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Management and treatment of common infections—antibiotic guidance for primary care: for consultation and local adaptation

  • This guidance aims to:
    • provide a simple, effective, economical and empirical approach to the management and treatment of common infections
    • minimise the emergence of antimicrobial resistance in the community

Principles of treatment

  • This guidance is based on the best available evidence, but use professional judgement and involve patients in management decisions
  • This guidance should not be used in isolation; it should be supported with patient information about safety netting, delayed/back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website
  • Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate
  • Consider a ‘no’ or ‘delayed/back-up’ antibiotic strategy for acute self-limiting upper respiratory tract infections and mild UTI symptoms
  • In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned
  • Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from your local microbiologist
  • Limit prescribing over the telephone to exceptional cases
  • Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs
  • Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course
  • For child doses, please refer to the BNF for Children
  • Refer to the BNF for further dosing and interaction information (e.g. the interaction between macrolides and statins), and check for hypersensitivity
  • Have a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice
  • Avoid widespread use of topical antibiotics, especially in those agents also available as systemic preparations (e.g. fusidic acid)
  • In pregnancy, take specimens to inform treatment. Where possible, avoid tetracyclines, aminoglycosides, quinolones, azithromycin, clarithromycin, and high dose metronidazole (2 g stat), unless the benefits outweigh the risks. Penicillins, cephalosporins, and erythromycin are safe in pregnancy. 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

Upper respiratory tract infections

ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT
INFLUENZA 
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 (including up to two weeks post-partum); children under six months; adults 65 years or older; chronic respiratory disease (including COPD and asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; diabetes mellitus; chronic neurological, renal or liver disease; 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
ACUTE SORE THROAT
  • Avoid antibiotics as 82% of cases resolve in 7 days, and pain is only reduced by 16 hours
  • Use FeverPAIN ScoreFever in last 24 hours; P urulence; A ttend rapidly under three days; severely I nflamed tonsils; N o cough or coryza
  • Score 0–1: 13–18% streptococci—no antibiotic
  • 2 3: 34–40% streptococci—3-day delayed antibiotic
  • 4–5: 62–65% streptococci—if severe, immediate antibiotic, or 48-hour delayed antibiotic
  • Advise paracetamol, self-care, and safety net
  • 10 days’ penicillin has lower relapse than 5 days in patients under 18 years of age  
Fever pain 0–1: self-care    
Fever pain 2–3: delayed prescription of phenoxymethylpenicillin 500 mg qds or 1 g bd (if mild)
If severe: 500 mg qds
5–10 days
Penicillin allergy:  clarithromycin 250 mg bd
If severe: 500 mg bd
5 days
Penicillin allergy in pregnancy:  erythromycin 250–500 mg qds 5 days
SCARLET FEVER
Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Observe immunocompromised individuals (diabetes; women in the puerperal period; chickenpox) as they are at increased risk of developing invasive infection. First line (mild): analgesia Phenoxymethylpenicillin 500 mg qds 10 days
Penicillin allergy:  clarithromycin 250–500 mg bd 5 days
ACUTE OTITIS MEDIA (child doses)
  • Optimise analgesia and target antibiotics. Acute otitis media (AOM) resolves in 60% of cases in 24 hours without antibiotics. Antibiotics reduce pain only at two days, and do not prevent deafness.
  • Consider 2 or 3-day delayed, or immediate antibiotics for pain relief if: <2 years and bilateral AOM bulging membrane, or symptom score >8 for: fever; tugging ears; crying; irritability; difficulty sleeping; less playful; eating less (0 = no symptoms; 1 = a little; 2 = a lot).
  • All ages with otorrhoea
  • Antibiotics to prevent mastoiditis
Amoxicillin Neonate: 30 mg/kg tds
1–11 months: 125 mg tds
1–4 years: 250 mg tds
>5 years: 500 mg tds
5 days
Penicillin allergy:  erythromycin <2 years: 125 mg qds
2–7 years: 250 mg qds
>8 years: 250–500 mg qds
5 days
or  clarithromycin

 

 

