Greater Manchester Antimicrobial Guidelines - October 2021 Version 10.0 Planned review date: January 2022 - GMMMG
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Greater Manchester Antimicrobial Guidelines October 2021 Version 10.0 Planned review date: January 2022
Greater Manchester Antimicrobial Guidelines October2021
DOCUMENT CONTROL
Document location
Copies of this document can be obtained from:
Name: Strategic Medicines Optimisation
Address: Greater Manchester Joint
Commissioning Team
Civic Centre
West Street
Oldham
OL1 1UT
Email: Oldccg.medsman@nhs.net
Revision history
The latest and master version of this document is held by Greater Manchester Health and Care Commissioning Medicines
Optimisation team:
REVISION
ACTIONED BY SUMMARY OF CHANGES VERSION
DATE
E Radcliffe
12/08/2021 V9.0 approved by GMMMG 9.0
18/08/2021 E Radcliffe Amended C diff section and other following commen ts received 9.1
Updated following responses from GM AMS task and finish group to
07/10/2021 E Radcliffe 9.2
clinical queries
25/10/2021 MGSG Approved v 10 10.0
Approvals
This document has been provided for information to:
NAME DATE OF ISSUE VERSION
GMMMG GMMMG website 9.0
GM AMS T&F group 11/10/2021 9.2
MGSG 25/10/2021 10.0
Changes to version 9.0 – see end of document.
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Aims
• to provide a simple, empirical approach to the treatment of common infections
• to promote the safe and effective use of antibiotics
• to minimise the emergence of bacterial resistance in the community
Principles of Treatment
1. This guidance is based on the best available evidence, but use professional judgement and involve patients in
decisions.
2. Please ensure you are using the most up to date version. The latest version will be held on the GMMMG website.
3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
4. When recommending analgesia or treatment with products available f rom pharmacies please follow the
guidance issued by NHS England (Conditions for which over the counter items should not routinely be
prescribed in primary care: Guidance for CCGs [Gateway approval number: 07851]). See the guidance for
exceptions to recommending self-care.
5. Consider a no, or delayed, antibiotic strategy for acute self -limiting infections e.g. upper respiratory tract
infections.
6. When prescribing an antibiotic it should be based on the severity of symptoms, risk of developing complications,
previous laboratory tests and any previous antibiotic use.
7. Limit prescribing over the telephone to exceptional cases. Except during COVID-19 pandemic where face-to-
face contact should be minimised by using telephone or video consultations
8. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight and
renal function. In severe or recurrent cases consider a larger dose or longer course.
9. Unless treatment choice is listed separately for children, then choices given are considered appropriate for
adults and children; bearing in mind any specific age limitations for use listed in the BNF for Children. A link to
the UK Paediatric Antimicrobial Guidelines can be found here
10. Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; con sider culture and
seek advice.
11. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (eg co-amoxiclav, quinolones and
cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridiodes
difficile, MRSA and resistant UTIs.
12. Where Off-label use is recommended: Prescribers should follow relevant professional guidance, taking full
responsibility for the decision, and obtaining and documenting informed consent. See the GMC's Good practice
in prescribing and managing medicines for more information.
13. Avoid widespread use of topical antibiotics (especially those agents also available as systemic pre parations,
e.g. fusidic acid).
14. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high dose metronidazole.
15. We recommend clarithromycin as the preferred macrolide as it has less side-effects than erythromycin, greater
compliance as twice rather than four times daily & generic ta blets are similar cost. The syrup formulation of
clarithromycin is only slightly more expensive than erythromycin and could al so be considered for children.
Erythromycin remains the drug of choice in pregnancy and should be used where clarithromycin is indicated.
16. Always advise to seek medical help if symptoms worsen at any time or do not improve within 48 hours of starting
an antibiotic or the person becomes systemically unwell.
17. Review antibiotic choice once culture and susceptibility results are available .
18. Wh e re an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained
f r om your local hos pital microbiology department.
19. This guidance should not be used in isolation; it should be supported with patient information about back-
up/delayed antibiotics, infection severity and usual duration, clinical staff education, and audits. Materials are
available on the RCGP TARGET website.
20. This guidance is developed alongside the NHS England Antibiotic Quality Premium (QP). In 2017/19 QP expects:
at least a 10% reduction in the number of E. coli blood stream infections across the whole health economy; at
least a 10% reduction in trimethoprim:nitrofurantoin prescribing rati o for UTI in primary care, and at least a 10%
reduction in trimethoprim items in patients > 70 years, based on CCG baseline data from 2015/16; and sustained
reduction in antimicrobial items per STAR-PU.
21. This guidance should be facilitated by the adoption of Antibiotic Stewards from front line to board level within
organisations, in line with NICE NG15: Antimicrobial stewardship, August 2015 . This sets out key activities and
responsibilities for individuals and organisations in responding to the concern of antimicrobial resistance.
22. Please note MHRA safety alert (issued 21 March 2019): Fluoroquinolone antibiotics: ciprofloxacin,
levofloxacin,moxifloxacin, ofloxacin: New restrictions and precautions due to very rare reports of disabling and
potentially long-lasting or irreversible side effects. Key details are below and referenced where the relevant
antimicrobials are advised in the guideline. Full letter can be viewed at DDL_fluoroquinolones_March-
2019_final.pdf.
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Contents
SECTION Page
UPPER RESPIRATORY TRACT INFECTIONS 6
Influenza treatment 6
Acute sore throat 6
Acute otitis media 6
Acute otitis externa 6
Acute sinusitis 7
LOWER RESPIRATORY TRACT INFECTIONS 7
Acute cough bronchitis 7
Acute exacerbation of Bronchiectasis (non-cystic fibrosis) 7
Acute exacerbation of COPD 8
Acute exacerbation of COPD – PROPHYLAXIS 8
Community acquired pneumonia treatment in the community (Adults) DURING
9
COVID-19 pandemic
Community acquired pneumonia treatment in the community (Children & young
10
people under 18 years.
