromised. A person can also become infected with C-difficile if they ingest the bacterium through cross infection and environmental contamination.

What can I do?
• A diagnosis of C-difficile should be considered in all patients who develop diarrhoea, which may be bloody and often contains mucus, whilst taking or following a course of broad-spectrum antibiotics and be especially vigilant in the higher risk groups identified or if the patient is known to have had C-difficile in the past.

• A distended abdomen and/or elevated white cell count may be an early sign of pseudomembranous colitis. Diarrhoea is not always present.
• Elderly patients with a low serum albumin are particularly at risk.
• The diagnosis can be confirmed by sending a stool sample to microbiology noting the antibiotic history on the request form.
• Treatment for suspected cases should not be delayed until a result is received. The first line treatment of choice is oral Metronidazole 400mg – 500mg 8 hourly for 10 – 14 days in severe or recurrent cases please refer to the treatment algorithm attached
• The Consultant Microbiologists in the acute Trusts are happy to discuss individual cases and give advice on antibiotic treatment.
• Patients with severe diarrhoea may require hospital admission.
• Restrict the use of quinolones (moxifloxacin, ciprofloxacin), cephalosporins and co-amoxiclav to where it is absolutely necessary and prescribe antibiotics inline with
• When prescribing antibiotics please be cautious in the high risk groups identified or if the patient is known to have had C-difficile in the past.
• Review all medication in particular those that may affect gut motility and flora e.g. PPI’s and aperients.
• If C-difficile is suspected do not prescribe anti-motility drugs e.g. Loperamide

Polio virus

Post Polio Postpolio syndrome

Postpolio syndrome (originally called the late effects of polio) is a descriptive term for the new weakness and muscle fatigue that may develop, on average 30–40 years after an initial polio infection
Following the initial acute polio infection, recovery, rehabilitation and sometimes surgery, many people were left with varying degrees of weakness, fatigue, muscle pain, breathing and orthopaedic problems. These often gradually improved and then stabilised, but several decades later further problems may occur. In some people, new symptoms are the result of the original weakness and orthopaedic problems, but in others the new weakness or muscle fatigue are considered to be a new neurological deterioration called postpolio syndrome (PPS)
PPS is a neurological condition that produces a cluster of symptoms in many people who had poliomyelitis (polio) years earlier, including some with apparent nonparalytic polio
Symptoms include gradual or abrupt new weakness or unaccustomed fatigue in muscles previously affected or apparently unaffected by polio, with or without other symptoms like muscle and/or joint pain, muscle atrophy, decreased endurance, functional loss, cold intolerance, breathing or swallowing problems
PPS typically occurs after a period of at least 15 years of functional and neurological stability following the initial episode of polio and a partial or fairly complete recovery
Symptoms occur irrespective of ageing and are not readily explainable by preexisting poliorelated or other medical, orthopaedic and neurological conditions, which may or may not also exist
These symptoms may sometimes appear to be triggered by various events like surgery, falls or immobility
Much can be done to manage some of the symptoms and enable the retention of an independent life, albeit with some modification of lifestyle

Management
There is no specific cure for PPS. The effects of polio and PPS on each person vary. Delay in diagnosis may lead to further deterioration than is necessary. Management of PPS involves appropriate referral for multidisciplinary assessment from healthcare professionals, ideally with knowledge of polio/PPS together with use of selfmanagement strategies
Energy management: overactivity or underactivity can lead to fatigue, increased weakness and pain. Although it is important to keep mobile, activity levels need to be balanced and paced, balancing rest and activity. Each person is an individual and professional guidance is recommended
Advice on general health: eating a healthy, wellbalanced diet, weight loss if appropriate, not smoking and keeping warm enough are all important
Review use of aids and equipment: equipment and adaptive strategies may enable a person to be as active as possible whilst managing their energy levels. Some people may need to consider use of a walking stick, callipers or orthopaedic footwear, respiratory ventilation, wheelchair or electric scooter. Appropriate advice and referral is important
Social and emotional support: support from friends, family or professionals can help people come to terms with changing health or increasing disability. Often people with polio were advised in the past to push their physical limits or to ignore their polio. Many will have been adapting strategies to manage their polio over the years – and will need to adapt again which may take time, support and information ¥
Information and peer support is often invaluable
Medication considerations: extra care may be needed when prescribing and monitoring sideeffects or dosage of certain medications, especially where these can cause or increase muscle or respiratory weakness, fatigue, dizziness and/or drowsiness, depression, insomnia or vasoconstriction. Examples include: anaesthesia or sedation, benzodiazepines, and ?blockers
Referral as appropriate: e.g. to a neurologist, orthopaedic consultant, respiratory consultant or specialist respiratory unit, rehabilitation consultant, orthotist, physiotherapist, occupational thera