1 month–11 years: 7.5 mg/kg–250 mg bd (weight dosing)
12–18 years: 250 mg bd
5 days
ACUTE OTITIS EXTERNA
  • 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
Second line: topical acetic acid 2% 1 spray tds 7 days 
Topical neomycin sulphate with corticosteroid 3 drops tds 7 days (min) to 14 days (max)
If cellulitis: flucloxacillin 250 mg qds
If severe: 500 mg qds
7 days
SINUSITIS (ACUTE)
  • Symptoms <10 days: do not offer antibiotics as most resolve in 14 days without, and antibiotics only offer marginal benefit after 7 days
  • Symptoms >10 days: no antibiotic, or back-up antibiotic if several of: purulent nasal discharge; severe localised unilateral pain; fever; marked deterioration after initial milder phase
  • Systemically very unwell, or more serious signs and symptoms: immediate antibiotic
  • Suspected complications: e.g. sepsis, intraorbital or intracranial, refer to secondary care
  • Self-care: paracetamol/ibuprofen for pain/fever. Consider high-dose nasal steroid if >12 years. Nasal decongestants or saline may help some
No antibiotics: self-care
First line for delayed:  phenoxymethylpenicillin 500 mg qds
1 g bd (if severe)
5 days
Penicillin allergy or intolerance:  doxycycline 200 mg stat then 100 mg od
or  clarithromycin 500 mg bd
Very unwell or worsening:  co‑amoxiclav 500/125 mg tds 5 days
Mometasone 200 mcg bd 14 days

Lower respiratory tract infections

ILLNESS AND GOOD PRACTICE POINTS   
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 quinolones (including levofloxacin) for proven resistant organisms
ACUTE COUGH and BRONCHITIS
  • Antibiotics have little benefit if no co-morbidity
  • Second line: 7-day delayed antibiotic, safety net, and advise that symptoms can last 3 weeks
  • Consider immediate antibiotics if >80 years of age and one of: hospitalisation in past year; taking oral steroids; insulin-dependent diabetic; congestive heart failure; serious neurological disorder/stroke, or >65 years with two of the above
  • Consider CRP  if antibiotic is being considered
  • No antibiotics if CRP<20 mg/l and symptoms for > 24 hours; delayedantibiotics if 20–100 mg/l; immediate antibiotics if >100 mg/l
First line:  self-care and safety netting advice
Second line: amoxicillin 500 mg tds 5 days
Penicillin allergy: doxycycline 200 mg stat then 100 mg od 5 days
ACUTE EXACERBATION OF COPD
  • Treat with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume
  • Risk factors for antibiotic resistance: severe COPD (MRC>3); co-morbidity; frequent exacerbations; antibiotics in the last 3 months
Amoxicillin 500 mg tds 5 days   
or doxycycline 200 mg stat then 100 mg od
or clarithromycin 500 mg bd
If at risk of resistance:  co-amoxiclav 500/125 mg tds  5 days
COMMUNITY-ACQUIRED PNEUMONIA
  • 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
  • Mycoplasma infection is rare in over 65s
CRB65=0: amoxicillin 500 mg tds 5 days; review at 3 days;
7–10 if poor response
or clarithromycin 500 mg bd 
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  7–10 days
and clarithromycin 500 mg bd
or doxycycline alone 200 mg stat then 100 mg od

Urinary tract infections

ILLNESS AND GOOD PRACTICE POINTS TREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT
Note: As antibiotic resistance and Escherichia coli bacteraemia in the community is increasing, use nitrofurantoin first line, always give safety net and self-care advice, and consider risks for resistance. Give TARGET urinary tract infection (UTI) leaflet, and refer to the PHE UTI guidance for diagnostic information
UTI IN ADULTS (LOWER)
  • All patients first line antibiotic: nitrofurantoin if GFR >45 ml/min
  • If GFR 30–45, only use if no alternative
  • Treat women with severe/≥3 symptoms
  • Women <65 years (mild/≤2 symptoms): pain relief, and consider delayed antibiotic
    If urine not cloudy, 97% NPV of no UTI
    If urine cloudy, use dipstick to guide treatment: nitrite, leukocyctes, blood all negative 76% NPV; nitrite plus blood or leukocytes 92% PPV of UTI
  • Men <65 years: consider prostatitis and send MSU, or if symptoms mild or non-specific, use negative dipstick to exclude UTI
  • >65 years: treat if fever >38°C, or 1.5°C above base twice in 12 hours, and >1 other symptom
  • If treatment failure: always perform culture

