Summary of antimicrobial prescribing guidance - managing common infections
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Summary of antimicrobial prescribing guidance – managing common infections
Aims of this guideline
To provide a simple, empirical approach to the treatment of common infections based on our local community and sensitivity patterns.
To promote the safe, cost-effective and appropriate use of antimicrobials by targeting those who may benefit most
To minimise the emergence of antimicrobial resistance in the community
Principles of Treatment
1. This guidance is based on the best available evidence at the time of development. Its application must be modified by professional judgement, based on knowledge
about individual patient co-morbidities, potential for drug interactions and involve patients in management decisions.
2. It is important to initiate antibiotic as soon as possible in severe infection or in those immunocompromised, particularly if sepsis is suspected. Refer to the NICE
guideline [NG51] Sepsis: recognition, diagnosis and early management for further information.
3. This guidance should not be used in isolation; it should be supported with patient information about safety netting, back-up/delayed antibiotics, self –care, infection
severity and usual duration, clinical staff education, and audits. The RCGP TARGET antibiotics toolkit is available via the RCGP website.
4. The majority of this guidance provides dose and duration of treatment for ADULTS. Doses may need modification for age, weight and renal function. Refer to
appropriate paediatric sources for information on paediatric doses.
5. Refer to BNF for further dosing and interaction information (e.g. interaction between macrolides and statins), ALWAYS check for hypersensitivity/allergy.
6. Have a lower threshold for antibiotics in immunocompromised or in those with multiple co- morbidities; send samples for culture and seek advice.
7. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit, giving alternative, non-antibiotic self –care advice where appropriate.
8. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections (e.g. acute sore throat, acute cough and acute sinusitis) and mild
UTI symptoms
9. ‘Blind’ antibiotic prescribing for unexplained pyrexia usually leads to further difficulty in establishing the diagnosis.
10. Limit prescribing over the telephone to exceptional cases.
11. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of
Clostridiodes difficile, MRSA and resistant Urinary Tract Infections (UTIs).
12. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, in most cases, topical use should be limited).
13. If diarrhoea or vomiting occurs due to an antibiotic or the illness being treated, the efficacy of hormonal contraception may be impaired and additional precautions should
be recommended.
14. Clarithromycin is now recommended over erythromycin, except in pregnancy and breastfeeding. It has fewer side-effects and twice daily rather than four times daily
dosing promotes compliance. Statins should be withheld when macrolide antibiotics are prescribed.
15. In pregnancy, take specimens to inform treatment. Penicillins, cephalosporins and erythromycin are not associated with increased risk of spontaneous abortion. If
possible, avoid tetracyclines, quinolones, aminoglycosides, azithromycin (except in chlamydial infection), clarithromycin and high dose metronidazole (2g stat) unless
the benefits outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also
unlikely to cause problems unless poor dietary folate intake, or taking another folate antagonist.
• Southend Hospital Microbiologist's contact details: Secretary Tel. 01702 385188 Ext. 5188; 5211 for Jo Elfick & 5243 for Javeed Ahmed.
Secretary's Email: hayley.steedman@southend.nhs.uk or hayley.steedman@nhs.netBroomfield Hospital Broomfield Hospital 01245 515019
• Basildon Hospital Microbiology contact details: 01268 524900 Ext. 3024
• For all PHE guidance, follow PHE’s principles of treatment. **Adjustments based on local population needs are in red italics**
• See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.
1 of 30
Key: Click to access doses for children Click to access NICE’s printable visual summary
Jump to section on:
Upper RTI Lower RTI UTI Meningitis GI Genital Skin Eye Dental
Doses Visual
Infection Key points Medicine Length
Adult Child summary
Upper respiratory tract infections
Acute sore First choice: 500mg QDS
throat 5 to 10 days
Advise paracetamol, or if preferred and suitable, phenoxymethylpenicillin or 1000mg
ibuprofen for pain. Penicillin allergy: 250mg to
5 days
Medicated lozenges may help pain in adults. clarithromycin OR 500mg BD
Use FeverPAIN or Centor to assess symptoms: erythromycin (preferred if 250mg to 5 days
FeverPAIN 0-1 or Centor 0-2: no antibiotic; pregnant) 500mg QDS
FeverPAIN 2-3: no or back-up antibiotic; or
FeverPAIN 4-5 or Centor 3-4: immediate or back- 500mg to
Public Health
up antibiotic. 1000mg BD
England
Systemically very unwell or high risk of
complications: immediate antibiotic.
*5 days of phenoxymethylpenicillin may be enough
Last updated: for symptomatic cure; but a 10-day course may
Jan 2018
increase the chance of microbiological cure.
For detailed information click the visual summary icon.
1D 1D,2A+
Annual vaccination is essential for all those ‘at risk’ of influenza. Antivirals are not recommended for healthy adults.
Influenza 1D
Treat ‘at risk’ patients with 5 days oseltamivir 75mg BD, when influenza is circulating in the community, and ideally within 48 hours of onset (36 hours for
1D,3D 1D,2A+
zanamivir treatment in children), or in a care home where influenza is likely.
Public Health At risk: pregnant (and up to 2 weeks post-partum); children under 6 months; adults 65 years or older; chronic respiratory disease (including COPD and
England asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; chronic neurological, renal or liver disease; diabetes mellitus;
4D 4D
morbid obesity (BMI>40). See the PHE Influenza guidance for the treatment of patients under 13 years. In severe immunosuppression, or oseltamivir
Last updated: Feb 2019 5A+,6A+ 4D
resistance, use zanamivir 10mg BD (2 inhalations twice daily by diskhaler for up to 10 days) and seek advice.
Access supporting evidence and rationales on the PHE website.
2 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Scarlet fever Prompt treatment with appropriate antibiotics
2D
(GAS) significantly reduces the risk of complications.
1D
Phenoxymethylpenicillin
2D 500mg QDS 10 days3A+,4A+,5A+
Public Health Vulnerable individuals (immunocompromised, the Not available.
England comorbid, or those with skin disease) are at Access supporting
Last updated: Oct 2018 increased risk of developing complications.1D 250mg to 500mg evidence and
Penicillin allergy: 5 days2D,5A+
2D BD rationales on the
clarithromycin 2D
PHE website
erythromycin (preferred if
pregnant)
2D
Optimise analgesia and give safety netting advice
Acute otitis Regular paracetamol or ibuprofen for pain (right dose First choice: amoxicillin -
media for age or weight at the right time and maximum 5 to 7 days
doses for severe pain). Penicillin allergy:
-
Otorrhoea or under 2 years with infection in both clarithromycin OR 5 to 7 days
ears: no, back-up or immediate antibiotic. erythromycin (preferred if
-
Otherwise: no or back-up antibiotic. pregnant) 5 to 7 days
Public Health
England Systemically very unwell or high risk of Second choice or if 5A
complications: immediate antibiotic. systemically very unwell 7 days
For detailed information click on the visual summary. or high risk of -
Last updated: Feb
2018
complications:
co- amoxiclav
1D,2D
Second line:
First line: analgesia for pain relief, and apply topical acetic acid 2%
2D,4B-
1 spray TDS
5A-
localised heat (such as a warm flannel).
2D 7 days (min) to 14
OR days (max)
3A+ Not available.
