How to Take Antibiotic for Common Infection
Antibiotic choices for common infectionsIncreasing antimicrobial resistance is now a worldwide problem, compounded by the lack of development of new antimicrobial medicines. This leaves the prudent use of antimicrobial medicines, along with infection control, as the major strategies to counter this emerging threat.A safe and effective strategy for antibiotic use involves prescribing an antibiotic only when it is needed and selecting an appropriate and effective medicine at the recommended dose, with the narrowest spectrum of antimicrobial activity, fewest adverse effects and lowest cost.General principles of antibiotic prescribing:
Respiratory
COPD – acute exacerbations |
|
Management |
Many exacerbations
are triggered by viruses and antibiotic treatment provides limited benefit. Antibiotic treatment is most helpful
in patients with severe exacerbations (e.g. purulent sputum
and increased shortness of breath and/or
increased volume of sputum) and those with more severe airflow obstruction at baseline. |
Common pathogens |
Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis |
Antibiotic treatment |
Acute exacerbation of COPD |
First choice |
Amoxicillin Adult: 500 mg, three
times daily, for five days |
Alternatives |
Doxycycline Adult: 200 mg, on day
one (loading dose),
followed by 100
mg, once daily, on days two to five |
Pertussis (Whooping cough) |
|
Management |
Antibiotic treatment is
recommended to reduce transmission, if initiated within three weeks of the onset of the cough, as
after this time most people are no longer infectious. Antibiotic treatment is unlikely to alter the clinical course of
the illness unless given early (in the catarrhal stage). If the duration of the cough is unknown, give antibiotic treatment. Women who are in their third trimester of pregnancy should
also receive antibiotic treatment, regardless of the duration
of cough. The patient should be
advised to avoid contact with others, especially
infants and children, until at least five days of antibiotic treatment has been taken. Prophylactic antibiotics are recommended for high risk contacts: children aged less than one year, people caring
for children aged less than one year, pregnant women,
and people at risk of complications, e.g.
severe asthma, immunocompromised. |
Common pathogens |
Bordetella pertussis |
Antibiotic treatment |
Pertussis (Whooping cough) |
First choice |
Azithromycin (first-line for children, alternative for adults) Child < 45 kg: 10 mg/kg/dose, once daily, on day one, followed by
5 mg/kg/dose, once daily,
on days two to five Adult and Child > 45 kg: 500 mg on day one, followed by 250 mg,
once daily,
on days two to five Erythromycin (first-line for adults, alternative for children
aged over one year) Child: 10 mg/kg/dose, four times daily,
for 14 days Adult: 400 mg, four times daily, for 14 days N.B. Erythromycin ethyl succinate is currently the only fully subsidised form
of oral erythromycin available in New Zealand. Treatment and prophylaxis is recommended for 14 days with erythromycin ethyl succinate. There is
evidence that seven days of treatment with erythromycin estolate (which has superior tissue
and serum concentrations compared with the other
erythromycin salts), is as effective as 14 days treatment. However, erythromycin estolate is not
currently available in New Zealand. |
Alternatives |
None |
Pneumonia – adult |
|
Management |
Chest x-ray is not routinely recommended, however, it may
be appropriate when the diagnosis
is unclear, there is dullness to percussion or other signs of an effusion or collapse, and when the likelihood of malignancy is increased, such as in a smoker aged over 50 years. Patients with one or more of the following features: age
> 65 years, confusion,
respiratory rate >30/min, systolic BP < 90 mm Hg, diastolic BP <60 mm Hg, have a predicted increased mortality rate and admission to hospital should be considered. Patients can generally be adequately treated with an
agent that covers S. pneumoniae. Ciprofloxacin should not be used as it does
not reliably treat
infections due to S. pneumoniae. |
Common pathogens |
Respiratory
viruses, Streptococcus pneumoniae,
Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophilia pneumonia, Legionella pneumophila, Staphylococcus aureus |
Antibiotic treatment |
Pneumonia – adult |
First choice |
Amoxicillin Adult:
500 mg – 1 g, three times daily, for five to seven days If
M. pneumoniae,
C. pneumoniae or
L. pneumophila are
suspected or if the patient has not improved after 48 hours, add either roxithromycin 300 mg, once daily, for seven days or doxycycline 200 mg, twice daily*, on day one, followed by 100 mg, twice daily,
from days two to seven * Increased dose as recommended by ADHB pneumonia guidelines |
Alternatives |
Monotherapy with roxithromycin or doxycycline is
acceptable for people
with a history
of penicillin allergy. |
Pneumonia – child |
|
Management |
Referral to hospital
should be considered for any child with one or more of the following factors: aged less than six months,
drinking less than half
their normal amount,
oxygen saturation ≤92% on pulse oximetry, severe tachypnoea, decreased
respiratory effort, temperature
< 35°C or > 40°C, decreased breath sounds or dullness to percussion, difficult to rouse. In addition, if there is no response
to treatment in 24 – 48 hours,
review diagnosis and consider referral to hospital. |
Common pathogens |
Respiratory viruses,
Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus |
Antibiotic treatment |
Pneumonia – child |
First choice |
Amoxicillin Child: 25 – 30 mg/kg/dose, three times daily, for five to seven
days (maximum 500 mg/dose age three
months to five years, 1000 mg/ dose age > five years) |
Alternatives |
Erythromycin Child: 10 – 12.5 mg/kg/dose, four times daily,
for seven days N.B. Can be first-line in school-aged children where the likelihood of atypical pathogens is higher. Roxithromycin Child: 4 mg/kg/dose, twice daily, for
seven to ten days N.B. Only available in tablet form,
therefore only if the child
can swallow tablets; whole or half
tablets may be crushed. |
Ear,
nose and throat
Otitis externa – acute |
|
Management |
Gentle debridement of the ear canal may be necessary to enhance the effectiveness of topical treatment.
