Skin and Soft Tissue Infection Dermatophyte Take samples only if oral treatment is being considered.

hyte Take samples only if oral treatment is being considered. Antibiotic guidelines for the
infections of Skin or foot -Terbinafine ● 1% topical OD-BD for 7-14 days
Impetigo Small localised Fusidic acid 2% ● cream or ointment TDS for 5 days the skin Groin or foot - ‘azole’ ● 1% topical OD-BD for 4-6 weeks. management of infection in
Small localised MRSA positive only: use Mupirocin 2% ● cream or Alternative for foot only: primary care – 2016
ointment TDS for 5 days Topical Undecanoates (Mycota®) ● BD continued for 1-2 weeks after
Generalised; Flucloxacillin▲ 500mg PO QDS, for 7 days healing
Clarithromycin● 250-500mg PO BD, for 7 days Candida infection: Principles
‘azole’ ● 1% topical OD-BD continued for 1-2 weeks after healing 1) This guidance is based on the best available evidence, as referenced, but
MRSA Nasal: Naseptin ● nasal cream QDS for 10 days or (if allergic to
If intractable, send skin scrapings before starting oral treatment: professional judgement should be used and patients should be involved in
(meticillin- peanut, soya or chlorhexidine) 2% Mupirocin ● in paraffin base TDS
Terbinafine ● 250mg oral OD the decision.
resistant for 5 days
Skin: 4 weeks Groin: 2-4 weeks Foot: 2-6 weeks
Staphylococc Skin: 4% Chlorhexidine gluconate ● wash/shampoo OD for 5 days 2) Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics
or Itraconazole ●
us aureus) Alternatives: 7.5% Povidone iodine● or 2% Octenidine ● / Octenisan (eg co-amoxiclav, quinolones and cephalosporins) when narrow spectrum
Skin or groin: either 100 mg OD for 15 days, or 200 mg OD for 7 days
● OD for 5 days antibiotics remain effective, as they increase risk of Clostridium difficile,
Foot: either 100mg oral OD for 30 days or 200mg BD for 7 days
ACTIVE TREATMENT: for MRSA confirmed by lab results: MRSA and resistant UTIs.
Doxycycline● alone 100mg bd for 7 days or Trimethoprim● 200mg Fungal nail Take nail clippings and only start treatment if infection is confirmed by
BD for 7 days 3) A dose and duration of treatment for adults is usually suggested, but may
infections the laboratory.
need modification for age, weight and renal function. In severe or recurrent
Superficial only: Amorolfine ● 5% nail lacquer, 1-2x / weekly
Cellulitis Consider admission for severe and rapid detrition cases. If slow cases consider a larger dose or longer course.
Fingernails: 6 months , Toenails:12 months
response to PO treatment, continue for a further 7 days.
1st line: Terbinafine ● 250mg PO OD 4) Lower threshold for antibiotics in immunocompromised or those with
Flucloxacillin▲ 500mg QDS PO or 7 days
Clarithromycin● 500mg PO BD or Doxycycline ● 200mg stat and
Fingernails: 6-12 weeks Toenails: 3-6 months multiple morbidities; consider culture and seek advice.
then 200mg OD thereafter for 7 days 2nd line: Itraconazole●200mg po BD for 7 days each month.
Fingernails: 2 courses Toenails: 3 courses 5) Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
Mild Facial Flucloxacillin ▲ 500mg QDS or Doxycycline ● 200mg stat and then 6) Consider a no, or delayed, antibiotic strategy for acute self-limiting upper
Scabies Permethrin 5% cream, two applications 7 days apart.
cellulitis (no 200mg od thereafter for 7 days respiratory tract infections A+
eye involvement) If allergy: Malathion ● 0.5% aqueous liquid. In two applications, 7 days
Continue for a further 7 days if slow response.
apart 7) Limit prescribing over the telephone to exceptional cases.
