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1. Streptococcus pneumoniae, Haemophilus influenza,

2. Amoxicillin 500mg PO, TDS for 5 days

Reference:

1. National Antimicrobial Guidelines 2019

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exercise 1
1) Group A Streptococcus pyogenes
2) - Tab Penicillin 500 mg QID x 5-10 days
- Tab Amoxicillin 500mg TDS x 5-10 days
- IM Benzathine Penicillin 1.2 MU one single dose
3) 5-10 days
4) Tab Erythromycin 800mg BD x 5-10 days
Tab Cephalexin 25-50 mg/kg per day in two divided doses x 10days

exercise 2
1) infection in normal genitourinary systems
2) - E.coli
3) Tab Nitrofurantoin 50-100 mg QID x 5days
Tab Cephalexin 500mg BD x 3-5days (cystitis)
Tab Amoxicillin 625mg TDS x 14days
Tab Ampicillin 375-750 mg BD x 14 days (pyelonephritis)
4) Tab Nitrofurantoin
- female 3days
- male 7 days

Exercise 3
Bacterial aetiologies :
Staphlococcus aureus, streptococcus pneumonia, haemophilus influenza

Tx:
Chloramphenicol 0.5% eyedrop QID
Ciprofloxacin  0.3% eyedrop QID

Other aetiologies:
Herpes simplex virus
Acanthamoeba sp.
Toxoplasma gondii
Cytomegalovirus

exercise 4
1) Streptococcus pneumoniae
Haemophilus influenza
2) Tab Amoxicillin 500mg TDS x 5days

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EXERCISE 1

i) Most episodes of pharyngitis are viral. However, if it is bacterial infection, what is the most common bacterial aetiology?

Streptococcal pyogenes

ii) Which antibiotic group is the first line (primary) antibiotic treatment for this condition recommended by the current guidelines? Name three antibiotic options. State the dose and frequency of the treatment.
• Tab Amoxicillin 500 mg TDS 5 to 10 d
• Tab Phenoxymethyl penicillin 500 mg QID 5 to 10 d
• IM benzthine penicillin 1.2 MU, single dose.

iii) What is the recommended duration of the treatment?
• 5 to 10 days

iv) If the patient is allergic to the above antibiotic group, what are the other alternative antibiotics? Name two antibiotic options. (Include the dose and frequency).
• Tab erythromycin ethylsuccinate 800 mg BD 5 to 10 d
• C Clindamycin HCL 300 mg QID 10 days

Exercise 2

i) Urinary tract infection (UTI) is common in the primary care setting. How do you define uncomplicated UTI?

Infection that are develop in healthy man or women, with completely normal genitourinary sys.

ii) What is the commonest bacterial aetiology for UTI?

Escherichia coli

iii) State two first-line antibiotic therapies for uncomplicated UTI? Give the dose and frequency.
• Tab Nitrofurantoin monohydrate 100 mg QID 5 to 7 days
• Tab Sulfamethoxazole 400mg Trimetoprim 80mg (bactrim) BD 3 days
iv) What is the recommended duration of the treatment? Is there any difference for men and women?
• Nitrofurantoin in male 7 days while female 3 days only

EXERCISE 3

There are several causes of conjunctivitis. If it is bacterial conjunctivitis, list down the bacterial aetiologies of this condition.
• Strep aureus
• Strep pneumonae
• H. Influenza
What are the eye-drops and eye ointments available at the health centres? How do you prescribe these medications?
• Chloramphenicol 0.5% eye drop QID
What are other aetiologies of conjunctivitis?
• Neisseria Gonorrhea
• Chlamydia trachomitis
• Corynebacterium diphteria
• Adenovirus

Exercise 4

Acute otitis media commonly occurs in children. If it is bacterial infection, name two types of bacteria which commonly cause this condition.
• H. Influenza
• Strep. Pneumonia
• Moraxella catarrhalis
What is the first-line antibiotic therapy for acute otitis media? How do you prescribe the antibiotic? (dose, frequency, route and duration).
• C amoxicillin 500 mg TDS 5 to 7 days (adult) If child syrup augmentin 25/kg/day in 2 divided dose

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1. Bacterial aetiologies for conjunctivitis

a) Staphylococcus aureus

b) Streptococcus pneumoniae

c) Haemophilus influenzae

2. Eyedrop Chloramphenicol 0.5% QID for 1 week

3. Neisseria gonorrhea / Chlamydia trachomatis

Ref : National Antimicrobial Guidelines (2019)