MENINGITIS 11
Suspected meningococcal disease 11
URINARY TRACT INFECTIONS 11
Lower UTI in non-pregnant women 11
Catheter associated UTI 12
Lower UTI in pregnancy 12
Lower UTI in men 12
Recurrent UTI in non-pregnant women 3 or more UTIs per year 13
Acute prostatitis 13
Acute pyelonephritis in adults (Upper UTI) 13
Lower UTI in children 14
Acute Pyelonephritis in children (Upper UTI) 14
GASTRO INTESTINAL TRACT INFECTIONS 14
Oral candidiasis 14
Eradication of Helicobacter pylori 14
Infectious diarrhoea 14
Clostridioides difficile
15
Acute diverticulitis 15
Traveller’s diarrhoea 16
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SECTION Page
GENITAL TRACT INFECTIONS 17
STI screening 17
Chlamydia trachomatis/ urethritis 17
Epididymitis 17
Vaginal candidiasis 17
Bacterial vaginosis 17
Gonorrhoea 17
Trichomoniasis 17
Pelvic inflammatory disease 18
SKIN INFECTIONS 18
MRSA 18
Impetigo 18
Eczema 19
Leg ulcer 20
Diabetic Foot 20
Cellulitis and erysipelas 21
Mastitis - Lactational 21
Mastitis – Non-Lactational 22
Insect Bites and Stings 22
Bites - Human and Animal 23
Lyme disease – Tick bite 24
Dermatophyte infection - skin 24
Dermatophyte infection - nail 24
Varicella zoster/chicken pox 24
Herpes zoster/shingles 24
Scarlet Fever (GAS)
Cold sores 25
Acne Vulgaris 25
PARASITES 26
Scabies 26
Head lice 26
Threadworms 26
EYE INFECTIONS 26
Conjunctivitis 26
Changes to version 9.0 27
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Greater Manchester Antimicrobial Guidelines
UPPER RESPIRATORY TRACT INFECTIONS
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults antivirals not
Influenza recommended.
treatment Treat ‘at risk’ patients, when influenza is circulating in the community and ideally within 48 hours of onset (do
not wait for lab report) or in a care home where influenza is likely. At risk: pregnant (including up to two weeks
Back to Contents post-partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant
cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal
or liver disease, morbid obesity (BMI 40 or greater). See PHE seasonal influenza guidance for current
treatment advice and: GMMMG: GP guide - Influenza outbreak in an adult care homes, January 2019
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Avoid antibiotics as 90% resolve in 7 days without, and pain only reduced by 16 hours.
Acute sore Advise self-care in line with NHS England guidance.
throat Use FeverPAIN Score Phenoxymethylpenicillin 500mg Penicillin Allergy:
(this has replaced CENTOR): four times a day or Clarithromycin 500mg twice a
▪ Fever in last 24 hours 1g twice a day day
▪ Purulence
▪ Attend rapidly under 3d ays Duration: 10 days Duration: 5 days
▪ severely Inflamed tonsils
NICE Visual Summary ▪ No cough or coryza Phenoxymethylpenicillin is first
NG 84 choice due to a significantly
Score:
Back to Contents lower rate of resistance in Group
0 to 1: 13 to 18% streptococci. Do not
A streptococcus compared with
offer an antibiotic.
clarithromycin.
2 to 3: 34 to 40% streptococci.
Consider* no antibiotic or a back-up
antibiotic prescription.
Greater than 4: 62 to 65% streptococci.
Consider* an immediate antibiotic or
a back-up antibiotic prescription.
See NICE NG84 (Sore throat (acute):
antimicrobial prescribing).
No antibiotics – 80% resolve without antibiotics. Advise self-care in line with NHS England guidance.
Acute otitis
Recommend appropriate analgesia. Amoxicillin 500mg to 1g three Penicillin Allergy:
media times a day Clarithromycin 500mg twice a
60% are better in 24hrs without
antibiotics, which only reduce pain at day
2 days and do not prevent deafness. Duration: 5 days
Duration: 5 days
Consider 2 or 3-day delayed or
immediate antibiotics for pain relief if:
NICE Visual Summary ➢ Less than 2 years AND bilateral
NG 91 acute otitis media or
Back to Contents ➢ any age with otorrhoea
See NICE NG91 (Otitis media (acute):
antimicrobial prescribing).
Mild infection: No antibiotics. Advise self-care in line with NHS England guidance.
Acute otitis
First recommend analgesia. Moderate infection: Moderate infection:
externa
Cure rates similar at 7 days for topical Acetic acid 2% Neomycin sulphate with
Back to Contents acetic acid or antibiotic plus or minus a 1 spray three times a day corticosteroid
steroid. 3 drops three times a day
Duration: 7 days
Duration: 7 to 14 days
If cellulitis or disease extends outside Severe infection:
ear canal, or systemic signs of Flucloxacillin 250mg/ 500mg four times a day
infection.
If the inner ear is exposed, treat as per Duration: 7 days
Acute Otitis Media
If microbiology is consistent with Pseudomonas infection for age >1year:
pseudomonas infection Ciprofloxacin (as hydrochloride) 2 mg/ ml Ear drops
Instil contents of one ampoule into affected ear twice daily
Duration: 7 days
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
No antibiotics – 80% resolve in 14 days and only 2% are complicated by bacterial infection.
Acute Sinusitis Advise self-care in line with NHS England guidance.
Symptoms less than 10 days: No Amoxicillin Penicillin allergy:
antibiotics. Recommend self-care. 500mg to 1g three times a day Doxycycline (not for under 12
Paracetamol / ibuprofen for pain / fever. years) 200mg stat then 100mg
Nasal decongestant may help. Duration: 5 days
daily
Symptoms greater than 10days: Only
consider back-up antibiotics if no Duration: 5 days
NICE Visual summary improvement in symptoms.
NG 79 Mometasone 50microgram
Consider* high dose nasal steroid if
Back to Contents older than 12 years. nasal spray.
Two actuations (100mcg) in For children under 12 years:
At any time if the person is: each nostril twice a day for 14
days (off-label use) Clarithromycin
▪ systemically very unwell,
Duration 5 days
▪ or has symptoms and signs of a more Preferred choice if
serious illness or condition, systemically very unwell,
▪ or has high risk of complications symptoms and signs of a
Offer* immediate antibiotic or investigate more serious illness or
and manage in line with NICE guidance condition, or at high risk of
on respiratory tract infections (self- complications:
limiting) Co-amoxiclav 625mg three
See NICE NG79 (Sinusitis (acute): times a day
antimicrobial prescribing) Duration: 5 days
LOWER RESPIRATORY TRACT INFECTIONS
Low doses of penicillins are more likely to select out resistance, we recommend at least 500mg of amoxicillin. Do not use quinolone
(ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones for proven resistant organis ms.
Only offer* / consider* treatment if:
Acute cough Acute cough and higher risk of complications $ (at face-to-face examination): consider* immediate or
bronchitis back-up antibiotic.
Acute cough and systemically very unwell (at face to face examination): offer* immediate antibiotic.
Acute cough with upper respiratory Doxycycline 200mg stat then Amoxicillin 500mg three times
tract infection: no antibiotic. 100mg daily a day.