Second line: topical acetic acid or topical antibiotic Access
2D,3A+,4B- topical neomycin sulphate
Acute otitis +/- steroid: similar cure at 7 days. 2D,5A- supporting
with corticosteroid evidence and
externa If cellulitis or disease extends outside ear 5A-
(consider safety issues if 3 drops TDS rationales on the
canal, or systemic signs of infection, start oral
perforated tympanic PHE website
Public Health flucloxacillin and refer to exclude malignant otitis 6B-
1D membrane)
England externa.
If cellulitis: 250mg QDS2D 7 days
2D
flucloxacillin7B+
Last updated:
Nov 2017
3 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Sinusitis First choice:
500mg QDS 5 days
Phenoxymethylpenicillin
Advise paracetamol or ibuprofen for pain. Little
evidence that nasal saline or nasal decongestants Penicillin allergy:
200mg on day
help, but people may want to try them. doxycycline (not in under
1, then 100mg
Symptoms for 10 days or less: no antibiotic. 12s) OR
OD
Symptoms with no improvement for more than 5 days
10 days: no antibiotic or back-up antibiotic clarithromycin OR 500mg BD
Public Health depending on likelihood of bacterial cause. erythromycin (preferred if 250 to 500mg
England Consider high-dose nasal corticosteroid (if over pregnant) QDS or
12 years). 500 to 1000mg BD
Systemically very unwell or high risk of
complications: immediate antibiotic. Second choice or first
For detailed information click on the visual summary. choice if systemically very
Last updated:
Oct 2017
unwell or high risk of 500/125mg TDS 5 days
complications:
co-amoxiclav
Lower respiratory tract infections
Acute Many exacerbations are not caused by bacterial 200mg on day 1,
exacerbation of infections so will not respond to antibiotics. First choice: then 100mg OD
-
COPD Consider an antibiotic, but only after taking into doxycycline OR (see BNF for
account severity of symptoms (particularly sputum severe infection)
colour changes and increases in volume or 5 days
500mg TDS
thickness), need for hospitalisation, previous amoxicillin OR (see BNF for -
exacerbations, hospitalisations and risk of severe
complications, previous sputum culture and infection)
susceptibility results, and risk of resistance with
repeated courses. clarithromycin 500mg BD -
Some people at risk of exacerbations may have Second choice: use alternative first choice
antibiotics to keep at home as part of their Alternative choice (if
Public Health exacerbation action plan.
England person at higher risk of
Note on co-amoxiclav from Southend 500/125mg TDS -
treatment failure): 5 days
microbiologist: Haemophilus is significant in co-amoxiclav OR
COPD, and about 16% of Southend haemophilus
is resistant to co-amoxiclav, as such we use co-trimoxazole OR 960mg BD -
doxycycline as first line and clarithromycin as
second line
For detailed information click on the visual
summary. See also the NICE guideline on
COPD in over 16s.
4 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
levofloxacin (with specialist
advice if co-amoxiclav or
Last updated:
co-trimoxazole cannot be 500mg OD -
Dec 2018 used; consider safety
IV antibiotics (click on visual summary)
Rescue Pack (for initial management of exacerbation)
Prescribe prednisolone 5mg tablets - Take SIX tablets in the morning for 7-14 days and Amoxicillin 500mg capsules Take ONE capsule THREE times a day for 5 days OR
Doxycycline 200mg first day then 100mg daily total 5 days course
NB: this dosing schedule differs from the dosing schedule for acute bronchitis
If a patient is using two or more packs in a year they need a specialist review.
Acute First choice empirical
exacerbation of Send a sputum sample for culture and treatment:
bronchiectasis susceptibility testing. 500mg TDS
(non-cystic amoxicillin (preferred if
Offer an antibiotic. pregnant) OR
fibrosis) 7 to 14 days
When choosing an antibiotic, take account of doxycycline (not in under 200mg on day 1,
severity of symptoms and risk of treatment failure. 12s) OR then 100mg OD
People who may be at higher risk of treatment
failure include people who’ve had repeated clarithromycin 500mg BD
courses of antibiotics, a previous sputum culture
with resistant or atypical bacteria, or a higher risk Offer erythromycin if 250-500mg QDS or
of developing complications. pregnant and penicillin 500mg-1g BD
allergy
Course length is based on severity of
Alternative choice (if
broncheictasis, exacerbation history, severity of
person at higher risk of
exacerbation symptoms, previous culture and
treatment failure) 500/125mg TDS
Public Health susceptibility results, and response to treatment.
empirical treatment:
England co-amoxiclav OR
Do not routinely offer antibiotic prophylaxis to
prevent exacerbations.
levofloxacin (adults only:
Seek specialist advice for preventing with specialist advice if
exacerbations in people with repeated acute co-amoxiclav cannot be 500mg OD or BD
7 to 14 days
exacerbations. This may include a trial of antibiotic used; consider safety
prophylaxis after a discussion of the possible issues) OR
Last
benefits and harms, and the need for regular ciprofloxacin (children only:
updated:
review. with specialist advice if
Dec 2018
co-amoxiclav cannot be -
For detailed information click on the visual summary. used; consider safety
issues)
IV antibiotics (click on visual summary)
When current susceptibility data available: choose antibiotics accordingly
5 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute cough Consider no or 7 day back up/delayed antibiotic with Adults first choice: 200mg on day 1,
self-care and safety netting and advise that symptoms -
can last 3 weeks. doxycycline then 100mg OD
Some people may wish to try honey (in over 1s), Adults alternative first
the herbal medicine pelargonium (in over 12s), choices:
500mg TDS -
cough medicines containing the expectorant amoxicillin (preferred if
guaifenesin (in over 12s) or cough medicines pregnant) OR
containing cough suppressants, except codeine, 5 days
250mg to 500mg
(in over 12s). These self-care treatments have clarithromycin OR -
BD
limited evidence for the relief of cough symptoms.
Acute cough with upper respiratory tract 250mg to 500mg
infection: no antibiotic. erythromycin (preferred if QDS or
pregnant) -
Acute bronchitis: no routine antibiotic. 500mg to 1000mg
BD
Acute cough and higher risk of complications
(at face-to-face examination): immediate or back- Children first choice: -
Public Health up antibiotic.
England amoxicillin
Acute cough and systemically very unwell (at Children alternative first -
face to face examination): immediate antibiotic. choices:
Higher risk of complications includes people with clarithromycin OR
pre-existing comorbidity; young children born
prematurely; people over 65 with 2 or more of, or erythromycin OR -
over 80 with 1 or more of: hospitalisation in
doxycycline (not in under - 5 days
previous year, type 1 or 2 diabetes, history of
congestive heart failure, current use of oral 12s)
Last updated:
Feb 2019 corticosteroids.
Do not offer a mucolytic, an oral or inhaled
bronchodilator, or an oral or inhaled corticosteroid
unless otherwise indicated.
For detailed information click on the visual summary.
See also the NICE guideline on pneumonia for
prescribing antibiotics in adults with acute bronchitis who
have had a C-reactive protein (CRP) test (CRP100mg/l: immediate antibiotic).
6 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Assess severity in adults based on clinical Doxycycline is preferred because it has a broader spectrum of cover than amoxicillin,
judgement guided by mortality risk score (CRB65 particularly against Mycoplasma pneumoniae and Staphylococcus aureus, which are more
or CURB65). See the NICE guideline on likely to be secondary bacterial causes of pneumonia during the COVID-19 pandemic.
pneumonia for full details: First choice (low severity
500mg TDS (higher
low severity – CRB65 0 or CURB65 0 or 1 in adults or non-severe in
doses can be used,
moderate severity – CRB65 1 or 2 or CURB65 2 children):
see BNF)
amoxicillin
high severity – CRB65 3 or 4 or CURB65 3 to 5.
