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Summary of antimicrobial prescribing guidance—managing common infections

Important notice

This summary is in the process of being updated (estimated date of publication: 1 April 2019). In the mean time, please refer to the most up-to-date guideline on the NICE website.

  • NICE and Public Health England (PHE) have brought together information on managing common infections into a summary table. A summary of new NICE guidance will be added as it's published. Where new guidance is in development is also indicated.
  • The evidence and rationales underpinning the information in the table can be accessed by clicking on the hyperlinks or the visual summary icons.
  • The processes used by each organisation to develop their guidance differ. The process for developing the NICE guidelines can be found in the interim process guide. The process for developing the PHE guidance is briefly outlined on the PHE website in the PHE context, references and rationales document with further information available upon request. 

Upper respiratory tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSES LENGTH
ACUTE SORE THROAT—NICE guidance (last updated: January 2018)

 

  • Advise paracetamol, or if preferred and suitable, ibuprofen for pain
  • Medicated lozenges may help pain in adults
  • Use FeverPAIN or Centor to assess symptoms:
    • FeverPAIN 0–1 or Centor 0–2: no antibiotic
    • FeverPAIN 2–3: no or back-up antibiotic
    • FeverPAIN 4–5 or Centor 3–4: immediate or back-up antibiotic
  • Systemically very unwell or high risk of complications: immediate antibiotic.

 

View visual summary

 

First choice:  phenoxymethylpenicillin

500 mg qds or

1000 mg bd

 

View child doses here

5–10 days
Penicillin allergy: clarithromycin

250–500 mg bd

 

View child doses here

5 days
or erythromycin (preferred if pregnant) 

250–500 mg qds

500–1000 mg bd

 

View child doses here

5 days
INFLUENZA—Public Health England guidance (last updated: February 2019)
  • Annual vaccination is essential for all those 'at risk' of influenza. Antivirals are not recommended for healthy adults.
  • Treat 'at risk' patients with five days oseltamivir 75 mg bd, when influenza is circulating in the community, and ideally within 48 hours of onset (36 hours for zanamivir treatment in children), or in a care home where influenza is likely
  • 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 asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; chronic neurological, renal or liver disease; diabetes mellitus; morbid obesity (BMI>40). See the PHE influenza guidance for the treatment of patients under 13 years of age. In severe immunosuppression, or oseltamivir resistance, use zanamivir 10 mg bd (two inhalations by diskhaler for up to 10 days) and seek advice

 

View supporting evidence and rationales

SCARLET FEVER (GAS)—Public Health England guidance (last updated: October 2018)
  • Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Vulnerable individuals (immunocompromised, the comorbid, or those with skin disease) are at increased risk of developing complications

 

View supporting evidence and rationales

Phenoxymethylpenicillin

500 mg qds

 

View child doses here

10 days

Penicillin allergy:  clarithromycin

250–500 mg bd

 

View child doses here

5 days

Optimise analgesia and give safety netting advice

ACUTE OTITIS MEDIANICE guidance (last updated: February 2018)
  • Regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain)
  • Otorrhoea or under 2 years with infection in both ears: no, back-up, or immediate antibiotic
  • Otherwise: no or back-up antibiotic
  • Systemically very unwell or high risk of complications: immediate antibiotic

 

View visual summary

First choice: amoxicillin

1 to 11 months: 125 mg tds

1 to 4 years: 250 mg tds

5 to 17 years: 500 mg tds

5–7 days

Penicillin allergy:  clarithromycin

1 month to 11 years:

Under 8 kg: 7.5 mg/kg bd

8–11 kg: 62.5 mg bd

12–19 kg: 125 mg bd

20–29 kg: 187.5 mg bd

30–40 kg: 250 mg bd

or

12 to 17 years: 250–500 mg bd

5–7 days

or erythromycin (preferred if pregnant)

1 month to 1 year: 125 mg qds or 250 mg bd

2 to 7 years: 250 mg qds or 500 mg bd

8 to 17 years: 250 mg–500 mg qds or 500–1000 mg bd

5–7 days

Second choice: co-amoxiclav

1 to 11 months: 0.25 ml/kg of 125/31 suspension tds

1 to 5 years: 5 ml of 125/31 suspension tds or 0.25 ml/kg of 125/31 suspension tds

6 to 11 years: 5 ml of 250/62 suspension tds or 0.15 ml/kg of 250/62 suspension tds

12 to 17 years: 250/125 mg tds or 500/125 mg tds

5–7 days
ACUTE OTITIS EXTERNA—Public Health England guidance (last updated: November 2017)
  • First line: analgesia for pain relief, and apply localised heat (e.g. a warm flannel)
  • Second line: topical acetic acid or topical antibiotic +/- steroid: similar cure at 7 days
  • If cellulitis or disease extends outside ear canal, or systemic signs of infection, start oral flucloxacillin and refer to exclude malignant otitis externa

 

View supporting evidence and rationales

Second line:  topical acetic acid 2%

1 spray tds

 

View child doses here

7 days 

or topical neomycin sulphate with corticosteroid

3 drops tds

 

View child doses here

7 days (min) to 14 days (max)

If cellulitis: flucloxacillin

250 mg qds

If severe: 500 mg qds

 

View child doses here

7 days

SINUSITISNICE guidance (last updated: October 2017)

 

  • Advise paracetamol or ibuprofen for pain. Little evidence that nasal saline or nasal decongestants help, but people may want to try them
  • Symptoms for 10 days or less: no antibiotic
  • Symptoms with no improvement for more than 10 days: no antibiotic or back-up antibiotic depending on likelihood of bacterial cause
  • Consider high-dose nasal corticosteroid (if over 12 years)
  • Systemically very unwell or high risk of complications: immediate antibiotic