Anthrax

Brucellosis

Brucellosis @ HPA

Lyme Disease

European Tick Borne Encephalitis

Weils

Syphilis – treponema pallidum

250textbooks/syphilis-stis

Legionella Legionnaires’ disease

Legionnaires’ disease @ HPA

Psittacosis

Toxoplasmosis

Toxoplasmosis @ HPA

Orf

Hepatitis viruses

Hepatitis A virus

Hepatitis B virus

Hepatitis C virus

Blood-borne virus, spread mainly through blood-to-blood contact
? Can damage the liver, potentially causing cirrhosis and primary liver cancer
? Symptoms can take years or decades to occur
An estimated 200,000 people are chronically infected in England
HCV has been associated with injecting drug use, but there are a variety of ways in which it can be transmitted

Why should I be proactive in diagnosing HCV?
The majority of those infected in England are probably unaware of it
Treatment can successfully clear the virus in more than half of patients treated overall

Who is at risk of HCV?
Hepatitis C testing should also be offered to anyone who:
Has unexplained abnormal liver function tests (e.g. elevated ALT), or unexplained jaundice
Has ever injected drugs in the past (including anabolic steroids) using shared equipment, however long ago, even if this was only once or twice
Has had a blood transfusion in the UK before September 1991 or received any blood products before 1986
Has received medical or dental treatment in countries where infection control may be poor
Is the child of a mother with HCV
Is a regular sexual partner of someone with HCV
Has been accidentally exposed to blood where there is a risk of transmission of HCV
Has had tattoos, piercings, acupuncture or electrolysis where infection control procedures are poor

HCV Testing
The primary screening test is a blood test for antibodies to the virus (anti-HCV), which indicates if a person has ever been infected with HCV. A positive test should be confirmed by
testing a second sample. It can take three months for antibodies to become detectable. A negative test should be repeated if the exposure was within three months of the test.
About 20–40% of people will clear the virus naturally, so a test to detect HCV RNA is required to establish if the patient is still infected.

Pre-test discussion should include:
Hepatitis C, its natural history and the benefits offered by treatment
What the test involves, testing timescale and confidentiality of results
Assessment of exposure risks and establishing when the last risk activity took place
Implications of a positive result for the individual and his/her family or close contacts
What personal support network the individual may have; information about national/local organisations that provide support
It may also offer the opportunity to advise injecting drug users about harm minimisation and to offer them the hepatitis A and hepatitis B vaccine.

Post-test discussion
Post-test discussion should also include:
Negative antibody result Further testing will be required if the last exposure risk occurred in the preceding three month ‘window period’ Ways of avoiding infection in the future

Positive antibody result
Positive antibody results should be confirmed on a second blood sample, when tests for HCV RNA can also be performed if the positive antibody results are confirmed
Advise not to donate blood or carry an organ donor card

Positive HCV RNA result
Patients should be referred to a specialist for further assessment
Stop or reduce alcohol consumption (associated with more rapid progression of liver disease)
Ways of avoiding infecting others
Consider the need to test other family members or close contacts
Negative HCV RNA result
A positive antibody and negative HCV RNA test indicates a previously resolved infection, but not immunity to further infection
Patients who are antibody positive but HCV RNA negative should have a second HCV RNA test after 4–6 weeks to confirm their negative status

Hepatitis C Quick reference guide for primary care

Hepatitis D virus

Hepatitis E virus

Influenza virus

Seasonal flu

Flu vaccination

at-risk groups eligible to recieve a free flu jab:
pregnant women (in any stage of pregnancy)
anyone with a long-term condition including diabetes, asthma, liver disease, kidney disease or heart or chest problems
people undergoing medical treatment who may have a compromised immune system
people with a neurological condition such as multiple sclerosis (MS) or cerebral palsy
frontline health or social care workers
people living in a residential or nursing home
a main carer for an elderly or disabled person whose welfare may be at risk if they fall ill
anyone aged 65 or over