Alternative first choice
1 point for each parameter: confusion, (urea >7 5 days*
(low severity in adults or 200mg on day 1,
mmol/l), respiratory rate ≥30/min, low systolic
non-severe in children): then 100mg OD
(Hospital- Mild to moderate HAP can be treated in the First choice (non-severe 500/125 mg TDS
acquired community if it starts following discharge, and not higher risk of
5 days then review
pneumonia after 5 days or more of in-patient stay. resistance):
If symptoms or signs of pneumonia start within co-amoxiclav
48 hours of hospital admission, see community Adults alternative first 200mg on day 1,
acquired pneumonia. choice (non-severe and then 100mg OD
not higher risk of
Offer an antibiotic. Start treatment as soon as resistance)
possible after diagnosis, within 4 hours (within 1
Public Health Choice based on specialist -
hour if sepsis suspected and person meets any
England microbiological advice and
high risk criteria – see the NICE guideline on
sepsis). local resistance data
When choosing an antibiotic, take account of Options include:
Last updated: Sept
2019 severity of symptoms or signs, number of days in doxycycline
hospital before onset of symptoms, risk of cefalexin (caution in 500 mg BD or TDS 5 days then review
developing complications, local hospital and ward- penicillin allergy) (can increase to 1
-
based antimicrobial resistance data, recent to 1.5g TDS or
antibiotic use and microbiological results, recent QDS)
contact with a health or social care setting before co-trimoxazole 960mg BD -
current admission, and risk of adverse effects with levofloxacin (only if 500mg OD or BD
broad spectrum antibiotics. switching from IV
No validated severity assessment tools are levofloxacin with specialist -
available. Assess severity of symptoms or signs advice; consider safety
based on clinical judgement. issues)
Higher risk of resistance includes relevant Children alternative first -
comorbidity (such as severe lung disease or choice (non-severe and
immunosuppression), recent use of broad not higher risk of
spectrum antibiotics, colonisation with multi-drug resistance):
resistant bacteria, and recent contact with health clarithromycin -
and social care settings before current admission. Other options may be
If symptoms or signs of pneumonia start within suitable based on specialist
days 3 to 5 of hospital admission in people not at microbiological advice and
higher risk of resistance, consider following local resistance data
community acquired pneumonia for choice of For first choice IV antibiotics (severe or higher risk of resistance) and
antibiotic. antibiotics to be added if suspected or confirmed MRSA infection see
For detailed information click on the visual summary. visual summary
See also the NICE guideline on pneumonia.
8 of 30 Urinary tract infections
Doses Visual
Infection Key points Medicine Length
Adult Child summary
Non-pregnant women first
choice: 100mg m/r BD (or if
Lower urinary Advise paracetamol or ibuprofen for pain. unavailable 50mg -
tract infection nitrofurantoin (if eGFR QDS)
Non-pregnant women: back up antibiotic (to use 3 days
≥45 ml/minute) OR
if no improvement in 48 hours or symptoms
worsen at any time) or immediate antibiotic. trimethoprim (if low risk of
200mg BD -
resistance)
Pregnant women, men, children or young
people: immediate antibiotic. Non-pregnant women
100mg m/r BD (or if
second choice:
When considering antibiotics, take account of unavailable 50mg - 3 days
nitrofurantoin (if eGFR
severity of symptoms, risk of complications, QDS)
≥45 ml/minute) OR
previous urine culture and susceptibility results,
previous antibiotic use which may have led to pivmecillinam (a penicillin) 400mg initial dose,
- 3 days
resistant bacteria and local antimicrobial resistance OR then 200mg TDS
data. 3g single dose
Fosfomycin (on microbiologist - single dose
If people have symptoms of pyelonephritis (such advice only)
sachet
as fever) or a complicated UTI, see acute
Pregnant women first
pyelonephritis (upper urinary tract infection) for 100mg m/r BD (or if
choice: nitrofurantoin (avoid
antibiotic choices unavailable 50mg - 7 days
at term) – if eGFR
For detailed information click on the visual summary. QDS)
≥45 ml/minute
See also the NICE guideline on urinary tract infection in
under 16s: diagnosis and management and the Public Pregnant women second
Public Health Health England urinary tract infection: diagnostic tools choice: Cefalexin* (only if
England 500mg BD -
for primary care. culture results available and 7 days
susceptible) OR
Amoxicillin 500mg TDS -
For male UTI a properly collected MSU is vital Treatment of asymptomatic bacteriuria in pregnant women: choose from
with attention given to following up results. nitrofurantoin (avoid at term), amoxicillin or cefalexin based on recent culture and
People > 65 years: do not treat asymptomatic susceptibility results. *Local adjustment as about 60 % urine E.coli are resistant
bacteriuria; it is common but is not associated with to amoxicillin
increased morbidities
Men first choice:
200mg BD -
trimethoprim OR
7 days
100mg m/r BD (or if
Last updated: nitrofurantoin (if eGFR
unavailable 50mg -
Oct 2018 ≥45 ml/minute)
QDS)
Men second choice: consider alternative diagnoses basing antibiotic choice on
recent culture and susceptibility results
9 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Children and young
people (3 months and
over) first choice: -
trimethoprim (if low risk of
resistance) OR
nitrofurantoin (if eGFR
-
≥45 ml/minute)
Children and young
people (3 months and -
over) second choice:
-
nitrofurantoin (if eGFR
≥45 ml/minute and not used
as first choice) OR
amoxicillin (only if culture
results available and -
susceptible) OR
cefalexin -
10 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute Advise paracetamol (+/- low-dose weak Non-pregnant women and 500mg BD or TDS
pyelonephritis opioid) for pain for people over 12. men first choice: (up to 1g to 1.5g
- 7 to 10 days
(upper urinary Offer an antibiotic. TDS or QDS for
tract) cefalexin OR severe infections)
When prescribing antibiotics, take account of
severity of symptoms, risk of complications, co-amoxiclav (only if culture
previous urine culture and susceptibility results, results available and 500/125mg TDS - 7 to 10 days
previous antibiotic use which may have led to susceptible) OR
resistant bacteria and local antimicrobial trimethoprim (only if culture
resistance data. results available and 200mg BD - 14 days
susceptible) OR
Avoid antibiotics that don’t achieve adequate ciprofloxacin (consider
levels in renal tissue, such as nitrofurantoin. 500mg BD - 7 days
safety issues)
For detailed information click on the visual summary. Non-pregnant women and men IV antibiotics (click on visual summary)
See also the NICE guideline on urinary tract infection
in under 16s: diagnosis and management and the Pregnant women first 500mg BD or TDS
Public Health England urinary tract infection: choice: (up to 1g to 1.5g
- 7 to 10 days
Public Health diagnostic tools for primary care. cefalexin TDS or QDS for
England severe infections)
Pregnant women second choice or IV antibiotics (click on visual summary)
Children and young
people (3 months and
Check BNF
over) first choice: cefalexin
OR -
co-amoxiclav (only if culture
results available and Check BNF
Last updated: Oct susceptible)
2018
Children and young people (3 months and over) IV antibiotics (click on visual
summary)
11 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Catheter- Antibiotic treatment is not routinely needed for Non-pregnant women and
associated asymptomatic bacteriuria in people with a urinary men first choice if no 100mg m/r BD (or if
urinary tract catheter. upper UTI symptoms: unavailable 50mg Check
infection Consider removing or, if not possible, changing the nitrofurantoin (if eGFR ≥45 QDS) BNF
catheter if it has been in place for more than 7 ml/minute) OR
days. But do not delay antibiotic treatment. 7 days
trimethoprim (if low risk of
200mg BD Check
Advise paracetamol for pain. resistance) OR
BNF
Advise drinking enough fluids to avoid dehydration. amoxicillin (only if culture
Antibiotics will not eradicate asymptomatic results available and 500mg TDS -
bacteriuria. Only offer antibiotics if systemically susceptible)
unwell or pyelonephritis likely. Non-pregnant women and
men second choice if no 400mg initial dose,
When prescribing antibiotics, take account of upper UTI symptoms: - 7 days
then 200mg TDS
severity of symptoms, risk of complications,
previous urine culture and susceptibility results, pivmecillinam (a penicillin)
previous antibiotic use which may have led to Non-pregnant women and 500mg BD or TDS
resistant bacteria and local antimicrobial resistance men first choice if upper (up to 1g to 1.5g
Public Health UTI symptoms: -
data. TDS or QDS for
England
Do not routinely offer antibiotic prophylaxis to cefalexin OR severe infections) 7 to 10 days
people with a short-term or long-term catheter. co-amoxiclav (only if culture
For detailed information click on the visual summary. results available and 500/125mg TDS -
See also the Public Health England urinary tract susceptible) OR
infection: diagnostic tools for primary care.