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1.  Infection that develop in healthy men or women with completely normal genitourinary system

2. Escherichia coli

3. 2 first line antibiotic for uncomplicated UTI

a) Nitrofurantoin 50-100mg PO QID for 5 days

b) Cephalexin 500mg PO BD for 3-5days

4. Recommended duration: 5 days. There is no difference between male and women

References

1. National Antimicrobial Guidelines 2019

2. Medscapes: Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females -- https://emedicine.medscape.com/article/233101-overview

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i) uncomplicated UTI involve urinary bladder as a host without underlying renal abnormality and metabolic disease

ii) Escherichia Coli

iii) Tab Nitrofurantoin 50-100mg BD for 5 days
Tab Cephalexin 500mg BD 3-5 days

iv) Female 5-7 days, Male 10-14 days (because male UTI is usually complicated UTI)

References:  NAG, medscape UTI

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Exercise 3

1. Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia trachomatis
2. Chloramphenicol 0.5 % eye drop QID
3. Virus (HSV, adenovirus), allergens (smoke, pollen, dust, perfumes, cosmetics), chemicals (acid/alkali)

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1. Streptococcus Pneumoniae and Haemophilus Influenza
2. Tab. Augmentin 625mg BD for 10-14 days/ CMC Chloramphenicol 5%

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Exercise 1
1. Streptococcus pyogene
2. T. Penicillin 25-50mg/kg/day for 10 days
T. Amoxicillin 50mg/kg/day for 10 days
T. Erythromycin 40-50mg/kg/day
3. 5-10 days
4. Cephalexin 25-50mg kg/day PO for 10 days in divided doses
Clindamycin 150-300mg kg/day 6 hourly

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1) Group A Beta Haemolytic Streptococcus (Streptococcus pyogenes)
2)
- Penicillin V 500 mg TDS/QID
- Benzathine penicillin 1.2 megaunit IM
- Amoxicillin 250mg - 500 mg TDS
3) 6 to 10 days
4)
- Erythromycin 400 mg 6 hourly
- Clindamycin 150 mg - 300 mg QID 6 hourly
- Cephalexin 1 - 4 g OD

Exercise 2
1) Infection that develops in healthy men or women with completely normal genitourinary system
2) E coli
3)
- Nitrofurantoin 50 - 100 mg PO q6h
- Cephalexin 500 mg PO q12h
4) 3 to 5 days
- Female: 50 - 100 mg QID for 3 days
- Male: 50 - 100 mg QID for 7 days

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039527/#:~:text=This%20suggests%2C%20when%20prescribing%20empirically,and%20seven%20days%20for%20males

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Christopher C. Butler, Academic Editor

Abstract

Current antimicrobial prescribing guidelines indicate that male and female patients with urinary tract infections (UTIs) should be treated with same antimicrobials but for different durations. The aim of this study was to explore the differences in reconsultations and antimicrobial prescribing for UTI for both males and females. A total of 2557 adult suspected UTI patients participating in the Supporting the Improvement and Management of Prescribing for urinary tract infection (SIMPle) study from 30 general practices were analyzed. An antimicrobial was prescribed significantly more often to females (77%) than males (63%). Nitrofurantoin was prescribed more often for females and less often for males (58% vs. 41%), while fluoroquinolones were more often prescribed for males (11% vs. 3%). Overall, reconsultation was 1.4 times higher in females, and if the antimicrobial prescribed was not the recommended first-line (nitrofurantoin), reconsultation after empirical prescribing was significantly higher. However, the reconsultation was similar for males and females if the antimicrobial prescribed was first-line. When a urine culture was obtained, a positive culture was the most important predictor of reconsultation (Odds ratio 1.8 (95% CI 1.3-2.5)). This suggests, when prescribing empirically, that male and female UTI patients should initially be treated with first-line antimicrobials (nitrofurantoin) with different durations (50-100 mg four times daily for three days in females and seven days for males). However, the consideration of a culture test before prescribing antimicrobials may improve outcomes.

