Pharmacy first
structure of pharmacy first clinical pathways
explore management of specific conditions
acute otitis media for 1-17yo, impetigo for 1+, infected insect bites 1+, shingles 18+, sinusitis 12+, sore throat 5+, UTI 16-64 women
if pt is exempt then no rx charge otherwise normal rx charge → not private
AOM
ear pain, fever and irritation
use of otoscopic exam
use of analgesia like paracetamol
antibiotics if needed - amoxicillin (age 1-4 use 250mg TDS 5/7 OR 5-17 then 500mg TDS 5/7)
red flags:
neck stiffness mottled skin = meningitis
pain, soreness and swelling - mastoiditis
severe hedache, confusion, muscle weakness = brain abscess
otoscopic exam:
if they have earache, rubbing or tugging of ear
fever, headache, crying etc
if there is perforation or discharge then amoxicillin and refer to Dr, otherwise self care unless it has been more than 3 days with self care
treatment:
eardrops with phenazone and lidocaine - 4 drops BD/TDS for 7 days
amoxicillin like above (1-11months then 125mg TDS 5-7/7)
penicillin allergy then give clarithromycin
if pregnant and allergic then erythromycin
worsening symptoms: co-amoxiclav
Analgesia First: The cornerstone of management is adequate analgesia (e.g., paracetamol/ibuprofen) for 48-72 hours before considering antibiotics, as many cases are viral or self-limiting.
Antibiotic Choice: Amoxicillin is first-line. Clarithromycin is the preferred alternative in true penicillin allergy.
impetigo:
red sores, blisters and coloured crusts around mouth area
3 or less lesions = hydrogen peroxide 1% cream TDS 5/7
4+ lesions then oral flucloxacillin QDS for 5 days → 1yo then 125mg, 2-9 then 250 and 10+ is 500mg
penicillin allergies → clarithromycin 5 days or erythromycin if pregnant
if hydrogen peroxide not suitable then give fusidic acid cream for 5 days (usually for eye area or ineffective previously)
infected insect bite
redness, swelling, hot to touch, pus and increased pain
can give oral histamine or topical steroid
antibiotics: oral flucloxacillin 500mg QDS for 5 days
refer if bleeding, bite from animal or human, lyme disease suspicion or from travel.
more than 48hrs then antibiotics and refer, otherwise self care for now and come back.
Shingles
painful unilateral rash, blisters and tingling sensation
use patient history for assessment
paracetamol or ibuprofen if less than 72 hrs
aciclovir 800mg 5 times a day for 7 days if it has been more than 72hrs
immunocompromised then give valacidovir
usually resolves in 4 weeks otherwise refer
go to GP if more vesicles form after 7 days of treatment
hydration is needed
chicken pox from shingles is not communicable unless person has not had chickenpox or varicella vaccine
Antiviral Window: Aciclovir/Valaciclovir are most effective if started within 72 hours of rash onset. The 72-hour window is for starting treatment, not a contraindication after that time, though efficacy is reduced.
Referral: Urgently refer if the rash affects the ophthalmic division of the trigeminal nerve (forehead, nose, eye) due to risk of ocular complications.
sinusitis:
nasal congestion, facial pain, headache, pain in jaw or teeth
nasal corticosteroids - fluticasone 27.5mg spray (avamys)
paracetamol or ibuprofen prn
saline decongestants
antibiotics: phenoxymethylpenicillin 500mg QDS for 5/7
if more than 10 days with high fever, deterioation, purulent nasal discharge and pain then give high dose nasal corticosteroids otherwise antibiotics
penicillin allergy → clarithromycin or doxycycline or if pregnant then erythromycin
sore throat:
throat pain, difficulty swallowing, fever and purulence
hydration and lozenges or sprays
antibiotics like phenoxymethylpenicillin QDS for 5/7, 5yo then 125mg, 6-11yo then 250mg, 12+ then 500mg
fever pain score: fever over 38C, purulence, if within 3 days, severely inflamed tonsils, no cough or cold symptoms.
score of 0-1 → self care and return in 1 week if not resolved
score 2-3 → self care and come back within 3-5 days if not resolved
if patient returns then offer antibiotics
score of 4-5 → mild symptoms then self care otherwise antibiotics
penicillin allergy then clarithromycin, erythromycin if pregnant
UTI:
dysuira, frequency and urgency
hydration, paracetamol or ibuprofen
antibiotics: nitrofurantoin 100mg mr caps BD for 3 days
refer if they have kidney issues, flu, shaking, fever, nausea and vomiting
vaginal discharge, sti check, lighter periods, vaginal atrophy or immunosuppressed then refer to sexual health clinic
First-Line Antibiotic: Nitrofurantoin is first-line, but it is contraindicated in patients with an eGFR <45 mL/min due to lack of efficacy and increased risk of side effects. In this case, trimethoprim is an alternative.