trimethoprim (only if culture
results available and 200mg BD - 14 days
susceptible) OR
ciprofloxacin (consider
Last updated: 500mg BD - 7 days
Nov 2018
safety issues)
Non-pregnant women and men IV antibiotics (click on visual summary)
Pregnant women first 500mg BD or TDS
choice: (up to 1g to 1.5g
- 7 to 10 days
TDS or QDS for
cefalexin severe infections)
Pregnant women second choice or IV antibiotics (click on visual summary)
12 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Children and young
people (3 months and
over) first choice: -
trimethoprim (if low risk of
resistance) OR
amoxicillin (only if culture
results available and - -
susceptible) OR
cefalexin OR -
co-amoxiclav (only if culture
results available and -
susceptible)
Children and young people (3 months and over) IV antibiotics (click on visual
summary)
First choice (guided by
susceptibilities when
Acute available): 500mg BD -
prostatitis ciprofloxacin (consider
Advise paracetamol (+/- low-dose weak opioid) for safety issues) OR
14 days then
pain, or ibuprofen if preferred and suitable. ofloxacin (consider safety review
200mg BD -
Offer antibiotic. issues) OR
Review antibiotic treatment after 14 days and trimethoprim (if
either stop antibiotics or continue for a further fluoroquinolone not
200mg BD -
14 days if needed (based on assessment of appropriate; seek specialist
Public Health advice)
England history, symptoms, clinical examination, urine and
blood tests). Second choice (after
For detailed information click on the visual summary. discussion with specialist):
500mg OD - 14 days, then
levofloxacin (consider safety
Last updated: issues) OR review
Oct 2018
co-trimoxazole 960mg BD -
IV antibiotics - Refer to hospital (click on visual summary)
13 of 30Infection Key points Medicine Doses Length Visual
Adult Child Summary
Recurrent First advise about behavioural and personal First choice antibiotic 200mg single dose
urinary tract hygiene measures, and self-care (with D- prophylaxis: trimethoprim when exposed to a
-
infection mannose or cranberry products) to reduce the risk (avoid in pregnancy) OR trigger or
of UTI. 100mg at night
For recurrent infections a properly collected nitrofurantoin (avoid at 100mg single dose
MSU is vital with attention given to following term) - if eGFR when exposed to a
up results. ≥45 ml/minute trigger or -
For postmenopausal women, if no improvement, 50 to 100mg at
Public Health consider vaginal oestrogen (review within night
England 12 months). Second choice antibiotic 500mg single dose
For non-pregnant women, if no improvement, prophylaxis: when exposed to a
-
Last updated Oct consider single-dose antibiotic prophylaxis for amoxicillin OR trigger or
2018 250mg at night
exposure to a trigger (review within 6 months).
For non-pregnant women (if no improvement or cefalexin 500mg single dose
no identifiable trigger) or with specialist advice for when exposed to a
pregnant women, men, children or young people, trigger or
consider a trial of daily antibiotic prophylaxis 125mg at night
(review within 6 months).
For detailed information click on the visual -
summary. See also the NICE guideline on urinary
tract infection in under 16s: diagnosis and
management and the Public Health England
urinary tract infection: diagnostic tools for primary
care.
14 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Meningitis
1D,2D 5D 1D Not available.
Suspected 1D IV or IM benzylpenicillin ChildHelicobacter Always test for H.pylori before giving antibiotics. Always use PPI2D,3D,5A+,12A+ -
pylori Treat all positives, if known DU, GU,1A+ or First line and first relapse
low-grade MALToma.2D,3D NNT in non-ulcer and no penicillin allergy
dyspepsia: 14.4A+ PPI PLUS 2 antibiotics
Do not offer eradication for GORD.3D amoxicillin2D,6B+ PLUS 1000mg BD14A+
Public Health
England Do not use clarithromycin, metronidazole or clarithromycin2D,6B+ OR 500mg BD8A-
quinolone if used in the past year for any
infection.5A+,6B+,7A+ metronidazole2D,6B+ 400mg BD2D
See PHE quick
Penicillin allergy: use PPI PLUS clarithromycin
reference guide Penicillin allergy and -
PLUS metronidazole.2D If previous clarithromycin,
for diagnostic previous clarithromycin:
use PPI PLUS bismuth salt PLUS metronidazole
advice: PHE PPI WITH bismuth
PLUS tetracycline hydrochloride.2D,8A-,9D
H. pylori subsalicylate PLUS 2 - 7 days2D Not available.
Relapse and no penicillin allergy use PPI PLUS Access
amoxicillin PLUS clarithromycin or metronidazole antibiotics MALToma
bismuth subsalicylate13A+ 525mg QDS15D supporting
(whichever was not used first line) 2D 14 days7A+,16A+ evidence and
Last updated: PLUS rationales on the
Relapse and previous metronidazole and metronidazole2D PLUS
Feb 2019 400mg BD2D PHE website
clarithromycin: use PPI PLUS amoxicillin PLUS
either tetracycline OR levofloxacin (if tetracycline tetracycline2D 500mg QDS15D
not tolerated).2D,7A+ Relapse and previous -
Relapse and penicillin allergy (no exposure to metronidazole and
quinolone): use PPI PLUS metronidazole PLUS -
clarithromycin:
levofloxacin.2D PPI PLUS 2 antibiotics
Relapse and penicillin allergy (with exposure amoxicillin2D,7A+ PLUS 1000mg BD14A+
to quinolone): use PPI PLUS bismuth salt PLUS
metronidazole PLUS tetracycline.2D tetracycline2D,7A+ OR 500mg QDS15D
levofloxacin (if tetracycline 250mg BD7A+
Retest for H. pylori: post DU/GU, or relapse after
cannot be used)2D,7A+
second-line therapy,1A+ using UBT or SAT,10A+,11A+
Third line: -
consider referral for endoscopy and culture.2D - 10 days
Contact microbiologist
16 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Clostridium Review need for antibiotics,
1D,2D 3B-
PPIs, and First episode: 1D,2D 1D,4B-
2D,4B- 400mg TDS 10 to 14 days
difficile antiperistaltic agents and discontinue use where metronidazole
1D,2D
2D
possible. Mild cases (38.5, or WCC>15, rising creatinine, PHE website
2D
or signs/symptoms of severe colitis): treat with Recurrent or second line:
1D,2D,5A-
oral vancomycin, review progress Seek advice from 1 to 3 days1D,2D,3A+
Last updated: 1D,2D 2D
Oct 2018 closely, and consider hospital referral. microbiology. -
Traveller’s Standby: 1D,3A+
diarrhoea 500mg OD - Not available.