Immunisation of those at high risk of serious illness from influenza reduces hospital admissions and deaths. Immunisation can reduce mortality by up to 40%
(Up to 70% in repeated vaccination), and respiratory illness by up to 50%.
In October every year there is a marvellous influenza immunisation campaign run by primary care, the aim being to reduce morbidity and mortality. Current
work is looking into the role of children in transmission of the virus, as well as how the illness affects them. They may be part of new inclusion groups in future
campaigns that are sent out yearly by the Chief Medical Officer (CMO). The Department of Health’s flu campaign targets all people over 65 years and
all people over six months of age in the following risk groups:
all high-risk groups (cardiovascular disease, diabetes, immunosuppression and chronic diseases, including chronic liver disease)
all those in long-stay residential and nursing homes, as well as other long stay facilities
people who are the main carer for an elderly or disabled person whose welfare may be at risk if their carer falls ill (added 2005)
immunisation of healthcare workers (as part of what is called ‘prudent winter planning’)

CMO immunisation programme 2005 targets
A minimum target of 70% in those over 65 years of age. The World Health Organisation has set targets of 85% to be achieved by 2010 (alongside this the GP contract sets out percentages needing to be achieved in certain disease areas).
NHS employers should offer the vaccination to employees directly involved in patient care through the occupational health service, not their own GPs
(unless they have been specifically contracted). Vaccines for staff should not be obtained at the expense of vaccine for the high-risk groups.
A number of different articles in the British Journal of General Practice found variously that patients who decline flu vaccine:
consider influenza a mild disease
hope they won’t get flu
doubt the effectiveness of the vaccine
fear the side effects of the vaccine and that it will give them flu
lack campaign awareness
are apathetic
are unable to attend for immunisation (e.g. housebound or in residential care)
find the timing of immunisation clinics inconvenient
lack information about the vaccination.

Influenza immunization uptake and distribution in England and Wales using data from the general practice research database 1989/90-2003/04 JPublic Health 2005; Oct 5
Major changes to the influenza vaccination programme were introduced in 1998 and 2000 (immunisation of elderly patients became age-related rather than risk related).
This review examined groups by age and medical risk. Vaccine uptake among high-risk individuals over 65 years ofage increased from 36.7% in 1989/90 to 72.1%in 2003/04.
Vaccine uptake among high-risk individuals under 65 years increased from 10.8% in 1989/90 to 24.3% in 2003/04. This is still well below satisfactory levels.
It will be interesting to see the follow-through from implementation of the new contract.

Effectiveness of influenza vaccine in community-dwelling elderly NEJM 2007; 357(14): 1373
Resulting from concern that short-term studies may provide misleading pictures of long-term benefits, this study considered the effectiveness of influenza vaccine
from 20 cohorts (713 872 person-seasons) of community-dwelling elderly over 10 flu seasons. Vaccination was associated with a 27% reduction in the risk of
hospitalisation for pneumonia or influenza (adjusted odds ratio, 0.73; 95% CI 0.68-0.77), and a 48% reduction in the risk of death (adjusted odds ratio, 0.52;
95% CI 0.50-0.55).

As previously highlighted, monovalent H1N1 (pandemrix) vaccine can be used for those eligible groups if efforts to secure the trivalent seasonal flu vaccine are unsuccessful. The DH has advised individuals who received H1N1 vaccination last year, should still receive a further dose of pandemdrix this year (if the seasonal flu vaccine is unavailable). The rationale behind this decision is enclosed in the following attachment which states “the duration of protection from pandemrix given in 2009/2010 is uncertain. A further dose of pandemrix given now will provide protection against the H1N1v flu strain for the remainder of this flu season”.

I have also received several questions asking what clinicians should do if they give pandemrix now (as a substitute to the seasonal flu) and then go onto acquire some stocks of seasonal flu- would there need to be a recall of patients to have the trivalent flu vaccine.

Response from DH press conference dated 6th January-

“If trivalent seasonal flu vaccine subsequently becomes available in future weeks, then the clinician should apply clinical judgement on whether a dose of trivalent seasonal flu vaccine should be given to provide protection against the influenza B and influenza H3N2 strains. Judgement should be based on the risk of flu exacerbating any underlying disease an individual patient may have as well as the risk of serious illness from flu itself and whether flu is still circulating”.