Varicella Chicken pox—If started within 24 hours of onset of rash and patient is Treat whole body and household and close contacts within 24hr of each other
Zoster >14 years, or severe pain, dense or oral rash, secondary household 8) Avoid widespread use of topical antibiotics (especially those agents also
Cat or dog Review all infected bites at 24-48 hours
(chicken pox), case, smoker, severe respiratory disease or on steroids, then available as systemic preparations, e.g. fusidic acid).
bites Consider tetanus and rabies risk (animals) and HIV and hepatitis
Herpes Zoster consider treatment
(humans) 9) In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose
(shingles) & Shingles-treat if <72 h of rash onset and >50 years old or if non-
Co-amoxiclav▲ 250/125mg - 500/125mg PO TDS, 7 days. metronidazole (2 g). Short-term use of nitrofurantoin (at term, theoretical
Cold Sores truncal involvement or moderate/severe pain or rash. Urgent if
Metronidazole● 200 - 400mg PO TDS plus Doxycycline● 100mg PO risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
ophthalmic involvement
BD for 7 days Trimethoprim also unlikely to cause problems unless poor dietary folate
1st line chicken pox/shingles: Aciclovir● 800mg five times a day for 7
intake or taking another folate antagonist such as antiepileptic.
days Human bites Review all infected bites at 24-48 hours
Cold sore: Topical Aciclovir● 5% 4-hourly for 5-10 days Consider tetanus and rabies risk (animals) and HIV and hepatitis 10)We recommend clarithromycin as it has less side-effects than
2nd line for shingles if compliance a problem (humans) erythromycin, greater compliance as twice rather than four times daily &
Valaciclovir ● 1g TDS for 7 days Co-amoxiclav▲ 250/125mg - 500/125mg PO TDS , 7 days. generic tablets are similar cost. The syrup formulation of clarithromycin is
or Famciclovir ● 500mg TDS or 750mg BD for 7 days Metronidazole● 200-400mg PO TDS plus Doxycycline● 100mg PO BD only slightly more expensive than erythromycin and could also be
or Metronidazole● 200-400mg PO TDS plus Clarithromycin● 250- considered for children.
Scarlet Fever 1st line: 500mg PO BD for 7 days
(Scarletina) Phenoxymethylpenicillin ▲ Where ‘best-guess’ therapy has failed or special circumstances
Adults, 500 mg (increase to 1 g if necessary) every 6 hours, Leg Ulcers Ulcers are always colonised. Culture swabs and antibiotics indicated exist, advice can be obtained from a Medical Microbiologist at
Child up to 1 year; 62.5 mg (increase to 12.5 mg/kg if necessary) only if active infection. your local hospital:
every 6 hours Flucloxacillin▲ 500mg - 1g (dependant on BMI) PO QDS for 7 days. If Worthing Hospital: 01903 205111 ext 85569
1–6 years, 125 mg (increase to 12.5 mg/kg if necessary) every 6 slow response continue for a further 7 days St Richard’s Hospital: 01243 788122 ext 3547
hours Clarithromycin● 500mg PO BD for 7 days East Surrey Hospital: 01737 768511 ext 2778
6–12 years, 250 mg (increase to 12.5 mg/kg if necessary) every 6 If slow response continue for a further 7 days Crawley Hospital: 01293 600300 ext 3093
hours BSUH: 01273 696955 exts 4615, 4596 or 7516
12-17 years, 250mg – 500mg every 6 hours Meningitis PHE for Surrey and Sussex: Mon—Fri, 9am-5pm 0344 2253861
Out of hours 0844 9670069
2nd line Transfer all patients to hospital immediately as an emergency.. IF time before
Erythromycin● (doses may be doubled in severe infection) admission, and non-blanching rash, give IV benzylpenicillin or cefotaxime, unless
Adult and child over 8 years; 250–500 mg every 6 hours or 0.5–1 g
definite hypersensitivity. Give IV (or IM if cannot find vein). Clostridium difficile associated diarrhoea (CDAD) warning
every 12 hours Benzylpenicillin▲: Cefotaxime▼
Quinolones (ciprofloxacin and levofloxacin), cephalosporins and clindamycin
Child 1 month–2 years; 125 mg every 6 hours or 250 mg every 12 Neonate 75mg/kg Neonate 50mg/kg are powerful precipitates of CDAD. Use these antibiotics prudently. For the
hours
treatment of CDAD, see gastrointestinal infections
2–8 years; 250 mg every 6 hours or 500 mg every 12 hours. Child 1 month - 1year: 300mg Child 1 month - 12 years 50mg/kg (max 1g)
or Clarithromycin● (doses may be doubled in severe infection)
Child 1 year - 9 years: 600mg Child 12 - 18 years 1g
Adult and child over 12 years; 250 mg every 12 hours. Contains a penicillin. Do not use with patients known to be
Child 10 - 18 years: 1.2g Adult 1g ▲
Child body-weight under 8 kg; 7.5 mg/kg twice daily; penicillin-allergic.
