Vaccination

Annual vaccination is essential in all those at risk of complications from influenza. Annual guidance may change; Check the Public Health England (PHE) website (seasonal influenza) for latest updates.

Patients under 13 years- follow Public Health England (PHE) Influenza Advice.

Treatment

Oseltamivir and zanamivir are not licensed for use unless influenza is circulating in the community. In England, the formal announcement is made by the Department of Health.

Treat 'at risk' patients, when influenza is circulating in the community ideally within 48 hours of onset or in a care home, where influenza is likely. For otherwise healthy adults antivirals are not recommended.

At risk groups:

• Pregnancy (including up to two weeks post-partum)
• Age 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
• Morbid obesity (BMI 40 or greater)
• Children under 6 months of age.

See Public Health England (PHE) Influenza Advice regarding whether to use oseltamivir or inhaled zanamivir. In general use oseltamivir in all cases except in the severely immunocompromised, where the predominate circulating strain is H1N1, or the infection is with an oseltamivir resistant strain.

Refer to individual SPCs before prescribing

Please refer to NICE TA168: Amantadine, oseltamivir and zanamivir for the treatment of influenza (February 2009).

Prophylaxis

Oseltamivir and zanamivir are recommended, within their marketing authorisations, for the post-exposure prophylaxis of influenza if all of the NICE TA circumstances apply.

• See NICE TA158: Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza (September 2008) for more information.

Oseltamivir and zanamivir are not recommended for routine prophylaxis of seasonal influenza; they may be given for post-exposure prophylaxis when the virus is circulating in the community.

Amantadine is not recommended for the prophylaxis of influenza.

Vaccination is the first-line intervention to prevent influenza and its complications. This guidance should not detract from efforts to ensure that all eligible people receive vaccination.

See 5.3.4 Influenza

The information below is based on NICE NG84 Sore throat (acute): antimicrobial prescribing (January 2018).

Acute sore throat (including pharyngitis and tonsillitis) is self-limiting and often triggered by a viral infection of the upper respiratory tract.

Symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus). On average, antibiotics shorten the duration of symptoms by about 16 hours over 7 days, and the number of people improving with antibiotics is similar to the number experiencing adverse effects, such as diarrhoea.

For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021).

Self-care advice:

• Consider paracetamol or ibuprofen for pain or fever
• Drink adequate fluids
• Adult patients may wish to try medicated lozenges with local anaesthetic/ NSAID/ antiseptic, but these may only reduce pain in small amount

The following are not recommended due to a lack of evidence: non-medicated lozenges, mouthwashes, or local anaesthetic mouth spray without antiseptic.

NHS England (NHSE) have 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). One of these conditions is acute sore throat.

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.

The poor sensitivity and specificity of the previous sore throat grading criteria (CENTOR) have led to these being replaced with the FeverPAIN criteria.

FeverPAIN criteria are used to identify patients most likely to benefit from antibiotics. Higher scores suggest more severe symptoms and likely bacterial strep cause. (1 point for each, maximum score of 5):

• Fever - Fever in the preceding 24 hours (measured or subjective)
• P - Purulence on the tonsillar bed
• A - Attend (self-refer) promptly i.e. within three days of symptom onset
• I – Severely inflamed tonsils
• N - No cough or coryza (inflammation of mucus membranes in the nose)

Scores

• 0-1 – Do not offer an antibiotic
• 2-3 – (Likelihood of streptococcal disease <40%, review at three days or use delayed prescription) Consider no antibiotic or a delayed antibiotic prescription
• 4-5 – (Likelihood of streptococcal disease >60%) Consider an immediate antibiotic or a delayed antibiotic prescription

In all cases offer self-care advice, no scoring system can ever be completely accurate, consider safety net precautions.

Consider a 5-10 day prescription (delayed for 7 days) for patients presenting with symptoms which do not start to improve within the next 3 to 5 days or if they worsen rapidly or significantly at any time.

Reassess at any time if; symptoms worsen rapidly or significantly, or patient becomes very unwell.

Invasive Group A Streptococcal infections and other bacteria have increased in incidence and need to be assessed rapidly in hospital. Maintain a high index of suspicion in patients with a high fever, severe muscle aches, confusion, unexplained D&V, local muscle tenderness, or severe pain out of proportion to external signs, hypotension, and a flat red rash over large area of the body, conjunctival suffusion.

Consider antibiotic treatment if confirmed Group A streptococcus infection in a household member and patient presents with symptoms suggestive of Group A streptococcal infection, including acute sore throat.

Chronic carriage of Group A streptococcus: These are apparent bacteriological treatment failures without illness or immunological response. They have a low risk of spread and a low risk of suppurative and non-suppurative complications. Antibiotics are not required.