 

View visual summary

 

First choice:  phenoxymethylpenicillin

500 mg qds

 

View child doses here

5 days

Penicillin allergy:  doxycycline (not in under 12s)

200 mg on day one then 100 mg od

 

View child doses here

5 days

or clarithromycin

500 mg bd

 

View child doses here

or erythromycin (preferred if pregnant)

250–500 mg qds

or

500–1000 mg bd

 

View child doses here

Second choice or first choice if systemically very unwell or high risk of complications:  co‑amoxiclav

500/125 mg tds

 

View child doses here

5 days

Lower respiratory tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSES LENGTH
Note: Low doses of penicillins are more likely to select for resistance. Do not use quinolones (ciprofloxacin, ofloxacin) first line as there is poor pneumococcal activity. Reserve all fluoroquinolones (including levofloxacin) for proven resistant organisms

ACUTE EXACERBATION OF COPDNICE guidance (last updated: December 2018)

  • Many exacerbations are not caused by bacterial infections so will not respond to antibiotics. Consider an antibiotic, but only after taking into account severity of symptoms (particularly sputum colour changes and increases in volume or thickness), need for hospitalisation, previous exacerbations, hospitalisations and risk of complications, previous sputum culture and susceptibility results, and risk of resistance with repeated courses
  • Some people at risk of exacerbations may have antibiotics to keep at home as part of their exacerbation action plan

 

View visual summary

 

See NICE guideline on COPD in over 16s

First choice: amoxicillin 500 mg tds 5 days
or doxycycline 200 mg on day 1, then 100 mg od
or clarithromycin 500 mg bd
Second choice:  use alternative first choice
If at risk of treatment failure: co-amoxiclav 500/125 mg tds 5 days
or levofloxacin (consider safety issues) 500 mg od
or co-trimoxadole (consider safety issues) 960 mg bd
IV antibiotics (see visual summary)
ACUTE COUGHNICE guidance (last updated: February 2019)
  • Some people may wish to try honey (in over 1s), the herbal medicine pelargonium (in over 12s), cough medicines containing the expectorant guaifenesin (in over 12s) or cough medicines containing cough suppressants, except codeine, (in over 12s). These self-care treatments have limited evidence for the relief of cough symptoms
  • Acute cough with upper respiratory tract infection: no antibiotic
  • Acute bronchitis: no routine antibiotic
  • Acute cough and higher risk of complications (at face-to-face examination): immediate or backup antibiotic
  • Acute cough and systemically very unwell (at face to face examination): immediate antibiotic
  • 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
  • Do not offer a mucolytic, an oral or inhaled bronchodilator, or an oral or inhaled corticosteroid unless otherwise indicated.

 

View visual summary

 

See nice guideline on pneumonia (for prescribing antibiotics in adults with acute bronchitis who have had a C-reactive protein (CRP) test (CRP<20mg/l: no routine antibiotic, CRP 20 to 100mg/l: back-up antibiotic, CRP>100mg/l: immediate antibiotic).

Adults first choice:  doxycycline 200 mg on day 1, then 100 mg od

5 days

Adults alternative frst choice:  amoxicillin 500 mg tds
or clarithromycin 250 mg to 500 mg bd
or reythromycin (preferred if pregnant) 250 mg to 500 mg qds or 500 mg to 1000 mg bd
See child therapeutic options and doses here  
COMMUNITY-ACQUIRED PNEUMONIA—Public Health England guidance (last updated: November 2017)
  • Use CRB65 score to guide mortality risk, place of care, and antibiotics. Each CRB65 parameter scores one: C onfusion (AMT<8); R espiratory rate >30/min; B lood pressure systolic <90, or diastolic <60; age >65
  • Score 0: low risk, consider home-based care;
    1-2: intermediate risk, consider hospital assessment;
    3-4: urgent hospital admission
  • Give safety-net advice and likely  duration of different symptoms, e.g. cough 6 weeks
  • Clinically assess need for dual therapy for atypical
  • Mycoplasma infection is rare in over 65s.

 

View supporting evidence and rationales

CRB65=0: amoxicillin

500 mg tds

 

View child doses here

5 days; (review at 3 days);
7–10 days if poor response
or clarithromycin

500 mg bd 

 

View child doses here

or doxycycline 

200 mg stat, then 100 mg od

CRB65=1–2 and at home (clinically assess need for dual therapy for atypicals): amoxicillin

500 mg tds 

 

View child doses here

7–10 days
and clarithromycin

500 mg bd

 

View child doses here

or doxycycline alone

200 mg stat, then 100 mg od

Urinary tract infections

INFECTION AND KEY POINTS MEDICINEADULT DOSESLENGTH
LOWER URINARY TRACT INFECTIONNICE guidance (last updated: October 2018)
  • Advise paracetamol or ibuprofen for pain
  • Non-pregnant women: back up antibiotic (to use if no improvement in 48 hours or symptoms worsen at any time) or immediate antibiotic
  • Pregnant women, men, children or young people: immediate antibiotic
  • When considering antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data

 

View visual summary

 

See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management

Non-pregnant women first choice: nitrofurantoin (if eGFR ≥45 ml/minute) 100 mg m/r bd 3 days
or trimethoprim (if low risk of resistance)
200 mg bd 3 days
Non-pregnant women second choice: nitrofurantoin (if eGFR ≥45 ml/minute 100 mg m/r bd  3 days
or pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg tds  3 days
or fosfomycin 3 g single dose sachet  single dose
Pregnant women first choice: nitrofurantoin (avoid at term)—if eGFR ≥45 ml/minute 100 mg m/r bd  7 days 
Pregnant women second choice: amoxicillin (only if culture results available and susceptible) 500 mg tds  7 days 
or cefalexin 500 mg bd  7 days 
Treatment of asymptomatic bacteriuriain pregnant women: choose from nitrofurantoin (avoid at term), amoxicillin or cefalexin based on recent culture and susceptibility results

