2019 Recommendations on Rational Antibiotic Therapy

Management of common infections with antimicrobials guidance clinical practice guidelines were released in February 2019 by the National Institute for Health and Care Excellence (NICE).

Acute Sore Throat

For low-risk patients, use acetaminophen (first choice) or ibuprofen for pain. The decision for antibiotics is based on the FeverPAIN or Centor score.

High-risk patients should receive immediate antibiotic therapy.

Preferred antibiotics include penicillin VK (first choice) or clarithromycin (if penicillin allergy) or erythromycin (in pregnant patients).

Influenza

Annual vaccination is essential in at-risk patients. Oseltamivir is the first-line antiviral. Zanamivir is an alternative.

In otherwise healthy patients, antivirals are not recommended.

Scarlet Fever

Prompt antibiotic therapy reduces risk of complications.

Preferred antibiotics include penicillin VK (first choice) or clarithromycin (if penicillin allergy).

Sinusitis

Use acetaminophen or ibuprofen for pain.

Do not use antibiotics in patients with symptoms for 10 days or less. In patients with symptoms for more than 10 days with no improvement, use either no antibiotic or back-up antibiotic depending on likelihood of bacterial sinusitis. Consider high-dose nasal corticosteroid in patients older than 12 years.

High-risk patients should receive immediate antibiotic therapy.

The preferred antibiotic is penicillin VK. In patients with a penicillin allergy, use clarithromycin (if ≥12 years), clarithromycin, or erythromycin (preferred if pregnant). Amoxicillin/clavulanate is the second choice or first choice in high-risk patients.

Community-Acquired Pneumonia

Antibiotic therapy depends on CRB65 parameter score. Antibiotics for a score of zero include amoxicillin, clarithromycin, or doxycycline. Antibiotics for a score of 1-2 include amoxicillin plus either clarithromycin or doxycycline.

Lower Urinary Tract Infection

Advise acetaminophen or ibuprofen for pain.

In nonpregnant women, prescribe antibiotic as a back-up or immediately. Preferred antibiotics include nitrofurantoin (first choice if estimated glomerular filtration rate [eGFR] ≥45 mL/min) or trimethoprim (low risk of resistance). Second-line choices include nitrofurantoin (if eGFR ≥45 mL/min), pevmecillinam (not available in the United States), or fosfomycin.

In pregnant women, men, or children, prescribe an antibiotic immediately.

In pregnant women, the preferred antibiotic is nitrofurantoin (avoid at term) if the eGFR ≥45 mL/min. Second choices include amoxicillin or cephalexin.

In men, preferred antibiotics include trimethoprim or nitrofurantoin (if eGFR ≥45 mL/min).

In children older than 3 months, first choices include trimethoprim or nitrofurantoin (if eGFR ≥45 mL/min). Second-line agents include nitrofurantoin (if eGFR ≥45 mL/min and not used as first choice), amoxicillin, or cephalexin.

Acute Prostatitis

Advise acetaminophen (with or without a low-dose weak opioid) or ibuprofen for pain. Preferred antibiotics include ciprofloxacin, ofloxacin, or trimethoprim. Second-line agents include levofloxacin or cotrimoxazole.

Suspected Meningococcal Meningitis

The preferred agent is IV or IM penicillin G.

Oral Candidiasis

Preferred agents include miconazole oral gel (first choice), nystatin suspension (if miconazole not tolerated), or fluconazole capsules.

Chlamydia Trachomatis/Urethritis

The first-line agent is doxycycline. Azithromycin is the second-line choice and is preferred in pregnant or breastfeeding women or in patients with an allergy or intolerance to doxycycline.

Epididymitis

Preferred agents include doxycycline, ofloxacin, or ciprofloxacin.

Vaginal Candidiasis

Preferred agents include clotrimazole, fenticonazole, clotrimazole, or oral fluconazole.

Bacterial Vaginosis

Preferred agents include oral metronidazole, metronidazole 0.75% vaginal gel, or clindamycin 2% cream.

Genital Herpes

Preferred agents include oral acyclovir, valaciclovir, or famciclovir.

Gonorrhea

Preferred agents include ceftriaxone or ciprofloxacin (if known to be sensitive).

Trichomoniasis

Preferred agents include metronidazole (first choice) or clotrimazole (in pregnancy to treat symptoms).

Pelvic Inflammatory Disease

The first-line combination is ceftriaxone plus metronidazole plus doxycycline. Second-line agents include (1) metronidazole plus ofloxacin or (2) moxifloxacin monotherapy (first line for Mycoplasma genitalium pelvic inflammatory disease [PID]).

Impetigo

Preferred agents include topical fusidic acid, topical mupirocin (if methicillin-resistant Staphylococcus aureus [MRSA]), or, for more-severe infections, oral flucloxacillin or oral clarithromycin.

Eczema

Avoid antibiotics if there are no visible signs of infection.

If signs of infection are visible, use oral flucloxacillin or clarithromycin or topical treatment (as in impetigo).

Scabies

The first-line agent is permethrin. Use malathion in patients with permethrin allergy.

Mastitis

S aureus is the most common pathogen. Flucloxacillin is preferred for treatment. In patients with penicillin allergy, use erythromycin or clarithromycin.

Varicella Zoster/Herpes Zoster

For chickenpox and shingles, the first-line agent is acyclovir. Second-line choices in cases of poor compliance include famciclovir (not in children) or valaciclovir.

Tick Bites (Lyme Disease)

Use doxycycline for prophylaxis. For treatment, the first-line choice is doxycycline. The first alternative is amoxicillin.

Reposted from: Medscape