azithromycin 2 days 1D,2D,4A-
Public Health 1D Access
Prophylaxis rarely, if ever, indicated. Consider
England 3B- supporting
standby antimicrobial only for patients at high risk Prophylaxis/treatment: - 1 dose; repeat
2D 1D,2D 1D,2D evidence and
Last updated: of severe illness, or visiting high-risk areas. bismuth subsalicylate 2 tablets QDS in 2 weeks if rationales on the
Oct 2018 3B-
persistent PHE website
1D 3B-
Threadworm Treat all household contacts at the same time. Child >6 months: 1 dose; repeat Not available.
3B-
Public Health
1D
Advise hygiene measures for 2 weeks (hand 100mg stat in 2 weeks if Access
1D,3B 3B-
2D
hygiene; pants at night; morning shower, mebendazole persistent supporting
England
including perianal area).1D,2D Wash sleepwear, evidence and
Last updated: bed linen, and dust and vacuum.1D ChildDoses Visual
Infection Key points Medicine Length
Adult Child summary
Acute diverticulitis and systemically well: Consider First-choice 500/125mg TDS 5 days*
Acute
no antibiotics, offer simple analgesia (for example (uncomplicated acute
diverticulitis
paracetamol), advise to re-present if symptoms diverticulitis):
persist or worsen. Penicillin allergy or cefalexin: 500mg BD 5 days*
Acute diverticulitis and systemically unwell, co-amoxiclav or TDS (up to 1g to
immunosuppressed or significant comorbidity: unsuitable: 1.5g TDS or QDS for
offer an antibiotic. cefalexin (Avoid in severe infections)
Give oral antibiotics if person not referred to hospital severe penicillin metronidazole:
for suspected complicated acute diverticulitis. allergy) AND 400mg TDS
Give IV antibiotics if admitted to hospital with metronidazole
suspected or confirmed complicated acute For IV
OR
diverticulitis (including diverticular abscess). antibiotics in
Last updated: If CT-confirmed uncomplicated acute diverticulitis, trimethoprim: complicated
trimethoprim 5 days*
Nov 2019 review the need for antibiotics. 200mg BD acute
AND
* A longer course may be needed based on metronidazole metronidazole: diverticulitis
clinical assessment. OR 400mg TDS (including
diverticular
ciprofloxacin (only if abscess) see
ciprofloxacin: 5 days*
switching from IV visual summary
500mg BD
ciprofloxacin with specialist metronidazole:
advice; consider safety 400mg TDS
issues) AND metronidazole
Threadworm Treat all household contacts at the same time.1D Child >6 months: 100mg stat3B- 1 dose;3B- repeat in
Advise hygiene measures for 2 weeks1D (hand mebendazole1D,3B- 2 weeks if
Public Health hygiene;2D pants at night; morning shower, including
persistent3B
England perianal area).1D,2D Wash sleepwear, bed linen, and
dust and vacuum.1D ChildDoses Visual
Infection Key points Medicine Length
Adult Child summary
Chlamydia Opportunistically screen all sexually active 100mg BD4A+,11A-,
trachomatis patients aged 15 to 24 years for chlamydia First line: 12A+
1B-
/ urethritis annually and on change of sexual partner. doxycycline4A+,11A-,12A+ 7 days4A+,11A-,12A+
If positive, treat index case, refer to GUM and
initiate partner notification, testing and
2D,3A+ Second line/ 1000mg4A+,11A-,12A+ Stat4A+,11A-,12A+
treatment.
pregnant/breastfeeding/
As single dose azithromycin has led to increased Then
allergy/intolerance:
resistance in GU infections, doxycycline should azithromycin4A+,11A-,12A+ 500mg OD4A+,11A, 2 days4A+,11A-,12A+
4A+
be used first line for chlamydia and urethritis. 12A+ (total 3 days)
Advise patient with chlamydia to abstain from
sexual intercourse until doxycycline is completed
Public Health or for 7 days after treatment with azithromycin
England (14 days after azithromycin started and until
3A+,4A+
symptoms resolved if urethritis). Not available.
Access
If chlamydia, test for reinfection at 3 to 6 months supporting
following treatment if under 25 years; or consider - evidence and
1B-,3B+,
if over 25 years and high risk of re-infection. rationales on the
5B-
PHE website
Second line, pregnant, breastfeeding, allergy,
or intolerance: azithromycin is most
6A+,7D,8A+,9A+,10D
effective. As lower cure rate in
pregnancy, test for cure at least 3 weeks after end
3A+
of treatment.
Consider referring all patients with symptomatic
urethritis to GUM as testing should include
11A-
Mycoplasma genitalium and Gonorrhoea.
If M.genitalium is proven, use doxycycline
Last updated:
July 2019 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.11A-,12A+
Epididymitis Usually due to Gram-negative enteric bacteria in Doxycycline1A+,2D OR 100mg BD1A+,2D - 10 to 14 days1A+,2D Not available.
1A+,2D Access supporting
men over 35 years with low risk of STI. ofloxacin1A+,2D OR
1A+,2D 200mg BD1A+,2D 14 days1A+,2D evidence and
Public Health If under 35 years or STI risk, refer to GUM. rationales on the
England ciprofloxacin1A+,2D 500mg BD1A+,2D,3A+ 10 days1A+,2D,3A+ PHE website
Last updated:
Nov 2017
19 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
1A+,5D 1A+ 1A+
Clotrimazole OR 500mg pessary Stat
Vaginal All topical and oral azoles give over 80% clotrimazole OR
1A+
100mg pessary
1A+
6 nights
1A+
candidiasis cure.1A+,2A+ 1A+,3D - 1A+
oral fluconazole 150mg1A+,3D Stat Not available.
Pregnant: avoid oral azoles, the 7 day courses Access
Public Health are more effective than shorter ones.
1A+,3D,4A+ 150mg every supporting
England 1A+
Recurrent (>4 episodes per year): 150mg If recurrent: 72 hours 3 doses evidence and
THEN - rationales on the
oral fluconazole every 72 hours for 3 doses fluconazole
1A+ 1A+ PHE website
Last updated: induction, followed by 1 dose once a week for (induction/maintenance) 150mg once a 6 months
1A+
1A+
Oct 2018 6 months maintenance. week1A+,3D
1A+
Bacterial 400mg BD1A+,3A+ 7 days
vaginosis Oral metronidazole is as effective as topical oral metronidazole
1A+,3A+
OR OR OR
1A+ 2D Not available.
treatment, and is cheaper. 2D
2000mg1A+,2D Stat Access
Public Health 7 days results in fewer relapses than 2g stat at supporting
metronidazole 0.75% 5g applicator at -
England 4 weeks.