Men first choice:  trimethoprim

200 mg bd 7 days 
or nitrofurantoin (if eGFR ≥45 ml/minute) 100 mg m/r bd 7 days 
Men second choice: consider alternative diagnoses basing antibiotic choice on recent culture and susceptibility results

Children and young people (3 months and over) first choice: trimethoprim (if low risk of resistance)

View child doses here  

or  nitrofurantoin (if eGFR ≥45 ml/minute)

View child doses here
 

Children and young people (3 months and over) second choice:  nitrofurantoin (if eGFR ≥45 ml/minute and not used as first choice)

View child doses here
 
or amoxicillin (only if culture results available and susceptible) View child doses here
 
or cefalexin View child doses here  
ACUTE PYELONEPHRITIS (upper urinary tract)NICE guidance (last updated: October 2018)
  • Advise paracetamol (+/- low-dose weak opioid) for pain for people over 12
  • Offer an antibiotic
  • When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data

 

View visual summary

 

See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management

Non-pregnant women and men first choice:  cefalexin

500 mg bd or tds (up to 1–1.5 g tds or qds for severe infections) 7–10 days
or co-amoxiclav (only if culture results available and susceptible) 500/125 mg tds 7–10 days
or  trimethoprim (only if culture results available and susceptible) 200 mg bd 14 days
or ciprofloxacin (consider safety issues) 500 mg bd 7 days
IV antibiotics (see visual summay)
Pregnant women first choice: cefalexin 500 mg bd or tds (up to 1–1.5 g tds or qds for severe infections) 7–10 days
Pregnant women second choice or IV antibiotics  (see visual summary)
Children and young people (3 months and over) first choice: cefalexin View child doses here  
or co-amoxiclav (only if culture results available and susceptible)    
IV antibiotics  (see visual summary)
RECURRENT URINARY TRACT INFECTIONNICE guidance (last updated: October 2018)
  • First advise about behavioural and personal hygiene measures, and self-care (with D-mannose or cranberry products) to reduce the risk of UTI
  • For postmenopausal women, if no improvement, consider vaginal oestrogen (review within 12 months)
  • For non-pregnant women, if no improvement, consider single-dose antibiotic prophylaxis for exposure to a trigger (review within 6 months)
  • For non-pregnant women (if no improvement or no identifiable trigger) or with specialist advice for pregnant women, men, children or young people, consider a trial of daily antibiotic prophylaxis (review within 6 months)

 

View visual summary

First choice antibiotic prophylaxis: trimethoprim (avoid in pregnancy)

200 mg single dose when exposed to a trigger or

100 mg at night

 

View child doses here

 

 
or nitrofurantoin (avoid at term)—if eGFR ≥45 ml/minute

100 mg single dose when exposed to a trigger or

50–100 mg at night

 

View child doses here

 

 
Second choice antibiotic prophylaxis: amoxicillin

500 mg single dose when exposed to a trigger or

250 mg at night

 

View child doses here

 

 
or cefalexin

500 mg single dose when exposed to a trigger or

125 mg at night

 

View child doses here

 

 
CATHETER-ASSOCIATED URINATY TRACT INFECTIONNICE guidance (last updated: November 2018)
  • Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a urinary catheter
  • Consider removing or, if not possible, changing the catheter if it has been in place for more than 7 days. But do not delay antibiotic treatment
  • Advise paracetamol for pain
  • Advise drinking enough fluids to avoid dehydration
  • Offer an antibiotic for a symptomatic infection
  • When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data
  • Do not routinely offer antibiotic prophylaxis to people with a short-term or long-term catheter.

 

View visual summary

Non-pregnant women and men first choice if no upper UTI symptoms: nitrofurantoin (if eGFR ≥45 ml/minute) 100 mg m/r bd  
or trimethoprim (if low risk of resistance) 200 mg bd  
or amoxicillin (only if culture results available and susceptible) 500 mg tds  
Non-pregnant women and men second choice if no upper UTI symptoms: pivmecillinam (a penicillin) 400 mg initial dose, then 200 mg tds  
Non-pregnant women and men first choice if upper UTI symptoms: cefalexin  500 mg bd or tds (up to 1 g to 1.5 g tds or qds for severe infections)  
or co-amoxiclav (only if culture results available and susceptible) 500/125 mg tds  
or trimethoprim (only if culture results available and susceptible) 200 mg bd  
or ciprofloxacin (consider safety issues) 500 mg bd  
IV antibiotics (see visual summary)    
Pregnant women first choice: cefalexin 500 mg bd or tds (up to 1 g to1.5 g tds or qds for severe infections)  
Pregnant women second choice or IV antibiotics (see visual summary)
Children and young people (3 months and over) first choice: trimethoprim (if low risk of resistance) View child doses here  
or amoxicillin (only if culture results available and susceptible) View child doses here  
or  cefalexin  View child doses here  
or co-amoxiclav (only if culture results available and susceptible) View child doses here  
or IV antibiotics (see visual summary)  
ACUTE PROSTATITISNICE guidance (last updated: October 2018)
  • Advise paracetamol (+/- low-dose weak opioid) for pain, or ibuprofen if preferred and suitable
  • Offer antibiotic
  • Review antibiotic treatment after 14 days and either stop antibiotics or continue for a further 14 days if needed (based on assessment of history, symptoms, clinical examination, urine and blood tests).

