Antibiotics Part 1

Lambeth Antibiotic Guideline for Primary Care 2023

Aims
• To provide a simple, empirical approach to the treatment of common
infections
• To promote the safe, cost-effective and appropriate use of
antimicrobials by targeting those who may benefit most.
• To minimize the emergence of antimicrobial resistance in the
community.
Principles of Treatment
• 1. The application must be modified by professional judgement, based on
knowledge about individual patient co-morbidities, potential for drug
interactions and involve patients in management decisions.
• 2. It is important to initiate antibiotics as soon as possible in severe infection
or in those immunocompromised, particularly if sepsis is suspected
• 3. This guidance should not be used in isolation; it should be supported with
patient information about safety netting, back-up/delayed antibiotics, self –
care,..
• 5. Adjust dosing and check interaction information ALWAYS check for
hypersensitivity/allergy.
• 6. Drugs in RED are contra-indicated in true penicillin allergy. Drugs in
GREEN are considered safe in penicillin allergy.
 • 7. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit, giving alternative, non-
antibiotic self –care advice where appropriate.
• 8. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections (e.g.
acute sore throat, acute cough and acute sinusitis) and mild UTI symptoms
• 9. ‘Blind’ antibiotic prescribing for unexplained pyrexia usually leads to further difficulty in establishing the
diagnosis.
• 10. Limit prescribing over the telephone/eConsult to exceptional cases.
• 11. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow
spectrum antibiotics remain effective, as they increase the risk of all infections, including Clostridium
difficile, MRSA and resistant Urinary Tract Infections (UTIs).
• 12. Clarithromycin is now recommended over erythromycin, except in pregnancy and breastfeeding.
• Temporary advice to address multiple concurrent shortages of first-line antibiotics : Alternative
antibiotics (ex,,second lines)
Clarithromycin is often preferred over erythromycin for several reasons related to its improved
pharmacologic properties and patient tolerance:
1. *Better acid stability*: Clarithromycin is more acid-stable than erythromycin. This means it is better
absorbed in the stomach and can be taken without regard to meals, whereas erythromycin's absorption can be
affected by stomach acid and food intake.
2. *Improved bioavailability*: Clarithromycin has higher bioavailability compared to erythromycin.
3. *Longer half-life*: Clarithromycin has a longer half-life than erythromycin, which allows for less frequent
dosing. Clarithromycin is typically dosed twice daily, while erythromycin needs to be taken three to four
times daily. This can improve patient compliance with the treatment regimen.
 4. *Fewer gastrointestinal side effects*: Erythromycin
is known for causing gastrointestinal side effects,
including nausea, vomiting, and diarrhea, due to its
stimulation of motilin receptors (prokinetic drug,
off-label use in gastroparesis).
5. *Broader antimicrobial spectrum*:
6. *Less drug interactions*: erythromycin is a potent
LME inhibitor ( interfere with theophylline , statins
and numerous antiepileptics )
In general:
13. In pregnancy, take specimens to inform treatment.
Penicillins, cephalosporins and erythromycin are not
associated with increased risk of spontaneous
abortion. If possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin (except in chlamydial
infection), clarithromycin and high dose metronidazole (2g stat) unless the benefits outweigh the risks.
Trimethoprim is also unlikely to cause problems unless poor dietary folate intake or taking another folate
antagonist.

Self Care
Promote self-care where appropriate.
Treatments that are often available to purchase over the counter include:

• Analgesics (painkillers) for short-term use

• Topical antifungal treatment for short-term minor ailments
• Cold sore treatment
• Colic treatment
• Cough and cold remedies
• Eye treatments/lubricating products
• Head lice treatment and scabies treatment
• Threadworm tablets
• Topical acne treatment
• Warts and verruca treatment
If diarrhoea or vomiting occurs due to an antibiotic or the illness being treated, the efficacy of hormonal
contraception may be impaired and additional precautions should be recommended.