Suction cleaning is also a safe and effective method
of debridement. Most topical antibacterials are contraindicated in the presence of a perforated drum or grommets, however, they may need to be used if other
treatment options have
been unsuccessful. |
Common pathogens |
Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, polymicrobial infections |
Antibiotic treatment |
Otitis externa (acute) |
First choice |
Clioquinol + flumethasone (Locorten Vioform)* Adult and child > 2 years: 2 to 3 drops,
twice daily, for 7 days OR Dexamethasone + framycetin + gramicidin (Sofradex)* Adult and child: 2 to 3 drops, three to four times
daily, for 7 days Avoid excessive use, e.g. for longer than one week, as
this may result in fungal infection which can be difficult to treat |
Alternatives |
Acetic acid 2% (Vosol)* may be sufficient in mild cases. Ciprofloxacin + hydrocortisone (Ciproxin HC)* if Pseudomonas Flucloxacillin if there is spreading cellulitis or the patient is systemically unwell; also consider referral to hospital. |
* Currently subsidised brand |
Otitis media |
|
Management |
Antibiotic treatment is usually
unnecessary. Consider antibiotics for children at high risk such as
those with systemic symptoms, aged less than six months, aged less than two years
with severe or bilateral disease, or with perforation and/ or otorrhoea. Also consider
antibiotics in children who have had more than three episodes of otitis media. Otherwise treat
symptomatically, e.g. paracetamol, and arrange follow up or give a “back pocket” prescription to be
dispensed if no improvement in next 24 – 48 hours. |
Common pathogens |
Respiratory viruses,
Streptococcus
pneumoniae, Haemophilus influenzae, Moraxella catarrhalis |
Antibiotic treatment |
Otitis
media |
First choice |
Amoxicillin Child:
15 mg/kg/dose, three times daily, for five days (seven to ten days if age
< two years, underlying medical condition or perforated ear drum) Use
30 mg/kg/dose, three times daily, for five to seven days in severe or recurrent
infection (maximum 500 mg/dose age three months to five years, 1000 mg/dose age
> five years) |
Alternatives |
Co-trimoxazole Child
> 6 weeks: 0.5 mL/kg/dose oral liquid (40+200 mg/5 mL), twice daily, for five
to seven days (maximum 20 mL/dose) If
a child can swallow tablets, co-trimoxazole 80+400 mg tablets can be used
(one tablet is equivalent to 10 mL of co-trimoxazole oral liquid) N.B.
Co-trimoxazole should be avoided in infants aged under six weeks, due to the risk
of hyperbilirubinaemia. |
Pharyngitis |
|
Management |
Most pharyngitis is of viral origin. The major benefit of
treating Streptococcus
pyogenes pharyngitis is to prevent
rheumatic fever, therefore antibiotic treatment is recommended for those at increased risk of rheumatic fever, i.e. if the patient
has a history of past
rheumatic fever, is of Maori
or Pacific ethnicity, or is living
in a lower socioeconomic area of the
North Island, and
is aged 3 – 45 years. Patients who fulfil one or more of these criteria,
and who have features of group
A streptococcus infection: temperature >38°C, tender cervical
nodes, tonsillar swelling or exudate, and no cough, especially if aged 3–14 years, should have a throat swab taken and empiric antibiotic treatment either started
immediately or if Streptococcus pyogenes is isolated
from the swab. Avoid amoxicillin if infectious mononucleosis (EBV) is suspected due to an increased risk of rash. |
Common pathogens |
Respiratory viruses, Streptococcus pyogenes |
Antibiotic treatment |
Pharyngitis |
First choice |
Phenoxymethylpenicillin
(Penicillin V) Child: 10 mg/kg/dose, twice daily, for ten days (maximum 500 mg/dose) Adult: 500 mg, twice daily, for ten days OR Amoxicillin Child <30 kg: 750 mg, once daily, for
ten days Child >30 kg: 1500 mg, once
daily, for ten days OR (if compliance is likely to be an issue) IM benzathine penicillin (stat) Child <
20 kg: 450
mg (600 000 U) Child >
20 kg: 900 mg (1 200 000 U) Adult: 900 mg (1 200 000 U) |
Alternatives |
Erythromycin Child: 20 mg/kg/dose, twice daily or 10 mg/kg/dose, four times daily,
for ten days
(maximum 1 g/day) Adult: 400 mg, twice daily, for ten days N.B. Co-trimoxazole does not have reliable activity against S. pyogenes or eradicate pharyngeal carriage and should
not be used. |
Sinusitis – acute |
|
Management |
Most patients with sinusitis will not have a bacterial
infection. Even for those that do,
antibiotics only offer a marginal benefit
and symptoms will resolve in most patients in 14 days,