 

View visual summary

First choice (guided susceptibilities when available):  ciprofloxacin 500 mg bd 14 days then review
or ofloxacin 200 mg bd  14 days then review
or trimethoprim (if unable to take quinolone) 200 mg bd 14 days then review
Second choice (after discussion with specialist): levofloxacin 500 mg od  14 days then review
or co-trimoxazole 960 mg bd 14 days then review
IV antibiotics (see visual summary)

Meningitis

INFECTION AND KEY POINTSMEDICINEDOSESLENGTH
SUSPECTED MENINGOCOCCAL DISEASE—Public Health England guidance (last updated: February 2019)
  • Transfer all patients to hospital immediately
  • If time before hospital admission, and non-blanching rash, give i.v. benzylpenicillin or i.v. cefotaxime as soon as possible
  • Do not give i.v. antibiotics if there is a definite history of anaphylaxis; rash is not a contraindication.

 

View supporting evidence and rationales

i.v. or i.m. benzylpenicillin Child <1 year: 300 mg
Child 1–9 years: 600 mg
Adult/child 10+ years: 1.2 g
Stat dose; give i.m., if vein cannot be accessed
PREVENTION OF SECONDARY CASE OF MENINGITIS—Public Health England guidance (last updated: November 2017)
  • Only prescribe following advice from your local health protection specialist/consultant
  • Out of hours: contact on-call doctor

 

View supporting evidence and rationales

Gastrointestinal tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSES LENGTH
ORAL CANDIDIASIS—Public Health England guidance (last updated: October 2018)
  • Topical azoles are more effective than topical nystatin
  • Oral candidiasis is rare in immunocompetent adults; consider undiagnosed risk factors, including HIV
  • Use 50 mg fluconazole if extensive/severe candidiasis; if HIV or immunocompromised, use 100 mg fluconazole.

 

View supporting evidence and rationales

 

Miconazole oral gel

2.5 ml of 24 mg/ml qds (hold in mouth after food)

 

View child doses here

7 days; continue for 7 days after resolved
If not tolerated: nystatin suspension

1 ml; 100,000 units/ml qds (half in each side)

 

View child doses here

7 days; continue for 2 days after resolved
Fluconazole capsules

50 mg/100 mg od

 

View child doses here

7–14 days
INFECTIOUS DIARRHOEA—Public Health England guidance (last updated: October 2018)
  • Refer previously healthy children with acute painful or bloody diarrhoea, to exclude E. coli 0157 infection. 
  • Antibiotic therapy is not usually indicated unless patient is systemically unwell. If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin 250–500 mg bd for 5–7 days, if treated early (within 3 days)
  • If giardia is confirmed or suspected—tinidazole 2 g single dose is the treatment of choice.

 

View supporting evidence and rationales

HELICOBACTER PYLORI Public Health England guidance (last updated: February 2019) (see PHE quick reference guide for diagnostic advice)
  • Always test for H. pylori before giving antibiotics
  • Treat all positives, if known duodenal ulcer (DU), gastric ulcer (GU), or low grade MALToma. Number needed to treat in non-ulcear dyspepsia: 14
  • Do not offer eradication for GORD
  • Do not use clarithromycin, metronidazole or quinolone if used in the past year for any infection
  • Penicillin allergy: use PPI plus clarithromycin plus metronidazole. If previous clarithromycin, use PPI plus bismuth salt plus metronidazole plus tetracycline hydrochloride
  • Relapse and no penicillin allergy: use PPI PLUS amoxicillin PLUS clarithromycin or metronidazole (whichever was not used first line)
  • Relapse and previous metronidazole and clarithromycin: use PPI plus  amoxicillin plus either tetracycline or levofloxacin (if tetracycline not tolerated)
  • Relapse and penicillin allergy (no exposure to quinolone): use PPI PLUS metronidazole PLUS levofloxacin
  • Relapse and penicillin allergy (with exposure to quinolone): use PPI PLUS bismuth salt PLUS metronidazole PLUS tetracycline
  • Retest for H. pylori: post DU/GU, or relapse after second-line therapy, using urea breath test or stool antigen test, consider referral for endoscopy and culture.

 

View supporting evidence and rationales

Always use proton-pump inhibitor (PPI)

First line and first relapse and no penicillin allergy: PPI plus two antibiotics

View child doses here

First line 7 days

Relapse 10 days

MALToma 14 days

amoxicillin

1000 mg bd

 

View child doses here

plus clarithromycin

500 mg bd

 

View child doses here

or  metronidazole

400 mg bd

 

View child doses here

Penicillin allergy and previous clarithromycin:
PPI with bismuth subsalicylate and 2 antibiotics
bismuth subsalicylate 525 mg qds
plus metronidazole

400 mg bd

 

View child doses here

plus tetracycline hydrochloride 500 mg qds
Relapse:
PPI plus amoxicillin
amoxicillin

1000 mg bd 

 

View child doses here

plus tetracycline hydrochloride 500 mg qds 
or levofloxacin 250 mg bd
Third line on advice: PPI with 10 days
bismuth subsalicylate 525 mg qds
plus 2 antibiotics as above not previously used
or rifabutin 150 mg bd
or furazolidone 200 mg bd
CLOSTRIDIUM DIFFICILEPublic Health England (last updated: October 2018)
  • Review need for antibiotics, PPIs, and antiperistaltic agents and discontinue use where possible. Mild cases (<4 episodes of stool/day) may respond without metronidazole;
    • 70% respond to metronidazole in 5 days;
    • 92% respond to metronidazole in 14 days
  • If severe (T>38.5°C, or WWC>15, rising creatinine, or signs/symptoms of severe colitis): treat with oral vancomycin, review progress closely, and consider hospital referral.

