Whats New on Antibiotic Prescribing

Recently updated content on the website

Upper and Lower Respiratory: Acute Cough in Children - August 2022

  • A new section on the management of Acute Cough in Children (less than 3 weeks duration) has been added and includes information on appropriate management.

Lower Respiratory: Bronchiolitis in Children - August 2022

  • A new section on the management of Bronchiolitis has been added and includes information on appropriate management. Bronchiolitis is generally a self-limiting disease usually not requiring investigation or treatment.

HSE antimicrobial stewardship (AMS) guidance for all healthcare settings – August 2022

  • New AMS guidance for all healthcare settings published
  • Am of the document is to provide support and guidance to AMS teams, healthcare facility managers, and the individual healthcare worker by providing the evidence, expert guidance, and tools they need to initiate and sustain AMS programmes. 
  • Provides guidance to the development of curricula, educational courses, and training programmes

Antimicrobial stewardship – August 2022

  • Updated content
  • Updated AMS patient resources, resources for healthcare professionals and audit tools
  • New antimicrobial explainer infographic

Otitis Externa - August 2022

  • new guidance on treatment of acute otitis externa.
  • advice of self-care and how to apply ear drops.

Otitis Media in Children - August 2022

  • Additional clinical information provided.

Lower UTI and Asymptomatic Bacteriuria in Pregnancy - July 2022

  • Nitrofurantoin Prolonged Release Capsules added as treatment option
  • Caution added re dosing/frequency for the two different formulations of nitrofurantoin available- these are not interchangeable

Nipple and breast thrush - July 2022

  • Treat both mother and baby even if one of pair has no symptoms
  • Nystatin added as treatment option in infants
  • Miconazole for infants information updated to include dosing advice, risk of choking in infants < 4 months. Additional counselling required if prescribed in infants < 4 months.

Antimicrobial use in Residential Care Facilities - April 2022 

  • Report from Point Prevalence Survey on Antimicrobial Use in HSE Mental Health Residential Care facilities, Nov 2021- Jan 2022 now available. Check out ‘Prescribing in long-term care facilities/nursing homes’ section

Prescribing for Children - March 2022

  • Additional clinical information provided including guidance on the management of pain and discomfort in children, with new paracetamol and ibuprofen dosing tables. The addition of new dosing tables for doxycycline and metronidazole as well as updated dosing tables for all other antibiotics recommended for children in the guidelines.

Otitis Media in Children  - March 2022

  • Additional clinical information, paracetamol and ibuprofen paediatric dosing tables, and, the addition of a second choice antibiotic option.

Community Acquired Pneumonia in Children - March 2022

  • Additional clinical information provided as well as updated treatment tables. Doxycyline, for certain patients, is now recommended as a 2nd line option from 8 years of age.

UTI in Children - March 2022

  • Additional clinical information provided as well as guidance on dipstick testing.

Azithromycin prophylaxis - March 2022

  • New consensus guidance for use of azithromycin prophylaxis in reducing exacerbations of severe COPD, bronchiectasis and asthma in adults endorsed by the National Antimicrobial Stewardship Advisory Group.
  • Includes initiation criteria and baseline assessment recommendations. It should be initiated by a consultant in respiratory medicine or a consultant with a special interest in respiratory medicine.
  • Recommended review every 6-12 months and if there is no evidence of clinical benefit or there is evidence of adverse effects, it should be discontinued.

Lower Respiratory, Pneumonia and Aspiration Pneumonia in Nursing Homes / Residential Care Facilities - March 2022

  • New guideline for antibiotic treatment of pneumonia and aspiration pneumonia in nursing homes/ residential care facilities.
  • Recommendations take into consideration older age, polypharmacy, dysphagia and renal impairment.
  • Empiric antibiotic treatment for aspiration pneumonia generally does not require cover for anaerobic organisms.
  • Drive for five: If antibiotics warranted, the recommended duration to treat is 5 days therapy.

Genital Conditions, Chlamydia - March 2022

  • Update on use of Azithromycin therapy for chlamydia- only recommended if doxycycline contra-indicated. If indicated, stat dose of azithromycin not recommended- 3 day course is required.

Skin Conditions: Scabies - February 2022

  • General advice for diagnosis and management of scabies enhanced, with inclusion of images to aid diagnosis.
  • Technique of topical application of products added including dosing and contact time.
  • Patient Information Leaflet added.