Acute bronchitis: no routine antibiotic. Duration: 5 days Duration: 5 days
NICE Visual summary Advise self-care in line with NHS England
NG 120 guidance. Preferred choice for children For children less than 12
Back to Contents less than 12 years: years with Penicillin allergy:
Do not offer a mucolytic, an oral or
inhaled bronchodilator, or an oral or Amoxicillin Clarithromycin
inhaled corticosteroid unless otherwise
indicated. Duration 5 days Duration 5 days
$Higher risk
of complications includes people with pre-existing comorbidity; young children born prematurely;
people over 65 with 2 or more of, or over 80 with 1 or more of: hospitalisation in previous year, type 1 or 2
diabetes, history of congestive heart failure, current use of oral corticosteroids.
An acute exacerbation of bronchiectasis Amoxicillin 500mg three times a Doxycycline 200mg stat, then
Acute is sustained worsening of symptoms from day 100mg daily
exacerbation of a person’s stable state. OR
Duration #: 7 to 14 days #
Bronchiectasis Send a sputum sample for culture and
Clarithromycin 500mg twice a
(non-cystic susceptibility testing. When results
day
available, review choice of antibiotic.
fibrosis) Duration #: 7 to 14 days #
Offer* an antibiotic
When choosing antibiotics, take account
of:
▪ the severity of symptoms
▪ previous exacerbations,hospitalisations
NICE Visual summary
and risk of complications
NG 117
▪ previous sputum culture and
Back to Contents susceptibility results
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#Course length based on an assessment of the person’s severity
of bronchiectasis, exacerbation history, severity of exacerbation
symptoms, previous culture and susceptibility results, and
response to treatment.
Where a person is receiving antibiotic prophylaxis, treatment
should be with an antibiotic from a different class.
Prophylaxis should only be offered on specialist advice.
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Many exacerbations (including some severe exacerbations) are not caused by bacterial infections so
Acute will not respond to antibiotics.
exacerbation of
Sending sputum samples for culture is Doxycycline 200mg stat, then In severe infection:
COPD not recommended in routine practice. 100mg daily
Doxycycline 200mg stat, then
Consider* an antibiotic:
or 100mg twice a day
▪ Based on the severity of symptoms,
particularly sputum colour changes Amoxicillin 500mg three times a or
and increases in volume or thickness day
from the patient’s normal. Amoxicillin 1g three times a
NICE Visual summary ▪ Previous exacerbations and hospital Duration: 5 days. day
NG 114 admission history, and the risk of Duration 5 days
Back to Contents developing complications
▪ Previous sputum culture and
susceptibility results where available.
▪ The risk of AMR with repeated
courses of antibiotics.
Patients identified as suitable for having ‘rescue packs’ should normally only be provided with steroids, as
these have been shown to improve lung function alone, with advice to seek medical attention if symptoms
suddenly worsen or do not improve within 48 hours of starting treatment. Any decision to include antibiotics
should be based on clinical need, do not use the higher dose in ‘rescue packs’. Patients will need to notify
prescribers when they use their ‘rescue pack’ medication, and to ask for replacements.
Refer to a respiratory specialist for a Duration: Review treatment after the first 3 months and then at
Acute decision to prescribe oral prophylactic least every 6 months. Only continue treatment if continued
exacerbation of antibiotic therapy in patients with COPD. benefits outweigh the risks.
COPD – Consider* treatment only for people if Before starting prophylactic antibiotics, ensure that the person has
PROPHYLAXIS they: had:
▪ do not smoke and
Back to Contents ▪ sputum culture and sensitivity (including tuberculosis culture),
▪ have optimised non -pharmacological
to identify other possible causes of persistent or recurrent
management and in haled therapies,
infection that may need specific treatment
relevant vaccinations and (if
▪ training in airway clearance techniques to optimise sputum
appropriate) have been referred for
clearance
pulmonary rehabilitation and
▪ a CT scan of the thorax to rule out bronchiectasis and other
▪ continue to have 1 or more of the
lung pathologies.
following, particularly if they have
Also carry out the following:
significant daily sputum production:
▪ an electrocardiogram (ECG) to rule out prolonged QT interval
• frequent (typically 4 or more per
and
year) exacerbations with sputum
production ▪ baseline liver function tests.
For people who are still at risk of exacerbations, provide an
• prolonged exacerbations with
antibiotic from a different class. to keep at home as part of their
sputum production ‘rescue pack’
• exacerbations resulting in Be aware that it is not necessary to stop prophylactic treatment
hospitalisation. during an acute exacerbation of COPD.
NICE guidance - Chronic obstructive Monitoring for long-term therapy: See BNF
pulmonary disease in over 16s: diagnosis
and management (NG115)
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
If a patient shows typical COVID 19 As COVID-19 pneumonia is Alternative :
COVID-19 symptoms, follow UK government caused by a virus, antibiotics are
Community guidance on investigation and initial ineffective. Amoxicillin 500mg three times
acquired clinical management of possible cases. Do not offer an antibiotic for a day
This includes information on testing and Duration: 5 days
pneumonia isolating patients.
treatment or prevention of
pneumonia if:
treatment in the For patients with known or suspected
community • COVID-19 is likely to be the If atypical pathogens
COVID-19 follow UK guidance on
cause and suspected AND moderately
(Adults) infection prevention and control
Minimise face-to-face contact. Use the • symptoms are mild. severe symptoms based on
clinical judgement (or CRB =1
BMJ remote assessment tools.
[DURING
or 2):
Offer an oral antibiotic for Amoxicillin
COVID-19 • The clinical diagnosis of community- treatment of pneumonia in people 500 mg 3 times a day (higher
pandemic] acquired pneumonia of any cause in who can or wish to be treated in doses can be used – see BNF)
an adult can be informed by clinical the community if: Duration: 5 days
signs or symptoms such as: PLUS
Back to Contents temperature >38°C • the likely cause is bacterial or Clarithromycin
500 mg twice a day
• respiratory rate >20 breaths per • it is unclear whether the cause Duration: 5 days
minute is bacterial or viral and
• heart rate >100 beats per minute symptoms are more concerning
or
• new confusion If high severity based on
Assessing shortness of breath • they are at high risk of clinincal judgement (or CRB65
(dyspnoea) is important but may be complications because, for
= 3 or 4) & patient able to take
difficult via remote consultation. Use example, they are older or frail,
oral medicines and safe to
online tools such as dyspnoea scale, or or have a pre-existing
remain at home
CEBM review. comorbidity such as
Co-amoxiclav 500/125mg
immunosuppression or
three times a day
significant heart or lung disease Duration: 5 days
Where pulse oximetry is available use (for example bronchiectasis or AND
oxygen saturation levels below 92% COPD), or have a history of Clarithromycin 500mg twice a
(below 88% in people with COPD) on severe illness following previous
day
room air at rest to identify seriously ill lung infection.
Duration 5 days
patients.