"Red Flag" Symptoms: Refer immediately for suspected pyelonephritis (fever >38°C, flank pain, nausea/vomiting, rigors) or sepsis.
QUESTIONS
Part 1: Single Best Answer (SBA) Questions
1.
A 22-year-old woman presents with symptoms of an uncomplicated UTI (dysuria, frequency). She has no known drug allergies. Her medical history includes stage 3b chronic kidney disease (eGFR 40 mL/min). What is the most appropriate initial management under the Pharmacy First service?
a) Supply Nitrofurantoin 100mg MR BD for 3 days.
b) Supply Trimethoprim 200mg BD for 3 days.
c) Advise paracetamol and increased fluid intake, and refer her to her GP.
d) Supply Phenoxymethylpenicillin 500mg QDS for 5 days.
Answer:
c) Advise paracetamol and increased fluid intake, and refer her to her GP.
*Nitrofurantoin is contraindicated at this eGFR. Trimethoprim could be considered, but the presence of significant CKD places her outside the standard Pharmacy First pathway for UTI (which is for otherwise healthy women aged 16-64), warranting GP referral for further assessment and management.*
2.
A mother brings her 3-year-old child to the pharmacy. The child has had a fever and earache for 24 hours. They are otherwise well, with no red flag symptoms. On otoscopic exam, the tympanic membrane appears red and bulging. What is the most appropriate initial advice?
a) Immediately supply Amoxicillin 250mg TDS for 5 days.
b) Recommend paracetamol or ibuprofen for pain and fever, and advise the mother to return if symptoms persist beyond 72 hours.
c) Supply eardrops containing phenazone and lidocaine.
d) Refer directly to A&E due to the bulging tympanic membrane.
Answer:
b) Recommend paracetamol or ibuprofen for pain and fever, and advise the mother to return if symptoms persist beyond 72 hours.
*For AOM, the initial management is analgesia. A 72-hour wait-and-see approach is often appropriate before initiating antibiotics, as many cases resolve spontaneously. Antibiotics (a) would be considered if symptoms persist or worsen after this period.*
3.
A 45-year-old man presents with a painful, vesicular rash on the left side of his chest that appeared 48 hours ago. He is otherwise healthy. What is the recommended management under Pharmacy First?
a) Recommend paracetamol and calamine lotion, as it's too late for antivirals.
b) Supply Aciclovir 800mg five times daily for 7 days.
c) Refer him urgently to his GP for assessment.
d) Supply Valaciclovir and advise him to see his GP if it doesn't improve.
Answer:
b) Supply Aciclovir 800mg five times daily for 7 days.
*The rash is within the 72-hour window for effective antiviral treatment. As he is immunocompetent and the rash is not in a high-risk area (e.g., the face), he can be managed under the Pharmacy First pathway with aciclovir.*
4.
When using the FeverPAIN score for a sore throat, which of the following combinations of symptoms would score 4 points, making an immediate antibiotic prescription appropriate?
a) Fever in the last 24 hours, Purulent tonsils, Attend within 3 days of symptom onset.
b) Fever in the last 24 hours, Purulent tonsils, No cough, Severely inflamed tonsils.
c) Attend within 3 days of symptom onset, No cough, History of fever.
d) Purulent tonsils, History of fever, Severely inflamed tonsils.
Answer:
b) Fever in the last 24 hours, Purulent tonsils, No cough, Severely inflamed tonsils.
*This scores: Fever (1), Purulence (1), No Cough (1), Severe Inflammation (1). Total = 4. A score of 4 or 5 suggests a bacterial cause, and immediate antibiotics should be offered.*
Part 2: Extended Matching Questions (EMQ)
Questions 5-7:
For each clinical presentation, select the MOST appropriate first-line antibiotic treatment under the Pharmacy First service, assuming no drug allergies.
Options:
A. Amoxicillin 500mg TDS for 5 days
B. Flucloxacillin 500mg QDS for 5 days
C. Phenoxymethylpenicillin 500mg QDS for 5 days
D. Nitrofurantoin 100mg MR BD for 3 days
E. Clarithromycin 250mg BD for 5 days
5.