 

First line: nitrofurantoin 100 mg m/r bd, or 50 mg i/r qds (bd dose increases compliance) Women: 3 days
Men: 7 days
If low risk of resistance:  trimethoprim 200 mg bd
If first line unsuitable and GFR <45 ml/min: pivmecillinam 400 mg stat then 200 mg tds (400 mg if high resistance risk)
If organism susceptible:  amoxicillin 500 mg tds
If high resistance risk:  fosfomycin Women: 3 g stat
Men: 3 g stat 3 days later (unlicensed)
  • Low risk of resistance: younger women with acute UTI and no risk
  • Risk factors for increased resistance include: care-home resident; recurrent UTI; hospitalisation for >7 days in the last 6 months; unresolving urinary symptoms; recent travel to a country with increased resistance; previous UTI resistant to trimethoprim, cephalosporins, or quinolones
  • If risk of resistance: send urine for culture and susceptibilities; safety net
UTI IN PATIENTS WITH CATHETERS

UTI in patients with catheters: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely. Do not use prophylactic antibiotics for catheter change unless there is a history of catheter-change-associated UTI or trauma. Take sample if new onset of delirium, or one or more symptoms of UTI.

UTI IN PREGNANCY
  • Send mid-stream urine (MSU) for culture; start antibiotics in all with significant positive culture, even if asymptomatic
  • First line: nitrofurantoin, unless at term
  • Second line: trimethoprim; avoid if low folate status, or on folate antagonist
  • Third line: cephalosporins, as risk of C. difficile
First line: nitrofurantoin (avoid at term) 100 mg m/r bd or 50 mg i/r qds 7 days   
Second line:  trimethoprim (give folate if first trimester) 200 mg bd (off-label)
Third line:  cefalexin 500 mg bd
ACUTE PROSTATITIS   
  • Send MSU for culture and start antibiotics
  • 4 week course may prevent chronic prostatitis
  • Quinolones achieve high prostate concentrations
Ciprofloxacin 500 mg bd  28 days
or ofloxacin 200 mg bd
Second line:  trimethoprim 200 mg bd
UTI IN CHILDREN
  • Child <3 months: refer urgently for assessment
  • Child > 3 months: use positive nitrite to guide antibiotic use; send pre-treatment MSU
  • Imaging: refer if child <6 months, or recurrent or atypical UTI
Lower UTI: nitrofurantoin or trimethoprim 3 days
Second line:  cefalexin  
If organism susceptible:  amoxicillin  
Upper UTI: refer to paediatrics to: obtain a urine sample for culture; assess for signs of systemic infection; consider systemic antimicrobials
ACUTE PYELONEPHRITIS
  • If admission not needed, send MSU for culture and susceptibility testing, and start antibiotics
  • If no response within 24 hours, seek advice
  • If extended-spectrum beta-lactamase risk, and on advice from a microbiologist, consider i.v. antibiotic via outpatient parenteral antimicrobial therapy
Ciprofloxacin 500 mg bd 7 days
or co-amoxiclav 500/125 mg tds 7 days
If organism sensitive:  trimethoprim 200 mg bd 14 days
RECURRENT UTI IN NON-PREGNANT WOMEN (2 IN 6 MONTHS or≥3 IN A YEAR)
  • First line: advise simple measures, including hydration; ibuprofen for symptom relief. Cranberry products work for some women
  • Second line: stand-by or post-coital antibiotics
  • Third line: antibiotic prophylaxis. Consider methenamine if no renal/hepatic impairment
Antibiotic prophylaxis:
First line:
nitrofurantoin
100 mg m/r At night or post-coital stat (off-label) 3–6 months, then review recurrence rate and need
Second line:  ciprofloxacin 500 mg
If recent culture sensitive:  trimethoprim 100 mg
Methenamine hippurate 1 g bd 6 months

Meningitis

ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT 
SUSPECTED MENINGOCOCCAL DISEASE   
  • Transfer all patients to hospital immediately
  • If time before hospital admission, and non-blanching rash, give i.v. benzylpenicillin or i.v. cefotaxime. Do not give i.v. antibiotics if there is a definite history of anaphylaxis; rash is not a contraindication
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
or
i.v. or i.m. cefotaxime
Child <12 years: 50 mg/kg
Adult/child ≥12 years: 1 g
Prevention of secondary case of meningitis: only prescribe following advice from your local health protection specialist/consultant