The usefulness of throat swabs is limited by:

• Their low sensitivity and specificity, they do not distinguish between carriage and infection with haemolytic streptococci
• It takes time to obtain results (48-72 hours)

Immediate prescription of antibiotics is recommended in patients who:

• Are systemically very unwell
• Show signs and symptoms suggestive of serious illness
• Are at risk of developing complications because of pre-existing co-morbidity, including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely
• Are older than 65 years with acute cough and two or more of the following criteria; or older than 80 years with acute cough and one or more of the following criteria:
  • Hospitalisation in previous year
  • Type 1 or type 2 diabetes
  • History of congestive heart failure
  • Current use of oral glucocorticoids

Please see local referral guidelines if recurrent acute tonsillitis/ tonsillectomy.

• Northern locality
• Eastern locality

Where antibiotics are indicated

Phenoxymethylpenicillin

(including pregnancy)

• Adults and children over 12 years of age:
  • 500mg four times a day for 5-10 days or
  • 1000mg twice daily for 5-10 days
• Child 1 month to 11 years (doses given for 5-10 days)
  • 1 month to 11 months: 62.5mg four times a day or 125mg twice daily
  • 1 to 5 years: 125mg four times a day or 250mg twice daily
  • 6 to 11 years: 250mg four times a day or 500mg twice daily

Penicillin allergy

Clarithromycin

• Adults and children over 12 years of age:
  • 250mg to 500mg twice daily for 5 days
• Children 1 month to 11 years (doses given twice daily for 5 days):
  • Body-weight under 8 kg: 7.5mg/kg
  • Body-weight 8–11 kg: 62.5mg
  • Body-weight 12–19 kg: 125mg
  • Body-weight 20–29 kg: 187.5mg
  • Body-weight 30–40 kg: 250mg

Penicillin allergy in pregnancy

Erythromycin

• 250mg to 500mg four times a day for 5 days

See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides

The information below is based on NICE NG91 Otitis media (acute): antimicrobial prescribing (March 2018).

Acute otitis media is a self-limiting infection that mainly affects children; it can be caused by viruses and bacteria with symptoms lasting for about three days, but can last for up to one week.

Self-care advice:

• Consider paracetamol or ibuprofen for pain or fever

The following are not recommended due to a lack of evidence: decongestants or antihistamines.

The routine commissioning of Otigo (phenazone with lidocaine) ear drops is not accepted in Devon for the treatment of acute otitis media pain (see Commissioning Policy for more information).

Most children and young people get better within three days without antibiotics.

Antibiotics make little or no difference in reducing ear pain and their use should be balanced against the risk of causing adverse effects such as vomiting, diarrhoea or rashes. Antibiotics make little difference to the number of children with common complications of acute otitis media such as recurrence of infection, short term hearing loss and perforated eardrum; and make little difference to the number of children whose symptoms improve. Complications (such as mastoiditis) are rare with or without antibiotics.

Advise to seek medical help if symptoms do not start to improve after 3 days if the child or young person becomes very unwell.

For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021)

Consider a delayed prescription for use if symptoms do not start to improve within 3 days. Advise to seek medical help if symptoms worsen rapidly or significantly at any time.

Consider a delayed prescription or immediate prescription of antibiotics in:

• Children and young people with acute otitis media and otorrheoa (discharge following ear drum perforation)
• Children under 2 years of age with acute otitis media in both ears

Offer an immediate prescription in:

• Patients who are systemically very unwell
• Patients who show signs and symptoms suggestive of serious illness
• Children at high risk of serious complications because of pre-existing co- morbidity (e.g. significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely)

For children under 3 months, have a low threshold for prescribing antibiotics or admitting.

Reassess at any time if symptoms worsen rapidly or significantly, taking account of:

• Alternative diagnoses, such as otitis media with effusion (glue ear);
• Any symptoms or signs suggesting a more serious illness or condition
• Previous antibiotic use, which may lead to resistant organisms

The following Referral Guidelines are available locally:

• Management of discharging ear; northern locality and eastern locality
• Perforated Tympanic Membrane; northern locality and eastern locality

Where antibiotics are indicated

1st line

Amoxicillin

(including pregnancy)

• Children and young people under 18 years of age:
  • 1 month to 11 months: 125mg three times a day for 5 to 7 days
  • 1 to 4 years: 250mg three times a day for 5 to 7 days
  • 5 to 17 years: 500mg three times a day for 5 to 7 days

Penicillin allergy

Clarithromycin

• Children and young people 12 to 17 years of age:
  • 250mg to 500mg twice daily for 5 to 7 days
• Children 1 month to 11 years of age (doses given twice daily for 5 to 7 days):
  • Body-weight under 8 kg: 7.5mg/kg
  • Body-weight 8–11 kg: 62.5mg
  • Body-weight 12–19 kg: 125mg
  • Body-weight 20–29 kg: 187.5mg
  • Body-weight 30–40 kg: 250mg

Penicillin allergy in pregnancy

Erythromycin

• Children and young people:
  • 12 to 17 years: 250mg to 500mg four times a day or 500mg to 1,000mg twice daily for 5 to 7 days

See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides

2nd line

If worsening of symptoms on first choice taken for at least 2 to 3 days.

