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Summary of antimicrobial prescribing guidance—managing common infections

  • This guidance aims to:
    • improve the management of common infections in primary care
    • minimise the emergence of antimicrobial resistance in the community

Principles of treatment

  1. The PHE sections of the summary table are based on the best available evidence, but use professional judgement and involve patients in management decisions
  2. PHE sections of this summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website
  3. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate
  4. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
  5. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice
  6. 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
  7. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from your local microbiologist
  8. Limit prescribing over the telephone to exceptional cases
  9. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs
  10. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited
  11. 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
  12. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects
  13. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity
  14. The PHE sections of the table summary support the 2017 to 2019 NHS England Antibiotic Quality Premium ambition to reduce inappropriate antibiotic prescribing in the management of infections in primary care

Upper respiratory tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSES (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
ACUTE SORE THROAT

 

  • 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.

 

First choice:  phenoxymethylpenicillin

500 mg qds or

1000 mg bd

For child doses, see NG84

5–10 days
Penicillin allergy: clarithromycin

250–500 mg bd

For child doses, see NG84

5 days
or erythromycin (preferred if pregnant) 

250–500 mg qds

500–1000 mg bd

For child doses, see NG84

5 days
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 (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
SCARLET FEVER (GAS)
  • 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

Phenoxymethylpenicillin

500 mg qds

10 days

Penicillin allergy:  clarithromycin

250–500 mg bd

5 days

Optimise analgesia and give safety netting advice

ACUTE OTITIS MEDIA (child doses)
  • 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

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
  • 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 

or 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

 

  • 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

 

First choice:  phenoxymethylpenicillin

500 mg qds

For child doses, see NG91

 5 days

Penicillin allergy: doxycycline (not in under 12s)

200 mg on day one then 100 mg od

For child doses, see NG91

5 days

or clarithromycin

500 mg bd

For child doses, see NG91

or erythromycin (preferred if pregnant)

250–500 mg qds

or

500–1000 mg bd

For child doses, see NG91

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

500/125 mg tds

For child doses, see NG91

5 days

Lower respiratory tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSES (SEE BNF FOR CHILDREN FOR CHILD DOSE)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 COPD

  • Treat with antibiotics only if purulent sputum and increased shortness of breath and/or increased sputum volume
  • Consider 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
ACUTE COUGH and BRONCHITIS
  • Antibiotics have little benefit if no co-morbidity
  • First line:  self-care and safety netting advice
  • 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; delayed antibiotics if 20–100 mg/l; immediate antibiotics if >100 mg/l
Second line: amoxicillin 500 mg tds

5 days

Penicillin allergy: doxycycline 200 mg stat then 100 mg od
COMMUNITY-ACQUIRED PNEUMONIA
  • Use CRB65 score to guide mortality risk, place of care, and antibiotics. Each CRB65 parameter scores one: Confusion (AMT<8); Respiratory rate >30/min; Blood 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 days 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

INFECTION AND KEY POINTS MEDICINEADULT DOSES (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
LOWER URINARY TRACT INFECTION
  • 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
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 cephalexin 500 mg bd  7 days 
Treatment of asymptomatic bacteriuria in pregnant women: choose from nitrofurantoin (avoid at term), amoxicillin or cephalexin 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)

For child doses, see NG109  

or  nitrofurantoin (if eGFR ≥45 ml/minute)

For child doses, see NG109  

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

For child doses, see NG109  
or amoxicillin (only if culture results available and susceptible) For child doses, see NG109  
or cephalexin For child doses, see NG109  
ACUTE PYELONEPHRITIS (upper urinary tract)
  • 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

Non-pregnant women and men first choice: cephalexin

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 NG111)
Pregnant women first choice: cephalexin 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 NG111)
Children and young people (3 months and over) first choice: cephalexin For child doses, see NG111  
or co-amoxiclav (only if culture results available and susceptible) For child doses, see NG111  
IV antibiotics (see NG111)
RECURRENT URINARY TRACT INFECTION
  • 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)
First choice antibiotic prophylaxis: trimethoprim (avoid in pregnancy)

200 mg single dose when exposed to a trigger or

100 mg at night

For child doses, see NG112

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

For child doses, see NG112

Second choice antibiotic prophylaxis: amoxicillin

500 mg single dose when exposed to a trigger or

250 mg at night

For child doses, see NG112

or cephalexin

500 mg single dose when exposed to a trigger or

125 mg at night

For child doses, see NG112

ACUTE PROSTATITIS
  • 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)
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 NG110)

Meningitis

INFECTION AND KEY POINTSMEDICINEDOSESLENGTH
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
  • Out of hours: contact on-call doctor

Gastrointestinal tract infections

INFECTION AND KEY POINTSMEDICINEADULT DOSES (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
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 2.5 ml of 24 mg/ml qds (hold in mouth after food) 7 days; continue for 7 days after resolved
If not tolerated: nystatin suspension 1 ml; 100,000 units/ml qds (half in each side) 7 days; continue for 2 days after resolved
Fluconazole capsules 50 mg/100 mg od 7–14 days
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)
  • If giardia is confirmed or suspected—tinidazole 2 g single dose is the treatment of choice
HELICOBACTER PYLORI (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 previous metronidazole and clarithromycin: use PPI plus  amoxicillin plus either tetracycline or levofloxacin (if tetracycline not tolerated)
  • 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 two antibiotics

