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1741. Addison's disease: Scenario: Management

or are prescribed antibiotics for an infection until they are recovered. The person should take 20 mg hydrocortisone orally and sip oral rehydration solution (such as Dioralyte®) if they experience severe nausea (often with headache). If they are taking an alternative glucocorticoid (such as dexamethasone or prednisolone), consult their care plan, or seek advice from an endocrinologist regarding the dose. If the person has vomited, they should use their emergency hydrocortisone injection and seek immediate

2016 NICE Clinical Knowledge Summaries

1742. Cerebral palsy: Scenario: Adult with confirmed cerebral palsy

, to assess swallowing. If a person with CP is at high risk of lower respiratory tract infection, consider referral to physiotherapy for a prophylactic chest care review. Prophylactic antibiotics for lower respiratory tract infections may be initiated by a respiratory specialist with expertise in neurodisability management if the person is at high risk of respiratory impairment. These may then be prescribed by a primary care physician as part of a shared care arrangement. Be aware that adults

2016 NICE Clinical Knowledge Summaries

1743. Pruritus vulvae: What are the possible causes of pruritus vulvae?

and hyperpigmentation occurs when dermatitis is chronic. It can be caused by: Proprietary creams (especially those containing local anaesthetics). Topical antibiotic preparations (for example, neomycin). Barrier contraceptives or lubricants. Perfumes, soaps, bubble baths, or wet wipes. Detergents, fabric conditioners, bleaches, or dyes. Psoriasis — due to the moisture and friction of skin folds, the classic psoriatic lesion (well-demarcated border, with erythematous plaques and silvery scale) is replaced (...) is based on expert opinion in narrative reviews Vulvar dermatoses: a practical approach to evaluation and management [ ], and Recognition and management of vulvar dermatologic conditions: lichen sclerosus, lichen planus, and lichen simplex chronicus [ ]. What systemic conditions may cause pruritus vulvae? Any cause of generalized pruritus may cause vulvar pruritus, including: Drug reactions, for example tetracycline antibiotics, such as doxycycline, and nonsteroidal anti-inflammatory drugs (NSAIDs

2016 NICE Clinical Knowledge Summaries

1744. Molluscum contagiosum

. Treatment may be required if: Itching is problematic — an emollient and a mild topical corticosteroid (for example, hydrocortisone 1%) may be useful. The skin looks infected — a topical antibiotic (for example, fusidic acid 2%) may be useful. Referral may be necessary in some circumstances: Children with extensive problematic lesions may need referral to a Dermatologist. People with eyelid-margin or ocular lesions and associated red eye require an urgent referral to an Ophthalmologist. HIV-positive

2016 NICE Clinical Knowledge Summaries

1745. Cholesteatoma: When should I suspect cholesteatoma?

Cholesteatoma: When should I suspect cholesteatoma? Diagnosis | Diagnosis | Cholesteatoma | CKS | NICE Search CKS… Menu Diagnosis Cholesteatoma: When should I suspect cholesteatoma? Last revised in June 2019 When should I suspect cholesteatoma? Note that cholesteatoma may be asymptomatic in its early stages. Suspect cholesteatoma in a person with: Recurrent or chronic purulent aural discharge, which may be unresponsive to antibiotic therapy. Discharge is malodorous and may be scant. Hearing

2016 NICE Clinical Knowledge Summaries

1746. Cholesteatoma: Scenario: Suspected cholesteatoma

out in secondary care will include an audiology assessment and a CT scan. Prior to surgical treatment, aural discharge may be treated with topical antibiotics. A commonly-employed surgical treatment for cholesteatoma is a canal wall up mastoidectomy, which allows removal of cholesteatoma but leaves the canal wall intact. This usually necessitates a second-look procedure after 9 to 12 months to examine for residual/recurrent disease. Arrange emergency admission for people who have: A facial nerve

2016 NICE Clinical Knowledge Summaries

1747. Cholecystitis - acute: Scenario: Management

, and serum amylase). Monitoring (for example blood pressure, pulse, and urinary output). Treatment (may include intravenous fluids, antibiotics, and analgesia). Surgical assessment for cholecystectomy. Basis for recommendation Admission to hospital The Royal College of Surgeons' Commissioning guidance: gallstone disease states that if acute cholecystitis is suspected the person should be referred to hospital as an emergency [ ]. Urgent admission to secondary care is recommended because of the high (...) the respiratory and haemodynamic state of a person with acute cholecystitis in preparation for emergency surgery [ ]. This information is also consistent with a review article [ ]. Treatment (may include intravenous fluids, antibiotics, and analgesia). This is consistent with recommendations from the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland to admit people with acute cholecystitis to hospital for fluid resuscitation, antibiotics, and analgesia [ ] and is also supported

2016 NICE Clinical Knowledge Summaries

1748. Cholecystitis - acute

(for example blood pressure, pulse, and urinary output). Treatment (may include intravenous fluids, antibiotics, and analgesia). Surgical assessment for cholecystectomy. © .

