Bacterial infections 3-day review tool

• Review all patients prescribed antibiotics at three days.
  • Review the patient in-person if they initially presented with, or have subsequently reported, signs and symptoms of severe infection, including:
    • symptoms that suggest the patient is systemically unwell (i.e. elevated temperature, chills, malaise)
    • swelling in the face, neck or jaw
    • swelling in the mouth
    • unresolved pain
  • A telephone review is suitable if the patient did not initially present with signs and symptoms of severe infection and has not contacted the practice to report worsening symptoms.

At the three-day review:

• Assess the patient for any red flag signs and symptoms of severe or rapidly progressing spreading infection.
  • The FATLIPS acronym*  is a useful prompt of aspects that should be considered during this assessment:
    • Failed previous treatment(s)
    • Airway compromise (difficulty breathing)
    • Trismus (difficulty opening mouth)
    • Look (lower border mandible, orbit, oral, neck swelling)
    • Immunosuppression
    • Pyrexia (fever)
    • Swallowing difficulties
• Urgently refer/transfer patients with difficulty breathing, swallowing or opening mouth to hospital.
  • For any patient with airway compromise, for example in cases of Ludwig’s angina or sepsis (link to sepsis section), call 999 for an ambulance and provide any necessary medical emergency care.
• Review the diagnosis and the effectiveness of previous local measures. Points to consider include:
  • Is the patient systemically unwell?
  • Are they able to eat and drink?
  •  Is the swelling resolved/ resolving significantly?
  •  Is pain controlled?
• If the patient has no red flag signs and symptoms, their pain is resolving, they are eating and drinking normally and there are no ongoing signs of infection, advise the patient to stop taking the antibiotic. Record this decision in the clinical notes.
  • Provide safety netting advice on what to do if symptoms recur or deteriorate.
  • Advise the patient to return any unused antibiotics to a pharmacy.
• If the patient still has ongoing signs of infection, advise them to complete the 5-day course of treatment. Record this decision in the clinical notes.
  • Provide safety netting advice on what to do if symptoms deteriorate.
  • Second-line antibiotics should only be considered if symptoms have not significantly resolved or are worsening after the initial 5 days of antibiotic treatment. In this case, either refer the patient or consider speaking to a specialist before prescribing second-line antibiotics.
• If the patient has red flag signs and/or symptoms of severe or rapidly progressing spreading infection, refer/escalate to another healthcare professional (e.g. general medical practitioner, NHS 24 or emergency department). 

*Cole-Healy Z, Adam D, Noh K, Graham RM. Introducing the FATLIPS acronym for assessing the red flag clinical features of dental infection. British Dental Journal. 2021 Feb;230(3):170-172.