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Remember to check allergy status

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Adult Treatment - Lower Respiratory Tract Infections

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 2 B-. Reserve all quinolones (including levofloxacin) for proven resistant organisms.

Acute exacerbation of COPD

NICE 12
Gold
NICE-CKS

Treat exacerbations promptly with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume 1-3 B+.

Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD (MRC >3), frequent exacerbations, antibiotics in last 3 months. 2

Medicine Calendar

amoxicillin

500mg TDS

5 days 4 C

or
doxycycline

200mg stat on Day 1 and from Day 2 onwards 100mg OD

5 days 4 C

or clarithromycin

500mg BD

5 days 4 A

If at risk of resistance: co-amoxiclav

500/125mg TDS

5 days 4 A

Acute cough, bronchitis

NICE-CKS
NICE 69

Antibiotics have little benefit if no co-morbidity.[1A+,2A-]

Second line: 7-day delayed antibiotic,[3D] safety net, and advise that symptoms can last 3 weeks.[3D]

Consider CRP if antibiotic is being considered.[4A-]
No antibiotics if CRP<20mg/L and symptoms for >24 hours; delayed antibiotics if 20-100mg/L; immediate antibiotics if >100mg/L.[5D]

Medicine Calendar

First line: self-care and safety netting advice

Second line: amoxicillin

500mg TDS

5 days

If penicillin allergic: doxycycline

200mg STAT then 100mg OD

5 days

Community acquired pneumonia 2,3

BTS 2009
Guideline (PDF)

Use CRB65 score to guide mortality risk, place of care and antibiotics.1

Each CRB65 parameter scores 1:

Confusion (AMT<8);
Respiratory rate >30/min;
BP systolic <90 or diastolic ≤ 60; Age >65;

  • Score 0: low risk, suitable for home treatment
  • Score 1-2: intermediate risk, hospital assessment or admission
  • Score 3-4: urgent hospital admission

Always give safety-net advice and likely duration of symptoms. Mycoplasma infection is rare in over 65s1

Medicine Calendar

IF CRB65=0:
amoxicillin A+ Or
clarithromycin A-Or
doxycycline D

amoxicillin 500mg TDS or clarithromycin 500mg BD or doxycycline 200mg stat on day 1 then 100mg OD

5 days. Review at 3 days & extend to 7-10 days if poor response

IF CRB65=1,2 and AT HOME
Clinically assess need for dual therapy for atypicals: amoxicillin AND clarithromycin A- or doxycycline alone

amoxicillin 500mg TDS AND clarithromycin 500mg BD or doxycycline 200mg stat on day 1 then 100mg OD

7-10 days

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).