without antibiotics. Consider antibiotics for patients with severe sinusitis symptoms (e.g. purulent nasal discharge, nasal congestion and/or facial pain or pressure) for more than five to seven days plus any of the following features: fever, unilateral maxillary sinus tenderness, severe headache, symptoms worsening after initial improvement. |
Common pathogens |
Respiratory viruses,
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, anaerobic bacteria |
Antibiotic treatment |
Sinusitis (acute) |
First choice |
Amoxicillin Child: 15 mg/kg/dose, three times daily, for seven days Use 30 mg/kg/dose, three
times daily, for seven days in severe or recurrent infection (maximum 500 mg/dose
age three months
to five years, 1000 mg/dose age > five years) |
Antibiotic treatment |
Sinusitis
(acute) – continued |
Alternatives |
Doxycycline Adult and child > 12 years: 200 mg on day one, followed by 100 mg, once daily, on days two to seven Amoxicillin clavulanate (if symptoms persist despite a treatment
course of amoxicillin) Child: 10 mg/kg/dose (amoxicillin component), three times daily,
for seven days (maximum 500 mg/dose amoxicillin component) Adult: 500+125 mg, three times daily, for seven days |
Eyes
Conjunctivitis |
|
Management |
Can be viral,
bacterial or allergic. Bacterial infection is usually associated with mucopurulent discharge. Most bacterial conjunctivitis is self-limiting and the majority of people improve
without treatment, in two to five days. In
newborn infants, consider Chlamydia
trachomatis or Neisseria gonorrhoeae, in which case, do not use topical treatment. Collect
eye
swabs, and refer
to a Paediatrician. |
Common pathogens |
Viruses, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus Less commonly: Chlamydia trachomatis or
Neisseria gonorrhoeae |
Antibiotic treatment |
Conjunctivitis |
First choice |
Chloramphenicol 0.5% eye drops Adult and child > 2 years: 1 – 2 drops, every two hours for the first
24 hours, then every four hours +/– chloramphenicol eye ointment at night until 48 hours after symptoms have cleared |
Alternatives |
Fusidic acid eye gel Adult and child: 1 drop, twice
daily until 48 hours after
symptoms have cleared |
CNS
Bacterial meningitis and suspected meningococcal sepsis |
|
Management |
Immediately refer all people with suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) or bacterial meningitis (without a non-blanching rash) to hospital. Give benzylpenicillin before transport to hospital, as long as this does
not delay the transfer. Notifiable on suspicion. |
Common pathogens |
Neisseria meningitidis, Streptococcus pneumoniae Less common: Listeria monocytogenes, Haemophilus influenzae |
Antibiotic treatment |
Bacterial meningitis and suspected meningococcal sepsis |
First choice |
Benzylpenicillin (penicillin G) Child < one year: 300 mg IV or IM Child one to nine years: 600
mg IV or IM Adult and
child > ten years:
1.2 g IV or IM |
Alternatives |
Ceftriaxone Adult
and child: 50
– 100 mg/kg up to 2 g IV or IM N.B. Almost any parenterally
administered antibiotic in an appropriate dosage will inhibit
the growth of meningococci, so if benzylpenicillin or ceftriaxone are not available, give any other penicillin or cephalosporin antibiotic. |
Skin
Bites – human and animal (Includes injury to fist from contact with teeth) |
|
Management |
Clean and debride wound thoroughly and assess the need for
tetanus immunisation. All infected bites should be treated with antibiotics.
Prophylactic antibiotic treatment is appropriate for human and cat bites, or dog bites
if severe or deep, and any bites that occur to the hand, foot, face, tendon or ligament, or in immunocompromised people. Consider referral to hospital if there is bone or joint involvement. |
Common pathogens |
Polymicrobial infection, Pasteurella multocida, Capnocytophaga canimorsus (cat and dog bites), Eikenella corrodens (fist injury), Staphylococcus aureus, streptococci and
anaerobes |
Antibiotic treatment |
Bites – human and animal |
First choice |
Amoxicillin clavulanate Child: 10 mg/kg/dose (amoxicillin component), three
times daily, for seven days (maximum 500 mg/dose, amoxicillin component) Adult: 500+125 mg, three times daily, for seven days |
Alternatives |
Adult and child > 12 years: Metronidazole 400 mg, three times daily, + doxycycline 200
mg on day one, followed by 100 mg, once daily,
on days two
to seven Metronidazole + co-trimoxazole is an alternative for children aged
under 12 years
(doxycycline contraindicated) |
Boils |
||
Management |
Most lesions may be treated with incision and drainage alone. Antibiotics may be considered if there is fever,
surrounding cellulitis or co-morbidity, e.g. diabetes, or if the lesion is in a site associated with complications, e.g.