Pandemrix should be considered a seasonal flu vaccine for the purpose of administration. Payment will therefore be paid using the arrangements under the Seasonal Influenza Local Enhanced Service (LES) for Influenza 2010/2011 not the Pandemic Influenza (H1N1) LES.

Patients with Egg Allergy
Preflucel MASTA patients over the age of 18 who have confirmed anaphylaxis to egg or egg allergy with uncontrolled asthma (British Thoracic Society SIGN step 4 or above).

eguidelines flu vaccintion campaign

2010 flu advice to patients

GMHPU Guidance for primary care clinicians approached for advice from patients during the forthcoming flu season

(1) ANTIVIRALS
Flu A and Flu B viruses, the H1N1 (2009) virus is now regarded as one of the group of seasonal flu viruses in general circulation and therefore the NICE recommendations on the use of antivirals for treatment and prophylaxis will apply during the 2010/11 influenza season.
Antivirals should be used when:
• A person with a flu-like illness is in an ‘at-risk’ group and can start treatment within 48 hours (or within 36 hours for zanamivir treatment in children) of the
onset of symptoms as per licensed indications AND • National surveillance has indicated that influenza viruses are circulating in the community.
One change is that from 1 November 2010, the regulations have been updated so that the
groups of people ‘at clinical risk’ who are eligible to receive antivirals prescribed by General Practitioners will be widened to include pregnant women.
NICE guidance on the use of antivirals Treatment Prophylaxis

(2) MICROBIOLOGICAL TESTING
Recommended for clinical/infection control purposes in patients where the result will influence management (at the discretion of the responsible clinician)

(3) VACCINE SAFETY
This season’s flu vaccine is expected to have a similar safety profile as past seasonal flu vaccines. A recent study in UK and a comprehensive literature review in Australia found no evidence of a link between influenza vaccine and Guillain-Barre syndrome.

http://www.healthemergency.gov.au/internet/healthemergency/publishing.nsf/Content/national-vaccination-program#atagi

(4) INFECTION CONTROL
Standard infection control measures and droplet precautions should be used when caring for people with respiratory infections such as influenza.
Information on droplet precautions can be found in guidance produced by Heath Protection Scotland

Infection control care of those known or suspected to have Influenza in healthcare settings – Droplet Precautions

(5) INSTITUTIONAL SETTINGS (SCHOOLS/NURSERIES/CARE HOMES/PRISONS)
PCT infection control teams may be contacted for advice:
(a) for individual cases in these settings, advice should follow the standard principles of care for seasonal flu (including (1) contacting the GP by phone, if concerned and (2) exclusion from school/nursery till asymptomatic)
(b) where there is suspicion of a cluster of cases/outbreak of respiratory illness, institutions should be advised to contact Greater Manchester HPU (GMHPU) on 0161 786 6710 for further advice.

Pandemic Flu H1N1 (infections)

SARS (infections)

Meningitis infections

HIV AIDS virus

Kaposi

Konjunctivitis
AIDS defining illness
Palate lesions
Other sites eg lungs lymph nodes
Skin
Indigestion GIT

HIV management

http://youtu.be/1RGkM1Y49oU

Fungal infections

Fungal infections Medscape Infectious Diseases (scroll down)

