(refractory) forms of periodontal disease. Doxycycline p. 352
has a longer duration of action than tetracycline p. 354 or
oxytetracycline p. 354 and need only be given once daily; it is
reported to be more active against anaerobes than some
other tetracyclines.
Doxycycline may have a role in the treatment of recurrent
aphthous ulceration, or as an adjunct to gingival scaling and
root planing for periodontitis.
Macrolides
The macrolides are an alternative for oral infections in
penicillin-allergic patients or where a beta-lactamase
producing organism is involved. However, many organisms
are now resistant to macrolides or rapidly develop
resistance; their use should therefore be limited to short
courses.
Clindamycin
Clindamycin p. 327 should not be used routinely for the
treatment of oral infections because it may be no more
effective than penicillins against anaerobes and there may be
cross-resistance with erythromycin-resistant bacteria.
Clindamycin can be used for the treatment of dentoalveolar
abscess that has not responded to penicillin or to
metronidazole.
Metronidazole and tinidazole
Metronidazole is an alternative to a penicillin for the
treatment of many oral infections where the patient is
allergic to penicillin or the infection is due to beta-
lactamase-producing anaerobes. It is the drug offirst choice
for the treatment of acute necrotising ulcerative gingivitis
(Vincent’s infection) and pericoronitis; amoxicillin is a
suitable alternative. For these purposes metronidazole for
3 days is sufficient, but the duration of treatment may need
to be longer in pericoronitis. Tinidazole p. 335 is licensed for
the treatment of acute ulcerative gingivitis.
Respiratory system infections,
antibacterial therapy
Epiglottitis (Haemophilus influenzae)
.Cefotaxime p. 320 (orceftriaxone p. 322 )
▶If history of immediate hypersensitivity reaction to penicillin
or to cephalosporins, chloramphenicol p. 354
Community-acquired pneumonia
Children under 2 years with mild symptoms of lower
respiratory tract infection (particularly those vaccinated with
pneumococcal polysaccharide conjugate vaccine (adsorbed)
p. 793 and haemophilus type b conjugate vaccine) are
unlikely to have pneumonia; antibacterial treatment may be
considered if symptoms persist.
.Neonate, benzylpenicillin sodium p.^338 + gentamicin
p. 312
.Child 1 month– 18 years, amoxicillin p. 339 (orampicillin
p. 341 ) by mouth
▶Pneumococci with decreased penicillin sensitivity have
been isolated in the UK, but are not common.
▶If no response to treatment, add clarithromycin p. 330 (or
azithromycin p. 329 orerythromycin p. 331 )
▶If staphylococci suspected (e.g. in influenza or measles),
give by mouth amoxicillin +flucloxacillin p. 345 orco-
amoxiclav p. 343 alone
▶If septicaemia, complicated pneumonia, or if oral
administration not possible, initiate treatment with i/v
amoxicillinori/v co-amoxiclavori/v cefuroxime p. 319 or
i/v cefotaxime (orceftriaxone)
▶Suggested duration of treatment 7 days (may extend
treatment to 14 days in some cases e.g. if staphylococci
suspected)
.Child 1 month– 18 years, if penicillin-allergic, clarithromycin
(orazithromycinorerythromycin)
▶Suggested duration of treatment 7 days (may extend
treatment to 14 days in some cases e.g. if staphylococci
suspected)Pneumonia possibly caused by atypical pathogens
.Clarithromycin (orazithromycinorerythromycin)
▶Suggested duration of treatment 10 – 14 days
.Alternative for chlamydial or mycoplasma infections in
children over 12 years, doxycycline p. 352
▶Suggested duration of treatment 10 – 14 daysHospital-acquired pneumonia
.Early-onset infection(less than 5 days after admission to
hospital), treat as for severe community-acquired
pneumonia of unknown aetiology; if life-threatening
infection, or if recent history of antibacterial treatment, or
if resistant organisms suspected, treat as for late-onset
hospital-acquired pneumonia
.Late-onset infection(more than 5 days after admission to
hospital), an antipseudomonal penicillin (e.g. piperacillin
with tazobactam p. 337 )oranother antipseudomonal beta-
lactam
▶If meticillin-resistantStaphylococcus aureussuspected, add
vancomycin p. 325.
▶If severe illness caused byPseudomonas aeruginosa, add an
aminoglycoside.
▶Suggested duration of treatment 7 days (longer if
Pseudomonas aeruginosaconfirmed)Lung infection in cystic fibrosis (Staphylococcus
spp.)
.Flucloxacillin
▶If child already takingflucloxacillin prophylaxis or if
severe exacerbation, add fusidic acid p. 357 or rifampicin
p. 364 ;useflucloxacillin at treatment dose
.If penicillin-allergic, clarithromycin (orazithromycinor
erythromycin) or clindamycin p. 327
▶Use clarithromycin only if micro-organism sensitiveLung infection in cystic fibrosis (Haemophilus
influenzae)
.Amoxicillinora broad-spectrum cephalosporin
▶In severe exacerbation use a third-generation
cephalosporin (e.g. cefotaxime)Lung infection in cystic fibrosis (Pseudomonasspp.)
.Ciprofloxacin p. 348 +nebulisedcolistimethate sodium
p. 346
▶For severe exacerbation, an antipseudomonal beta-lactam
antibacterial + parenteral tobramycin p. 313Skin infections, antibacterial
therapy
Impetigo: small areas of skin infected
Seek local microbiology advice before using topical
treatment in hospital.
.Topical fusidic acid p. 357
▶Suggested duration of treatment 7 days is usually adequate
(max. 10 days).
.Alternatively, if meticillin-resistant Staphylococcus aureus,
topical mupirocin p. 724BNFC 2018 – 2019 Bacterial infection 309
Infection5