Keywords: urinary tract infection, reconsultation, general practice, antimicrobial prescribing, treatment, culture test, male and female

1. Introduction

Research on urinary tract infections (UTIs) has mainly been focused on women because of the higher incidence and prevalence in women compared to men [ 1, 2]. Treatment recommendations for UTI differ for males and females, mainly regarding the duration of treatment. The Irish antimicrobial guidelines for treatment of UTI indicate the treatment of females and males with the same first-line antimicrobials (Nitrofurantoin and Trimethoprim) but for different durations (three days vs. seven days) [ 3]. However, the Scottish Intercollegiate Guideline Network (SIGN guidelines) UK indicate a 7 day first-line (Trimethoprim and Nitrofurantoin) treatment regimen for males with uncomplicated UTI, but antimicrobial treatment is not recommended for females [ 4]. One common conception in general practice is that males generally have complicated UTIs, and that therefore treatment recommendations for uncomplicated UTI in women are not appropriate for men. In an observational study of male veterans, treatment outcome (recurrence) was compared with the duration of treatment. The study showed that a longer duration of treatment (greater than seven days) was associated with increased late recurrence (30 days after the prior episode) [ 5]. They also found a link between the longer duration of treatment and the occurrence of C. difficile associated diarrhea in patients. Considering the risks associated with long courses of antimicrobials and no clinical benefit of the longer duration of treatment, Trautner suggests in her commentary for a more judicious use of antimicrobials for UTI in males [ 6]. A German observational study conducted in 2004 in 90 males concluded that UTI in males should not be treated empirically or based on dipstick results and clinical information. Their study showed that 60% of males had a positive culture even though half of them had low colony counts, and that the antibiotic prescribed to 36% of the males was not well targeted. The authors recommended to await urine culture results before a treatment decision is made [ 7]. A Dutch study of UTI in males reported that dipstick information in combination with clinical diagnosis was as accurate as the recommended care based on culture results [ 8]. The subsequent study comparing uropathogens and their resistance between male and female UTI patients similarly suggested that given the heterogeneous population of uropathogens causing UTI in males, empiric treatment should be avoided and treatment should be based on culture results [ 9]. Differences in treatment between these studies may be cultural or related to differences in the study populations and shows the need for more research to elucidate the epidemiology, diagnosis, and treatment of UTI in males. Also, in the wake of the global spread of antimicrobial resistance, limiting the use of antimicrobials is essential.

In this study, we aim to describe the differences between males and females UTI patients attending to General Practices with respect to antimicrobial prescribing, and the frequency of reconsultation.

2. Results

A total of 3561 UTI consultations were recorded over a 15-month period, 372 (10.5%) males and 3187 (89.5%) females. There were 2557 (71.8%) index consultations (280/2557 males, 2275/2557 females and 2/2557 unknown) and 1004 (28.2%) additional consultations with a similar distribution of males (92/1004) and females (912/1004). The additional consultations were made within 30 days of the first visit (reconsultation) in the case of 512 (20%) of the index patients. An overview of the index consultation is presented in Table 1 . Males were older than females and were more often patients holding a medical card.

Table 1

Characteristics

Male

Female

p-Value

N

%

N

%

E. coli/ coliform

40

14.3

442

19.4
0.03

Proteus spp.

2

3.3

17

2.4

ns

Staphylococcus
0

28

2.1. Antimicrobial Prescribing

Overall, an antimicrobial was prescribed to 75% of the patients at the index consultation and this was significantly higher for females (77%) compared to males (63% ( Table 1 )). When prescribed an antimicrobial, most received nitrofurantoin (75%) while 7% received trimethoprim and 5% received a fluoroquinolone (not shown in Table 1 ). Females were prescribed nitrofurantoin significantly more often (58% vs. 41%) while males received fluoroquinolones more often compared to females (11% vs. 3.1%). No significant differences were observed for the other antimicrobials. The duration of treatment, measured as the duration of the dose dispensed, was significantly higher for males compared to females ( Table 1 ). The median duration of treatment for nitrofurantoin was significantly higher for males compared to females; seven days for males (median quantity 28/4 times daily (QDS)) and three days for females (median quantity 12, QDS) ( Figure 1 ). There were no differences in the duration of fluoroquinolones and co-amoxiclav prescriptions between males and females ( Table 1 ).

2.2. Urine Culture

A urine sample was obtained during 1286 or 50% of the index consultations. Samples were submitted from 135 (48%) males and 1150 (51%) females ( Table 1 ). A lower percentage of the urine samples from male patients showed a positive culture compared to the female urine samples (36% vs. 45%). The percentage breakdown of species identified as positive culture results for males and females is shown in Table 1 .