 

View supporting evidence and rationales

First episode:  metronidazole

400 mg tds

 

View child doses here

10–14 days
Severe/type 027/recurrent: oral vancomycin

125 mg qds

 

View child doses here

10–14 days, then taper
Recurrent or second line: fidaxomicin 200 mg bd 10 days
TRAVELLER'S DIARRHOEAPublic Health England guidance (last updated: October 2018)
  • Prophylaxis rarely, if ever, indicated. Consider standby antimicrobial only for patients at high risk of severe illness, or visiting high risk areas

 

View supporting evidence and rationales

Stand-by:  azithromycin 500 mg od 1–3 days
Prophylaxis/treatment:  bismuth subsalicylate 2 tablets qds 2 days
THREADWORMPublic Health England guidance (last updated: November 2017)
  • Treat all household contacts at the same time
  • Advise hygiene measures for 2 weeks (hand hygiene; pants at night; morning shower, including perianal area). Wash sleepwear, bed linen, and dust and vacuum
  • Child <6 months, add perianal wet wiping or washes 3-hourly

 

View supporting evidence and rationales

Child >6 months: mebendazole 

100 mg stat

 

View child doses here

1 dose; repeat in 2 weeks if persistent
Child <6 months or pregnant (at least in 1st trimester): only hygiene measures for six weeks  

Genital tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSE LENGTH
SEXUALLY TRANSMITTED INFECTION SCREENINGPublic Health England guidance (last updated: November 2017)
  • People with risk factors should be screened for chlamydia, gonorrhoea, HIV, and syphilis. Refer individual and partners to genitourinary medicine (GUM)
  • Risk factors: <25 years; no condom use; recent/frequent change of partner; symptomatic partner; area of high HIV

 

View supporting evidence and rationales

CHLAMYDIA TRACHOMATIS/URETHRITISPublic Health England guidance (last updated: February 2019)
  • Opportunistically screen all sexually active patients aged 15 to 24 years for chlamydia annually and on change of sexual partner
  • If positive, treat index case, refer to GUM and initiate partner notification, testing and treatment
  • As single dose azithromycin has led to increased resistance in GU infections, doxycycline should be used first line for chlamydia and urethritis. 4A+ Advise patient to abstain from sexual intercourse for 7 days after treatment
  • Test positives for reinfection at 3 months following treatment
  • Second line, pregnant, breastfeeding, allergy, or intolerance: azithromycin is most effective. As lower cure rate in pregnancy, test for cure at least 3 weeks after end of treatment
  • Consider referring all patients with symptomatic urethritis to GUM as testing should include Mycoplasma genitalium and Gonorrhoea
  • IfM.genitalium is proven, use doxycycline followed by azithromycin using the same dosing regimen.

 

View supporting evidence and rationales

 

 

First line:  doxycycline 100 mg bd 7 days
Second line/ pregnant/breastfeeding/ allergy/intolerance: azithromycin 1000 mg 

Stat

then 500 mg

2 days (3 days total)

EPIDIDYMITISPublic Health England guidance (last updated: November 2017)
  • Usually due to Gram-negative enteric bacteria in men over 35 years with low risk of STI
  • If under 35 years or STI risk, refer to GUM

 

View supporting evidence and rationales

Doxycycline 100 mg bd 10–14 days
or ofloxacin 200 mg bd 14 days
or ciprofloxacin 500 mg bd  10 days
VAGINAL CANDIDIASISPublic Health England guidance (last updated: October 2018)
  • All topical and oral azoles give over 80% cure
  • Pregnant: avoid oral azoles, the 7 day courses are more effective than shorter ones
  • Recurrent (>4 episodes per year): 150 mg oral fluconazole every 72 hours for three doses induction, followed by one dose once a week for six months maintenance

 

View supporting evidence and rationales

Clotrimazole 500 mg pessary Stat
or fenticonazole 600 mg pessary Stat
or clotrimazole 100 mg pessary 6 nights

or oral fluconazole

150 mg Stat
If recurrent: fluconazole (induction/maintenance) 150 mg every 72 hours  3 doses
then  150 mg once a week 6 months

BACTERIAL VAGINOSISPublic Health England guidance (last updated: November 2017)

  • Oral metronidazole is as effective as topical treatment, and is cheaper
  • 7 days results in fewer relapses than 2 g stat at four weeks
  • Pregnant/breastfeeding: avoid 2 g dose. Treating partners does not reduce relapse

 

View supporting evidence and rationales

Oral metronidazole 400 mg bd 7 days
or 2000 mg Stat
or  metronidazole 0.75% vaginal gel 5g applicator at night 5 nights
or clindamycin 2% cream 5g applicator at night 7 nights
GENITAL HERPESPublic Health England guidance (last updated: November 2017)
  • Advise: saline bathing, analgesia, or topical lidocaine for pain, and discuss transmission
  • First episode: treat within five days if new lesions or systemic symptoms, and refer to GUM
  • Recurrent: self-care if mild, or immediate short course antiviral treatment, or suppressive therapy if more than six episodes per year

 

View supporting evidence and rationales

Oral aciclovir 400 mg tds 5 days
800 mg tds (if recurrent)  2 days
or  valaciclovir 500 mg bd 5 days
or famciclovir  250 mg tds 5 days
1000 mg bd (if recurrent) 1 day
GONORRHOEAPublic Health England guidance (last updated: February 2019)
  • Antibiotic resistance is now very high
  • Use i.m. ceftriaxone if susceptibility not known prior to treatment
  • Use Ciprofloxacin only If susceptibility is known prior to treatment and the isolate is sensitive to ciprofloxacin at all sites of infection
  • Refer to GUM. Test of cure is essential.