Systemic Fungal Infections

Fungal Skin and Nail Infections

http://www.youtube.com/watch?v=0TZ8dt31yzw

Tinea pedis, scalp, cruris, corporis, onychomycosis: Unless there is true Tx failure-
Itchy scaly patches with leading edge on torso/ groin; 1 or 2 nails and 4th web involvement.
May coexist in psoriatic nails NB Id response
Is this true treatment failure? Review the diagnosis! Don’t just repeat Tx or prescribe a different antifungal, don’t treat it if its not there!
Were clippings/ scrapings taken with confirmation of infection either on microscopy or culture
( 40% +ve on microscopy neg on culture, Tx as positive)
Has adequate treatment been prescribed and taken? Scalps: For Tinea Terbinafine ( Lamisil) better than Griseofulvin and OK in kids even though off licence ( children’s BNF, Prescriber, Dr Higgins in Mims Dermatology)
if Tx adequate Has the family been screened? Is this reinfection?
If they have their hair clipped may be better to have own clippers once tx has settled.
Take scraping/ clippings including debris, give good clinical details; If there is a lot of scale take scraping as well as brushings as you’ll get a result within a week and can instigate Tx. Ask about children/ sibs and consider taking a brushing straight away if they have come too. Weigh children.
Tx
ScalpsNizoral shampoo in the interim, If proven Terbinafine 250mg od ( adults) orally for 1/12 (weight related dosage as per children’s BNF)unless its Microsporum canis; + Brushings from scalps of family.
Torso/ limbs: await mycology or if clinically very likely use topical Terbinafine ( even in infants) for 2 (-4) weeks then oral Terbinafine . For microsporum use Griseofulvin.
Groin: start with topical Terbinafine but often need oral Terbinafine as above for 2-4 weeks
Nails: Do they need Tx at all? If so 3/12 of oral Terbinafine (LFTs 1st) usually effective, sometimes 4/12 in the elderly. Elderly nails take many months to grow out and may never do so.

Infestations

250textbooks/infestations-dermatology

Worms

Tropical Worms

Threadworms Pinworms

Round Worm
ascaris lumbricoides far east & tropical africa eggs in human faeces
http://www.youtube.com/watch?v=Dl2WUH2m69I

Hook Worm
anncylostma duodenale tropics & subtropics soil

http://www.youtube.com/watch?v=IMIDIAUBF8Y

Whip Worm
Trichuris trichiura far east & tropics soil

Tapeworm
Taenia saginata middle east & tropical africa undercooked pork & beef
Taenia solium

http://www.youtube.com/watch?v=4DQIGjP8vnU

Exotic and tropical Diseases

250textbooks/exotic-disease-2

Zoonoses

Working with animals Rural Health West au

Fish Pedicures

Public Health risks from fish pedicures HPA

Immunisation and vaccination

Vaccination schedules

hacking-medschoo/immunisation-schedules

Types of vaccines

Types Of Vaccines
Toxoid	diptheria tetanus
Inactivated Vaccine	pertussis typhoid anthrax rabies polio
Live Vaccine	MMR BCG Oral Polio Yellow Fever

Vaccine types history of vaccines.org

Live Vaccines CI

Incomplete and Accelerated Courses

Vaccination Clinic Procedures

1. Often conducted with the health visitors/practice nurse
2. Check availability of up-to-date ampoules of 1 in 1 000 adrenaline in case of a severe anaphylactic reaction
3. Explain the procedure to the mother and make sure consent has been obtained
4. Check with the mother on the contraindications to the proposed immunization
5. Check on current health of the child note that a simple snuffly cold would not be a contraindication
6. Carry out the immunization procedure
7. Warn of the possible side-effects (mild measles-like illness in 8 day, etc.)
8. Ensure you have entered the immunization on the child’s record

10 Minute Consultation BMJ Aug 2011 Egg Allergy and MMR

Vaccine safety

Thimerosal in vaccines

Mercury-based antimicrobial preservative that is found in some vaccine preparations alleged but disproved to be related to autism

Tetanus Vaccination

see Tetanus Acute Care

Human Tetanus Immunoglobulin

HTIG

MMR

An effective vaccine to prevent measles is available and is part of the measles, mumps and rubella (MMR) vaccine, which is routinely offered to
children between 12 to 18 months of age. A second dose is offered as part of the routine pre-school booster programme.
MMR vaccine CAN be used to prevent transmission of measles in susceptible
contacts (people without a history of infection or vaccination). This is because
vaccine-induced measles antibodies develop more rapidly than following
natural infection. It is preferable to give vaccine within 3 days of exposure.
For immunocompromised contacts MMR is contraindicated and in children
under 12 months old vaccine response is poor. These people should be
offered immunoglobulin. MMR should be offered to a child given
immunoglobulin after an interval of three months or when the child is over 12
months old, whichever is the later.

