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NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include acute diarrhoea in adults, and threadworms.
Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
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
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
If people are still symptomatic after first-line treatment:
MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
MHRA Drug Safety Update (March 2019): Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects
MHRA Drug Safety Update (December 2020): Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk
Refer to 5.1.12 Quinolones for further details.
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.
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
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.
Discuss all cases with microbiology
Stop unnecessary antibiotics and/or proton pump inhibitors
Signs suggesting increased severity include:
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 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:
Admit if severe:Temperature greater than 38.50C; WCC greater than 15, rising creatinine or signs/symptoms of severe colitis.
Recurrent disease will be experienced by up to one third of patients. A tapering course of vancomycin may prevent relapse
In the event of a treatment failure, return to six hourly vancomycin and repeat.
Only consider standby antibiotics for remote areas or people at high-risk of severe illness with traveller's diarrhoea.
If standby treatment appropriate give:
See section: 5.1.12 Quinolones
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.
Mebendazole not licensed in this age group but 6 weeks strict hygiene may be sufficient to clear infection and prevent re-infection.
Manage mild disease with diet, paracetamol and consider IBS treatment.
If marked abdominal pain and fever, consider oral antibiotics.
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.