 

View supporting evidence and rationales

Ceftriaxone 1000 mg i.m. Stat
or  ciprofloxacin (only if known to be sensitive) 500 mg Stat 
TRICHOMONIASISPublic Health England guidance (last updated: November 2017)
  • Oral treatment needed as extravaginal infection common
  • Treat partners, and refer to GUM for other STIs
  • Pregnancy/breastfeeding: avoid 2 g single dose metronidazoleclotrimazole for symptom relief (not cure) if metronidazole declined.

 

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Metronidazole 400 mg bd 5–7 days
2 g (more adverse effects) Stat
Pregnancy to treat symptoms: clotrimazole 100 mg pessary at night 6 nights
PELVIC INFLAMMATORY DISEASEPublic Health England guidance (last updated: February 2019)
  • Refer women and sexual contacts to GUM
  • Raised CRP supports diagnosis, absent pus cells in HVS smear good negative predictive value
  • Exclude: ectopic, appendicits, endometriosis, UTI, irritable bowel, complicated ovarian cyst, functional pain.
  • Moxifloxacin has greater activity against likely pathogens, but always test for gonorrhoea, chlamydia, and M. genitalium.  IfM. genitalium tests positive use moxifloxacin.

 

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First line therapy: Ceftriaxone 1000 mg i.m. Stat
plus  metronidazole 400 mg bd 14 days
plus  doxycycline 100 mg bd 14 days
Second line therapy: metronidazole
400 mg bd 14 days
plus  ofloxacin 400 mg bd 14 days
or  moxifloxacin alone (first line for M. genitalium associated PID) 400 mg od 14 days

Skin and soft tissue infections

INFECTION AND KEY POINTSMEDICINEADULT DOSELENGTH
Note: Refer to RCGP Skin Infections online training. For MRSA, discuss therapy with microbiologist.
IMPETIGOPublic Health England guidance (last updated: November 2017)
  • Reserve topical antibiotics for very localised lesions to reduce risk of bacteria becoming resistant. Only use mupirocin if caused by MRSA
  • Extensive, severe, or bullous: oral antibiotics

 

View supporting evidence and rationales

Topical fusidic acid

Thinly tds

 

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5 days
If MRSA: topical mupirocin 

2% ointment tds

 

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5 days
More severe:  oral flucloxacillin

250–500 mg qds

 

View child doses here

7 days
or  oral clarithromycin

250–500 mg bd

 

View child doses here

7 days
COLD SORESPublic Health England guidance (last updated: November 2017)
  • Most resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12–18 hours
  • If frequent, severe, and predictable triggers: consider oral prophylaxis: aciclovir 400 mg, twice daily, for 5–7 days

 

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PANTON-VALENTINE LEUKOCIDIN-STAPHYLOCOCCUS AUREUS Public Health England guidance (last updated: November 2017)
  • Panton-Valentine leukocidin (PVL) is a toxin produced by 20.8–46% of S. aureus from boils/abscesses. PVL strains are rare in healthy people, but severe
  • Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking
  • Risk factors for PVL: recurrent skin infections; invasive infections; MSM; if there is more than one case in a home or close community (school children; millitary personnel; nursing home residents; household contacts)

 

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ECZEMAPublic Health England guidance (last updated: November 2017)
  • No visible signs of infection: antibiotic use (alone or with steroids) encourages resistance and does not improve healing
  • With visible signs of infection: use oral flucloxacillin or clarithromycin, or topical treatment (as in impetigo)

 

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LEG ULCERPublic Health England guidance (last updated: February 2019)
  • Ulcers are always colonised
  • Antibiotics do not improve healing unless active infection (purulent exudate/odour; increased pain; cellulitis; pyrexia)

 

View supporting evidence and rationales

Flucloxacillin

500 mg qds

 

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7 days. If slow response continue for another 7 days
or clarithromycin 

500 mg bd

 

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Non-healing ulcers: antimicrobial reactive oxygen gel may reduce bacterial load.
ACNEPublic Health England guidance (last updated: November 2017)
  • Mild  (open and closed comedones) or moderate (inflammatory lesions):
    • first-line: self-care (wash with mild soap; do not scrub; avoid make-up).
    • second-line: topical retinoid or benzoyl peroxide.
    • third-line: add topical antibiotic, or consider addition of oral antibiotic
  • Severe (nodules and cysts): add oral antibiotic (for 3 months maximum) and refer

 

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Second-line: topical retinoid

Thinly od

 

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6–8 weeks
or benzoyl peroxide

5% cream od–bd

 

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6–8 weeks
Third-line: topical clindamycin

1% cream, thinly bd

 

View child doses here

12 weeks
If treatment failure/severe: oral tetracycline

500 mg bd

 

View child doses here

6–12 weeks
or oral doxycycline

100 mg od

 

View child doses here

6–12 weeks
CELLULITIS and ERYSIPELASPublic Health England guidance (last updated: October 2018)
  • Class I: patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone
  • If river or sea water exposure: seek advice
  • Class II: patient febrile and ill, or comorbidity, admit for intravenous treatment, or use outpatient parenteral antimicrobial therapy
  • Class III: if toxic appearance, admit
    Adding clindamycin does not improve outcomes
  • Erysipelas: often facial and unilateral
    Use flucloxacillin for non-facial erysipelas.