OR
Erythromycin (in pregnancy)
Use of the NEWS2 tool in the Doxycycline 200mg stat then 500 mg 4 times a day orally
community for predicting the risk of 100mg daily Duration: 5 days
clinical deterioration may be useful. Duration: 5 days
However a face to face consultation If penicillin allergy AND high
should not be arranged solely to severity
calculate a NEWS2 score. Levofloxacin (consider safety
Doxycycline is preferred because
it has broader spectrum of cover issues)
than amoxicillin, particularly 500 mg twice a day orally
against Mycoplasma Duration: 5 days
pneumoniae and Staphylococcus
aureus, which are more likely to
If preferred choice not suitable
be secondary bacterial causes of
consult microbiology or
pneumonia during the COVID-19
consider* urgent referral to
pandemic.
hospital.
If unable to take oral
Doxycycline should not be used medication refer urgently to
in pregnancy hospital.
In Pregnancy
Erythromycin
500 mg 4 times a day
Duration: 5 days
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Offer an antibiotic(s) within 4 hours of Children aged 1 month and Children aged 1 month and
Community establishing a diagnosis. over - if non-severe symptoms over - if non-severe symptoms
acquired Severity is assessed by clinical or signs (based on clinical or signs (based on clinical
pneumonia judgement. judgement) judgement)
treatment in the Amoxicillin Clarithromycin
community Give advice about: Duration: 5 days Duration: 5 days
(Children and ▪ possible adverse effects of antibiotics If severe symptoms or signs
young people ▪ seeking medical help if symptoms (based on clinical judgement);
Alternative choice for
under 18 years) worsen rapidly or significantly, or do guided by microbiological results
when available: children aged 12 years to 17
not improve within 3 days, or the
years.
person becomes systemically very Co-amoxiclav
unwell. PLUS (if atypical pathogen Doxycycline 200mg on first
suspected) day, then 100mg once a day.
Stop antibiotic treatment after 5 days Clarithromycin Duration: 5 days
unless microbiological results suggest a
Duration: 5 days
longer course length is needed or the
person is not clinically stable.
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
MENINGITIS
Transfer all patients to hospital Benzylpenicillin by intravenous or intramuscular injection
Suspected immediately. Age 10 plus years: 1200mg
meningococcal If time before hospital admission and if Children 1 to 9 years: 600mg
disease suspected meningococcal septicaemia or Children less than1 years: 300mg
non-blanching rash, give intravenous or Stat doses
Back to Contents intramuscular benzylpenicillin as soon as Give by intramuscular injection if vein cannot be found.
possible.
Do not give antibiotics if there is a definite
history of anaph ylaxis; rash is not a
contraindication.
Prevention of secondary case of meningitis.
Only prescribe following advice from Public Health England North West: 03442250562 option 3 (9 to 5 Mon to Fri)
Out of hours contact 0151 434 4819 and ask for PHE on call.
URINARY TRACT INFECTIONS
As antimicrobial resistance and E. coli bacteraemia is increasing use nitrofurantoin first line. Always give safety net and s elf-care advice
and consider risks for resistance. Give the appropriate TARGET Treat Your Infection UTI leaflet.
Do not perform urine dipsticks – For men and women over 65 years
Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have
bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it c auses a positive
urine dipstick, antibiotics are not beneficial and may cause harm.
For guidance on diagnosing UTIs and the need for dipsticks , in all ages, see PHE’s quick reference tool for primary care.
Treat women with severe/or 3 or more Nitrofurantoin MR (if eGFR 45 If preferred choice
Lower UTI in symptoms. ml/minute or greater) 100mg unsuitable:
Non-pregnant Women mild/or 2 or less symptoms twice a day Fosfomycin
Women advise self-care in line with NHS Duration: 3 days
3 g single dose sachet
England guidance and consider* back
up / delayed prescription. If low risk+ of resistance and CHECK AVAILABILITY AS
People over 65 years: do not treat preferably if susceptibility NOT ALL PHARMACIES
asymptomatic bacteriuria; it is demonstrated & no risk HOLD STOCK.
common but is not associated with factors£ (below):
NICE Visual summary increased morbidity. Treat if fever AND Trimethoprim 200mg twice a day
NG 109 dysuria OR 2 or more other symptoms.
Duration: 3 days
Back to Contents In treatment failure: always perform
culture.
+A
Symptoms: lower risk of resistance may be more likely if not used in the
Increased need to urinate. past 3 months, previous urine culture suggests susceptibility (but
Pain or discomfort when urinating. this was not used) or it is the first presentatio n of a UTI, and in
Sudden urges to urinate. younger women.
Feeling unable to empty bladder fully. £
Risk factors for increased resistance include: care home
Pain low down in your tummy. resident, recurrent UTI, hospitalisation for greater than 7 days in
Urine is cloudy, foul-smelling or contains the last 6 months, unresolving urinary symptoms, recent travel to a
blood. country with increased resistance, previous known UTI resistant to
Feeling unwell, achy and tired. trimethoprim, cephalosporins or quinolones.
If risk of resistance send urine for culture for susceptibility testing
& give safety net advice.
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
DO NOT DIPSTICK Lower UTI symptoms
Catheter Do not treat asymptomatic bacteriuria in Nitrofurantoin MR (if eGFR 45 Pivmecillinam
associated UTI people with a catheter. ml/minute or greater) 100mg 400mg initial dose, then
Advise paracetamol for pain. twice a day 200mg three times a day
Advise drinking enough fluids to avoid Duration: 7 days Duration: 7 days
dehydration.
Advise seeking medical help if symptoms OR
worsen at any time or do not start to Trimethoprim (if low risk of
NICE Visual summary improve within 48 hours, or the person resistance) 200mg twice a day
NG 113 becomes systemically very unwell
Duration: 7 days
Back to Contents Consider* removing or, if not possible,
changing the catheter if it has been in Upper UTI symptoms
place for more than 7 days. But do not
delay antibiotic treatment if considered Cefalexin 500mg twice or three Ciprofloxacin 500mg twice a
appropriate. times a day (up to 1g to 1.5g day
three times a day or four times a
Send a urine sample for culture and Duration: 7 days
day for severe infections)
susceptibility testing.
(See MHRA Safety Alert - note
When results of urine culture are Duration: 7 to 10 days
21 page 3)
available:
▪ review choice of antibiotic Pregnant women aged 12 years and over
▪ change antibiotic according to Cefalexin 500mg twice or three If vomiting, unable to take oral
susceptibility results if bacteria are times a day (up to 1g to 1.5g antibiotics or severely unwell
resistant, using narrow spectrum three times a day or four times a refer to hospital.
antibiotics when possible day for severe infections)
Duration: 7 to 10 days
Low risk of resistance is likely if not used in the past 3 months and previous urine culture suggests
susceptibility (but this was not used) or it is the first presentation of a UTI . Higher risk of resistance is likely with
recent use.
