Gastro-intestinal tract infections

Eradication of Helicobacter pylori

For people who test positive for H. pylori the following regimens should be taken for 7 days

Take into account previous exposure to clarithromycin, metronidazole or a quinolone, do not use if used in the past year for any infection.

Always give a formulary choice proton pump inhibitor (See section 1.3 Antisecretory drugs and mucosal protectants) every 12 hours

1st line treatment

  • Formulary choice proton pump inhibitor every 12 hours, plus
  • Amoxicillin 1g every 12 hours and metronidazole 400mg every 12 hours

or

  • Amoxicillin 1g every 12 hours and clarithromycin 500mg every 12 hours
Penicillin allergy
  • Formulary choice proton pump inhibitor every 12 hours, plus
  • Clarithromycin 500mg every 12 hours and metronidazole 400mg every 12 hours

See NICE CG184: Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (November 2014) for people allergic to penicillin and who have previous exposure to clarithromycin

2nd line treatment

If people are still symptomatic after first-line treatment:

  • Formulary choice proton pump inhibitor every 12 hours, plus
  • Amoxicillin 1g every 12 hours, plus
  • Metronidazole 400mg every 12 hours or clarithromycin 500mg every 12 hours, whichever was not used first-line
Penicillin allergic, without prior quinolone exposure:
  • Formulary choice proton pump inhibitor every 12 hours, plus
  • Metronidazole 400mg every 12 hours, plus
  • Levofloxacin 250-500mg every 12 hours (unlicensed)

See NICE CG184 for people who are penicillin allergic and have prior quinolone exposure

See NICE CG184 for people who have previous exposure to clarithromycin and metronidazole.

Consider referral to a specialist service, people with H. pylori that has not responded to second-line eradication therapy.

PPI therapy should only be continued after H pylori eradication in the case of active peptic ulceration. Continue once daily PPI therapy for one month for duodenal ulcers and two months for gastric ulcers.

Gastroenteritis

Antibiotic therapy is usually not indicated unless systemically unwell and then should be based on stool culture result.

If immunocompromised or systemically unwell discuss antimicrobial treatment with microbiology.

Notify all confirmed and suspected cases of food poisoning: https://www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report

Infectious (bloody) diarrhoea

Antibiotic therapy not indicated unless systemically unwell.

Do not use anti-motility agents and assess/ treat dehydration in every child or elderly person. See NICE CG84: Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management (April 2009) for further guidance

Send stool culture.

Clostridium difficile

Discuss all cases with microbiology

Stop unnecessary antibiotics and/or proton pump inhibitors

Signs suggesting increased severity include:

  • Temperature greater than 38.5oC
  • WCC greater than 15
  • Rising creatinine
  • Signs/symptoms of severe colitis

Patients with severe infection should be admitted

All stool samples sent in to microbiology from patients over 65 or with a history of antibiotic use on their clinical details or if requested will be tested provided the patient has diarrhoea (Bristol Stool Chart 5-7) that is not clearly attributable to an underlying condition (e.g. inflammatory colitis, overflow) or therapy (e.g. laxatives, enteral feeding).

If 1st or 2nd episode and patient is well consider:
Metronidazole
  • Oral 400mg every 8 hours for 10-14 days
  • Ensure adequate hydration. Review patient regularly and escalate to severe if not improving. If the patient still requires antibiotics for the site of infection then discuss with microbiologist
Recurrent or severe C. difficile disease

If patient appears unwell and has any number of loose stools in 24 hours or the patient has had previous Clostridium difficile disease within the last 6 months:

Vancomycin
  • Oral 125mg every 6 hours for 14 days
  • Ensure Community Pharmacist is contacted to have stock available
  • If the patient still requires antibiotics for the site of infection then discuss with microbiologist. Ensure adequate hydration
  • Consider admission

Admit if severe:Temperature greater than 38.50C; WCC greater than 15, rising creatinine or signs/symptoms of severe colitis.

Recurrent disease

Recurrent disease will be experienced by up to one third of patients. A tapering course of vancomycin may prevent relapse

Oral vancomycin:

  • 125mg every 6 hours for 14 days.
  • 125mg every twelve hours for one week
  • 125mg once daily for one week
  • 125mg every other day for one week
  • 125mg every three days for 2 weeks

In the event of a treatment failure, return to six hourly vancomycin and repeat.

Traveller’s diarrhoea

Only consider standby antibiotics for remote areas or people at high-risk of severe illness with traveller's diarrhoea.

Many anti-diarrhoea treatments are cheap to buy and are readily available, along with advice, from pharmacies. Please click here for further information and a patient leaflet

If standby treatment appropriate give:

  • Ciprofloxacin 500 mg twice a day for 3 days (private prescription only, not on FP10).

Threadworm

Refer to CKS website for further details

Treat all household contacts at the same time plus advise hygiene measures for 2 weeks (hand hygiene, pants at night, morning shower) plus wash sleepwear, bed linen, dust, and vacuum on day one.

Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet.

Adults and children over 6 months

Mebendazole
  • 100mg single dose (off-label if under 2 years of age)
  • If reinfection occurs a second dose may be needed after 2 weeks

Children under 6 months

Mebendazole not licensed in this age group but 6 weeks strict hygiene may be sufficient to clear infection and prevent re-infection.

Diverticulitis

Manage mild disease with diet, paracetamol and consider IBS treatment.

If marked abdominal pain and fever, consider oral antibiotics.

Metronidazole
  • 400mg every 8 hours for 7 days

Cholecystitis

The pathophysiology of acute cholecystitis is cystic duct obstruction, which causes an acute sterile inflammation. Secondary infection of the gallbladder space by bacteria may follow.

Doxycycline
  • 200mg single dose, then 100mg daily for total of 7 days

plus

Metronidazole
  • 400mg every 8 hours for 7 days

 

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