 

View supporting evidence and rationales

Flucloxacillin

500 mg qds

 

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7 days; if slow response, continue for a further 7 days
Penicillin allergy: clarithromycin

500 mg bd

 

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Penicillin allergy and taking statins: doxycycline

200 mg stat, then 100 mg od

 

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Facial (non-dental): co-amoxiclav

500/125 mg tds

 

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BITESPublic Health England guidance (last updated: October 2018)
  • Human: thorough irrigation is important. Antibiotic prophylaxis is advised. Assess risk of tetanus, rabies, HIV, and hepatitis B and C
  • Cat: always give prophylaxis
  • Dog: give prophylaxis if: puncture wound; bite to hand, foot, face, joint, tendon, or ligament; immunocompromised, cirrhotic, asplenic, or presence of prosthetic valve/joint
  • Penicillin allergy: Review all at 24 and 48 hours, as not all pathogens are covered

 

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Prophylaxis/treatment: co-amoxiclav

375–625 mg tds

 

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7 days
Human penicillin allergy: metronidazole

400 mg tds

 

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7 days

and clarithromycin

250–500 mg bd

 

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Animal penicillin allergy:  metronidazole

400 mg tds

 

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7 days
and doxycycline

100 mg bd

 

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If pregnant, and rash after penicillin:  ceftriaxone 1–2 g od i.v. or i.m. N/A
SCABIESPublic Health England guidance (last updated: October 2018)

 

  • First choice permethrin: Treat whole body from ear/chin downwards, and under nails.
  • If using permethrin and patient is under 2 years, elderly or immunosuppressed, or if treating with malathion: also treat face and scalp.
  • Home/sexual contacts: treat within 24 hours

 

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Permethrin

5% cream

 

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2 applications, 1 week apart
Permethrin allergy:  malathion

0.5% aqueous liquid

 

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MASTITISPublic Health England guidance (last updated: November 2017)
  • S. aureus is the most common infecting pathogen. Suspect if woman has: a painful breast; fever and/or general malaise; a tender, red breast.
  • Breastfeeding: oral antibiotics are appropriate, where indicated. Women should continue feeding, including from the affected breast

 

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Flucloxacillin 500 mg qds 10–14 days
Penicillin allergy:  erythromycin 250–500 mg qds
or clarithromycin 500 mg bd
DERMATOPHYTE INFECTION: SKINPublic Health England guidance (last updated: February 2019)

 

  • Most cases: use terbinafine as fungicidal; treatment time shorter than with fungistatic imidazoles. If candida possible, use imidazole
  • If intractable, or scalp: send skin scrapings, and if infection confirmed: use oral terbinafine or itraconazole
  • Scalp: oral therapy, and discuss with specialist

 

View supporting evidence and rationales

Topical terbinafine

1% od–bd

 

View child doses here

1–4 weeks
or topical imidazole

1% od–bd

 

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4–6 weeks
For athlete's foot:  topical undecenoates (such as Mycota®)

od–bd

 

View child doses here

DERMATOPHYTE INFECTION: NAILPublic Health England guidance (last updated: October 2018)
  • Take nail clippings; start therapy only if infection is confirmed. Oral terbinafine is more effective than oral azole. Liver reactions 0.1–1% with oral antifungals. If candida or non-dermatophyte infection is confirmed, use oral itraconazole. Topical nail lacquer is not as effective.
  • To prevent recurrence: apply weekly 1% topical antifungal cream to entire toe area
  • Children: seek specialist advice

 

View supporting evidence and rationales

First line:  terbinafine

250 mg od

 

View child doses here

Fingers: 6 weeks
Toes: 12 weeks
Second line:  itraconazole

200 mg bd

 

View child doses here

1 week a month
Fingers: 2 courses
Toes: 3 courses
Stop treatment when continual, new, healthy, proximal nail growth
VARICELLA ZOSTER/CHICKENPOX and HERPES ZOSTER/SHINGLESPublic Health England guidance (last updated: October 2018)
  • Pregnant/immunocompromised/neonate: seek urgent specialist advice
  • Chickenpox: consider aciclovir if: onset of rash <24 hours, and one of the following: >14 years of age; severe pain; dense/oral rash; taking steroids; smoker
  • Give paracetamol for pain relief.
  • Shingles: treat if >50 years (postherpetic neuralgia rare if <50 years) and within 72 hours of rash, or if one of the following: active ophthalmic; Ramsey Hunt; eczema; non-truncal involvement; moderate or severe pain; moderate or severe rash. 
  • Shingles treatment not within 72 hours: consider starting antiviral drug up to one week after rash onset, if high risk of severe shingles or continued vesicle formation; older age; immunocompromised; or severe pain

 

View supporting evidence and rationales

First line for chicken pox and shingles:  aciclovir

800 mg five times daily

 

View child doses here

7 days
Second line for shingles if poor compliance: not for children:  famciclovir 250–500 mg tds or 750 mg bd 7 days
or valaciclovir

1 g tds

 

View child doses here

TICK BITES (LYME DISEASE)Public Health England guidance (last updated: October 2018)
  • Prophylaxis: not routinely recommended in Europe. In pregnancy, consider amoxicillin.
  • If immunocompromised, consider prophylactic doxycycline. Risk increased if high prevalence area and the longer tick is attached to the skin. Only give prophylaxis within 72 hours of tick removal. Give safety net advice about erythema migrans and other possible symptoms that may occur within one month of tick removal
Prophylaxis: doxycycline

200 mg

 

View child doses here

Stat
  • Treatment: Treat erythema migrans empirically; serology is often negative early in infection.
  • For other suspected Lyme disease such as neuroborreliosis (cranial nerve palsy, radiculopathy) seek advice

 

View supporting evidence and rationales

Treatment:  doxycycline

100 mg bd

 

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21 days
First alternative:  amoxicillin

1000 mg tds

 

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Eye infections

INFECTION AND KEY POINTSMEDICINEADULT DOSELENGTH
CONJUNCTIVITISPublic Health England guidance (last updated: October 2018)
  • First line:  bath/clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water, to remove crusting
  • Treat only if severe, as most cases are viral or self-limiting
  • Bacterial conjunctivitis: usually unilateral and also self-limiting. It is characterised by red eye with mucopurulent, not watery discharge. 65% and 74% resolve on placebo by days 5 and 7.
  • Third line: fusidic acid as it has less gram-negative activity