Send MSU for culture and start Up to 34 weeks Amoxicillin (only if culture
Lower UTI in antibiotics. Nitrofurantoin MR (if eGFR 45 results available and
pregnancy Short-term use of nitrofurantoin in
ml/minute or greater) 100mg susceptible)
twice a day 500mg to 1g three times a day
pregnancy is unlikely to cause problems
to the foetus but avoid at term (from 34 OR
Duration: 7 days
weeks onwards). Cefalexin 500mg twice a day
After 34 weeks use alternative Duration: All for 7 days
Treatment of asymptomatic bacteriuria in
NICE Visual summary pregnant women: choose from
NG 109 nitrofurantoin (avoid at term), amoxicillin
Back to Contents or cefalexin based on recent culture and
susceptibility results.
Consider prostatitis and send pre- Trimethoprim 200mg twice a day Consider alternative diagnoses
Lower UTI in treatment MSU basing antibiotic choice on
Duration: 7 days
Men Consider STIs. recent culture and
Or susceptibility results
Nitrofurantoin MR (if eGFR 45
ml/minute or greater and no
prostate involvement) 100mg
twice a day
NICE Visual summary Duration: 7 days
NG 109
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
First advise about behavioural and Choice should be based on culture and susceptibility results.
Recurrent UTI personal hygiene measures, and self-
in non pregnant care (with D-mannose or cranberry
Single dose when exposed to a Single dose when exposed to
products) to reduce the risk of UTI.
women having 3 trigger a trigger
or more UTIs For postmenopausal women, if no Trimethoprim 200mg (off-label) Amoxicillin 500 mg (off-label)
improvement, consider vaginal oestrogen
per year (review within 12 months).
Or Or
Nitrofurantoin MR (if eGFR 45 Cefalexin 500 mg (off-label)
If no improvement, consider single-dose ml/minute or greater) 100mg
antibiotic prophylaxis for exposure to a (off-label)
trigger (review within 6 months).
If no improvement or no identifiable Continuous prophylaxis
NICE Visual summary
trigger consider a trial of daily antibiotic Continuous prophylaxis
NG 112 Trimethoprim 100mg at night
prophylaxis (review within 6 months).
Or Amoxicillin 250mg at night (off-
Back to Contents Advice to be given: label)
Nitrofurantoin (if eGFR 45
▪ how to use (in particular for single ml/minute or greater) 50mg to Or
dose prophylaxis) 100mg at night Cefalexin 125mg at night (off-
label)
▪ possible adverse effects of antibiotics,
Duration for all: 3 to 6 months
particularly diarrhoea and nausea Duration for all: 3 to 6 months
then review
▪ returning for review within 3 to 6 then review
months Monitoring for long-term therapy: See BNF
▪ seeking medical help if symptoms of
an acute UTI develop
Send MSU for culture and start Ciprofloxacin (See MHRA Safety If unable to take quinolone:
Acute antibiotics. Alert – note 21 page 3) Trimethoprim 200mg twice a
prostatitis Review antibiotic treatment after 14 days 500mg twice a day day
and either stop antibiotics or continue for Duration: up to 28 days Duration: up to 28 days
a further 14 days if needed (based on
assessment of history, symptoms, clinical
examination, urine and blood tests).
NICE Visual summary
NG 110
Back to Contents
Send MSU for culture & susceptibility. Cefalexin 500mg twice a day or Co-amoxiclav (only if culture
Acute Offer an antibiotic. three times a day (up to 1g to results available and
pyelonephritis in When prescribing antibiotics, take
1.5g three times a day or four susceptible) 500/125mg three
adults times a day for severe times a day
account of severity of symptoms, risk of infections)
(Upper UTI) complications, previous urine culture and Duration: 7 to 10 days
susceptibility results, previous antibiotic Duration: 7 to 10 days
Or
use which may have led to resistant If known ESBL positive in urine,
Trimethoprim (only if culture
bacteria. please discuss with
results available and
If no response within 24 hours, admit for microbiologist.
susceptible)
IV antibiotics. 200mg twice a day
Pregnant women:
NICE Visual summary Consider referral. Duration: 14 days
NG 111 If cefalexin contraindicated or
Or
Back to Contents not tolerated consult
microbiologist. Ciprofloxacin (See MHRA
Safety Alert – note 21 page 3)
500mg twice a day
Duration: 7 days
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Child under 3 mths: refer urgently for assessment.
Lower UTI in
3 months and over 3 months and over
children Child ≥ 3 mths: use positive nitrite to
guide. Start antibiotics, also send pre- Nitrofurantoin (if eGFR 45 Amoxicillin (only if culture
treatment MSU. ml/minute or greater) results available and
If recurrent UTI, refer to paediatrics. If [If children can swallow them, susceptible)
antibiotics required in recurrent UTI, 100mg M/R capsules (older than OR
12yrs) should be used in preference
seek specialist advice. Cefalexin
to the liquid formulation. 50mg
NICE Visual summary tablets can be considered for lower Duration: 3 days
NG 109 doses. Do not crush tablets or
open capsules]
Back to Contents
OR
Trimethoprim (if low risk of
resistanceΩ)
Duration: 3 days
Ω
A lower risk of resistance may be more likely if not used in the past 3 months and previous urine culture
suggests susceptibility (but this was not used) or it is the first presentation of a UTI . A higher risk of resistance
may be more likely with recent use.
Refer children under 3 months to paediatric specialist
Acute
Send a urine sample for culture and Cefalexin Co-amoxiclav (only if culture
pyelonephritis susceptibility testing in line with the NICE results available and
in children guideline, Urinary tract infection in under
Duration: 7 to 10 days
susceptible)
under 16 years 16s: diagnosis and management (CG54).
Duration: 7 to 10 days
(Upper UTI) Offer* an antibiotic.
When prescribing antibiotics, take
account of severity of symptoms, risk of
complications, previous urine culture and
susceptibility results, previous antibiotic
NICE Visual summary use which may have led to resistant
NG 109 bacteria. Assess and manage fever in under 5s in line with NICE guidance -
If no response within 24 hours, admit for Fever in under 5s: assessment and initial management (CG160)
Back to Contents
intravenous antibiotics.
GASTRO INTESTINAL TRACT INFECTIONS
Oral candidiasis is a minor condition that can be treated without the need for a GP consultation or
Oral candidiasis prescription in the first instance.
Advise self-care in line with NHS England guidance.
Back to Contents
Topical azoles are more effective than Fluconazole capsules If miconazole not tolerated:
topical nystatin. 50mg to 100mg daily Nystatin suspension
100,000 units four times a day
Oral candidiasis rare in Duration: 7 days & further 7
after meals
immunocompetent adults. days if persistent
Or Duration: 7 days or until 2
days after symptoms
Miconazole oral gel
2.5ml four times a day after
meals
Duration: 7 days or until 2 days
after symptoms.