1A+,2D
1A+,2D,3A+ 5 nights1A+,2D,3A+ evidence and
3A+,4D
vaginal gel OR night1A+,2D,3A+ rationales on the
Pregnant/breastfeeding: avoid 2g dose.
5A+ 5g applicator at PHE website
Last updated: Treating partners does not reduce relapse. clindamycin 2% cream
1A+,2D
7 nights1A+,2D,3A+
Nov 2017 night1A+,2D
1A+,3A+ 1A+
400mg TDS 5 days
1A+,2D,3A+,4A+
Genital herpes 1A+ 1A+
Advise: saline bathing, analgesia, or topical oral aciclovir OR 800mg TDS (if 1A+
1A+ 1A+ 1A+ 2 days Not available.
lidocaine for pain, and discuss transmission. recurrent) Access
1A+,3A+,4A+ 1A+ 1A+
Public Health First episode: treat within 5 days if new lesions valaciclovir OR 500mg BD 5 days supporting
1A+,2D 2D evidence and
England or systemic symptoms, and refer to GUM. -
2D rationales on the
Recurrent: self-care if mild, or immediate short PHE website
1A+,2D
course antiviral treatment, or suppressive
1A+,2D
therapy if more than 6 episodes per year.
Last updated:
Nov 2017
20 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
1D,2D
Gonorrhoea Antibiotic resistance is now very high.
2D 2D 2D
Public Health Use IM ceftriaxone if susceptibility not known prior ceftriaxone OR 1000mg IM Stat Not available.
England to treatment .
2D Access
Last updated: supporting
Use Ciprofloxacin only If susceptibility is known 2D - evidence and
Feb 2019 ciprofloxacin
prior to treatment and the isolate is sensitive to 2D 2D rationales on the
ciprofloxacin at all sites of infection
1D,2D (only if known to be 500mg Stat
PHE website
3B- 2D sensitive)
Refer to GUM. Test of cure is essential.
1A+
Trichomoniasis Oral treatment needed as extravaginal infection 400mg BD1A+,6A+ 5 to 7 day
1D 1A+,2A+,3D,6A+
common. metronidazole Stat1A+,6A+ Not available.
1D
Treat partners, and refer to GUM for other 2g (more Access
Public Health supporting
STIs.
1D adverse -
England 6A+ evidence and
effects)
Pregnant/breastfeeding: avoid 2g single dose 5D rationales on the
2A+,3D Pregnancy to treat 100mg pessary 6 nights
Last updated: metronidazole; clotrimazole for symptom symptoms: 5D PHE website
2A+,4A-,5D at night
Nov 2017 relief (not cure) if metronidazole declined. 2A+,4A-,5D
clotrimazole
1A+
Refer women and sexual contacts to GUM. First line therapy:
Pelvic Raised CRP supports diagnosis, absent pus cells ceftriaxone1A+,3C,4C PLUS 1000mg IM
1A+,3C
Stat1A+,3C
inflammatory in HVS smear good negative predictive value.
1A+
1A+,5A+ 1A+ 1A+
metronidazole PLUS 400mg BD 14 days
disease
Exclude: ectopic pregnancy, appendicitis, doxycycline
1A+,5A+
100mg BD
1A+
14 days
1A+
endometriosis, UTI, irritable bowel, complicated Not available.
ovarian cyst, functional pain. Second line therapy: 1A+ 1A+ Access
1A+,5A+ 400mg BD 14 days supporting
Moxifloxacin has greater activity against likely metronidazole PLUS -
Public Health evidence and
England pathogens, but always test for gonorrhoea, Ofloxacin 1A+,2A-,5A+ rationales on the
1A+ 400mg BD1A+,2A- 14 days
1A+
chlamydia, and M. genitalium . OR PHE website
1A+
If M. genitalium tests positive use moxifloxacin .
Last updated: Basildon and Southend Hospitals has levofloxacin Levofloxacin or moxifloxacin
1A+ 1A+ 1A+
Feb 2019 as an alternative. Please continue prescribing alone 400mg OD 14 days
levofloxacin as advised by hospital. (first line for M. genitalium
associated PID)
21 of 30 Skin and soft tissue infections
1D 1D
Note: Refer to RCGP Skin Infections online training. For MRSA, discuss therapy with microbiologist.
Doses Visual
Infection Key points Medicine Length
Adult Child summary
Cold sores
1A-,2A- 1A-,2A-,3A-
Public Health Most resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12 to 18 hours.
England If frequent, severe, and predictable triggers: consider oral prophylaxis:
4D,5A+
aciclovir 400mg, twice daily, for 5 to 7 days.
5A+,6A+
Last updated: Access supporting evidence and rationales on the PHE website
Nov 2017
1B+,2B+,3B-
Panton-Valentine leukocidin (PVL) is a toxin produced by 20.8 to 46% of S. aureus from boils/abscesses. PVL strains are rare in healthy people,
PVL-SA but severe.
2B+
Public Health Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking.
4D
England 2B+ 2B+ 3B- 2B+,3B-
Risk factors for PVL: recurrent skin infections; invasive infections; MSM; if there is more than one case in a home or close community
Last updated: 3B- 3B- 3B- 3B-
Nov 2017
(school children; military personnel; nursing home residents; household contacts).
Access the supporting evidence and rationales on the PHE website.
Eczema 1A+ 1A+
Public Health No visible signs of infection: antibiotic use (alone or with steroids) encourages resistance and does not improve healing.
2D 2D 2D
England With visible signs of infection: use oral flucloxacillin or clarithromycin, or topical treatment (as in impetigo).
Last updated: Access the supporting evidence and rationales on the PHE website.
Nov 2017
Impetigo Localised non-bullous impetigo: Topical antiseptic:
Hydrogen peroxide 1% cream (other topical 5 days*
antiseptics are available but no evidence for hydrogen peroxide 1% BD or TDS
impetigo).
If hydrogen peroxide unsuitable or ineffective, short- Topical antibiotic:
course topical antibiotic. First choice:
fusidic acid 2% TDS 5 days*
Public Health Widespread non-bullous impetigo:
England Short-course topical or oral antibiotic. Fusidic acid resistance
Take account of person’s preferences, practicalities suspected or confirmed: TDS
of administration, previous use of topical antibiotics mupirocin 2%
because antimicrobial resistance can develop Oral antibiotic:
Last updated: rapidly with extended or repeated use, and local
Feb 2020 First choice: 500mg QDS
antimicrobial resistance data.
flucloxacillin
Bullous impetigo, systemically unwell, or high
Penicillin allergy or
risk of complications: 250mg BD 5 days*
flucloxacillin unsuitable:
Short-course oral antibiotic.
clarithromycin OR
Do not offer combination treatment with a topical
and oral antibiotic to treat impetigo. erythromycin (in pregnancy)
250 to 500mg QDS
*5 days is appropriate for most, can be increased to
7 days based on clinical judgement. If MRSA suspected or confirmed – consult local microbiologist
22 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Mild (open and closed comedones)1D or moderate Second line: topical retinoid Thinly OD 3A+ 1D
6 to 8 weeks Supporting
Acne (inflammatory lesions):1D 1D,2D,3A+ OR
5% cream OD - BD 3A+ evidence and
First line: self-care1D (wash with mild soap; do not benzoyl peroxide
1A-,2D,3A+,4A- rationales on the
1D
scrub; avoid make-up).1D 6 to 8 weeks PHE website
Public Health Second line: topical retinoid or benzoyl peroxide.2D
England Third-line: add topical antibiotic,1D,3A+ or consider
addition of oral antibiotic.1D Third-line: topical 1% cream, thinly 1A-,2D
12 weeks
Severe (nodules and cysts):1D add oral antibiotic 3A+ (combined
BD 3A+
clindamycin
(for 3 months max)1D,3A+ and refer.1D,2D
Last updated:
Nov 2017 If treatment failure/severe: 3A+ 3A+
1A-,3A+ 500mg BD 6 to 12 weeks
oral tetracycline OR
lymecycline 408mg OD
3A+ 3A+
100mg OD 6 to 12 weeks
3A+,4A-
oral doxycycline
Cellulitis and Exclude other causes of skin redness First choice:
erysipelas (inflammatory reactions or non-infectious causes). Flucloxacillin 500mg to 1g QDS 5 to 7 days*
Consider marking extent of infection with a single-
use surgical marker pen.