A 25-year-old woman with a sore throat and a FeverPAIN score of 4.
Answer:
C. Phenoxymethylpenicillin 500mg QDS for 5 days
This is the first-line antibiotic for sore throat (Strep A) under Pharmacy First.
6
A 30-year-old woman with dysuria and frequency, with no fever or flank pain.
Answer:
D. Nitrofurantoin 100mg MR BD for 3 days
*This is the first-line antibiotic for uncomplicated UTI in women aged 16-64.*
7.
An 8-year-old child with multiple honey-coloured crusted lesions on their face and arms.
Answer:
B. Flucloxacillin 500mg QDS for 5 days
*For widespread impetigo (>3 lesions), oral flucloxacillin is first-line. The dose for a 10+ year old is 500mg; for a 2-9 year old it would be 250mg.*
Part 3: Clinical Scenarios (OSCE/Patient Style)
Scenario 1:
The Sore Throat Consultation
Patient: "I've had a really sore throat for two days. It's agony to swallow. I need some antibiotics to knock it out."
How do you, as the pharmacist, conduct this consultation?
Gather Information: "I'm sorry to hear that. Let's go through a few quick questions to find the best way to help you. Do you have a fever? Have you looked at your throat in the mirror – are there white spots or pus? Are you coughing? And when did the symptoms start?"
Calculate FeverPAIN Score & Explain: "Based on your answers, your score is [e.g., 3]. This suggests it's more likely to be a viral infection, and antibiotics often won't help and can cause side effects like thrush or diarrhoea."
Manage Expectations & Offer Delayed Prescription: "The best approach right now is to use painkillers like paracetamol, throat lozenges, and plenty of fluids. However, I can give you an antibiotic prescription today with the advice that you only use it if your symptoms haven't started to improve in the next 2-3 days. How does that sound?"
Safety Netting: "If you get a lot worse, develop a rash, or have trouble breathing, you should seek immediate medical help."
Scenario 2:
Managing Infected Insect Bite vs. Referral
Patient: "I got bitten on the leg by something a few days ago, and now it's really red, hot, and painful. It's getting bigger."
What are your key assessment questions, and when would you refer?
Assess the Lesion & Patient: "Let's have a look. How long ago did you notice it becoming red and swollen? Is there any pus? Do you have a fever or feel unwell? Do you have any medical conditions like diabetes or a weakened immune system?"
Assess for Red Flags: "It's important I ask: was the bite from an animal or a person? Have you been abroad recently? Is the red streak spreading up your leg?"
Decision Point:
If no red flags and systemically well: "This looks like a localised infection. I can supply an antibiotic called flucloxacillin for 5 days. It's crucial to keep the area clean and monitor it. If the redness continues to spread, you develop a fever, or you don't see improvement in 2-3 days, you must see your GP."
If red flags are present (e.g., animal bite, systemic symptoms, spreading cellulitis): "Given [the animal bite/your fever], this needs to be assessed by a doctor today. I recommend you go to your GP surgery or a walk-in centre. They might need to consider different antibiotics or further treatment."
Part 4: Treatment & Referral Criteria
Question 8:
Shingles Referral
A 70-year-old patient presents with a painful, blistering rash on the tip of their nose and forehead. The rash appeared 36 hours ago. What is the most appropriate action and why?
Answer:
Action: Urgent referral to their GP or an eye hospital.
Reason: The rash is in the ophthalmic (V1) distribution of the trigeminal nerve. This carries a high risk of ocular involvement (herpes zoster ophthalmicus), which can lead to serious complications like keratitis, uveitis, and potential vision loss. This is a medical emergency that requires immediate specialist assessment, even though it is within the 72-hour antiviral window.
Question 9:
Sinusitis Management
A patient with sinusitis symptoms for 8 days asks for antibiotics. They have no high fever and their symptoms are not severe. What is the recommended first-line management?
Answer:
First-line management is NOT antibiotics.
The recommended approach is:
Supportive Care: Advise regular analgesia (e.g., paracetamol/ibuprofen) and saline nasal douching/irrigation.
Intranasal Corticosteroids: Consider a trial of a corticosteroid nasal spray (e.g., fluticasone/mometasone) as they can reduce inflammation.
Antibiotic Consideration: Explain that antibiotics are not usually helpful for sinusitis and are only considered if symptoms persist for more than 10 days without improvement, or if they suddenly get much worse after initial improvement.