Refer to BNF or GMMMG
Eradication of Do not offer eradication for GORD. (PPI for 4 weeks).
Helicobacter Do not use clarithromycin, metronidazole or quinolone if used in past year for any infection.
pylori Retest for H.pylori post DU/GU or relapse after second line therapy: using breath or stool test OR consider
Back to Contents endoscopy for culture and susceptibility.
Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection.
Infectious Antibiotic therapy usually not indicated unless systemically unwell.
diarrhoea If systemically unwell and campylobacter suspected consider Clarithromycin 250 to 500mg twice a day for 7
Back to Contents days, if treated within 3 days of onset.
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Consult microbiology for all cases. First episode; mild moderate First episode; mild moderate
Clostridioides Stop unnecessary antibiotics and/or PPIs or severe: or severe:
difficile and gastro drugs e.g. laxatives Vancomycin Fidaxomicin
Back to Contents Review Medicines that may cause 125mg four times a day 200 mg orally twice a day
problems during dehydration. E.g.
Duration: 10 days Duration: 10 days
NSAIDs, ACEi, AIIRA, diuretics
CHECK AVAILABILITY AS
Treating suspected or confirmed C. NOT ALL PHARMACIES HOLD
STOCK. If first and second line
difficile infection in adults ineffective for the first episode
Offer an oral antibiotic In the community, REFER for specialist advice in
consider seeking prompt specialist advice secondary care
NICE Visual summary Further episode (relapsed
before starting treatment If oral medicines
NG 199 within 12 weeks of symptom
cannot be taken, seek specialist advice
resolution):
about other enteral routes for antibiotics
(nasogastric tube or rectal catheter)
Fidaxomicin
200 mg orally twice a day
ADVICE:
• drinking enough to avoid dehydration Duration: 10 days
• preventing the spread of infection
• seek medical help if symptoms worsen Further episode (recurrence Further episode (recurrence
rapidly or significantly at any time more than 12 weeks after more than 12 weeks after
symptom resolution): symptom resolution):
Use clinical judgement to determine Fidaxomicin
whether antibiotic treatment Vancomycin 200 mg orally twice a day
for C. difficile is ineffective. It is not 125mg four times a day
usually possible to determine this until Duration: 10 days
day 7 because diarrhoea may take 1 to Duration: 10 days
2 weeks to resolve.
Consider referring people in the
community to hospital if they could be at
high risk of complications or recurrence
because of individual factors such as
age, frailty or comorbidities.
With severe symptoms (below) review
progress closely and/or consider hospital
referral.
Definition of severe: Temperature
greater than 38.5oC, or WCC greater
than 15, or rising creatinine or
signs/symptoms of severe colitis.
Consider watchful waiting if person: For patients who do not Trimethoprim 200mg BD
Acute require urgent hospital
▪ Systemically well PLUS metronidazole 400mg
Diverticulitis ▪ admission and infection is
No co-morbidities TDS
Back to Contents ▪ No suspected infection. suspected:
Advise analgesia (avoid NSAIDs and Co-amoxiclav 625mg three Only if switching from IV
opioids), clear liquids with gradual times a day
reintroduction of solid food if symptoms
ciprofloxacin with
improve. Consider checking for raised Duration: 5 days specialist advice;
white cell count and CRP, which may consider safety issues
suggest infection. Ciprofloxacin (See MHRA
Safety Alert – note 21 page 3)
ng147-visual- Patients should be reviewed after 72
500mg twice a day
summary hours and if there is n o improvement,
and/or fever and leukocytosis persist, PLUS
urgent hospital admission is advised. Metronidazole 400mg three
times a day
Duration: 5 days
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Arrange immediate urgent hospital admission for those with:
Rectal bleeding
Unmanageable abdominal pain
Dehydrated or at risk of dehydration
Unable to take or tolerate oral antibiotics (if needed) at home
Frail / significant co -morbidities and or / is immunocompro mised.
Prophylaxis rarely, if ever indicated. If standby treatment appropriate If prophylaxis / treatment
Traveller’s Only consider standby antibiotics for give azithromycin 500mg each consider bismuth subsalicylate
diarrhoea high risk areas for people at high -risk of day for 3 days on a private (Pepto Bismol) (Private
severe illness. prescription. purchase)
Back to Contents 2 tablets four times a day for 2
days.
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
GENITAL TRACT INFECTIONS
People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and
STI screening partners to GUM service.
Risk factors: less than 25 years, no condom use, recent (less than 12momths)/frequent change of partner,
Back to Contents
symptomatic partner, area of high HIV.
Opportunistically screen all sexually Doxycycline 100mg twice a day Pregnant, breastfeeding,
Chlamydia active patients aged 15 to 24 years for Duration: 7 days allergy, or intolerance:
trachomatis/ chlamydia annually and on change of Azithromycin 1g stat, then
urethritis sexual partner. 500mg daily for the following 2
If positive, treat index case, refer to GUM days.
Back to Contents and initiate partner notification, testing
and treatment. Advise patient with chlamydia to abstain from sexual intercourse
until doxycycline is completed or for 7 days after treatment with
As single dose azithromycin has led to azithromycin (14 days after azithromycin started and until
increased resistance in GU infections, symptoms resolved if urethritis).
doxycycline should be used first line for
chlamydia and urethritis. If chlamydia, test for reinfection at 3 to 6 months following
treatment if under 25 years; or consider if over 25 years and high
Consider referring all patients with risk of re-infection.
symptomatic urethritis to GUM as testing
As lower cure rate in pregnancy, test for cure at least 3 weeks
should include Mycoplasma genitalium
and Gonorrhoea. after end of treatment.
If M.genitalium is proven, use
doxycycline followed by azithromycin
using the same dosing regimen and
advise to avoid sex for 14 days after start
of treatment and until symptoms have
resolved.
For suspected epididymitis in men over Ofloxacin 200mg twice a day Doxycycline 100mg twice a
Epididymitis 35 years with low risk of STI. (See MHRA Safety Alert – note day
(High risk, refer to GUM) 21 page 3)
Back to Contents Duration: 14 days
Duration : 14 days
All topical and oral azoles give 75% Clotrimazole 500mg pessary Fluconazole 150mg orally
Vaginal cure. or 10% cream stat stat
candidiasis Pregnant:
In pregnancy: avoid oral azoles and Pregnant:
Back to Contents Clotrimazole 100mg pessary
use intravaginal treatment for 7 days. Miconazole 2% cream, 5g
at night intravaginally twice a day
Duration: 6 nights Duration: 7 days
Oral metronidazole is as effective as Metronidazole 400mg twice a Metronidazole 0.75% vaginal
Bacterial topical treatment and is cheaper. day gel 5g applicator at night
vaginosis Less relapse with 7 day than 2g stat. Duration: 7 days Duration: 5 nights
Back to Contents Pregnant/breastfeeding: avoid 2g stat. Or or
Treating partners does not reduce Metronidazole 2g stat (use 5 x Clindamycin 2% cream 5g
relapse. 400mg tablets) applicator at night.