face. For management of recurrent boils,
see: “Recurrent skin
infections” (Page 14). |
|
Common pathogens |
Staphylococcus aureus Consider MRSA
if there is a lack
of response to flucloxacillin. |
|
Antibiotic treatment |
Boils |
|
First choice |
Flucloxacillin Child: 12.5 mg/kg/dose, three to four
times daily, for seven days Adult: 500 mg, four times daily, for five to seven days OR (if flucloxacillin not tolerated in
children) Cephalexin Child: 12.5 – 25 mg/kg/dose, twice daily, for five to seven days |
|
Alternatives |
Cephalexin Adult: 500 mg, four times daily, for five to seven days Erythromycin Child aged < 12 years: 20 mg/kg/dose, twice daily, or 10 mg/kg/
dose, four times daily,
for five to seven days (maximum 1 g/day) Adult: 800 mg, twice daily, or 400 mg, four times daily, for
five to seven days Co-trimoxazole (if MRSA
present): Child > 6 weeks: 0.5 mL/kg
oral liquid (40+200
mg/ 5 mL), twice daily, for
five to seven
days (maximum 20 mL/dose) N.B. Co-trimoxazole should
be avoided in infants aged under six weeks, due to the
risk of hyperbilirubinaemia. Adult and child >12 years: 160+800 mg (two tablets), twice daily, for five
to seven days |
|
Cellulitis |
||
Management |
Keep affected area elevated (if applicable) for comfort
and to relieve oedema. Assess
response to treatment in seven days. Consider referral for IV antibiotics if cellulitis is severe or systemic symptoms are present, e.g.
fever, nausea, vomiting. For periorbital or facial cellulitis, in all but very
mild cases consider referral for IV antibiotics. |
|
Common pathogens |
Streptococcus
pyogenes, Staphylococcus aureus,
Group C or Group G streptococci |
|
Antibiotic treatment |
Cellulitis |
|
First choice |
Flucloxacillin Child: 12.5 mg/kg/dose, four times daily,
for seven days Adult: 500 mg, four times daily, for five to seven days OR (if flucloxacillin not tolerated) Cephalexin Child: 12.5
mg/kg/dose, four times daily, for seven to ten days (maximum 500 mg/dose) Adult: 500 mg, four times daily, for seven days |
|
Alternatives |
Erythromycin Child < 12
years: 20 mg/kg/dose, twice daily,
or 10 mg/kg/dose, four times daily,
for seven to ten days
(maximum 1 g/day) Adult: 800 mg,
twice daily, or 400
mg, four times daily,
for seven days Co-trimoxazole (if MRSA
present): Child > 6 weeks: 0.5 mL/kg/dose oral
liquid (40+200 mg/5
mL), twice daily, for five to seven days
(maximum 20 mL/dose) N.B. Co-trimoxazole should
be avoided in infants aged under six weeks, due to the
risk of hyperbilirubinaemia. Adult and child aged over 12 years: 160+800 mg (two tablets), twice daily,
for five to seven days |
|
Diabetic foot infections |
||
Management |
Antibiotics (and culture)
are not necessary unless there are signs of infection in the wound.
However, in people
with diabetes and other conditions where perfusion and immune response are
diminished, classical clinical
signs of infection are not
always present, so the threshold for suspecting infection and testing a wound should be lower. Referral to hospital should be considered if it is
suspected that the infection
involves the bones of the feet, if there is no sign of healing after four weeks of treatment, or if other
complications develop. |
|
Common pathogens |
Early infection is usually due to Staphylococcus aureus and/or streptococci. Later infection may be polymicrobial with a mixture
of Gram-positive cocci,
Gram-negative bacilli and anaerobes. |
|
Antibiotic treatment |
Diabetic foot infections |
|
First choice |
Amoxicillin clavulanate Adult: 500+125 mg, three times daily, for five to seven days |
|
Alternatives |
Cephalexin 500 mg, four times
daily, + metronidazole 400 mg, twice to three times
daily, for five
to seven days OR (for patients with penicillin hypersensitivity) Co-trimoxazole 160+800 mg (two tablets), twice daily, + clindamycin* 300 mg, three times
daily, for five
to seven days * Requires specialist endorsement for > 4 capsules |
|
Impetigo |
||
Management |
Remove crusted area and apply topical antibiotic ointment to localised areas of impetigo. Keep
affected areas covered and exclude from school or preschool until
24 hours after
treatment initiated. Assess and treat other infected household members. Oral antibiotics are recommended for more extensive, widespread, impetigo, or if systemic symptoms are present. Recurrent impetigo may be the result of chronic nasal carriage of Staphylococcus aureus (patient or household contact), or re-infection from
fomite colonisation, e.g. clothing, linen, and may require decolonisation. See: “Recurrent skin
infections” (Page 14). N.B. Streptococcus pyogenes has caused outbreaks of necrotising fasciitis in residential care
facilities, and if this is suspected it is important to use systemic treatment to eradicate carriage, and prevent infection to others. |
|
Common pathogens |
Streptococcus pyogenes, Staphylococcus aureus |
|
Antibiotic treatment |
Impetigo |
|
First choice |
Topical (localised patches): Fusidic acid 2% cream or ointment applied three times