Genital Conditions - February 2022
Approach to an STI consultation in Primary Care

  • New section on Vaginal discharge- includes Quick reference guide for Vaginal discharge (Bacterial Vaginosis, Vaginal Candidiasis and Trichomoniasis)
  • Patient resources section consolidated

Candida, Genital Thrush

  • Updated treatment recommendation for recurrent candidiasis in pregnant women

Skin/Soft Tissue: Hidradenitis Suppurativa - January 2022

  • Content updated and expanded with Hurley system of staging for HS added with images
  • Treatment options updated as per staging
  • Lymecycline added as an oral treatment option for papules or nodules associated with Hurley stage I or mild Hurley stage II.

 

Influenza: December 2021

COVID-19 acute respiratory infection (Adults) Dec 2021

  • This guidance has been reviewed and the “Interim Guidance on Potential Role of Inhaled Budesonide for Persons in Community with COVID-19” has been removed. 
  • Inhaled budesonide should no longer be considered a potential treatment option for individuals with COVID-19 infection.

Epididymo-orchitis: December 2021

  • Additional guidance on diagnosis and referral

Acute Prostatitis: December 2021

  • Additional guidance on symptoms, diagnosis and STI  screening if relevant.

Rosacea: December 2021

  • Significant update. New content for examination, diagnosis and images added to aid diagnosis.
  • New guidance on dosage, duration, and place in therapy for topical and/or oral agents for moderate and severe papules/pustules.
  • For moderate papules/pustules, topical ivermectin or azelaic acid recommended.
  • For severe papules/pustules, topical ivermectin plus low-dose doxycycline (or lymecycline) recommended.
  • Guidance on use of Brimonidine for temporary treatment of redness added.

Acne Vulgaris: December 2021

  • Significant update. New content for examination, diagnosis and images added to aid diagnosis and staging.
  • New guidance on dosage, duration, and place in therapy for topical and/or oral agents for mild, moderate and severe acne.
  • For mild acne, all treatment options are topical with Benzoyl Peroxide recommended first-line. Other options listed dependent on presence of comedones and/or inflammatory lesions (pustules).
  • For moderate acne not responding to topical treatment, use of oral lymecycline in combination with a non-antibiotic topical is recommended first-line. Oral antibiotics are not recommended in combination with topical antibiotics. Oral antibiotics should be reviewed and limited to 3months if possible (max 6 months).
  • Referral considerations for Isoretinoin added.

Asymptomatic Bacteriuria in Pregnancy: Section update December 2021

  • Cefalexin dosing updated

Lower UTI in Pregnancy: December 2021

  • Warning signs added for when to consider Upper UTI/ Pyelonephritis
  • Cefalexin (2nd choice treatment option) dose changed to 500 mg every 8 hours for 7 days
  • Fosfomycin guidance on when to prescribe in pregnancy and directions on how to take fosfomycin for best absorption

What’s new – Lyme disease November 2021

  • Additional guidance added on when to test, when to treat and when to refer
  • Update on recommended duration of antibiotic treatment
  • New guidance of prophylaxis of Lyme disease in children
  • Section added on safety of doxycycline in children and prescribing/administration of dispersible doxycycline in children

Toolkit for Antimicrobial Stewardship in Residential Care Facilities November 2021

  • A collection of supporting tools, documents and practice points for AMS in residential care
  • NEW Decision-aid for Management of Suspected UTI
  • HSELand module for Prevention & Management of UTI signposted
  • Report of findings of Extended PPS of Antimicrobial Use in HSE RCFs for Older Persons published (includes data for CHO 2, 6,7, 9)

Upper and Lower Respiratory Tract infections: November 2021

  • Guidelines reviewed and updated for Sinusitis, Pharyngitis/Sore throat, Acute Bronchitis/Cough, Infective exacerbation of COPD, CAP in Adults, COVID-19
  • Drive for five: If antibiotics warranted, all these indications now recommended to treat with 5 days therapy.
  • All CAP treated in community now recommended at duration of 5 days including CRB-65 score 1-2 (reduced from 7days).
  • COPD: Link to new National NCEC Clinical Guideline added.

NEW: Position statements for ‘The use of dipstick urinalysis to assess for evidence of urinary tract infection in adults’. September 2021:

  • Consensus best-practice statements for the use of dipstick urinalysis endorsed by the National Antimicrobial Advisory Group.
  • Inappropriate use of dipstick urinalysis can lead to unnecessary antibiotic prescribing which does not benefit the patient and may cause considerable harm.
  • Best-practice statements include advice on the use of dipstick urinalysis to assess for evidence of UTI in several patient cohorts  such as:
    • Females (non-pregnant) <65yrs
    • Males <65yrs
    • Pregnant females
    • All persons >65yrs
    • All persons with a urinary catheter
    • Asymptomatic persons

Treatment of urinary tract infections in adults reviewed and updated, September 2021:

Guidelines on genital conditions updated July 2021, of particular note:

  • Chlamydia: Additional information on rectal infection with invasive chlamydia types (Lymphogranuloma (LGV) types), test of cure and window period
  • Anogenital warts: Updated HPV vaccine recommendations and drug treatment option
  • Genital Herpes: Patient resources updated
  • Candida: Update on use of high vaginal swab and treatment options
  • Gonorrhea: Referral criteria to GUM clinic; window period; treatment options and resistance information
  • Trichomoniasis: Updates on referral criteria; window period, test of cure information; drug counselling points
  • Bacterial Vaginosis: Update on use of high vaginal swab and drug counselling points
  • PID: Referral criteria to GUM clinic, including Mycoplasma genitalium guidance

Approach to an STI consultation in Primary Care, July 2021

  • Incudes quick reference guides for asymptomatic screening in primary care
  • Additional information on sexual history and STI testing
  • Window period explained, lookback periods/partner notification information listed for the different STIs
  • Also includes information on non-specific urethritis, HIV pre-exposure prophylaxis and genital care resources available for patients
  • Links to further resources for healthcare professionals and patients

Conjunctivitis: May 2021

  • The use of Chloromycetin® Eye Drops contraindicated in children under 2 years (due to presence of excipient Boron).
  • Printable content added regarding self-care advise for the patient presenting with sticky eye/conjunctivitis.
  • Content added regarding when to swab, refer or seek specialist input.

Antimicrobial Stewardship in Community July 2021

Suspected Meningococcal Disease May 2021

  • Section updated with administration information added

COVID-19 acute respiratory tract infection May 2021

  • Interim guidance on role for inhaled budesonide.

Oral Infections (previously Dental infections) March 2021

  • Treatment of oral and dental infections revised and updated.

Acute Dento-Alveolar Abscess:

  • If antibiotics are indicated, phenoxymethylpenicillin now preferred option instead of amoxicillin (unless adherence likely to be challenging)

Angular Cheilitis:

  • Additional guidance provided regarding eradication of bacterial or fungal reservoir.
  • Terbinafine 1% provided as option for patients on warfarin where use of miconazole should be avoided.

Fungal Infections

  • Additional guidance provided regarding management of breast-feeding mother for an infant with oral candida infection.
  • Use of oral fluconazole should be reserved for severe cases or those who are non-responsive to first-line therapies.
  • All patients who require fluconazole should be seen by their GP for investigation into possible underlying causes.

Gastro Conditions March 2021

Clostridium difficile

  • Name change: Clostridium difficile → Clostridioides difficile. Criteria for assessing non-severe versus severe C. Diff added.

Threadworms

  • Removal of piperazine as a  treatment option – no longer available in Ireland
  • Additional information re. 2nd dose of mebendazole administered after 2-4 weeks
  • Mebendazole is unlicensed in < 2year olds but some evidence to support use at >6months age.

Travelers' Diarrhoea

  • Change from Ciprofloxacin to Azithromycin as recommended antibiotic if treatment is required.
  • Additional clinical information and links have been added.

Respiratory tract infections February 2021

  • For pregnancy, if macrolide considered necessary, azithromycin added as an option for all trimesters.

Pregnancy and Postpartum infections February 2021

  • Additional Patient information resources added to all sections
  • Additional Healthcare Professional information resources added to Prescribing Antimicrobials in Pregnancy and Lactation page

Asymptomatic Bacteriuria in Pregnancy new content! February 2021

  • Advice on when and how to test for and treat asymptomatic bacteriuria in pregnancy
  • Urine culture remains the gold standard for detection of asymptomatic bacteriuria
  • Dipstick testing is not sufficient to screen for bacterial UTIs in pregnancy.
  • Drug treatment based on the bacteria isolated in urine culture and trimester of pregnancy

Nipple and breast thrush: February 2021

  • The use of all-purpose nipple ointment is not recommended as treatment option.
  • Additional information points on use of miconazole for mother and baby.

Helicobacter pylori: December 2020

  • H. Pylori duration of treatment for all treatment regimens has been increased from 7 days to 14 days in line with published national guidelines.
  • A Bismuth quadruple regimen, if available, has been added as a 1st line treatment option. A levofloxacin regimen has also been added but should be reserved as a 2nd line option for failed treatment eradication.

Pharyngitis/ sore throat / tonsillitis: December 2020

  •  Cefalexin is an option for non-severe penicillin allergy, if antibiotic deemed necessary.
  •  Majority are viral however if antibiotics deemed necessary, recommended duration now 5 days (instead of 10 days)

Lyme Disease, Nov 2020

  • Criteria for post-exposure prophylaxis updated

Seasonal Influenza, Nov 2020

  • Seasonal Influenza page updated for 2020/2021 season. 
  • Duration of treatment for oseltamivir in immunocompromised patients changed to 10 days. 
  • Links to Coronavirus COVID-19 information added.  