 

View supporting evidence and rationales

Second line:  chloramphenicol 0.5% eye drop or 1% ointment

2 hourly for 2 days, then reduce frequency
3-4 times daily, or just at night if using eye ointment 

 

View child doses here

48 hours after resolution 
Third line:  fusidic acid 1% gel

bd

 

View child doses here

BLEPHARITISPublic Health England guidance (last updated: November 2017)
  • First line: lid hygiene for symptom control, including: warm compresses; lid massage and scrubs; gentle washing; avoiding cosmetics
  • Second line: topical antibiotics if hygiene measures are ineffective after 2 weeks
  • Signs of meibomian gland dysfunction, or acne rosacea: consider oral antibiotics

 

View supporting evidence and rationales

Second line: topical chloramphenicol

1% ointment bd

 

View child doses here

6-week trial
Third line: oral oxytetracycline

500 mg bd

 

View child doses here

4 weeks (initial)
250 mg bd 8 weeks (maintenance)
or oral doxycycline

100 mg od

 

View child doses here

4 weeks (initial)
50 mg od 8 weeks (maintenance)

Suspected dental infections in primary care (outside dental setting)

INFECTION AND KEY POINTSMEDICINEADULT DOSELENGTH
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
Note: Antibiotics do not cure toothache. First-line treatment is with paracetamol and/or ibuprofen; codeine is not effective for toothache
MUCOSAL ULCERATION and INFLAMMATION (SIMPLE GINGIVITIS)Public Health England guidance (last updated: November 2017)
  • Temporary pain and swelling relief can be attained with saline mouthwash (½ tsp salt in warm water). Use antiseptic mouthwash if more severe, and if pain limits oral hygiene to treat or prevent secondary infection
  • The primary cause for mucosal ulceration or inflammation (aphthous ulcers; oral lichen planus; herpes simplex infection; oral cancer) needs to be evaluated and treated 

 

View supporting evidence and rationales

Chlorhexidine 0.12–0.2%, (do not use within 30 mins of toothpaste)

1 min bd with 10 ml

 

View child doses here

  • Always spit out after use
  • Use until lesions resolve or less pain allows for oral hygiene
or hydrogen peroxide 6%

2–3 mins bd–tds with 15 ml in ½ glass warm water

 

View child doses here

ACUTE NECROTISING ULCERATIVE GINGIVITISPublic Health England guidance (last updated: November 2017)
  • Refer to dentist for scaling and hygiene advice
  • Antiseptic mouthwash if pain limits oral hygiene
  • Commence metronidazole if systemic signs and symptoms

 

View supporting evidence and rationales

Chlorhexidine 0.12–0.2% (do not use within 30 minutes of toothpaste)

1 minute bd with 10 ml

 

View child doses here

Until pain allows for oral hygiene
or hydrogen peroxide 6%

2–3 mins bd–tds with 15 ml in ½ glass warm water

 

View child doses here

Metronidazole

400 mg tds

 

View child doses here

3 days  
PERICORONITISPublic Health England guidance (last updated: November 2017)
  • Refer to dentist for irrigation and debridement
  • If persistent swelling or systemic symptoms, use metronidazole or amoxicillin
  • Use antiseptic mouthwash if pain and trismus limit oral hygiene

 

View supporting evidence and rationales

Metronidazole 

400 mg tds

 

View child doses here

3 days
or amoxicillin 

500 mg tds

 

View child doses here

3 days
Chlorhexidine 0.2% (do not use within 30 minutes of toothpaste)

1 minute bd with 10 ml

 

View child doses here

Until less pain allows for oral hygiene
or hydrogen peroxide 6%

2–3 minutes bd–tds with 15 ml in ½ glass warm water

 

View child doses here

DENTAL ABSCESSPublic Health England guidance (last updated: October 2018)
Regular analgesia should be the first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscesses are not appropriate. Repeated antibiotics alone, without drainage, are ineffective in preventing the spread of infection. Antibiotics are only recommended if there are signs of severe infection, systemic symptoms, or a high risk of complications. Patients with severe odontogenic infections (cellulitis, plus signs of sepsis; difficulty in swallowing; impending airway obstruction) should be referred urgently for hospital admission to protect airway, for surgical drainage and for i.v. antibiotics. The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients, and should only be used if there is no response to first line drugs
  • If pus is present, refer for drainage, tooth extraction, or root canal
  • Send pus for investigation
  • If spreading infection (lymph node involvement or systemic signs, i.e. fever or malaise) ADD metronidazole
  • Use clarithromycin in true penicillin allergy and, if severe, refer to hospital

 

View supporting evidence and rationales

Amoxicillin

500 mg–1000 mg tds

 

View child doses here

Up to 5 days, review at 3 days
or phenoxymethylpenicillin

500 mg–1000 mg qds

 

View child doses here

Metronidazole

400 mg tds

 

View child doses here

Penicillin allergy:  clarithromycin

500 mg bd

 

View child doses here

ABBREVIATIONS
bd=twice a day; eGFR=estimated glomerular filtration rate; i.m.=intramuscular; i.v.=intravenous; MALToma=mucosa-associated lymphoid tissue lymphoma; m/r=modified release; MRSA=methicillin-resistant Staphylococcus aureus; MSM=men who have sex with men; stat=given immediately; od=once daily; tds=3 times a day; qds=4 times a day

full guideline available from…
www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care
www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/antimicrobial-prescribing-guidelines

Public Health England. Summary of antimicrobial prescribing guidance: managing common infections—PHE context, references and rationales. Updated October 2018.
Public Health England, National Institute for Health and Care Excellence. Summary of antimicrobial prescribing guidance—managing common infections. Updated October 2018.

First included: August 2015, updated November 2018.