daily, for seven days Oral (extensive lesions): Flucloxacillin Child: 12.5 mg/kg/dose four times daily, for seven days (maximum
500 mg/dose) Adult: 500 mg, four times daily, for seven days OR Cephalexin Child: 12–25 mg/kg/dose, twice daily, for seven days Adult: 500 mg, four times daily or 1 g, twice daily, for seven
days |
|
Alternatives |
If topical treatment fails, use oral treatment as above. Erythromycin (alternative oral treatment) Child aged < 12 years: 20 mg/kg/dose, twice daily, or 10
mg/kg/ dose, four times daily, for seven to ten days (maximum 1 g/day) Adult: 800 mg, twice daily, or 400 mg, four times daily, for
seven days Co-trimoxazole (if MRSA present) Child > 6 weeks: 0.5 mL/kg/dose oral liquid (40+200 mg/5
mL), twice daily, for five to seven days (maximum 20 mL/dose) N.B. Co-trimoxazole should be avoided in infants aged under
six weeks, due to the risk of hyperbilirubinaemia. Adult and child > 12 years: 160+800 mg (two tablets), twice
daily, for five to seven days |
|
Mastitis |
||
Management |
Treat with antibiotic and continue to breast feed from
both breasts. This is an important component of treatment and poses no risk to the infant. |
|
Common pathogens |
Staphylococcus
aureus in lactating women, S. aureus and anaerobes in non-lactating females, or in males |
|
Antibiotic treatment |
Mastitis |
|
First choice |
Flucloxacillin Adult: 500 mg, four times daily, for seven days |
|
Antibiotic treatment |
Mastitis
– continued |
|
Alternatives |
Cephalexin Adult:
500 mg, four times daily, for seven days Erythromycin Adult:
400 mg, four times daily, for seven days Treat
mastitis in males or non-lactating females with amoxicillin clavulanate 500+125
mg, three times daily, for seven days |
|
Recurrent skin
infections |
||
Management |
Take a swab of the lesion to rule out MRSA infection. Decolonisation should
not be attempted until the lesions
have healed. Take a nasal swab and if indicated by results,
perform staphylococcal decolonisation. The patient should
be advised to shower daily
for one week
using triclosan 1% or chlorhexidine 4% body wash,
applied with a clean cloth, with special attention to axillae, groin and
perineum. Also recommend hot drying, ironing or bleaching towels, facecloths, sheets,
other linen and underclothes for the duration
of treatment. For children, adding half cup of unscented household bleach (sodium
hypochlorite 3–5%) to a bath, followed by a fresh water rinse,
two to three times weekly, may be effective and preferable to showering with triclosan, particularly if the child has underlying atopic eczema. Treatment of other
household contacts with recurrent infection should occur at the same time. There
is some evidence that skin infections are reduced if these
measures are performed for all household contacts, but compliance and motivation may be barriers. |
|
Antibiotic treatment |
Recurrent skin infections |
|
First choice |
For clearance of staphylococcal carriage: Depending on susceptibility Fusidic acid 2% cream or ointment Mupirocin
2% ointment (usually reserved for MRSA) Apply inside the nostrils with a cotton bud or finger,
twice daily, for five days N.B. Excessive use of topical antibiotics has led to high
rates of resistance in S. aureus. |
|
Alternatives |
Nil |
Gastrointestinal
Campylobacter enterocolitis |
|
Management |
Most people will recover with symptomatic treatment only. Antibiotics have little impact
on the duration
and severity of symptoms but eradicate stool
carriage. Treatment is indicated for severe or prolonged infection, for pregnant women nearing term
and for people
who are immunocompromised. Treatment may also be appropriate for food handlers,
childcare workers and those caring for immunocompromised patients. Campylobacter
enterocolitis is a notifiable disease. |
Common pathogens |
Campylobacter jejuni |
Antibiotic treatment |
Campylobacter enterocolitis |
First choice |
Erythromycin Child: 10 mg/kg/dose, four times daily, for five days Adult: 400 mg, four
times daily, for five
days |
Clostridium difficile colitis |
|
Management |
Disease is due to overgrowth of the colon with Clostridium difficile which produces
toxins. A common cause is broad spectrum antibiotic treatment. Discontinue current antibiotic
treatment if/ when possible – in some cases this may lead to clinical resolution of symptoms. Antibiotic treatment is recommended in adults if the patient
has diarrhoea or other symptoms consistent with colitis,
and a positive test for C. difficile toxin. Consider referral
to hospital if there
is evidence of worsening
colitis. Relapse may occur after
treatment. In children, detection of C. difficile commonly represents colonisation rather than pathological infection, and antibiotic treatment is not generally required in the community setting. Antidiarrhoeals, e.g. loperamide, should be avoided
as the toxin
may be retained and worsen colitis. |
Common pathogens |
Clostridium difficile |
Antibiotic treatment |
Clostridium difficile colitis |
First choice |