COVID-19 acute respiratory infection, Nov 2020

  • Link to HSE COVID-19 repository added
  • Updated re advice on penicillin allergy in pregnancy.

Drug Interactions Table update, Nov 2020

  • Drug interactions information updated for Neuraminidase inhibitors

Upper Respiratory Tract Infections, Nov 2020

  • Pharyngitis: Majority are viral however if antibiotics deemed necessary, recommended duration now 5 days (instead of 10 days)
  • Sinusitis (adults): Majority are viral however if antibiotics deemed necessary, doxycycline (first line if penicillin allergy) can be dosed at 200mg daily.

Lower Respiratory Tract Infections Nov 2020

  • Doxycycline (often first line if penicillin allergy) can be dosed at 200mg daily across the range of lower respiratory tract infections.
  • Duration of recommended therapy for community-acquired pneumonia reduced; 5 days for CRB-65 score 0 (instead of 5-7days), 7 days for CRB-65 score 1-2 (instead of 7-10 days)
  • Recommend higher dose amoxicillin (1g tds as opposed to 500mg tds) for community-acquired pneumonia CRB-65 score 1-2

New content to support deprescribing UTI prophylaxis, Nov 2020

  • All UTI prophylaxis should be reviewed at 3-6mths with a view to stopping as many patients can stop without a return of symptoms.
  • There is no evidence of additional benefit beyond 3-6 months but there is significant evidence of harm.

About Us, Nov 2020

  • Contact details for community antimicrobial pharmacists added.
  • List of contributors updated

UTI in Long Term Care Residents over 65, Nov 2020

Diagnosis & Management of Urinary Tract Infection (UTI) in Residential/Long Term Care/Nursing Home Residents (non-catheter associated)

  • Nitrofurantoin now first choice for uncomplicated UTI (Trimethoprim removed), or Cefalexin if nitrofurantoin unsuitable. 
  • Recommended duration for uncomplicated UTI is 3 days for females, 7 days for males
  • Cefalexin now recommended first choice for acute pyelonephritis (duration 7-10 days)

Diagnosis & Management of Catheter-Associated Urinary Tract Infection (CA-UTI) in Residential/Long-Term Care/Nursing Home Residents

  • Non-specific signs & symptoms of CA-UTI in elderly residents included (but consider COVID-19) 
  • Cloudy urine or foul-smelling urine do not indicate an infection in absence of signs and symptoms of infection.
  • CA-UTI to be treated like an upper UTI, with cephalexin 1st choice (unless guided otherwise by culture). Use of nitrofurantoin or trimethoprim for CA-UTI removed.

Green/Red antibiotic quality improvement initiative. Nov 2020

  • Includes background information and a summary of positive key trends observed with this important quality improvement initiative.

Videos on safe Antibiotic use - Nov 2020

Renal Impairment Summary Sept 2020

  • Medicines list expanded to include anti-fungals and anti-helmintics
  • Advice on Fosfomycin updated (avoid if CrCl <10ml/min)
  • Advice on Nitrofurantoin updated (contraindicated if CrCl <30ml/min, caution in use if CrCl 30-45ml/min)

Animal and Human Bites Sept 2020 

  • Content of both pages merged
  • Expanded advice on general management and antibiotic prophylaxis
  • Duration of prophylaxis 5 days, duration of treatment 7 days

COVID-19 acute respiratory infection May 2020

  • COVID-19 is a viral infection.
    Antivirals or agents with antiviral properties for COVID-19 should not be prescribed for treatment or prophylaxis in the community, unless as part of a clinical trial.
    Secondary bacterial infection appears uncommon in COVID-19 patients.

Key messages from AMRIC to community prescribers March 2020

  • Tips on safe us of clarithromycin, and important safety concerns for fluoroquinolones especially moxifloxacin are just some of the items covered

Recurrent UTI in Adult, Non-Pregnant Females March 2020

  • This guideline refers to symptomatic culture-proven recurrent urinary tract infection (UTI)
    It covers non-antimicrobial measures, antibiotic prophylaxis. It is important to remember that recurrent or persistent lower urinary tract symptoms are not always due to recurrent UTI. Other conditions such as STI, postmenopausal atrophic vaginitis and dermatological conditions often cause similar symptoms.
    Antimicrobial prophylaxis should be reviewed after 3-6 months with a view to stopping