8–11 kg; 62.5 mg twice daily Adult: 1.2g
12–19 kg; 125 mg twice daily Do not use in patients known to have anaphylaxis to penicillins
Prevention of secondary cases of meningitis - only prescribe following advice from ▼
20–29 kg; 187.5 mg twice daily Public Health Doctor - contact via local hospital switchboard. - discuss these with a Microbiologist
30–40 kg; 250 mg twice daily PHE for Surrey and Sussex: Mon—Fri, 9am-5pm 0344 2253861 ●
Out of hours 0844 9670069 Suitable for use if any penicillin allergy.
Genital Tract Infection
Vaginal 1st line: non-pregnant
candidosis Clotrimazole● 10% vaginal cream stat or 500mg pessary, PV at
night (stat dose) or Fluconazole● 150mg PO stat.
1st line: pregnant
Clotrimazole ● 100 mg pessary at night for 6 nights or Miconazole ●
2% cream 5 g intravaginally bd for 7 days
Bacterial Metronidazole● 400mg PO BD for 5-7 days or 2g PO stat, (not in
vaginosis pregnancy) or Metronidazole● 0.75% vaginal gel, 1 applicatorful
(5g) at night for 5 days or Clindamycin● 2% vaginal cream, 1
applicatorful (5g) at night for 7 days
Chlamydia Opportunistically screen all patients aged 15-25years
trachomatis Treat partners and refer to GUM clinic. If pregnant, refer GUM/
sexual health services
Non pregnant: Azithromycin● 1g stat or Doxycycline● 100mg BD for
7 days .
Pregnant: Erythromycin ● 500mg bd for 14 days
OR Amoxicillin ▲ 500mg tds for 7 days
OR Azithromycin ● 1g (off-label use) stat (only use if alternatives are
inappropriate) or breastfeeding
Trichomoniasis Treat partners and refer to GUM service
Metronidazole● 400mg PO BD for 5 to 7 days or 2g PO stat (avoid
stat dose if pregnant or breastfeeding). If metronidazole treatment
declined - Clotrimazole ● PV 100mg ON for 6 nights.
Pelvic Refer sexual contacts to GUM service.
inflammatory If low risk of Gonococcal infection - Metronidazole● 400mg PO BD
Disase (PID) plus Ofloxacin● 400mg PO BD for 14 days
If high risk of GC (partner has it, severe symptoms, sex abroad) -
Ceftriaxone ▼ 500mg IM stat plus Metronidazole ● 400mg PO BD
and Doxycycline● 100mg BD for 14 days
Balanitis For suspected non-specific dermatitis, with or without candidal
colonization:2
Clotrimazole ● 1% or Miconazole ● 2% cream BD until symptoms
settle
or oral Fluconazole ● 150mg stat
If suspected / confirmed Gardnerella-associated: Metronidazole ●
400mg bd for 7 days
If suspected / confirmed Streptococcal balanitis: Flucloxacillin ▲
500mg QDS for 7 days or if penicillin allergic: Erythromycin ●
500mg QDS for 7 days or Clarithromycin ● 250mg BD for 7 days.