H influenzae vaccination

Hib

Hepatitis B vaccination

Influenza vaccination

hacking-medschool.com/influenza-vaccination

Pneumococcal Vaccine

Asplenic Patients

Asplenia Hyposplenia Guidelines Notts University Hospitals

Splenectomy or splenic dysfunction
All patients should receive< Pneumococcal vaccine
Hib/Men C, 2 doses two months apart if not previously immunised or single dose if fully immunised as part of the routine programme (no further boosters required).
Influenza vaccine, annually.
Vaccines should be given a minimum of 2 weeks prior to elective splenectomy or 2 weeks post splenectomy.
Life-long prophylactic antibiotics:Penicillin V 500mg twice daily or Erythromycin 500mg once daily.
Department of Health Leaflet and card

The spleen
1 x 3 x 5 inches x 7oz lying obliquely between 9th and 11th ribs

Vaccine contraindications and notes

General contraindications to live vaccines
1. Pregnancy
2. Any acute febrile illness-NOT just a snuffly cold
3. Patients who are immunosuppressed or receiving radiotherapy
4. Patients with malignant conditions (including leukaemia andlymphomas)
5. Patients on steroids
6. Within 3 weeks of receiving another live vaccine

Specific Vaccine Notes

Diphtheria

Tetanus

Rubella

BCG

Specific Routine vaccines

DTaP/IPV(polio)/Hib

PCV (pneumococcal conjugate vaccine)

MenC (Meningitis C)

Hib/MenC

DTaP/IPV

HPV

Td/IPV

BCG Heaf

BCG

In July 2005 the SEHD introduced an improved targeted programme directed towards those most at risk that will replace the current universal (schools) BCG programme.

Those now recommended to receive BCG are:

*

All infants living in UK areas where the incidence of TB is 40/100,000 or greater (no NHS Board areas in Scotland fall into that high risk category)
*

Infants whose parents or grandparents were born in a country with a TB prevalence of 40/100,000 or higher
*

Previously unvaccinated new immigrants from high prevalence countries for TB.
*

Children who would otherwise have been offered BCG through the schools’ programme will now be screened for TB risk factors, and tested and vaccinated if appropriate

The contact, occupational and travel related recommendations remain unchanged.

The Mantoux test will replace the Heaf test as the standard method of tuberculin skin testing. Training in use of the Mantoux method should be arranged locally. SEHD will ensure that supplementary training materials will be supplied in due course.

The full SEHD advice can be viewed at the following link: http://www.show.scot.nhs.uk/sehd/cmo/CMO(2005)05.pdf

UK production of tuberculin PPD has now ceased and the SEHD has obtained alternative supplies of tuberculin PPD for Mantoux testing manufactured by Statens Serum Institute (SSI) in Denmark. This is available as an unlicensed medicine in the UK. There are important differences between Tuberculin Mantoux PPD from SSI and Tuberculin Mantoux PPD formerly provided in the UK. Users must carefully read the label and package insert. Full details of the differences and the SSI SPC with instructions for testing can be viewed at the following link:

http://www.show.scot.nhs.uk/sehd/cmo/CMO(2005)6.pdf

Chickenpox vaccine

Varicella zoster NHS Choices

@@@ Fever PUO

Fever is generally a sign of the bodies response to infection.

A high fever is considered to be a core temperature above 40° (104°). A sustained high fever or a fever greater than 41.1°C (106°F) is considered a medical emergency and can lead to unconsciousness, seizures, and permanent brain damage if not treated.

Red Flag Warnings

Sustained high temperature 40°C (104C) or greater
Lethargy or decreased level of consciousness
Hypotension Collapse
Tachycardia Tachycpnoea Sweating Rigors Hypoxia (cjeck 02 satts)
Petechial or purpuric Rash (consider Meningitits)
Cold mottled Extremeties Cyanosis Severe Joint and muscle pains Abdo pains

Immediate Care Considerations

Administer antipyretic
Insert Intravenous Catheter for fluid replacement if dehydration is suspected
If persistent fever greater than 40°C begin rapid cooling methods( ice packs to axilla and groin, or apply cooling blanket). With any rapid cooling method, continuos monitoring of the patients oral or rectal temperature should be observed to ensure the patient does not cool to quickly

3. Background Information
Fever is the body’s natural defense mechanism to an underlying condition, usually infection. It is costly in energy terms and is thus thought to confer some evolutionary purpose.. Increased body temperatures is thoyght to increases the activity of the immune system and may kill some infectious organisms which cannot survive at higher temperatures. Antipyretics or cooling methods can hinder the body’s natural defenses .against the infection, therefore it is not now recommended to routinely lower temperature.

