There has been a resent increase in cases of Legionnaires Disease in the North West. So remember to request Urine Legionella Antigen test, if you have suspicions.
Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.
In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.
Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.
To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]
Combined Country/Animal & Exposure Risk
Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.
If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)
You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]
Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400
- Keep your suspicions high – early signs it may not be clear
- Sepsis Kills – give antibiotics & fluid early
- Consider Acyclovir
- Give Dexamethasone with Antibiotics – it can reduce neurological sequelae
- Consider indications for CT before LP
- Get SENIOR support early
Acute sore throats are often caused by a virus, last about a week and get better without antibiotics. withholding antibiotics rarely causes complications. Antibiotic stewardship is everyone’s responsibility to prevent resistance developing.
Are there any concerns regarding airway compromise? – If yes – transfer to resus, give high flow Oxygen, IV steroids, IV antibiotics, Nebulised adrenaline 1:1000, IV fluids, take bloods and refer to both anaesthetics and ENT registrar.
Assess all under 5s with a temperature as per the NICE fever guidelines
Assess the patient for signs of severe sepsis – if present use the severe sepsis guidelines
If no signs of sepsis assess patient, exclude Quinsey (unilateral swelling, paina nd trismus) and calculate the FeverPAIN score and Centor score
FeverPAIN = 1 point for each of –
- Purulent tonsillar exudate
- Attendance within 3 days of onset
- severely Inflamed tonsils
- No cough/coryza
Centor = 1 point for each of –
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenititis
- History of fever >38
- No cough
Can the aptient swallow fluids and medication – if not give a stat dose of IV Dexametasone, IV antibiotics, IV fluids and analgesia – review in 2 hours. If they can swallow at this time then you can consider discharge with a patient information leaflet.
FeverPAIN = 0 or 1/ Centor = 0,1 or 2 – no antibiotics, self care advice
FeverPAIN = 2 or3 – no antibiotics or a script for 3-5 days time if no better, self care advice
FeverPAIN = 4 or 5 / Centor 3 or 4 = give Antibiotics immediately, self care advice
Patients to seek medical advice if become more unwell or not improving after 1 week
Self care advice – Paracetamol, Ibuporfen, Adequate fluids, Medicated lozenges
Phenoxymethylpenicillin 5-10 days
If Penicillin allergy – Clarithromycin or Erythromycin 5 days
Ideally use the above links
Covid-19 antibiotic regime no different – unless confirmed or not responding then add: Flucloxacillin 2g IV QDS or Linezolid 60mg IV/PO BD
Can’t find it in our drug cupboard
try the Emergency Drug Cupboard
British Society of Thoracic Imaging (BSTI) have released a free learning resource containing CXR and CT of confirmed Covid-19 cases, will short history including time image was taken from onset of symptoms.
From the China experience CXR/CT doesn’t seem to be a rule out strategy in ED at the moment – However, its a useful resource to help recognition of Covid-19 CXR’s
2 video links to PHE how to Don and Doff your PPE
Often patients with cellulitis, need more than oral antibiotic management. However, they are not so sick to require hospital admission. OPAT allows suitable patients to be managed through the ambulatory services rater than being admitted. Read more
CAP is far less common than URTI’s, however, it needs to be considered within your differentials. Depending on severity there is a guide to investigation and treatment.
First Aid (ALL)
- Encourage bleeding
- Wash with copious amounts of water or saline
- Don’t Suck
- Don’t use Caustic agents