Acute Patients >35 years send MSU for culture and patients <35 send first
prostatitis catch urine
1st line: Ciprofloxacin● 500mg PO BD or Ofloxacin● 200mg PO BD
for 28 days
2nd line: Trimethoprim ● 200mg PO BD for 28 days
Ear Nose and Throat Infections Consider NO or DELAYED antibiotics
Acute sore Phenoxymethylpenicillin▲ 500mg QDS or 1g BD for 10 days, (1g
throat (viral) QDS when severe) Clarithromycin● 250-500mg BD for 5 days
Acute otitis 1st line: Acetic acid● 2% ear spray (EarCalm) TDS for 7 days
externa 2nd line: Neomycin + steroid ● 3 drops TDS for 7 -14 days
(usually Oral antibiotics are rarely indicated:
Pseudomonas) Flucloxacillin▲ 500mg QDS for 7 days.
Clarithromycin● 500mg BD for 7 days
Otitis Media Acute: Amoxicillin▲ TDS Clarithromycin● BD for 5 days
Acute sinusitis 1st line: Amoxicillin▲ 500mg TDS (1g if severe) for 7 days
(Many are viral) 2nd line : Co-amoxiclav▲ 500/125mg TDS (if persistent) for 7 days
Doxycycline● 200mg stat then 100mg OD for 7 days (200mg OD if
severe)
Urinary Tract Infections
Treat women with:
Uncomplicated
UTI in women  severe or ≥ 3 symptoms (frequency, urgency, dysuria,
polyuria, suprapubic tenderness, haematuria)
 mild or ≤ 2 symptoms: perform dipstick on cloudy urine to
guide treatment .
1st line: Nitrofurantoin●100mg M/R BD or Trimethoprim●
200mg BD for 3 days
2nd line: Perform culture in all treatment failures
Pivmecillinam ▲400mg TDS for 3 days
Amoxicillin▲ resistance is common; Use only if susceptible.
Community multi-resistant Extended-spectrum Beta-
lactamase (ESBL) E., if confirmed: consider nitrofurantoin●
(or fosfomycin ● 3g stat on advice of microbiologist)
Lower UTI in Treat for 7 days
pregnancy 1st line: Amoxicillin▲ 500mg TDS (if known to be
susceptible) or Nitrofurantoin● 100mg M/R BD or
Trimethoprim● 200mg BD (Off label). Give Folic acid 5mg OD
if 1st trimester
2nd line: Cefalexin▼ 500mg BD or 250mg QDS
UTI in children Refer urgently for assessment if < 3 months
(send MSU & refer Uncomplicated lower UTI >3 months old
to NICE guidelines) 1st line: Nitrofurantoin● (3 day course is off label) (not M/R
See Children’s unless > 12 years old) or Trimethoprim● for 3 days
BNF for all doses. 2nd line: Amoxicillin▲ (if susceptible) or Cefalexin▼
Upper UTI — consider hospital admission:
1st line: Co-amoxiclav▲ for 7-10 days
2nd line: Cefixime▼ for 7-10 days
Acute Admit if not improved after 24 hrs of commencing antibiotics.
pyelonephritis First line: Ciprofloxacin● 500mg BD for 7 days or
Trimethoprim ● 200mg BD for 14 days (if susceptible)
2nd line: Co-amoxiclav▲ 500/125mg TDS for up to 14 days
as deemed necessary
Recurrent UTI in Post-coital doses are off-label
women Infection associated with intercourse: Nitrofurantoin● 50-
(> 3 UTIs/year) 100mg or Trimethoprim● 100mg stat post-coital dose to be
taken within 2 hours of intercourse
(Prophylaxis) Long-term low dose prophylaxis: Nitrofurantoin ● 50-100mg
at night
or Trimethoprim ● 100mg at night
(or Methenamine ● 1g every 12 hours after discussion with
Microbiology/Urology)
Catheter- Do not offer antibiotic prophylaxis routinely
associated UTI Lower UTI:
Nitrofurantoin● 100mg m/r BD for 7 days or
Trimethoprim● 200mg BD for 7 days (avoid if trimethoprim
taken in the last year)
Upper UTI: (fever or loin pain) See pyelonephritis
Lower UTI in Men A urine sample is recommended because UTI in men is
generally regarded as complicated (it results from an
anatomic or functional abnormality)
1st line: Treat for 7 days
Nitrofurantoin●100mg m/r BD or Trimethoprim ● 200mg BD
2nd line: Perform culture in all treatment failures
Pivmecillinam ▲400mg TDS for 7 days
Amoxicillin▲resistance is common; only use if
susceptible.Community multi-resistant Extended-spectrum
Beta-lactamase (ESBL) E., if confirmed: consider
nitrofurantoin● (or fosfomycin ● 3g stat plus 2nd 3g dose 3
days later on advice of microbiologist)
Gastro-intestinal Tract Infections
Eradication First and second line - twice daily dosing for 7 days
of H. pylori PPI with Amoxicillin ▲1g BD
plus either Clarithromycin ● 500mg BD or Metronidazole● 400mg
BD
Do not use Clarithromicin, Metronidazole or Quinolone if used
in the past year for any infection
Relapse & previous Metronidazole & Clarithromycin - 7 day dosing.