Thermoregulatory dysfunction of the brain may cause a sudden onset of fever that rises very quickly and extremely high. This can occur in life threatening disorders such as heat stroke, thyroid storm, or lesions of the CNS. It is important to note that the elderly may have an altered sweating mechanism and thermoregulatory mechanism therefore; they may be predisposed to heat stroke. When the body’s temperature rises too high damage can occur to cells in the body especially the nervous system.

Re-occuring or prolonged fevers are atypical and may suggest more complex disease such as Neoplasms, metastases, Malaria, or Immunological disease.

Alone a fever is a very vague symptom but when presenting with other complaints, a diagnosis or rationale for diagnostic test is achievable.
4. Investigations

Labs including Full blood count measures of inflammation and urine and blood cultures.
Monospot test for suspected glandular fever
Culture from suspected infected area
Nasopharyngeal swabs
Lumbar puncture for suspected meningitis
X-ray
Tuberculin skin test if TB is suspected
Antipyretics as appropriate
Non-steroidal Anti-inflammatory (NSAIDS)
Antibiotics/Antifungals/Antivirals
Maintenance of adequate hydration

5. Treatments
6. Discharge and Follow Up Considerations
Referral to specialist if further care investigation or treatment

Advise on proper use of antipyretics iIt is not now recommended that buprofen and paracetamol are given together in children
Avoid heavy layers of clothing or bed covers
Drink plenty of fluids 3-4 L/day unless otherwise contraindicated due to pre-existing condition

Fever
History duration
degree (if accurate thermometer used)
any other symptoms
headache
sore throaVcold
cough
dysuria/frequency
vomiting/diarrhoea
abdominal/loin pain
rash
drowsiness/photophobia
lactating
travel to tropical area in last 12 months
immunocompromised

Examination ears
(as suggested throat
by symptoms)
cervical lymph nodes
chest
rash (beware the petechial rash of meningitis)
neck stiffness (e.g. can a child kiss his knees)
breasts in lactating women
any painful area (e.g. sinuses, abdomen)
Tests test urine for nitrites, protein and blood if cause of fever
not obvious (to avoid contaminating the whole sample,
pour a little urine on the test strip)
send midstream urine (MSU) for culture if test positive or
any urinary symptoms
Action ample fluid intake
avoid overstrenuous activity
paracetamol/ibuprofen as needed to relieve discomfort
assume a viral cause if no other clues, fever less than
7 days’ duration and generally well
otherwise give treatment appropriate to cause
reduce anxiety about fever, by explaining that it is
produced by the body’s immune system in response to an
infection, is unlikely to cause any harm and may aid
recovery
Refer to doctor immediately if:
photophobia, neck stiffness, drowsiness or petechial rash
appears very unwell
unexplained fever lasting more than 7 days
immunocompromised
travel to tropical area in last 12 months
30 The minor illness manual
Caution

Hay fever
History
Examination
Tests
mastitis may cause ‘flulike symptoms in a breastfeeding woman with only minimal signs in the breast

malaria may cause an illness indistinguishable from ‘flu and taking malaria prophylaxis may not prevent malaria.
If patient has visited an area where falciparum malaria occurs, a ‘test and treat’ strategy is recommended, where empirical treatment is given without waiting for the test result

meningitis in its early stages is impossible to distinguish from a simple viral infection. Diarrhoea and vomiting may cause confusion with gastroenteritis, and the rash of meningococcal septicaemia may initially appear macular and blanch on pressure.
Ensure that the patient/parent knows that they should contact the appropriate NHS service if symptoms worsen

fever with no associated other symptoms or signs of a focus of infection may require thorough investigation in hospital to discover the hidden cause

Child doses

40mg/kg/day in 3 doses (max. 3g daily)

All for

For extensive, severe, or bullous impetigo, use oral antibiotics

Scalp: discuss with specialist

Take nail clippings: start therapy only if infection is confirmed by laboratory

If indicated:

aciclovir

Second line for shingles if compliance a problem, as ten times cost

valaciclovir

800 mg five times a day

Transfer all patients to hospital immediately.

If time before admission, give IV benzylpenicillin or cefotaxime unless hypersensitive ie history of difficulty breathing, collapse, loss of consciousness, or rash

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