2016 NICE Clinical Knowledge Summaries

1749. Otitis media - acute: Scenario: Recurrent acute otitis media

exposure to passive smoking, use of dummies, and flat, supine feeding. In children — ensuring they have had a complete course of pneumococcal vaccinations as part of the routine childhood immunization schedule, and that any gastro-oesophageal reflux disease (GORD) is managed appropriately. For more information, see the CKS topics on and . In adults — avoiding smoking and/or passive smoking. Do not start long-term prophylactic antibiotics in primary care. Basis for recommendation Urgent referral (within (...) AOM with middle ear effusion. US guidelines suggest referral of all adults with recurrent or persistent AOM, particularly if they have not got a lifelong history of middle ear disease [ ]. Expert opinion in a review article also advises referral if recurrent episodes are unexplained or cholesteatoma is suspected [ ]. The recommendation to refer a person with complications is also extrapolated from the NICE guideline Otitis media (acute): antimicrobial prescribing , which advises referral

2016 NICE Clinical Knowledge Summaries

1750. Otitis media - acute: Scenario: Persistent acute otitis media - treatment failure

-quality evidence), but the sample sizes were small and the adverse effects were infrequent [ ]. Use of antibiotics This recommendation is extrapolated from the NICE guideline Otitis media (acute): antimicrobial prescribing [ ]. This advises that most people get better within 3 days without antibiotics and recommends using a back up antibiotic prescription if symptoms do not start to improve within 3 days with watchful waiting. It therefore seems reasonable to prescribe an antibiotic for a person (...) for whom an episode of AOM fails to improve or worsens who has not already had antibiotic treatment. This is supported by a US guideline which advises starting antibiotic treatment if a child with AOM worsens or does not improve within 48–72 hours of symptom onset [ ]. Choice of first-line antibiotics Recommendations on the choice and duration of antibiotic are based on the NICE guideline Otitis media (acute): antimicrobial prescribing [ ], the PHE publication Management of infection guidance

2016 NICE Clinical Knowledge Summaries

1751. Otitis media - acute: Scenario: Acute otitis media - initial presentation

serious illness or condition, or are at high risk of complications The recommendation to offer an immediate antibiotic prescription to people who are systemically unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications is based on the expert opinion of the NICE committee for the guideline Otitis media (acute): antimicrobial prescribing [ ]. This recommendation is in line with US guidelines and a Canadian position statement on the management of AOM (...) [ ; ]. Antibiotic prescribing strategies for other groups The recommendations on antibiotic prescribing strategies reflect the expert opinion of the NICE committee for the guideline Otitis media (acute): antimicrobial prescribing [ ], taking into account evidence from a Cochrane systematic review [ ]. The committee accepted that most children with acute otitis media require no antibiotic or a back up antibiotic prescription as recommended in the NICE guideline on Respiratory tract infections (self-limiting

2016 NICE Clinical Knowledge Summaries

1752. Otitis media - acute: How should I make a diagnosis of acute otitis media?

emphasises the importance of accurate diagnosis to determine which children have AOM that will get better more quickly with antibiotics to minimise the risk of antibiotic resistance and adverse effects [ ]. CKS has also included information from a systematic review of the literature regarding precision and accuracy of history taking and physical examination in diagnosing AOM in children [ ], and expert opinion in review articles on the diagnosis and treatment of AOM [ ; ; ; ; ]. There is no gold standard

2016 NICE Clinical Knowledge Summaries

1753. Otitis media - acute: Erythromycin

(or people concomitantly receiving potentially hepatotoxic drugs) — erythromycin is principally excreted by the liver. Conditions which predispose to QT interval prolongation such as electrolyte disturbances. Myasthenia gravis — macrolide antibiotics may aggravate the symptoms of people with myasthenia gravis. [ ; ; ] Adverse effects Nausea, vomiting, abdominal discomfort, and diarrhoea are the most common adverse effects of macrolides. Consider pseudomembranous colitis if a person develops diarrhoea (...) that prolong the QT interval should be avoided because of the risk of torsade de pointes arrhythmias. Seek advice from a microbiologist regarding a suitable alternative antibiotic. Drugs that cause hypokalaemia (such as diuretics, corticosteroids, short-acting beta 2 -agonists). Hypokalaemia is a risk factor for QT prolongation — seek advice from a microbiologist regarding a suitable alternative antibiotic. Statins — erythromycin is a potent inhibitor of liver enzyme cytochrome P450 CYP3A4, which

2016 NICE Clinical Knowledge Summaries

1754. Otitis media - acute: Co-amoxiclav

jaundice or hepatic dysfunction. Prescribe co-amoxiclav with caution in people with: Hepatic impairment – monitor closely. Chronic kidney disease (CKD) — reduce the dose if the estimated glomerular filtration rate (eGFR) is 30 mL/minute/1.73 m 2 or less. Acute lymphocytic leukaemia, chronic lymphocytic leukaemia, cytomegalovirus infection, glandular fever — increased risk of erythematous rashes. [ ; ] Adverse effects Gastrointestinal — nausea and vomiting (common), diarrhoea (very common), antibiotic (...) of amoxicillin, but not clavulanic acid. [ ; ; ; ] Pregnancy and breastfeeding Pregnancy Co-amoxiclav is not known to be harmful in pregnancy, but the manufacturer advises avoidance of use during pregnancy unless considered essential. Breastfeeding Trace amounts of co-amoxiclav are found in breastmilk and it may cause diarrhoea or fungal infection of mucous membranes in the infant. Penicillins (and cephalosporins) are the antibiotics of choice in women who are breastfeeding. [ ; ; ] © .