Penicillin allergy or if flucloxacillin unsuitable:
Offer an antibiotic. Take account of severity, site of
infection, risk of uncommon pathogens, any clarithromycin OR 500mg BD 5 to 7 days*
microbiological results and MRSA status. erythromycin (in pregnancy) 500mg QDS
Infection around eyes or nose is more concerning OR
because of serious intracranial complications. doxycycline (adults only) 200mg on day 1, -
Public Health OR then 100mg OD
England *A longer course (up to 14 days in total) may be
needed but skin takes time to return to normal, and co-amoxiclav (children only: -
full resolution at 5 to 7 days is not expected. not in penicillin allergy)
Do not routinely offer antibiotics to prevent If infection near eyes or nose:
recurrent cellulitis or erysipelas. co-amoxiclav 500/125mg TDS 7 days*
Last updated:
Sept 2019 For detailed information click on the visual
summary. If infection near eyes or nose (penicillin allergy):
clarithromycin AND 500mg BD 7 days*
For alternative choice antibiotics for metronidazole (only add in 400mg TDS
severe infection, suspected or children if anaerobes
confirmed MRSA infection and IV suspected)
antibiotics contact microbiology
23 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Diabetic foot In diabetes, all foot wounds are likely to be Mild infection: first choice
infection colonised with bacteria. Diabetic foot infection has Flucloxacillin 500mg to 1g QDS - 7 days*
at least 2 of: local swelling or induration; erythema;
local tenderness or pain; local warmth; purulent
discharge. Mild infection (penicillin allergy):
Severity is classified as: clarithromycin OR 500mg BD
Mild: local infection with 0.5 to less than 2cm
erythema
Moderate: local infection with more than 2cm erythromycin (in - 7 days*
500mg QDS
erythema or involving deeper structures (such as pregnancy) OR
abscess, osteomyelitis, septic arthritis or fasciitis)
Severe: local infection with signs of a systemic 200mg on day
inflammatory response. doxycycline 1, then 100mg
Public Health
Start antibiotic treatment as soon as possible. OD (can be
England
increased to
Take samples for microbiological testing before, or 200mg daily)
as close as possible to, the start of treatment
When choosing an antibiotic, take account of For antibiotic choices for moderate or severe infection, infections where
severity, risk of complications, previous Pseudomonas aeruginosa or MRSA is suspected or confirmed, and IV
Last updated:
microbiological results and antibiotic use, and antibiotics click on the visual summary
Oct 2019
patient preference.
*A longer course (up to a further 7 days) may
be needed based on clinical assessment.
However, skin does take time to return to
normal, and full resolution at 7 days is not
expected.
Do not offer antibiotics to prevent diabetic foot
infection.
Infected wounds For severe infections, MRSA First line: -
(including post- skin/soft tissue infections, or if Flucloxacillin PLUS 500mg to 1g
operative wound patients not improving within 48-72 QDS 5 days, then
infections) hours – speak to microbiology. review
Metronidazole if 400mg TDS
abdominal/ pelvic wound
Adapted from MID For tetanus prone wound assess
Essex formulary
and treat/refer for vaccine or Second line: -
immunoglobulin. See BNF/Green book for details 7 days, then
Doxycycline PLUS 200mg STAT
review
then 100mg
OD or BD
Metronidazole if 400mg TDS
abdominal/ pelvic wound
24 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Scabies permethrin
1D,2D,3A+
5% cream
1D,2D
First choice permethrin: Treat whole body from
1D,2D 1D,2D Not available.
ear/chin downwards, and under nails. Access
Public Health If using permethrin and patient is under 2 years, 2 applications, supporting
England elderly or immunosuppressed, or if treating with 1 week apart
1D
evidence and
1D,2D
malathion: also treat face and scalp. rationales on the
Last updated: 1D Permethrin allergy: 0.5% aqueous PHE website
Home/sexual contacts: treat within 24 hours. 1D 1D
Oct 2018 malathion liquid
Tick bites Treatment: Treat erythema migrans empirically;
3D
(Lyme disease) serology is often negative early in infection. Treatment: 100mg BD
2D,3D
2D,D
doxycycline
For other suspected Lyme disease such as
Public Health neuroborreliosis (CN palsy, radiculopathy) seek
Not available.
England advice.
3D
Access supporting
2D,3D evidence and
Last updated: 21 days rationales on the
Feb 2020 Alternative:
2D,3D 2D,3D PHE website
amoxicillin 1,000mg TDS
25 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Human and Prophylaxis and 7 days3D
1A+,2D treatment
animal bites Human: thorough irrigation is important.
Antibiotic prophylaxis is advised.
1A+,2D,3D
Assess 375mg to 625mg
co-amoxiclav2D,3D
1A+
risk of tetanus, rabies, HIV, and hepatitis B and TDS3D
C.3D Not available.
Penicillin allergy: Review all at 24 and Penicillin allergy or if co- Access supporting
3D 2D,3 amoxiclav is unsuitable:
Public Health 48 hours, as not all pathogens are covered. evidence and
England 200 mg on first rationales on the
doxycycline3D AND PHE website
P. multocida is the most common cause of wound day, then 100 mg
infections after dog or cat bites. This organism is or 200 mg daily
intrinsically resistant to clindamycin and macrolides 7 days3D
which should be avoided. metronidazole 3D,4A+ 400 mg three times a
day
Last updated:
Nov 2020
Alternative first-choice
oral antibiotics in Seek specialist
pregnancy for penicillin advice
allergy or if co-amoxiclav
is unsuitable
26 of 30Doses Visual
Infection Key points Medicine Length summary
Adult Child
2D
Mastitis S. aureus is the most common infecting flucloxacillin 500mg up to 1g
2D
pathogen.1D Suspect if woman has: a painful QDS Not available.
breast;2D fever and/or general malaise;2D a tender, Access supporting
Public Health evidence and
red breast.2D - 10 to 14 days
2D
England Penicillin allergy: 250mg to 500mg rationales on the
Breastfeeding: oral antibiotics are appropriate, 2D 2D
erythromycin OR QDS PHE website
where indicated.2D,3A+ Women should continue
Last updated:
Nov 2017
feeding,1D,2D including from the affected breast.2D
2D 2D
clarithromycin 500mg BD
Most cases: use terbinafine as fungicidal, topical terbinafine
3A+,4D
OR 2A+ 3A+
Dermatophyte 1% OD to BD 1 to 4 weeks
treatment time shorter and more effective than with
infection: skin 1D,2A+,
fungistatic imidazoles or undecenoates. If Not available.
