Influenza treatment:
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals are not recommended. Treat ‘at risk’ patients, only when influenza is circulating in the community and within 48 hours of onset or in a care home where influenza is likely. At risk: pregnant (including up to 2 weeks post partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal or liver disease. Patients over 12 years use Oseltamivir 75 mg oral capsule BD for 5 days (for OD prophylaxis see NICE guidance) OR Zanamivir 10 mg (2 inhalations by diskhaler) BD for 5 days if there is resistance to oseltamivir.
Pharyngitis / sore throat / tonsillitis:
The majority of sore throats are viral and most patients do not benefit from antibiotics. The clinical distinction between viral and streptococcal pharyngitis is difficult. Fortunately, serious streptococcal complications are rare. Patients with 3 of 4 Centor criteria (history of fever, purulent tonsils, cervical adenopathy, absence of cough) or history of otitis media may benefit more from antibiotics. Antibiotics only shorten duration of symptoms by 8 hours. There is little evidence of significant benefit being achieved by prescribing an antibiotic unless quinsy or diphtheria are suspected. Note amoxicillin may produce a rash in patients with glandular fever.
1st line: Penicillin V 500mg QDS for 10 days
If allergic to penicillin: Clarithromycin 500mg BD for 10 days
Otitis media (child doses):
Many are viral. Resolves in 80% without antibiotics. Poor outcome unlikely if no vomiting or temp <38.5oC. Ibuprofen or paracetamol used as pain relief is adequate in most cases. Consider antibiotics if not settled in 48-72 hours. Studies question the need for antibiotics unless recurrent or in children <2yrs old.
1st line: Amoxicillin for 3 days*, <1yr old: 62.5mg TDS; Others: 125mg TDS. Consider double doses in severe infections
If allergic to penicillin: Clarithromycin for 3 days*, 1-2yrs old: 7.5mg/kg BD; 3-6 yrs: 62.5mg BD; 7-9 yrs: 125mg BD. Others: 250-500mg BD.
Treatment failure: Co-Amoxiclav for 7 days (double dose in severe infection) <1yr old: 0.25mL/kg of 125/31mg TDS; 1-6 yrs: 5mL of 125/31mg
TDS; 6-12 yrs: 5mL of 250/62mg TDS; 12-18 yrs: 375mg TDS (increase to 625mg TDS in severe infection).
Acute diffuse Otitis externa
Oral antibiotics are NOT recommended for otitis externa noting that aggressive invasive infections need specialist advice.
If there is sufficient earwax or debris to obstruct topical medication, consider cleaning the external auditory canal (may require referral).
If there is extensive swelling of the auditory canal, consider inserting an ear wick (may require referral).
Provide appropriate self-care advice.
Remove or treat any precipitating or aggravating factors. Prescribe or recommend an analgesic for symptomatic relief. Paracetamol or ibuprofen are usually sufficient. Codeine can provide additional analgesia for severe pain.
Prescribe a topical ear preparation for 7 days. Options include:
preparations containing both an aminoglycoside antibiotic and a corticosteroid eg Otosporin (but aminoglycosides are contraindicated if the tympanic membrane is perforated) OR preparations containing both a non-aminoglycoside antibiotic and a corticosteroid e.g. flumetasone– clioquinol (Locorten–Vioform) ear drops. Otosporin is specifically indicated for pseudomonal infection.
Use of ciprofloxacin eye drops for otitis externa is unlicensed but may be used with specialist input.
Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after) for a maximum of a further seven days. Patients with symptoms beyond two weeks should be considered treatment failures and alternative management initiated.
Acetic acid ear drops are used for fungal infections or anaerobic infections.
Sinusitis acute or chronic
Many are viral and antibiotics are generally not required. Reserve for severe or symptoms >10 days.
Doxycycline 200mg stat then 100mg once daily for 7 days OR Amoxicillin 500mg TDS for 7 days OR Clarithromycin 500mg BD for 7 days
*Standing Medical Advisory Committee guidelines suggest a 3 day course. Longer courses may be needed for some patients.