First line 7 days

Relapse 10 days

MALToma 14 days

amoxicillin 1 g bd
plus clarithromycin 500 mg bd
or  metronidazole 400 mg bd
Penicillin allergy and previous clarithromycin:
PPI with bismuth subsalicylate and 2 antibiotics
bismuth subsalicylate 525 mg qds
plus metronidazole 400 mg bd
plus tetracycline hydrochloride 500 mg qds
Relapse:
PPI plus amoxicillin
amoxicillin 1 g bd
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 DIFFICILE
  • 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
First episode:  metronidazole 400 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 standby 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 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
Child >6 months:  mebendazole 100 mg stat 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 (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
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 15–24 years. Treat partners and refer to GUM. Test positives for reinfection at 3 months
  • Pregnancy/breastfeeding: azithromycin is most effective. As lower cure rate in pregnancy, test for cure at least 3 weeks after end of treatment

 

First line: azithromycin 1000 mg Stat
or doxycycline 100 mg bd 7 days
Pregnancy/breastfeeding: azithromycin 1000 mg  Stat
or erythromycin 500 mg bd 14 days 
or 500 mg qds 7 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 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
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 VAGINOSIS

  • 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
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 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
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
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 1000 mg 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 to treat symptoms: clotrimazole 100 mg pessary at night 6 nights
PELVIC INFLAMMATORY DISEASE
  • 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 culture for gonorrhoea and chlamydia, and test for Mycoplasma genitalium. 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 14 days
or moxifloxacin 400 mg od 14 days
Gonorrhoea suspected: ceftriaxone 500 mg i.m. Stat
plus metronidazole 400 mg bd 14 days
plus doxycycline 100 mg bd 14 days

Skin and soft tissue infections

INFECTION AND KEY POINTSMEDICINEADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
Note: Refer to RCGP Skin Infections online training. For MRSA, discuss therapy with microbiologist.
IMPETIGO
  • 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
Topical fusidic acid Thinly tds 5 days
If MRSA: topical mupirocin  2% ointment tds 5 days
More severe: oral flucloxacillin 250–500 mg qds 7 days
or 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; MSM; 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)
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 ulcers: antimicrobial reactive oxygen gel may reduce bacterial load.
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
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
    Adding clindamycin does not improve outcomes
  • 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
Facial (non-dental): co-amoxiclav 500/125 mg tds
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/treatment: co-amoxiclav 375–625 mg tds 7 days
Human penicillin allergy: metronidazole 400 mg tds

7 days

and clarithromycin

250–500 mg bd

Animal penicillin allergy: metronidazole 400 mg tds 7 days
and doxycycline 100 mg bd
If pregnant, and rash after penicillin: ceftriaxone 1–2 g od i.v. or i.m. N/A
SCABIES

 

  • 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

 

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: 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

 

Topical terbinafine 1% od–bd 1–4 weeks
or topical imidazole 1% od–bd 4–6 weeks
For athlete's foot: topical undecenoates (such as Mycota®) 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 0.1–1% 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
  • 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
First line for chicken pox and shingles: aciclovir 800 mg five times daily 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
TICK BITES (LYME DISEASE)
  • 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 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
Treatment: doxycycline 100 mg bd 21 days
First alternative: amoxicillin 1000 mg tds

Eye infections

INFECTION AND KEY POINTSMEDICINEADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
CONJUNCTIVITIS
  • 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
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 ointment 
48 hours after resolution 
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
Second line: topical 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)

Suspected dental infections in primary care (outside dental setting)

INFECTION AND KEY POINTSMEDICINEADULT DOSE (SEE BNF FOR CHILDREN FOR CHILD DOSE)LENGTH
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)
  • 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 
Chlorhexidine 0.12–0.2%, (do not use within 30 mins of toothpaste) 1 min bd with 10 ml
  • 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
ACUTE NECROTISING ULCERATIVE GINGIVITIS    
  • Refer to dentist for scaling and hygiene advice
  • Antiseptic mouthwash if pain limits oral hygiene
  • Commence metronidazole if systemic signs and symptoms
Chlorhexidine 0.12–0.2% (do not use within 30 minutes of toothpaste) 1 minute bd with 10 ml Until pain allows for oral hygiene
or hydrogen peroxide 6% 2–3 mins bd–tds with 15 ml in ½ glass warm water
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  400 mg tds 3 days
or amoxicillin  500 mg tds 3 days
Chlorhexidine 0.2% (do not use within 30 minutes of toothpaste) 1 minute bd with 10 ml Until less pain allows for oral hygiene
or hydrogen peroxide 6% 2–3 minutes bd–tds with 15 ml in ½ glass warm water
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 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
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
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.