2016 NICE Clinical Knowledge Summaries

1755. Otitis media - acute: Clarithromycin

Torsades de pointes arrhythmias. With severe hepatic failure in combination with renal impairment. With hypokalaemia. Prescribe clarithromycin with caution in people with: Moderate to severe renal impairment. Impaired hepatic function — clarithromycin is principally excreted by the liver. Conditions which predispose to QT interval prolongation such as electrolyte disturbances (for example, hypomagnesemia). Myasthenia gravis — macrolide antibiotics may aggravate the symptoms. Coronary artery disease

2016 NICE Clinical Knowledge Summaries

1756. Otitis media - acute: Amoxicillin

or after treatment with antibiotics may be a sign of pseudomembranous colitis (PMC). For more information, see the CKS topic on . In addition to rash, other skin symptoms include urticaria and pruritus. Very rarely, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, bullous and exfoliative dermatitis and acute generalised exanthematous pustulosis have been reported. Anaphylaxis (immediate or delayed) is a serious but rare adverse effect of amoxicillin. For more information, see (...) — may cause increased and prolonged blood levels of amoxicillin. Manufacturer recommends avoiding concurrent use. Tetracyclines — the bactericidal effects of amoxicillin may be affected by concurrent tetracycline use. [ ; ; ; ] Pregnancy and breastfeeding Pregnancy Amoxicillin is not known to be harmful in pregnancy [ ]. Penicillins are the antibiotics of choice in pregnancy [ ]. The UK Teratology Information Service (UKTIS) states that the most of a large amount of data shows no increased risk

2016 NICE Clinical Knowledge Summaries

1757. Palliative care - nausea and vomiting: Scenario: Known cause

. Choose an anti-emetic according to the cause of nausea and vomiting such as: (for example opioids, diuretics, nonsteroidal anti-inflammatory drugs, or antibiotics). (for example hypercalcaemia, renal failure, or tumour toxins) (for example raised intracranial pressure or brainstem/meningeal disease) (for example vestibular disease or tumour at the base of the skull) Ascertain the most appropriate route of administration of the anti-emetic. Prescribe anti-emetics regularly and as required. Review (...) opioids): give haloperidol via the most appropriate route of administration. Usual oral dose: 1.5 mg at night or twice daily, titrate up to a maximum dose of 10 mg daily (some experts suggest a lower starting dose of 0.5 mg). As-required dose: oral, 1.5mg; subcutaneous injection, 1.25–2.5 mg. Syringe driver dose per 24 hours: 2.5–10 mg. To manage gastrointestinal irritation (for example due to nonsteroidal anti-inflammatory drugs, some antibiotics, or iron supplements): change the drug if possible

2016 NICE Clinical Knowledge Summaries

1758. Palliative care - nausea and vomiting: Scenario: Assessment

medication — recent changes and coinciding symptoms (especially with opiates, anticholinergics, digoxin, and antibiotics). Chemotherapy — regimen and timing of last treatment. Anti-emetics — current and past use, and effectiveness. Radiation — area treated and number of treatments received. Medical history (for example ulcers or bowel surgery). Effect on nutrition (for example fluid and food intake in the past 24 hours). Effect on quality of life. For more information, see . Basis for recommendation

2016 NICE Clinical Knowledge Summaries

1759. Eczema - atopic

. If there is persistent, severe itch, or urticaria, a one-month trial of a non-sedating antihistamine should be considered. If itching is severe and affecting sleep, a short course of a sedating antihistamine should be considered (if appropriate). If there is severe, extensive eczema, a short course of oral corticosteroids should be considered. If eczema is weeping, crusted, or there are pustules, with fever or malaise, secondary bacterial infection should be considered, and antibiotic treatment should be prescribed

2016 NICE Clinical Knowledge Summaries

1760. Dyspepsia - unidentified cause: Scenario: Dyspepsia - unidentified cause

, aspirin, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, nitrates, nonsteroidal anti-inflammatory drugs (NSAIDs), theophyllines, and tricyclic antidepressants. If dyspepsia symptoms are associated with NSAID use, encourage the person to stop the NSAID, if possible and appropriate. Ask about the number and duration of any previous courses of antibiotics, which may affect the choice of Helicobacter pylori eradication regimen used (if needed). Offer one (...) to the alternative strategy (for example, offer a full-dose PPI for 1 month if the person has been tested for H. pylori infection and vice versa). For the initial detection of H. pylori infection, arrange: A carbon-13 urea breath test or stool antigen test — ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks, or Laboratory serological testing if these options are not available, providing the test has been locally validated. Do not arrange for routine re-testing unless

2016 NICE Clinical Knowledge Summaries

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