Duration: 7 nights
Refer to GUM for treatment.
Gonorrhoea
Antibiotic resistance is now very high. Ceftriaxone 1g stat, by Ciprofloxacin 500mg stat
Back to Contents intramuscular injection [ONLY IF KNOWN TO BE
SENSITIVE]
(See MHRA Safety Alert –
note 21 page 3)
Treat partners and refer to GUM service. Metronidazole 400mg twice a Clotrimazole
In pregnancy or breastfeeding: avoid 2g day 100mg pessary at night
Trichomoniasis single dose metronidazole.
Duration: 7 days Duration: 6 nights
Consider clotrimazole for symptom relief
Back to Contents (not cure) if metronidazole declined. OR
Metronidazole 2g stat (use 5 x
400mg tablets)
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Children under 12 years must be referred to a paediatrician.
Pelvic
Refer woman and contacts to GUM Ceftriaxone 1g stat by These treatment choices
inflammatory service for treatment. intramuscular injection [This is should only be used for true
disease Raised CRP supports diagnosis, absent an essential part of treatment cephalosporin allergy and a
pus cells in HVS smear good negative – refer patients to local low risk of gonococcal PID.
Back to Contents
predictive value. services if injection not Metronidazole 400mg twice a
available via GP practice] day
Exclude: ectopic pregnancy,
appendicitis, endometriosis, UTI, irritable PLUS PLUS
bowel, complicated ovarian cyst, Metronidazole 400mg twice a Ofloxacin 400mg twice a day
functional pain. day
Or
Moxifloxacin has greater activity against PLUS
likely pathogens, but always test for Moxifloxacin 400mg daily
Doxycycline 100mg twice a day alone.
gonorrhoea, chlamydia, and
Duration : 14 days (If M. genitalium tests positive
M. genitalium.
use moxifloxacin as an
Ofloxacin and moxifloxacin should be alternative.)
avoided in patients who are at high
risk of gonococcal PID. (See MHRA Safety Alert –
note 21 page 3)
Duration : 14 days
SKIN INFECTIONS
For active MRSA infection, refer to microbiology and only treat according to antibiotic susceptibilities confirmed
MRSA by lab results.
If identified as part of pre-op screening, treatment should be provided at that time by secondary care.
Back to Contents
Advise people with impetigo, and their Localised non-bullous impetigo (not systemically unwell or at
Impetigo parents or carers if appropriate, about high risk of complications)
good hygiene measures to reduce the
spread of impetigo to other areas of the Consider*: If hydrogen peroxide unsuitable
body and to other people. (e.g., if impetigo is around
Hydrogen peroxide 1% cream eyes) or ineffective:
Do not prescribe mupirocin (reserved Apply two or three times a day
NICE Visual summary for MRSA), unless advised by Fusidic acid 2% cream
NG 153 microbiology. Duration: 5 days § Apply thinly three times a day
Back to Contents
Do not offer combination treatment with a Duration: 5 days §
topical and oral antibiotic to treat
impetigo. Widespread non‑ bullous impetigo who are not systemically
unwell or at high risk of complications.
Advise people with impetigo, and their
parents or carers if appropriate, to seek Fusidic acid 2% cream Penicillin allergy or
medical help if symptoms worsen rapid ly flucloxacillin unsuitable:
Apply thinly three times a day
or significantly at any time, or have not
Clarithromycin 250mg ¥ twice a
improved after completing a course of Duration: 5 days §
day
treatment.
Or: Duration: 5 days §
See NICE NG153 (Impetigo:
Flucloxacillin 500mg four times
antimicrobial prescribing) for further
a day
guidance.
Duration: 5 days §
§
A 5-day course is appropriate for most
Bullous impetigo or impetigo in people who are systemically
people with impetigo but can be
unwell or at high risk of complications
increased to 7 days based on clinical
judgement, depending o n the severity Flucloxacillin 500mg four times Penicillin allergy or
and number of lesions. a day flucloxacillin unsuitable:
¥
Dosage can be increased to 500 mg Duration: 5 days § Clarithromycin 250mg ¥ twice a
twice a day, if needed for severe day
infections.
Duration: 5 days §
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If no visible signs of infection, do not use antibiotics (alone or with steroids) as this encourages resistance and
Eczema does not improve healing.
Do not routinely take a skin swab for microbiological testing in people with secondary bacterial infe ction of
eczema at the initial presentation.
In people who are not systemically unwell, do not routinely offer either a topical or oral antibiotic for secondary
bacterial infection of eczema.
Prescribing considerations Take account of: • the evidence, whi ch suggests a limited benefit with antibiotics •
NICE Visual summary the risk of antimicrobial resistance with repeated courses of antibiotics • the extent and severity of symptoms or
NG 190 signs • the risk of complications
Symptoms and signs of bacterial IF choosing between a topical or Alternative ORAL:
Back to Contents secondary infection can include oral antibiotic (topical might be For Penicillin allergy or
weeping, pustules, crusts, no more appropriate if the infection is flucloxacillin unsuitable or
treatment response, rapidly localised and not severe), also
worsening eczema, fever and take account of:
malaise Not all eczema flares are Clarithromycin: 250 mg twice a day
• patient preferences
caused by a bacterial infection, Duration: 5 to 7 days
• possible adverse effects
even if there are crusts and
• previous topical antibiotic use The dosage can be increased to
weeping Eczema is often
500 mg twice a day for severe
colonised with bacteria but may • local antimicrobial resistance infections
not be clinically infected data
Pregnancy:
First Choice TOPICAL:
Erythromycin: 250 mg to 500 mg
Fusidic acid 2%: Apply three times four times a day
a day
Duration: 5 to 7 days
Duration: 5 to 7 days
For localised infections only.
Extended or recurrent use may
increase the risk of developing
antimicrobial resistance.