Gastrointestinal tract infections

ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT
ORAL CANDIDIASIS   
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 Miconazole oral gel 20mg/ml qds (hold in mouth after food) 7 days; further 2 days after symptoms resolve
If not tolerated: nystatin suspension 4 ml; 100,000 units/ml qds (half in each side)
Fluconazole capsules 50 mg/100 mg od 7–14 days
HELICOBACTER PYLORI
  • Treat all positives, if known duodenal ulcer (DU), gastric ulcer (GU), or low grade MALToma
  • 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 previous metronidazole and clarithromycin: use PPI plus  amoxicillin plus either tetracycline or levofloxacin
  • 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
Always use proton-pump inhibitor (PPI)
PPI plus amoxicillin 1 g bd 7–14 days; MALToma 14 days           
plus clarithromycin 500 mg bd
or  metronidazole 400 mg bd
Penicillin allergy:
PPI plus bismuth subsalicylate
525 mg bd
plus metronidazole 400 mg bd
plus tetracycline hydrochloride 500 mg qds 
Relapse:
PPI plus amoxicillin
1 g bd
plus tetracycline hydrochloride 500 mg qds 
or levofloxacin 250 mg bd
Third line on advice 14 days PPI plus bismuth salt plus two antibiotics not previously used, or rifabutin 150 mg bd, or furazolidone 200 mg bd.
INFECTIOUS DIARRHOEA   
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)
CLOSTRIDIUM DIFFICILE
  • Stop unneccesary antibiotics, PPIs, and antiperistaltic agents. Mild cases (<4 episodes of diarrhoea/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
First episode: metronidazole 400–500 mg tds 10–14 days
Severe/type 027/recurrent: oral vancomycin 125 mg qds 10–14 days, then taper
Recurrent or second line:  fidaxomicin 200 mg bd 10 days
TRAVELLER'S DIARRHOEA
Prophylaxis rarely, if ever, indicated. Consider stand-by antimicrobial only for patients at high risk of severe illness, or visiting high risk areas Stand-by: azithromycin 500 mg od 1–3 days
Prophylaxis/treatment:  bismuth subsalicylate 2 tablets qds 2 days
THREADWORM
  • Treat all household contacts at the same time
  • Advise hygiene measures for two 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 three hourly
Child >6 months:  mebendazole 100 mg stat Stat dose; repeat in 2 weeks if persistent
Child <6 months: hygiene measures alone for six weeks