Of the 49 male patients who had a positive culture, 41 received an antimicrobial, which was generally nitrofurantoin (66%). Of the patients who received an antimicrobial, 13 had a subsequent reconsultation, of whom one may have been related to the non-susceptibility of the organism to the antimicrobial prescribed (i.e., nitrofurantoin was prescribed for Proteus spp.). Of the 522 females with positive cultures, 456 received an antimicrobial, of whom 76% received nitrofurantoin. Of the subsequent 129 reconsultations, seven may have been due to the non-susceptibility of the organism to the prescribed antimicrobials (one Proteus spp. where nitrofurantoin was prescribed, six organisms identified with resistance against the antimicrobial that was prescribed) ( Figure 2 flow chart).

2.3. Reconsultation

A logistic regression analysis with outcome reconsultation showed females to have a higher occurrence of reconsultation compared to males after correction for confounding factors (age, medical card status, and whether an antimicrobial was prescribed) ( Table 2 ). However, no significant differences were observed in reconsultation between males and females when an antimicrobial was the first-line (nitrofurantoin) ( Figure 3 flow chart). When an antimicrobial was prescribed empirically and was not nitrofurantoin, the odds of reconsultation were higher (OR 1.56, 95% CI (1.1-2.0)). There was no difference in reconsultations when quinolones were prescribed empirically, but the odds of reconsultation were significantly higher when trimethoprim was prescribed (OR 2.0 95% CI (1.3-3.1)) (not shown in Table 2 ). However, neither the gender nor the antimicrobial prescribing was significant in a model in which culture test results were included. In the subset of patients in which a urine culture was performed, the positive culture test was associated with reconsultation (OR = 1.8, 95% CI 1.3-2.5) (not shown in Table 2 ).

Table 2

Characteristics

OR

95% CI

p-Value

Gender

Male

reference

Medical card

No

reference

Prescribed antimicrobials

No

reference

Yes

1.2

0.96-1.5

0.1

Intervention

Control (arm C)

reference

3. Discussion

A urine sample was only available for approximately 50% of the patients. Even though there is no indication that patients without culture results had better or worse outcomes, it is unclear as to why no urine sample was obtained from the other half of the UTI patients. Studies indicate that empiric antimicrobial treatment without urine culture is appropriate for uncomplicated UTI in primary care, however for males, a urine culture rather than empiric treatment is recommended [ 5, 6, 8]. Conversely, the Scottish Intercollegiate Guidelines Network (SIGN) recommends both urine culture and empiric treatment for all male with symptoms of UTI [ 10].

Males were less often prescribed an antimicrobial empirically, but if an antimicrobial was prescribed, the duration of treatment was generally longer and the antimicrobial prescribed was more likely to be a fluoroquinolone. Cultures from males were less likely to be positive and re-consultations were less common. However, for both males and females, reconsultation was less common when nitrofurantoin was prescribed compared with prescription of any other antimicrobial or compared with no antimicrobial prescription. A study conducted in Germany also supports following local (first-line) antimicrobial guidelines for both males and females when prescribing empirically [ 7].

Conventional practice with respect to management of UTI has emphasized empiric antimicrobial prescribing at the first consultation. This is challenged by an emerging body of evidence that shows that symptomatic treatment and delayed antimicrobial use for UTI in females is safe and allows for spontaneous resolution in a high proportion of cases. Our study points to differences between males and females presenting with features suggestive of UTI with respect to the likelihood of a positive culture, management decisions, and frequency of reconsultation. Given these differences, it is important that studies reassess conventional practices with respect to UTI and address both male and female patients independently.

The data used in this study were obtained through a remote electronic download from the general practice patient management software through the Irish Primary Care Research Network (IPCRN), and are therefore reliable and complete. However, even though all the data on urinary tract infection coded as U71 consultations is captured, coding depends on the General Practitioners (GPs). GPs may have been less inclined to code for male consultations as it was not explicitly requested to include females and males. Even though this does not impact the outcome of reconsultation, the number of females may be over represented. Another limitation of the study was that no detailed information was available from any other UTI related consultation; only "suspected UTI" (U71) was recorded. If the GP considered a male UTI as complicated or if the consultation was not recorded as U71, no data was downloaded. Also, whether patients were referred to a urologist or other specialist for further investigation and management was not recorded. Similarly, no symptoms nor any further diagnostic information, such as dipstick results or other predictive indicators, were recorded in the GP patient management software as this was an observational study of patient records.