Antibiotics for diarrhea

Cefixime (Suprax®); potent oral 3rd generation cephalosporin with high gram -ve coverage. Ceftriaxone
(Rocephin®) & Cefotaxime (Claforan®); are potent injectable 3rd generation cephalosporins with increased gram -
ve coverage and some gram-positive bacteria.

• Fluoroquinolone antibiotics; such as Ciprofloxacin (Cipro®) and Levofloxacin (Tavanic®);

Drug of choice for traveler's diarrhea.

-Azithromycin (Zithromax®); good choice in traveler's diarrhea for pregnant women and children.

- Rifaximin (Xifaxan®) [Gastrobiotic®]; Neomycin (not absorbed from GIT) and Streptomycin; also used in
traveler's diarrhea.
- Doxycycline (Vibramycin®); is a good choice for Vibrio cholerae infection and can be used in traveler's
diarrhea prophylaxis.

-Sulfamethoxazole/Trimethoprim (Septrin®); Bismuth Subsalicylate (Pepto-Bismol ®);Can be used in traveler's

diarrhea prophylaxis.

- Vancomycin; orally for antibiotic-associated colitis (pseudomembranous colitis).

- -Nifuroxazide (Antinal®); is an oral nitrofuran antibiotic, is a broad-spectrum intestinal antiseptic for the
treatment of diarrhea & gastroenteritis (poorly absorbed from the GIT, act mainly locally).
*Pregnancy

• Oral Rehydration Solution (ORS); may be used during pregnancy;

• ORS is generally safe to use in pregnant women if expecting fluid and electrolyte loss during diarrhea or
morning sickness.

* Antimicrobial Agents;

• Most common causes of diarrhea in pregnancy if longer than 48 hours is infectious agents.
• Azithromycin are generally safe and they are a good option for antibiotics to be used.
• Metronidazole is FDA pregnancy category B, BUT it is contraindicated during the first trimester of
pregnancy.

Other medications:

• * Loperamide (Imodium®); can also be safely used.

• * Kaolin-Pectin (Kapect®), Zinc and Probiotics are generally safe.
 Quick reminder
Glycopeptide Antibiotics
#Vancomycin is active only against Gram +ve bacteria;
# It is not absorbed after oral administration.
## FIRST-LINE;
1) IV Infusion; complicated skin infections, bacteraemia, endocarditis, bone and joint infections, and meningitis
caused by Methicillin-resistant Staphylococcus aureus (MRSA) & Methicillin-resistant Staphylococcus
epidermidis (MRSE).
2) Oral; Pseudomembranous colitis caused by Clostridium difficile (Oral capsules; not absorbed & Vancomycin
act locally).
#Vancomycin-resistant Staphylococcus aureus (VRSA); are a strains of enterococci resist Vancomycin
### Side Effects;
# Red Man Syndrome (RMS) ### or Red Neck; infusion reaction
* Usually appearing rapidly after infusion.
*Non-specific mast cell degranulation↑ Histamine → Redness & hotness in face & neck.
Treatments; infusion rate, use emollients, topical steroids, antihistamines & antibiotics.
Prophylaxis; prolonging infusion period to 1-2 hours and pre-treatment with antihistamine.
# Nephrotoxicity & Ototoxicity; increases the toxicity of other nephrotoxins or ototoxins such as Aminoglycosides.
Vancomycin is FDA pregnancy category B.

Quick reminder
Macrocyclic Antibiotics
Fidaxomicin (Dificid)
#Fidaxomicin is a macrocyclic antibiotic (new class), with very narrow spectrum of activity limited to Gram +ve
only and bactericidal activity against Clostridium difficile.
Absorption; minimal systemic absorption and act locally in GIT (ideal for C. difficile).
Use: Clostridium difficile-associated diarrhea (CDAD).
# #Dose: Oral: 200 mg twice daily for 10 days.
-Side effects: Nausea, Gastrointestinal hemorrhage, abdominal pain, vomiting, anemia, neutropenia and
hypersensitivity reaction.
Don’t Rush To Crush