Genital tract infections

ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT
SEXUALLY TRANSMITTED INFECTION SCREENING
  • 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
CHLAMYDIA TRACHOMATIS/URETHRITIS
  • Opportunistically screen all patients aged 16–24 years. Treat partners and refer to GUM. Repeat test for cure in all at three months.
  • Pregnancy/breastfeeding: azithromycin is most effective. As lower cure rate in pregnancy, test for cure at least three weeks after end of treatment
First line: azithromycin 1 g Stat
or doxycycline 100 mg bd 7 days
Pregnancy/breastfeeding:  azithromycin 1 g  Stat
or erythromycin 500 mg bd 10–14 days 
or amoxicillin  500 mg tds  7 days
EPIDIDYMITIS
  • 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
Doxycycline 100 mg bd 10–14 days
or ofloxacin 200 mg bd 14 days
or ciprofloxacin 500 mg bd  10 days
VAGINAL CANDIDIASIS
  • All topical and oral azoles give over 70% cure
  • Pregnancy: avoid oral azoles and use intravaginal treatment for 7 days
  • Recurrent (>4 episodes per year): 150mg oral fluconazole every 72 hours for three doses induction, followed by one dose once a week for six months maintenance
Clotrimazole 500 mg pessary Stat
or 10% cream 14 nights
or miconazole 100 mg pessary Stat 
or oral fluconazole 150 mg
Recurrent: fluconazole (induction/maintenance)  150 mg every 72 hours  3 doses
THEN  150 mg once a week 6 months
BACTERIAL VAGINOSIS
  • Oral metronidazole is as effective as topical treatment, and is cheaper. Seven days results in fewer relapses than 2 g stat at four weeks
  • Pregnant/breastfeeding: avoid 2 g dose. Treating partners does not reduce relapse
Oral metronidazole 400 mg bd 7 days
2 g Stat
or  metronidazole 0.75% vaginal gel 5g applicator at night 5 nights
or clindamycin 2% cream 5g applicator at night 7 nights
GENITAL HERPES
  • 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
First line: 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
1 g bd (if recurrent) 1 day
GONORRHOEA
  • Antibiotic resistance is now very high
  • Use i.m. ceftriaxone and oral azithromycin; refer to GUM. Test of cure is essential
Ceftriaxone 500 mg i.m. Stat
plus oral azithromycin 1 g Stat 
TRICHOMONIASIS
  • Oral treatment needed as extravaginal infection common. Treat partners, and refer to GUM for other STIs
  • Pregnancy/breastfeeding: avoid 2 g single dose metronidazole; clotrimazole for symptom relief (not cure) if metronidazole declined
Metronidazole 400 mg bd 5–7 days
2 g (more adverse effects) Stat
Pregnancy for symptoms: clotrimazole 100 mg pessary at night 6 nights
PELVIC INFLAMMATORY DISEASE
  • Refer women and sexual contacts to GUM.
  • Always culture for gonorrhoea and chlamydia. If gonorrhoea likely (partner has it; sex abroad; severe symptoms), use regimen with ceftriaxone, as resistance to quinolones is high
Metronidazole 400 mg bd 14 days
plus ofloxacin 400 mg bd
GC: metronidazole 400 mg bd
plus doxycycline 100 mg bd
plus  ceftriaxone 500 mg i.m. Stat

Skin and soft tissue infections

ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT 
Note: Refer to RCGP Skin Infections online training. For MRSA, discuss therapy with microbiologist.
IMPETIGO
  • Localised lesions only: topical antibiotics to reduce risk of resistance. Only use mupirocin if caused by MRSA
  • Extensive, severe, or bullous: oral antibiotics
Topical fusidic acid Thinly tds 5 days
MRSA: topical mupirocin  2% ointment tds 5 days
Oral flucloxacillin 250–500 mg qds 7 days
Oral clarithromycin 250–500 mg bd 7 days
COLD SORES
  • 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
PANTON-VALENTINE LEUKOCIDIN STAPHYLOCOCCUS AUREUS  
  • 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; men who have sex with men; if there is more than one case in a home or close community (school children; millitary personnel; nursing home residents; household contacts)
ECZEMA
  • 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)
ACNE  
  • 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
First-line: self-care
Second-line: topical retinoid Thinly od 6–8 weeks
or benzoyl peroxide 5% cream od–bd 6–8 weeks
Third-line: topical clindamycin 1% cream, thinly bd 12 weeks
If treatment failure/severe: oral tetracycline 500 mg bd 6–12 weeks
or oral doxycycline 100 mg od 6–12 weeks
CELLULITIS and ERYSIPELAS
  • 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
  • Erysipelas: often facial and unilateral. Use flucloxacillin for non-facial erysipelas.
Flucloxacillin 500 mg qds 7 days; if slow response, continue for a further 7 days
Penicillin allergy: clarithromycin 500 mg bd
Penicillin allergy and taking statins: doxycycline 200 mg stat then 100 mg od
Unresolving:  clindamycin 300 mg qds
Facial (non-dental): co-amoxiclav 500/125 mg tds
LEG ULCER
  • Ulcers are always colonised. Antibiotics do not improve healing unless active infection (purulent exudate/odour; increased pain; cellulitis; pyrexia)
Flucloxacillin
500 mg qds As for cellulitis
or clarithromycin 500 mg bd
Non-healing: antimicrobial reactive oxygen gel may reduce bacterial load
BITES
  • 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
Prophylaxis or treatment: co-amoxiclav 375–625 mg tds 7 days
Penicillin allergy: Human:  metronidazole 400 mg tds
and clarithromycin 250–500 mg bd
Animal:  metronidazole 400 mg tds
and doxycycline 100 mg bd
SCABIES
  • Treat whole body from ear/chin downwards, and under nails
  • Under 2 years/elderly: also treat face/scalp
  • Home/sexual contacts: treat within 24 hours
Permethrin 5% cream 2 applications, 1 week apart
Permethrin allergy: malathion 0.5% aqueous liquid
MASTITIS
  • 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
Flucloxacillin 500 mg qds 10–14 days
Penicillin allergy: erythromycin 250–500 mg qds
or clarithromycin 500 mg bd
DERMATOPHYTE INFECTION: SKIN