Metronidazole Adult: 400 mg, three times daily, for 10 days |
Alternatives |
Vancomycin If patient has not responded to two courses of metronidazole;
discuss with an infectious diseases physician or clinical microbiologist. Oral
vancomycin (using the injection product) may be required. |
Giardiasis |
|
Management |
Antibiotic treatment is recommended for people who have tested positive for the organism, and symptomatic contacts. Avoid lactose-containing foods for one month after treatment. Giardiasis is a notifiable disease. |
Common pathogens |
Giardia lamblia |
Antibiotic treatment |
Giardiasis |
First choice |
Ornidazole Child < 35 kg: 125 mg/3 kg/dose,* once daily,
for one to two days Adult and child > 35 kg: 1.5 g, once daily,
for one to two days * N.B. Dose is per 3 kg bodyweight; ornidazole is only available in
tablet form, tablets
may be crushed, child dosing equates to one quarter
of a tablet per 3 kg. OR Metronidazole Child: 30 mg/kg/dose, once daily, for three days (maximum 2 g/dose) Adult: 2 g, once daily, for three days |
Alternatives |
For treatment failure with ornidazole: Exclude re-infection from asymptomatic family contacts,
e.g. children Metronidazole Child: 10 mg/kg/dose, three times daily,
for seven days, (maximum 400 mg/dose) Adult: 400 mg, three times daily, for seven days N.B. Nitazoxanide (hospital treatment) may be considered for recurrent treatment failures. |
Salmonella enterocolitis |
|
Management |
Routine treatment with antibiotics is usually unnecessary and may prolong excretion. Treat patients with severe disease,
those who are immunocompromised and those with prosthetic vascular grafts. Discuss appropriate treatment for children with an infectious diseases physician. Salmonellosis is a notifiable disease. |
Common pathogens |
Salmonella enteritidis, Salmonella typhimurium |
Antibiotic treatment |
Salmonella enterocolitis |
First choice |
Ciprofloxacin Adult: 500 mg, twice
daily, for three days |
Alternatives |
Co-trimoxazole Adult: 160+800 mg (two tablets), twice daily, for three days |
Genito-urinary
Bacterial vaginosis |
|
Management |
Women with bacterial vaginosis are often asymptomatic. It is not usually necessary to treat bacterial vaginosis unless symptoms are present or an
invasive procedure is planned, e.g.
insertion of an IUD or termination of pregnancy. Treatment of male sexual
contacts is not
usually necessary. |
Common pathogens |
Gardnerella vaginalis, Bacteroides, Peptostreptococci, Mobilunculus and others |
Antibiotic treatment |
Bacterial vaginosis |
First choice |
Metronidazole Adult: 400 mg, twice
daily, for seven
days, or 2 g, stat,
if adherence to treatment is a concern, however,
this is associated with a higher relapse rate |
Alternatives |
Ornidazole 500 mg, twice
daily, for five
days or 1.5 g, stat
may be used instead of metronidazole, but is not recommended in
women who are pregnant as no study
data is available |
Chlamydia |
|
Management |
Advise avoidance of unprotected sexual intercourse for seven days after treatment has been initiated, and for at least seven days
after any sexual contacts have been treated, to avoid re- infection. A test of cure should be done
five weeks after initiation of treatment in pregnant women,
if a non-standard treatment has been
used, e.g. amoxicillin, or if symptoms do not resolve. Repeat STI screen in three months
for patients with confirmed chlamydia. |
Common pathogens |
Chlamydia trachomatis |
Antibiotic treatment |
Chlamydia |
First choice |
Azithromycin Adult: 1 g, stat OR Doxycycline Adult:
100 mg, twice daily, for seven days. Do not use in pregnancy or breast feeding. |
Alternatives |
Amoxicillin 500 mg, three times daily, for seven days (only in women who are pregnant who are unable
to take azithromycin) |
Epidiymo-orchitis |
|
Management |
Epididymo-orchitis may occur
due to a variety of pathogens, but STI
pathogens are more likely in males aged < 35 years, with a history
of more than one sexual
partner in the past 12 months, and urethral discharge. Test for
chlamydia, gonorrhoea and
UTI. If symptoms are initially severe
or signs and symptoms do not resolve (or worsen) after
24 to 48 hours, refer
to hospital. |
Common pathogens |
Majority due to Chlamydia
trachomatis or Neisseria gonorrhoeae. Also E. coli, Bacteroides species, Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, Trichomonas vaginalis, Streptococcus agalactiae and others |
Antibiotic treatment |
Epidiymo-orchitis |
First choice |
If
STI pathogens suspected: Ceftriaxone Adult: 500 mg IM, stat (make up with 2 mL of lignocaine 1% or according to data sheet) AND Doxycycline Adult: 100 mg, twice daily, for 14 days If
UTI pathogens suspected: Ciprofloxacin Adult: 500 mg, twice daily, for 10 days |
Alternatives |
Amoxicillin clavulanate 500+125 mg, three times daily, for 10 days (if UTI pathogens suspected and
contraindications to quinolones) |
Gonorrhoea |
|
Management |
Advise avoidance of unprotected sexual intercourse for seven days after treatment has been initiated, and for at least seven
