What are the standard first-line treatments for common general practice conditions, including Upper Respiratory Tract Infections (URTI), Acute Bronchitis, Asthma, Hypertension, Type 2 Diabetes Mellitus, Acute Gastroenteritis, Urinary Tract Infections (UTI), and others?

Standard First-Line Treatments for Common General Practice Conditions

The most effective approach to treating common general practice conditions involves using evidence-based first-line medications tailored to specific diagnoses, with antibiotics reserved only for clear bacterial infections.

Upper Respiratory Tract Infections (URTI)

Common Cold/Viral URTI

• First-line treatment: Supportive care only 1
  • Paracetamol 500-1000mg PO q4-6h PRN for fever/pain (max 4g/day)
  • Dextromethorphan 10-20mg PO q6-8h PRN for dry cough 1
  • Adequate hydration and rest
• Important: Expectorants, mucolytics, antihistamines, and bronchodilators should NOT be prescribed for acute LRTI in primary care 1

Acute Bronchitis

• First-line treatment: Primarily supportive care
• Antibiotics: Generally NOT indicated as most cases are viral 1
• When to consider antibiotics: Only if high-risk patient (age >75 with fever, cardiac failure, insulin-dependent diabetes, or serious neurological disorder) 1

Pneumonia

• Diagnosis: Suspect when acute cough plus one of: new focal chest signs, dyspnea, tachypnea, or fever >4 days 1
• First-line antibiotics: Amoxicillin or tetracycline 1
  • Alternative if hypersensitivity: Macrolides (azithromycin, clarithromycin, erythromycin)
  • Duration: 5-7 days 1

COPD Exacerbation

• Antibiotics indicated when: All three present: increased dyspnea, increased sputum volume, and increased sputum purulence 1
• First-line: Amoxicillin or tetracycline 1
• Alternative: Amoxicillin-clavulanate if high frequency of beta-lactamase producing H. influenzae in the area 1

Asthma

Mild/Moderate Exacerbation

• First-line:
  • Salbutamol inhaler 2 puffs q4-6h PRN
  • Inhaled corticosteroid (e.g., Budesonide 200mcg BID)
• For moderate exacerbation: Add oral prednisolone 30-40mg OD x 5 days

Hypertension (Newly Diagnosed/Uncomplicated)

• First-line: Lifestyle modifications (salt restriction, weight loss, exercise)
• Medication: Amlodipine 5mg PO OD (if needed)
• Monitoring: Regular BP checks

Type 2 Diabetes Mellitus (Newly Diagnosed)

• First-line: Lifestyle modifications (diet, exercise, weight loss)
• Medication: Metformin 500mg PO OD, titrate up to BID or TID as tolerated
• Note: Patients with diabetes have increased risk of infections, particularly lower respiratory tract, urinary tract, and skin infections 2

Acute Gastroenteritis

• First-line:
  • Oral rehydration solution (ORS)
  • Paracetamol for fever
• Antibiotics: Only if bacterial etiology suspected (bloody diarrhea, high fever)
  • Ciprofloxacin 500mg PO BID x 3-5 days

Urinary Tract Infection (Uncomplicated, Female)

• First-line antibiotics:
  • Nitrofurantoin 100mg PO BID x 5 days, OR
  • Fosfomycin 3g PO single dose

Skin Infections

Cellulitis

• First-line: Amoxicillin-Clavulanate 625mg PO TID x 7 days

Impetigo

• First-line: Topical Mupirocin ointment TID x 5 days

Allergic Rhinitis

• First-line:
  • Cetirizine 10mg PO OD
  • Fluticasone nasal spray 1-2 sprays/nostril OD

Headache

Tension Headache

• First-line: Paracetamol 500-1000mg PO q6h PRN

Migraine

• First-line:
  • Sumatriptan 50mg PO at onset (max 100mg/day)
  • Domperidone 10mg PO TID PRN for nausea

Musculoskeletal Pain

• First-line:
  • Paracetamol 500-1000mg PO q6h PRN
  • Ibuprofen 400mg PO TID PRN (if no contraindication)
  • Local heat, rest, physiotherapy

Depression/Anxiety (Mild to Moderate)

• Non-pharmacologic: Counseling, CBT
• Medication: Escitalopram 10mg PO OD

Dyspepsia/Gastritis

• First-line: Pantoprazole 40mg PO OD x 2-4 weeks
• Adjunct: Antacid syrup PRN

Key Considerations for Antibiotic Use

1. When to suspect pneumonia 1:

   • Acute cough PLUS one of: new focal chest signs, dyspnea, tachypnea, fever >4 days
   • Confirm with chest X-ray if available

2. When antibiotics are indicated for LRTI 1:

   • Suspected/confirmed pneumonia
   • COPD exacerbation with all three: increased dyspnea, increased sputum volume, increased sputum purulence
   • Age >75 years with fever
   • Cardiac failure
   • Insulin-dependent diabetes
   • Serious neurological disorder

3. Monitoring response to antibiotics 1:

   • Clinical effects should be expected within 3 days
   • Advise patients to return if no improvement after 3 days
   • For seriously ill patients, follow-up within 2 days

Special Populations

1. Immunocompromised patients: Higher risk of atypical and severe infections; consider early antibiotic therapy and close monitoring 3

2. Diabetic patients: Higher risk of respiratory, urinary tract, and skin infections; may require earlier intervention 2

3. Elderly patients (>65 years): Consider antibiotics more readily, especially with comorbidities 1

Pitfalls to Avoid

1. Overuse of antibiotics: Most URTIs are viral and self-limiting 4, 5

2. Inappropriate symptomatic treatments: Expectorants, mucolytics, antihistamines, and bronchodilators are NOT recommended for acute LRTI 1

3. Delayed treatment of bacterial pneumonia: Can lead to increased morbidity and mortality

4. Missing high-risk patients: Those >75 years, with comorbidities, or with signs of severe illness may need earlier intervention 1