 

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

 

Topical terbinafine 1% od–bd 1–4 weeks
or topical imidazole 1% od–bd 4–6 weeks
For athlete's foot:  topical undecenoates (e.g. undecenoic acid with zinc undecenoate cream) od–bd
DERMATOPHYTE INFECTION: NAIL
  • Take nail clippings; start therapy only if infection is confirmed. Oral terbinafine is more effective than oral azole. Liver reactions 0.1 to 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
First line:  terbinafine 250 mg od Fingers: 6 weeks
Toes: 12 weeks
Second line:  itraconazole 200 mg bd 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/SHINGLES
  • 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
  • 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
  • Treatment not within 72 hours: consider starting antiviral drug up to one week after rash onset, if high risk of severe shingles or complications (continued vesicle formation; older age; immunocompromised; severe pain)
Aciclovir 800 mg five times daily 7 days
Second line for shingles if poor compliance:  valaciclovir 1 g tds
or  famciclovir 250–500 mg bds
or  750 mg bd

Eye infections

ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT
CONJUNCTIVITIS
  • 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. Second line: fusidic acid as it has less gram-negative activity
First line:
self-care
   
Second line: chloramphenicol 0.5% eye drop 2 hourly for 2 days, then reduce frequency
3-4 times daily, or just at night if using eye drops
48 hours after resolution   
or 1% ointment
Third line: fusidic acid 1% gel bd
BLEPHARITIS
  • 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
First line: self-care
Second line: chloramphenicol
1% ointment bd 6 week trial
Third line:  oral oxytetracycline 500 mg bd 4 weeks (initial)
250 mg bd 8 weeks (maintenance)
or oral doxycycline 100 mg od 4 weeks (initial)
50 mg od 8 weeks (maintenance)

Dental infections in primary care (outside dental setting)

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

 
ILLNESS AND GOOD PRACTICE POINTSTREATMENTADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)DURATION OF TREATMENT 
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)
  • Temporary pain and swelling relief can be attained with saline mouthwash. 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   
Saline mouthwash ½ tsp salt in warm water
  • Always spit out after use
  • Use until lesions resolve/less pain allows for oral hygiene
Chlorhexidine 0.12–0.2%, (do not use within 30 mins of toothpaste) 1 min bd with 10 ml
Hydrogen peroxide 6% (spit out after use) 2–3 mins bd–tds with 15 ml in ½ glass warm water
ACUTE NECROTISING ULCERATIVE GINGIVITIS    
  • Refer to dentist for scaling and hygiene advice
  • Antiseptic mouthwash if pain limits oral hygiene
  • Commence metronidazole in the presence of systemic signs and symptoms
Chlorhexidine 0.12–0.2% See above dosing for mucosal ulceration Until pain allows for oral hygiene
or hydrogen peroxide 6%
Metronidazole 400 mg tds 3 days  
PERICORONITIS 

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

Metronidazole  500 mg–1 g tds Up to 5 days; review at 3 days
or amoxicillin  500 mg–1g qds
Chlorhexidine 0.2%   400 mg tds
or hydrogen peroxide 6% 500 mg bd
DENTAL ABSCESS
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 IV 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
Amoxicillin 500 mg–1g tds Up to 5 days, review at 3 days
or phenoxymethylpenicillin 500 mg–1 g qds
Metronidazole 400 mg tds
Penicillin allergy: clarithromycin 500 mg bd

full guideline available from…
www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care

Public Health England. Management of infection guidance for primary care for consultation and local adaptation. Updated September 2017.
First included: August 2015, updated September 2017. 

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Read the Guidelines in Practice article Common infections: when is the right time to prescribe an antimicrobial? for more information on implementing the PHE guidance on Management and treatment of common infections—antibiotic guidance for primary care: for consultation and local adaptation

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