First Choice ORAL:
Flucloxacillin: 500 mg four times a
day
Duration: 5 to 7 days
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Background: If active infection
Leg ulcer ▪ There are many causes of leg ulcer;
Flucloxacillin 500mg to 1g four If penicillin allergic:
any underlying conditions, such as times a day # Clarithromycin 500mg twice a
venous insufficiency and oedema,
Duration: 7 days day
should be managed to promote
or
healing
Doxycycline 200mg stat then
NICE Visual summary ▪ Few leg ulcers are clinically infected
NG 152 100mg twice a day
▪ Most leg ulcers are colonised by
bacteria Duration: All 7 days
Back to Contents
▪ Antibiotics don't promote healing Do not take a sample for microbiological testing at initial
when a leg ulcer is not clinically presentation, even if the ulcer might be infected.
infected
Refer to hospital if there are symptoms or signs of a more serious
Symptoms and signs of an
illness or condition such as sepsis, necrotising fasciitis or
infected leg ulcer include: osteomyelitis
▪ redness or swelling spreading beyond
the ulcer Consider* referring or seeking specialist advice if the person:
▪ localised warmth ▪ has a higher risk of complications because of comorbidities
▪ increased pain such as diabetes or immunosuppression
▪ fever ▪ has lymphangitis
When choosing an antibiotic, ▪ has spreading infection not responding to oral antibiotics
take account of: ▪ cannot take oral antibiotics (to explore possible options for
▪ the severity of symptoms or signs intravenous or intramuscular antibiotics at home or in the
▪ the risk of complications community)
▪ previous antibiotic use A longer course (up to a further 7 days) may be needed based on
clinical assessment. However, skin does take some time to return
Reassess if symptoms worsen rapidly or
to normal, and full resolution of symptoms at 7 days is not
significantly at any time, do not start to
expected.
improve within 2 to 3 days, or the person
becomes systemically unwell or has
severe pain out of proportion to the
infection.
#The upper dose of 1 g four times a day would be off-label. Prescribers should follow relevant professional
guidance, taking full responsibility for the decision, and obtaining and documenting informed consent. See the
GMC's Good practice in prescribing and managing medicines for more information.
In diabetes, all foot wounds are likely to Flucloxacillin 500mg to 1g four If penicillin allergic:
Diabetic Foot be colonised with bacteria. times a day # Clarithromycin 500mg twice a
Diabetic foot infection has at least 2 of: Duration: 7 days day
▪ local swelling or induration or
▪ erythema Doxycycline 200mg on first
▪ local tenderness or pain day then 100mg twice a day
NICE Visual summary ▪ local warmth Duration: All 7 days
NG 19 ▪ purulent discharge
Back to Contents
Severity is classified as: Refer to hospital immediately and inform multidisciplinary foot care
▪ Mild - local infection with 0.5 to less service if there are limb- or life-threatening problems such as:
than 2 cm erythema ▪ ulceration with fever or any signs of sepsis, or
Refer the following to hospital: ▪ ulceration with limb ischaemia, or
▪ suspected deep-seated soft tissue or bone infection, or
▪ Moderate - local infection withmore
▪ gangrene
than 2 cm erythema or involving
For all other active diabetic foot problems, refer to foot service
deeper structures (such as abscess,
within 1 working day
osteomyelitis, septic arthritis or
A longer course (up to a further 7 days) may be needed based on
fasciitis)
clinical assessment. However, skin does take s ome time to return
▪ Severe - local infection with signs of a
to normal, and full resolution of symptoms at 7 days is not
systemic inflammatory response. expected.
#The upper dose of 1 g four times a day would be off-label. Prescribers should follow relevant professional
guidance, taking full responsibility for the decision, and obtaining and documenting informed consent. See the
GMC's Good practice in prescribing and managing medicines for more information.
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ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Exclude other causes of skin redness Flucloxacillin 500mg to 1g four If penicillin allergic:
Cellulitis and (inflammatory reactions or non-infectious times a day # Clarithromycin 500mg twice a
erysipelas causes). Give oral unless person unable day
Consider marking extent of infection with to take oral or severely unwell. Give oral unless person
a single-use surgical marker pen. unable to take oral or severely
Offer an antibiotic. Take account of If infection near eyes or nose unwell.
severity, site of infection, risk of (consider seeking specialist Clarithromycin 500mg twice a
uncommon pathogens, any advice): day IV
NICE Visual summary microbiological results and MRSA status.
NG141 Co-amoxiclav 625mg three or
Infection around eyes or nose is more times a day Doxycycline 200mg stat then
Back to Contents concerning because of serious
100mg twice a day
intracranial complications.
Consider referring to hospital or seeking Duration: All 7 days .
specialist advice if the person: Pregnancy:
▪ is severely unwell or has lymphangitis Erythromycin 500mg four
▪ has infection near the eyes or nose times a day
▪ may have uncommon pathogens e.g.
after a penetrating injury, exposure to If infection near eyes or
water-borne organisms, or an infection nose (Consider seeking
acquired outside the UK specialist advice):
▪ has spreading infection not responding Clarithromycin 500mg twice a
to oral antibiotics day AND
▪ cannot take oral antibiotics (to explore Metronidazole 400mg three
giving IV antibiotics at home or in the times a day (only add in
community if approp riate) children if anaerobes
Refer people to hospital if they have any suspected).
symptoms or signs suggesting a more Duration: All 7 days .
serious illness or condition, such as A longer course (up to 14 days in total) may be needed but skin
orbital cellulitis, osteomyelitis, septic
arthritis, necrotising fasciitis or sepsis. takes time to return to normal, and full resolution at 5 to 7 days is
# The upper dose of 1 g four times a day not expected.
would be off-label. Prescribers should If not responding after 14 days of antibiotic therapy then a holistic
follow relevant professional guidance, review of the wound and prescribing to date should be undertaken.
taking full responsibility for the decision, Consider:
and obtaining and documenting informed ▪ other possible diagnoses, such as an inflammatory reaction to
consent. See the GMC's Good practice in an immunisation or an insect bite, gout, superficial
prescribing and managing medicines for
thrombophlebitis, eczema, allergic dermatitis or deep vein
more information.
thrombosis
▪ any underlying condition that may predispose to cellulitis or
erysipelas, such as oedema, diabetes, venous insufficiency or
eczema
▪ any symptoms or signs suggesting a more serious i llness or
condition, such as lymphangitis, orbital cellulitis, osteomyelitis,
septic arthritis, necrotising fasciitis or sepsis
▪ any results from microbiological testing
▪ any previous antibiotic use, which may have led to resistant
bacteria.
Most cases of lactational mastitis are Flucloxacillin 500mg to 1g four If penicillin allergic:
Mastitis – not caused by an infection and do not times a day Clarithromycin♦ 500mg twice a
Lactational require antibiotics.
Duration: 7 to 14 days day
Advice is to take paracetamol or
Back to Contents Duration: 7 to 14 days
ibuprofen to reduce pain and fever, drink
plenty of fluids, rest and apply a warm
compress. ♦Epidemiologic
evidence indicates that the risk of hypertrophic
Breastfeeding: oral antibiotics are safe pyloric stenosis in infants might be increased by use of maternal
and appropriate, where indicated. macrolides, especially in infants exposed in the first 2 weeks after
Women should continue feeding, birth. The risk may be greater with erythromycin, which is why
including from the affected breast and be clarithromycin is recommended here.
advised to monitor the child for adverse
drug reactions e.g. diarrhoea and thrush .
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