PPI with Amoxicillin ▲ 1g BD plus tetracycline
hydrochloride ▲ 500mg QDS or levofloxacin ● 250mg BD
Penicillin allergy & previous Metronidazole & Clarithromycin
PPI with Bismuthate ● (De-nol tab®) 240mg BD
plus Metronidazole● 400mg BD plus Tetracycline hydrochloride ▲
500mg QDS, dosing for 7 days
Infectious Antibiotic therapy is not indicated unless the patient is systemically
unwell or treatment is advised by a microbiologist.
diarrhoea
If Campylobacter suspected consider Clarithromycin ● 250-500mg
BD for 5-7days if treated within 3 days
Threadworms 1st line for adults and children aged >6 months:
Mebendazole ● 100mg stat tablet (off label if <2yrs)
Repeat in 2 weeks if infestation persists
For children aged <6 months:
6 weeks strict hygiene to prevent faecal-oral re-infection
C. difficile First episode (mild and moderate CDI only):
diarrhoea Metronidazole ● 400-500mg TDS for 10 -14 days
Second episode or severe/type027:
Oral Vancomycin ●125mg QDS for 10-14 days
Recurrence The same antibiotic that had been used initially can be
used to treat the first recurrence. After a first recurrence, the risk of
another infection increases to 45–60%. In line with the recent
evidence, fidaxomicin should be preferred for patients with recurrent
CDI, whether mild, moderate or severe, because of their increased
risk of further recurrences.
Diverticulitis 1st line: Co-amoxiclav▲ 500/125mg TDS for at least 7 days (7-10
days)
2nd line or if allergic to co-amoxiclav:
Metronidazole ● 400mg TDS for 7 days plus
Ciprofloxacin ● 500mg BD for at least 7 days (7-10 days).
Respiratory Tract Infections
Amoxicillin▲ 500mg TDS for 5 days
Acute
cough/ Doxycycline● 200mg stat then 100mg OD for 5 days (total)
bronchitis Clarithromycin● 500mg BD for 5 days if amoxicillin and doxycycline
unsuitable
Acute Amoxicillin▲ 500mg TDS for 5 days
exacerbation If resistance risk factors: Co-amoxiclav▲ 500/125mg TDS for 5 days
of COPD Doxycycline● 200mg stat then 100mg—200mg OD for 5 days or
Clarithromycin● 500mg BD for 5 days
Community-acquired Pneumonia - treatment in the community
Use Confusion Respiratory rate BP 65 score to help guide and review.
If CRB65=0 Amoxicillin▲ 500mg TDS for 5 days or
Clarithromycin● 500mg BD for 5 days or Doxycycline● 200mg stat
then 100mg OD for 5 days
If CRB65=1 Amoxicillin▲ 500mg-1g TDS and Clarithromycin● 500mg BD both
and treated at for 7— 10 days
home Doxycycline● 200mg stat then 100mg—200mg OD for 7 –10 days
Influenza — Oseltamivir 75 mg BD for 5 days
also refer to Severely immunocompromised patients ≥ 5yr or where oseltamivir
NICE resistance suspected: Zanamivir 10 mg (2 inhalations by diskhaler)
recommendat BD for 5 days.
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