Co-amoxiclav

• Children 1 month to 17 years of age (doses given three times a day for 5 to 7 days):
  • 1 to 11 months: 0.25ml/kg (125/31mg/5ml suspension)
  • 1 to 5 years: 5ml or 0.25ml/kg (125/31mg/5ml suspension)
  • 6 to 11 years: 5ml or 0.15ml/kg (250/62mg/5ml suspension)
  • 12 to 17 years: 250/125mg or 500/125mg

If worsening of symptoms on second line treatment option, taken for at least 2-3 days, or penicillin allergy consult local microbiologist.

See 5.1.1 Penicillins

See guidance in 12.1.1 Otitis externa

The information below is based on NICE NG79 Sinusitis (acute): antimicrobial prescribing (October 2017).

Acute sinusitis is self-limiting and usually triggered by a viral infection of the upper respiratory tract.

Symptoms can last for 2 to 3 weeks – most people will get better within this time without treatment, regardless of cause (bacteria or virus).

For children under 5 years who present with fever refer to NICE NG143: Fever in under 5s: assessment and initial management (November 2021)

Self-care advice:

• Consider paracetamol or ibuprofen for pain or fever
• Patients may wish to try nasal saline or nasal decongestants, although there is not enough evidence to show that they help to relieve nasal congestion.

The following are not recommended due to a lack of evidence: oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs.

Consider prescribing a nasal corticosteroid for 14 days for adults and children aged 12 years and over (unlicensed use), see section 12.2.1 Drugs used in nasal allergy. Be aware that nasal corticosteroids may improve symptoms but are not likely to affect how long they last; could cause systemic effects, particularly in people already taking another corticosteroid; and may be difficult for people to use correctly.

Consider a 5-day prescription (delayed for 7 days) for patients presenting with symptoms for around 10 days or more with no improvement, taking account of evidence that antibiotics make little difference to how long symptoms last, or the proportion of people with improved symptoms.

Immediate prescription of antibiotics is recommended in the following patients (refer to 2nd line treatments below):

• Are systemically very unwell
• Show signs and symptoms suggestive of serious illness and/or complications
• Are at risk of developing complications because of pre-existing co-morbidity, including significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and young children born prematurely
• Are older than 65 years with acute cough and two or more of the following criteria; or older than 80 years with acute cough and one of more of the following criteria:
  • Hospitalisation in previous year
  • Type 1 or type 2 diabetes
  • History of congestive heart failure
  • Current use of oral glucocorticoids

Where antibiotics are indicated

1st line

If systemically very unwell, symptoms and signs of a more serious illness or condition, or at high risk of complications, refer to "2^nd line".

Phenoxymethylpenicillin

(including pregnancy)

• Adults over 18 years of age:
  • 500mg four times a day for 5 days
• Children 1 month to 17 years of age (doses given four times a day for 5 days):
  • 1 month to 11 months: 62.5mg
  • 1 to 5 years: 125mg
  • 6 to 11 years: 250mg
  • 12 to 17 years: 500mg

Penicillin allergy in adults/ children over 12 years

Doxycycline

• Adults and children over 12 years of age:
  • 200mg single starting dose, then 100mg daily for total of 5 days
• For children under 12 years of age, doxycycline is contraindicated: give clarithromycin (see below)
• Not for use in pregnancy: give erythromycin (see below)

Penicillin allergy in children under 12 years

Clarithromycin

• Children 1 month to 11 years of age (doses given twice daily for 5 days):
  • Body-weight under 8kg: 7.5mg/kg
  • Body-weight 8–11kg: 62.5mg
  • Body-weight 12–19kg: 125mg
  • Body-weight 20–29kg: 187.5mg
  • Body-weight 30–40kg: 250mg

Penicillin allergy in pregnancy

Erythromycin

• 250mg to 500mg four times a day for 5 days

See 5.1.1 Penicillins, 5.1.3 Tetracyclines, and 5.1.5 Macrolides

2nd line

If systemically very unwell, symptoms and signs of a more serious illness or condition, at high risk of complications, or if worsening of symptoms on first choice taken for at least 2 to 3 days.

Co-amoxiclav

• Adults over 18 years of age:
  • 625mg three times a day for 5 days
• Children 1 month to 17 years of age (doses given three times a day for 5 days):
  • 1 to 11 months: 0.25ml/kg (125/31mg/5ml suspension)
  • 1 to 5 years: 5ml or 0.25ml/kg (125/31mg/5ml suspension)
  • 6 to 11 years: 5ml or 0.15ml/kg (250/62mg/5ml suspension)
  • 12 to 17 years: 250/125mg or 500/125mg

If worsening of symptoms on second line treatment option, taken for at least 2-3 days, or penicillin allergy consult local microbiologist.

See 5.1.1 Penicillins