days after any sexual contacts have been treated, to avoid re- infection. A test of cure should be done
five weeks after initiation of treatment in pregnant women,
if a non-standard treatment has
been used
or if symptoms do not resolve. Repeat STI screen
in three months
for patients with confirmed gonorrhoea. As co-infection with chlamydia is very common, azithromycin is also routinely given. |
Common pathogens |
Neisseria gonorrhoeae |
Antibiotic treatment |
Gonorrhoea |
First choice |
Ceftriaxone Adult: 500 mg IM, stat
(make up with 2 mL of 1% lignocaine or according to data
sheet) AND Azithromycin Adult: 1 g, stat (including in pregnancy and
breastfeeding) |
Alternatives |
Ciprofloxacin 500 mg, stat + azithromycin 1 g, stat, only if the isolate
is known to be ciprofloxacin sensitive. Resistance rates vary by location. |
Pelvic inflammatory disease |
|
Management |
Pelvic inflammatory disease (PID) is usually caused by a
STI, particularly in women
aged under 25 years, women
who have had
recent change of sexual partner
or women with a previous history of gonorrhoea or chlamydia. Diagnosis of PID is clinical, taking
into account the
history, clinical findings and results of tests. However, STI tests will
often be negative and a low threshold for
treatment is appropriate. Treatment should cover infection with gonorrhoea, chlamydia and anaerobes. Women with severe
pelvic inflammatory disease
and women who
are pregnant require
referral for specialist assessment. Hospital
admission may be required for
IV antibiotics. |
Common pathogens |
Chlamydia trachomatis, Neisseria gonorrhoeae and others |
Antibiotic treatment |
Pelvic inflammatory disease |
First choice |
Ceftriaxone Adult: 500 mg IM, stat (make up with 2 mL of 1% lignocaine
or according to data sheet) AND Doxycycline Adult: 100 mg, twice daily, for 14 days AND Metronidazole Adult: 400 mg, twice daily, for 14 days (metronidazole may
be discontinued if not tolerated) |
Alternatives |
Ceftriaxone 500 mg IM, stat + azithromycin 1 g on day
one and day eight is an alternative if compliance is likely to be poor. Ornidazole may be considered as an alternative, if metronidazole is not tolerated. |
Pyelonephritis – acute |
|
Management |
Only treat in the community if mild symptoms, e.g. low fever and no nausea or vomiting. If systemically unwell,
dehydrated or vomiting refer to hospital for IV
treatment. A urine culture and susceptibility test should be performed. Infants and children
with pyelonephritis should
be referred to hospital for treatment. Nitrofurantoin or trimethoprim alone are not appropriate choices
for pyelonephritis. |
Common pathogens |
Escherichia coli, Proteus
spp., Klebsiella spp.,
Enterococcus spp. |
Antibiotic treatment |
Acute pyelonephritis |
First choice |
Amoxicillin clavulanate Adult: 500+125 mg, three times daily, for 10 days Co-trimoxazole Adult: 160+800 mg (two tablets), twice daily, for 10 days |
Alternatives |
Ciprofloxacin 500 mg, twice daily, for seven days – but should be reserved for isolates resistant to
initial empiric choices and avoided during pregnancy |
Trichomoniasis |
|
Management |
Advise avoidance of unprotected sexual intercourse for seven days
after treatment has
been initiated, and
for at least
seven days after
any sexual contacts have been treated, to avoid re-infection. Due to low sensitivity, culture of urethral swabs is
rarely positive in males, even if
infection is present, therefore empirical treatment of male sexual
contacts is recommended without testing, along
with a STI check. A test of cure is not usually required unless there
is a risk of re-
exposure. |
Common pathogens |
Trichomonas vaginalis |
Antibiotic treatment |
Trichomoniasis |
First choice |
Metronidazole Adult: 2 g, stat Can be used
in women who
are pregnant or breast feeding, but advise
to avoid breastfeeding for 12–24 hours
after dose |
Alternatives |
For those intolerant of the stat dose, use metronidazole 400 mg,
twice daily, for seven days Ornidazole 1.5 g, stat or 500 mg, twice daily, for five days may be used
instead of metronidazole, but is not recommended in women who are pregnant as no study
data is available |
Urethritis – acute
non-specific |
|
Management |
Non-specific urethritis is
a diagnosis of exclusion. A urethral swab and first void urine
sample should be taken to exclude gonorrhoea and chlamydia (or use combination testing if available). Treat sexual contacts. Advise avoidance of
unprotected sexual intercourse for
seven days after treatment has been initiated, and for at least seven
days after any sexual contacts have been treated, to avoid re-infection. Patients with symptoms
persisting for more than two weeks, or with recurrence of symptoms, should
be referred to a sexual
health clinic or urologist. |
Common pathogens |
Urethritis not attributable to Neisseria gonorrhoeae or Chlamydia trachomatis is termed non-specific urethritis and there
may be a number of organisms responsible, e.g. Ureaplasma urealyticum,