4. Materials and Methods

This is a secondary data analysis of the Supporting the Improvement and Management of Prescribing for Urinary tract infection (SIMPle) study [ 11]. The study was conducted in 30 general practices in the west of Ireland, for a period of 15 months, to improve the quality of antimicrobial prescribing for UTIs in general practice. GPs were requested to code all consultations (U71) with patients with suspected UTI. Remote electronic data collection was initiated from the practice's patient management software through the Irish Primary Care Research Network (IPCRN) [ 12], a national research network of general practices. At the start of the study, all practices received a workshop on consultation coding after which practices were allocated to intervention (arm A and B) and control groups (arm C). The intervention arm A received a workshop on appropriate prescribing for UTI supported by practice specific audit reports and the intervention arm B received a workshop on delayed prescribing including the intervention package in arm A. There was no specific intervention delivered to intervention arms in relation to the management of UTI in males.

From June 2013 to August 2014, data was collected on all adult patients with suspected UTI in the 30 general practices. No specific guidance was given regarding the diagnosis of UTI, in order to interfere as little as possible with daily clinical care. GPs were encouraged to submit a urine sample from all suspected UTI patients. The IPCRN provided data on patients' age, gender, medical card status, consultation date, type of prescription, and treatment (Anatomical Therapeutic Chemical (ATC) code). A medical card provides the holder with free healthcare and medication. Entitlement to a medical card is based on income and age-97% of those aged 70 and older and about one-third of the population under 70 have a medical card [ 13].

Ethical approval for the SIMPle study was obtained from the Irish College of General Practitioners (ICGP).

4.1. UTI and Urine Culture

A UTI episode was defined as a clinical consultation for which a U71 consultation code was entered. For each of these patients, information on previous and subsequent consultations as well as antimicrobial therapy was extracted. Urine culture results and antimicrobial susceptibility profiles of isolates were also extracted. Standard microbiological methods were used for the detection and identification of pathogens. UTI was considered laboratory confirmed when bacterial growth of >10 ⁵ pure culture/mL was detected. Susceptibility to amoxicillin, co-amoxyclav, trimethoprim, ciprofloxacin, nitrofurantoin, and cefpodoxime was performed by EUCAST disc diffusion and interpreted according to EUCAST guidelines [ 14].

4.2. Reconsultation

The first UTI episode was classified as the index consultation and reconsultation was identified as a further consultation within 30 days of the first visit for the same reason (UTI).

4.3. Empirical Prescribing

At the time of the study, nitrofurantoin and trimethoprim were recommended first-line treatment for males and females according to national guidelines. However, the guidelines recommend the use of these first-line antimicrobials when resistance levels among common pathogens is below a threshold of 20% [ 15]. As trimethoprim resistance in E. coli in this region has been greater than 20% for some years, this means that effectively nitrofurantoin is the only first-line treatment recommended [ 16]. According to the current national guidelines, the first-line recommended agent is used for different durations; seven days in males and three days in females. Fluoroquinolones (such as ciprofloxacin) were considered a reserve antimicrobial and should only be prescribed after culture results and susceptibility is known [ 3]. For the purpose of analysis, the dose dispensed (for instance 12 tablets four times daily equals a duration of 3 days) was considered as the duration of the treatment according to the recommended daily dose.

4.4. Statistical Analysis

The presented secondary analyses were performed with data generated during the SIMPle study. An overview of the patients is presented according to gender. General demographic profiles of the patients in relation to antimicrobial prescribing are presented in percentages as well as means and medians of age. A binary logistic regression model was applied and results were presented as an odds ratio (OR) and associated 95% confidence interval (CI). Interactions were tested and omitted from the models if they were not significant. Overall statistical analysis was performed with IBM SPSS Statistics for |Windows Version 21.0, (IBM Corporation released 2012, Armonk, NY, USA). Flow diagrams and figures presented in the paper were produced using Microsoft Visio 2010 and Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA, USA).

5. Conclusions

After allowing for differences in prescribing (first-line, non first-line, or no antimicrobial), no significance differences were observed in reconsultation among male and female UTI patients. When prescribing antimicrobial treatment for UTI empirically, first-line treatment (nitrofurantoin) should be the preferred choice for both males and females.

Acknowledgments

Sincere thanks to the Supporting the Improvement and Management of Prescribing for urinary tract infection (SIMPle) study team for providing the data for this secondary analysis and to the Health Research Board of Ireland for providing the opportunity to write this paper. We would also like to thank Marie Tierney for proof editing of our manuscript.

Author Contributions

M.T. performed the statistical analysis and wrote the draft manuscript. A.V. conceived and managed the study and provided statistical support. M.T., A.V., and S.D. were involved in drafting the final manuscript. M.C. and A.W.M. thoroughly revised the paper. All authors read and approved the final manuscript.

Conflicts of Interest

The authors declare that they have no competing interest.