4D Access supporting
candida possible, use imidazole. topical imidazole
2A+,3A+
1% OD to BD
2A+
4 to 6 weeks
2A+,3A+
Public Health 1D evidence and
If intractable, or scalp: send skin scrapings, Fingers:
England 1D,6D rationales on the
and if infection confirmed: use oral Alternative in athlete’s OD to BD
2A+ 6 weeks PHE website
1D,3A+,4D 2A+,3A+,5D
terbinafine or itraconazole. foot: Toes:
Last updated: 6D 1D,6D
Scalp: oral therapy, and discuss with topical undecenoates2A+ 12 weeks
Feb 2019 1D
specialist. (such as Mycota®)2A+
Dermatophyte Take nail clippings;1D start therapy only if First line: 250mg OD1D,2A+,6D Fingers:
infection: nail 1D,6D
infection is confirmed.1D Oral terbinafine is more terbinafine1D,2A+,3A+,4D,6D 6 weeks
effective than oral azole.1D,2A+,3A+,4D Liver Toes:
reactions 12 weeks
1D,6D
Public Health
England 0.1 to 1% with oral antifungals.3A+ If candida or 1D
non-dermatophyte infection is confirmed, use oral Second line: 200mg BD
1D,4D
1 week a month
itraconazole.
1D,3A+,4D
Topical nail lacquer is not as itraconazole1D,3A+,4D Fingers:
1D
Last updated: effective.
1D,5A+,6D
1 courses
1D
Oct 2018 To prevent recurrence: apply weekly 1% topical Toes: 3 courses
6D
antifungal cream to entire toe area. 6D
4D Stop treatment when continual, new, healthy, proximal nail growth.
Children: seek specialist advice.
27 of 30Doses Visual
Infection Key points Medicine Length
Adult Child summary
Eye infections
Eye drops: 2 hourly
1D,2A+
First line: bath/clean eyelids with cotton wool for 2 days,
Conjunctivitis dipped in sterile saline or boiled (cooled) water, to then reduce
1D Second line: 1D
remove crusting. 1D,2A+,4A-,5A+
frequency to 3 to
2A+ 3D chloramphenicol 1D
4 times daily. Eye Not available.
Treat only if severe, as most cases are viral 1D,2A+
or self-limiting.
2A+ 0.5% eye drop ointment: 3 to 4 Access
Public Health 48 hours after supporting
OR times daily or once
England Bacterial conjunctivitis: usually unilateral and 2A+,7D evidence and
2A+,3D 1D,5A+ daily at night if resolution
also self-limiting. It is characterised by red eye 1% ointment rationales on the
3D using antibiotic eye
with mucopurulent, not watery discharge. 65% PHE website
4A- drops during the
and 74% resolve on placebo by days 5 and 7. 1D 3D
Last updated: ,5A day. 6-week trial
July 2019
+ Third line: fusidic acid as it has less Gram-
negative activity.
6A-,7D Third line:
2A+,5A+,6A- BD1D,7D
fusidic acid 1% gel
Blepharitis First line: lid hygiene
1D,2A+
for symptom control,
1D Second line: 6-week trial3D
1D,2A+ 1% ointment
including: warm compresses; lid massage and topical BD2A+,3D Not available.
1D 1D 1D 1D,2A+,3A
scrubs; gentle washing; avoiding cosmetics. chloramphenicol Access
Public Health
supporting
England Second line: topical antibiotics if hygiene 3D 3D
1D,3A+ Third line: 500mg BD 4 weeks (initial) evidence and
measures are ineffective after 2 weeks. 1D,3D 3D 3D rationales on the
oral oxytetracycline 250mg BD 8 weeks (maint)
PHE website
OR
3D 3D 3D
Last updated: Signs of meibomian gland dysfunction, oral doxycycline
1D, 2A+,3D
100mg OD 4 weeks (initial)
3D 3D 3D
Nov 2017 or acne rosacea: consider oral 50mg OD 8 weeks (maint)
1D
antibiotics.
28 of 30Doses Visual
Infection Key points Medicine Length
Adult Child
Suspected dental infections in primary care (outside dental settings)
Derived from the Scottish Dental Clinical Effectiveness Programme (SDCEP) 2013 Guidelines. This guidance is not designed to be a definitive guide to oral conditions, as
GPs should not be involved in dental treatment. Patients presenting to non-dental primary care services with dental problems should be directed to their regular dentist, or if
this is not possible, to the NHS 111 service (in England), who will be able to provided details of how to access emergency dental care.
1D 1D 1D 1D
Note: Antibiotics do not cure toothache. First-line treatment is with paracetamol and/or ibuprofen; codeine is not effective for toothache.
Mucosal Temporary pain and swelling relief can be attained Chlorhexidine 0.12 0.2%
ulceration and with saline mouthwash (½ tsp salt in warm (can be purchased OTC)
1D Do not use within 30 1 minute BD with Always spit out Not available.
inflammation water) . Use antiseptic mouthwash if more 10 ml
1D 1D
1D minutes of toothpaste
1D after use. Access
(simple severe, and if pain limits oral hygiene to treat or
OR Use until lesions supporting
gingivitis) prevent secondary infection.
1D,2A-
The primary 1D
resolve or evidence and
Public Health cause for mucosal ulceration or inflammation 2 to 3 minutes rationales on the
1D 1D
(aphthous ulcers; oral lichen planus; herpes less pain allows for
England hydrogen peroxide (can be BD/TDS with 15ml 1D PHE website
1D 1D
simplex infection; oral cancer) needs to be oral hygiene
Last updated: 5A- 1D in ½ glass warm
evaluated and treated.
1D purchased OTC) 6% 1D
Nov 2017 water
Chlorhexidine 0.12 to
Acute 1 minute BD with
0.2%(can be purchased 1D
necrotising 10ml
1D,2D OTC) (Do not use within Not available.
ulcerative Refer to dentist for scaling and hygiene advice. 1D Until pain allows for Access
1D 30 minutes of toothpaste) 6D
gingivitis Antiseptic mouthwash if pain limits oral hygiene. OR oral hygiene supporting
Public Health Commence metronidazole if systemic signs and evidence and
hydrogen peroxide 6% (can 2 to 3 minutes rationales on the
England symptoms.1D,2D,3B-,4B+,5A- be purchased OTC)
1D
BD/TDS with 15ml PHE website
Last updated: in ½ glass warm
Nov 2017 water
metronidazole1D,3B-,4B+,5A- 400mg TDS
1D,2D
3 days1D,2D
1D
Pericoronitis Refer to dentist for irrigation and debridement. metronidazole
1D,2A+,3B+
OR 400mg TDS
1D
3 days1D,2A+
1D Not available.
If persistent swelling or systemic symptoms, use
1D,2A+,3B+ 1D,3B+ Access
metronidazole or amoxicillin. 1D,3B+ 1D 1D supporting
amoxicillin 500mg TDS 3 days
Public Health Use antiseptic mouthwash if pain and trismus limit evidence and
oral hygiene.
1D
chlorhexidine 0.2% (do not 1 minute BD with Until less pain rationales on the
England
use within 30 minutes of 10ml1D allows for oral PHE website
Last updated: toothpaste)1D OR hygiene1D
Nov 2017
hydrogen peroxide 6%1D 2 to 3 minutes
BD/TDS with 15ml in
½ glass warm water1D
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