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Remember to check allergy status

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Adult Treatment - Gastro-Intestinal Tract Infections

Clostridium difficile

DH & PHE

Stop unnecessary antibiotics and/or PPIs 1,2 B+
70% respond to metronidazole in 5 days; 92% in 14 days3

If severe symptoms or signs (below) should treat with
oral vancomycin, review progress closely and/or
consider hospital referral.

Admit if severe: T >38.5; WCC >15, rising creatinine
or signs/symptoms of severe colitis 1 C

Medicine Calendar

1st episode metronidazole 1 A-

400mg or 500mg TDS

10-14 days 1 C

2rd episode/severe/type 027 oral vancomycin 1 A-

125mg QDS

10-14 days 1 C

Recurrent disease see rationale: oral vancomycin OR fidaxomicin

Vancomycin 125mg, consider taper OR fidaxomicin 200mg BD

10-14 days or taper ; fidaxomicn treatment is 10 days1 C

Infectious diarrhoea

Antibiotic therapy not indicated unless systemically unwell. 2 C. If systemically unwell and Campylobacter spp suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin for 5–7 days if treated early (within 3 days). 3 C

Medicine Calendar

If systematically unwell and Campylobacter spp suspected, consider clarithromycin if treated early (within 3 days).3 C

250-500mg

5–7 days

Threadworm

NICE-CKS

Treat all household contacts at the same time PLUS advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower [include perianal area]) PLUS wash sleepwear, bed linen, dust, and vacuum on day one. 1 C
Child <6 mths add perianal wet wiping or washes 3 hourly during the day.

Medicine Calendar

mebendazole

100mg 1 C

stat dose but repeat after 2 weeks if infestation persists

Eradication of Helicobacter pylori

NICE dyspepsia
NICE H. pylori
PHE H.pylori
NICE-CKS

Treat all positives 2 in known DU, GU 1A+ or low grade MALToma. 2B+ In Non-Ulcer NNT is 14 3A+,4B+

Do not offer eradication for GORD1C
Do not use clarithromycin, metronidazole or quinolone if used in past year for any infection5A+,6A+

Penicillin allergy:use PPI plus clarithromycin & metronidazole; if previous clarithromycin use PPI + bismuthate + metronidazole + tetracycline. In penicillin allergy and relapse see NICE

Relapse and previous metronidazole or clarithromycin use: use PPI PLUS amoxicillin, PLUS either tetracycline or levofloxacin1

Retest for H. pylori post DU/GU or relapse after second line therapy: using breath or stool test OR consider endoscopy for culture and susceptibility1C

Medicine Calendar

Always Use PPI1,8
First Line and Second Line1A+:
PPI WITH Amoxicillin PLUS EITHER clarithromycin OR metronidazole

PPI TWICE DAILY WITH amoxicillin 1G BD PLUS either clarithromycin 500mg BD or metronidazole 400mg BD

All for 7 days1,9A

Penicillin allergy & previous metronidazole or clarithromycin use:1,7
PPI PLUS bismuthate (De-nol tab®) PLUS metronidazole PLUS tetracycline hydrochloride8C

PPI TWICE DAILY WITH De-nol tab® 240mg BD PLUS metronidazole 400mg BD PLUS tetracycline hydrochloride 500mg QDS

All for 7 days1,9A

Relapse & previous metronidazole or clarithromycin use:
PPI WITH amoxicillin PLUS tetracycline hydrochloride8C OR levofloxacin1

PPI TWICE DAILY with Amoxicillin 1G BD PLUS tetracycline hydrochloride 500mg QDS OR levofloxacin 250mg BD

MALToma 1 C 14 days

Oral candidiasis

CKS- Oral Candida

Topical azoles are more effective than topical nystatin.

Oral candidiasis rare in immunocompetent adults; consider undiagnosed risk factors including HIV.

Fluconazole if extensive/severe candidiasis. If HIV or immunosuppression use 100mg fluconazole.

Medicine Calendar

miconazole oral gel 1,2,3,A-7

20mg/mL QDS

7 days or until 2 days after symptoms 1A-

or nystatin suspension if miconazole not tolerated 1,2,4,5,7,A-

100,000 units QDS after meals

7 days or until 2 days after symptoms 7C

Fluconazole oral tablets 4,5,6,7A-

50mg OD or 100mg OD

7 days and a further 7 days if persistent 4

Traveller's diarrhoea

NICE-CKS

Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers’ diarrhoea 1,2 C.
If standby treatment appropriate give: ciprofloxacin 500 mg twice a day for 3 days (private Rx). 2 C,3 B+
If quinolone resistance high (eg south Asia): consider bismuth subsalicylate (Pepto Bismol®) 2 tablets QDS as prophylaxis 2 B+ or for 2 days treatment 4 B+

Medicine Calendar

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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).