References

2. Nicolle L.E. Epidemiology of Urinary Tract Infection. Infect. Med. 2001;18:153-162. doi: 10.1016/S0196-4399(02)80035-6. [[ CrossRef] Google Scholar]

4. SIGN Management of Suspected Bacterial Urinary Tract Infection in Adults: A National Clinical Guideline. [(accessed on 27 July 2016)]. Available online: http://www.sign.ac.uk/pdf/sign88.pdf

8. Den Heijer C.D., van Dongen M.C., Donker G.A., Stobberingh E.E. Diagnostic approach to urinary tract infections in male general practice patients: A national surveillance study. Br. J. Gen. Pract. 2012;62:e780-e786. doi: 10.3399/bjgp12X658313. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

9. Den Heijer C.D.J., Penders J., Donker G.A., Bruggeman C.A., Stobberingh E.E. The importance of gender-stratified antibiotic resistance surveillance of unselected uropathogens: A Dutch Nationwide Extramural Surveillance study. PLoS ONE. 2013;8:31. doi: 10.1371/journal.pone.0060497. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

11. Duane S., Callan A., Galvin S., Murphy A.W., Domegan C., O'Shea E., Cormican M., Bennett K., O'Donnell M., Vellinga A. Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): Protocol for a cluster randomized trial. Trials. 2013 doi: 10.1186/1745-6215-14-441. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

12. Irish Primary Care Research Network (IPCRN) [(accessed on 12 August 2015)]. Available online: http://www.ipcrn.ie/

13. Health Insurance Authority . Health Insurance Authority Consumers Survey. Health Insurance Authority; Dublin, Ireland: 2014. [ Google Scholar]

14. European Society of Clinical Microbiology and Infectious Disease (EUCAST) [(accessed on 12 November 2015)]. Available online: http://www.eucast.org/

16. Vellinga A., Galvin S., Duane S., Callan A., Bennett K., Cormican M., Domegan C., Murphy A.W. Intervention to improve the quality of antimicrobial prescribing for urinary tract infection: A cluster randomized trial. CMAJ. 2015 doi: 10.1503/cmaj.150601. [[ PMC free article] [ PubMed] [ CrossRef] Google Scholar]

Articles from Antibiotics are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

# data[].attributes.attachment_link.title
Reconsultation and Antimicrobial Treatment of Urinary Tract Infection in Male and Female Patients in General Practice

# data[].attributes.attachment_link.description
Christopher C. Butler, Academic Editor Current antimicrobial prescribing guidelines indicate that male and female patients with urinary tract infections (UTIs) should be treated with same antimicrobials but for different durations. The aim of this study was to explore the differences in reconsultations and antimicrobial prescribing for UTI for both males and females.

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Exercise 3(g4)

Causes: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, or, less commonly, Chlamydia trachomatis and Neisseria gonorrhoe
Abx: chloramphenicol 0.5% eye drop QID for 1 week
Chloramphenicol ointment ON 1 week

Exercise 4(g4)

Causes: Streptococcus pneumoniae and Haemophilus influenzae
Abx: Tab amoxicillin 500mg tds for 5 days or
Tab cefuroxime 500mg BD for 5 days

2nd line: Tab amoxicillin+clavulanate 500/125 mg TDS for 5 days

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1. Streptococcus Pyogene (GAS)

2. Beta lactamase

a) Phenoxymethylpenicillin (penicillin V) 500mg PO QID

b) Amoxicillin 500mg PO TDS

c) Erythromycin Ethylsuccinate 800mg PO BD

3. Recommended duration 5-10 days

4. Alternative if penicillin allergy

- Cephalexin 25-50mg/kg/dat PO in 2 divided dose for 10 days

- Erythromycin Ethylsuccinate 40-50mg/kg/day PO in 3-4 divided doses for 10 days

References

1. National Antimicrobial Guideline 2019

2. Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. Pharyngitis: Approach to diagnosis and treatment. Can Fam Physician. 2020 Apr;66(4):251-257.

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Exercise 2

1. Infection that develops in healthy men or women with completely normal genitourinary symptoms
2. E. coli
3. T nitrofurantoin 100mg QID, T bactrim 1/1 BD
4. 5-7 days female male longer 10-14 days

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Exercise 1

I. Streptococcus pyogene
2. Penicillin V 250mg QID, T amoxicillin 500mg BD, IM Penicillin G 1200000u
3. 10 days
4. T Cephalexin 500mg BD 10 days, T Clindamycin 300mg TDS 10days