Mycoplasma genitalium, Trichomonas vaginalis |
Antibiotic treatment |
Acute
non-specific urethritis |
First choice |
Azithromycin Adult:
1 g, stat OR Doxycycline Adult:
100 mg, twice daily, for seven days If
purulent discharge, treat as for gonorrhoea, i.e. ceftriaxone 500 mg IM, stat
+ azithromycin 1g, stat |
Alternatives |
Nil |
Urinary tract infection (UTI) – adult |
|
Management |
Antibiotic treatment is indicated for all people who are symptomatic. Asymptomatic bacteriuria
requires antibiotic treatment in women
who are pregnant but not in elderly women
or patients with long-term indwelling urinary catheters. Non-pregnant females with uncomplicated UTI do not require a urine culture. However, urine culture is recommended in
males, women who are pregnant, and those who fail to respond to empiric
treatment within two days. Women who are pregnant should
have repeat urine culture one to two weeks after completing treatment to ensure cure. |
Common pathogens |
Escherichia coli, Staphylococcus saprophyticus, Proteus spp., Klebsiella spp.,
Enterococcus spp. |
Antibiotic treatment |
Urinary tract
infection (UTI) – adult |
First choice |
Trimethoprim Adult: 300 mg, once daily,
for three days (avoid during
the first trimester of pregnancy) OR Nitrofurantoin Adult: 50
mg, four times daily, for five days (avoid at 36+ weeks in pregnancy, and in significant renal impairment) Treat for seven days in pregnant women and in males |
Alternatives |
Norfloxacin Adult: 400 mg, twice daily
for three days
– but should
be reserved for isolates
resistant to initial
empiric choices and avoided during
pregnancy |
Urinary tract infection (UTI) – child |
|
Management |
Refer children aged under
three months, those with severe illness, or
those with recurrent infection, to hospital. Also consider referral of children aged under
six months. Children aged over six
months, without renal tract abnormalities,
and who do not have acute pyelonephritis, may be treated with a short
course (three days)
of antibiotics. All children with suspected UTI should have a urine
culture collected as a clean
specimen (clean catch, catheter, midstream
urine) as it may be a marker for previously undetected renal malformations, particularly in younger
children. In older
children it can
be a marker for bladder
and/or bowel dysfunction. For information on collecting a urine specimen in
children, see: “Managing urinary tract infections in children”, BPJ 44 (May,
2012). |
Common pathogens |
Escherichia coli, Proteus spp., Klebsiella spp., Enterococcus spp. |
Antibiotic treatment |
Urinary tract
infection (UTI) – child |
First choice |
Co-trimoxazole Child: 0.5
mL/kg/dose oral liquid (40+200 mg/ 5 mL), twice daily, for three days (maximum 20 mL/dose) If a child can swallow tablets,
co-trimoxazole 80+400 mg tablets can
be used (one tablet is equivalent to 10 mL of co-trimoxazole oral liquid) |
Alternatives |
Cefaclor Child: 8 – 10 mg/kg/dose, three
times daily, for three days
(maximum 500 mg/dose) Amoxicillin clavulanate Child: 10 mg/kg/dose (amoxicillin component), three
times daily, for
three days (maximum
500 mg/dose,amoxicillin component) |
The following references were used in the development of this guide:
1. Australian Medicines Handbook. Adelaide; Australian Medicines Handbook Pty Ltd, 2011.
2. British Infection Association and Health Protection Agency. Management of infection guidance for primary care for consultation and local adaptation, 2012. Public Health England. Available from: www.hpa.org.uk
3. Ellis-Pegler R, Thomas M. Approaches to the management of common infections in general practice. Auckland; Diagnostic Medlab, 2003.
4. Lang S, editor. Guide to pathogens and antibiotic treatment. 7th ed, Auckland; Diagnostic Medlab 2004.
5. Lang S, Morris A, Taylor S, Arroll B. Management of common infections in general practice: Part 1. NZ Fam Phys 2004;31(3):176-8.
6. Lang S, Morris A, Taylor S, Arroll B. Management of common infections in general practice: Part 2. NZ Fam Phys 2004;31(4):258-60.
7. Michael M, Hodson E, Craig J, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2010;(1):CD003966.
8. New Zealand Formulary. Available from: www.nzformulary.org
9. NICE Clinical Knowledge Summaries. Available from: www.cks.nice.org.uk
10. Starship Children’s Health. Clinical guidelines. Available from: www.adhb.govt.nz/ starshipclinicalguidelines
11. The National Heart Foundation of New Zealand. Guidelines for rheumatic fever 2. 2008. Available from: www.heartfoundation.org.nz
12. The New Zealand Sexual Health Society (NZSHS). Best practice guidelines. Available from: www. nzshs.org/guidelines.html
The information in this publication is specifically designed to address conditions and requirements in New Zealand and no other country. BPAC NZ Limited assumes no responsibility for action or inaction by any other party based on the information found in this publication and readers are urged to seek appropriate professional advice before taking any steps in reliance on this information.