Oxfordshire-Antimicrobial-ADULT-Guidelines-Primary-Care - 2014

OXFORDSHIRE
ADULT
ANTIMICROBIAL
PRESCRIBING
GUIDELINES FOR
PRIMARY CARE
2nd Edition
May 2012
Version 2.2 (March 2014)

OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
GUIDELINES FOR PRIMARY CARE
Contents
Interim Update to Guidance– Approved by APCO March 2014 .................................. 4
INTRODUCTION................................................................................................................... 5
Aims ....................................................................................................................................... 5
Principles of Treatment ....................................................................................................... 5
Healthcare Associated Infections (HCAIs) ...................................................................... 6
Penicillin Allergy ................................................................................................................... 6
Useful Websites ................................................................................................................... 7
Current Version .................................................................................................................... 7
RESPIRATORY TRACT INFECTIONS ............................................................................. 8
UPPER RESPIRATORY TRACT INFECTIONS ............................................................ 8
Influenza ............................................................................................................................ 8
Acute Sore Throat ........................................................................................................... 9
Acute Otitis Media ........................................................................................................... 9
Acute Otitis Externa......................................................................................................... 9
Acute Rhinosinusitis ...................................................................................................... 10
Dental Abscess .............................................................................................................. 10
ANUG (Acute Necrotising Ulcerative Gingivitis) ....................................................... 11
Oral Candidiasis............................................................................................................. 11
LOWER RESPIRATORY TRACT INFECTIONS ....................................................... 12
Acute Bronchitis ............................................................................................................. 12
Acute Exacerbation of COPD ...................................................................................... 12
Community-Acquired Pneumonia ............................................................................... 13
Exacerbation of Bronchiectasis ................................................................................... 14
URINARY TRACT INFECTIONS..................................................................................... 15
UTI in Men & Women (including older people) ............................................................. 15
Recurrent UTI in Women.................................................................................................. 16
Recurrent UTIs in Men ...................................................................................................... 16
UTIs in a Person with a Catheter .................................................................................... 16
Acute Pyelonephritis ......................................................................................................... 17
UTIs in Pregnancy ............................................................................................................. 17
GENITAL TRACT INFECTIONS ..................................................................................... 18
STI screening ..................................................................................................................... 18
Chlamydia trachomatis infections ................................................................................... 18
Vaginal Candidiasis ........................................................................................................... 18
Bacterial Vaginosis ............................................................................................................ 19
Trichomoniasis ................................................................................................................... 19
Pelvic Inflammatory Disease ........................................................................................... 19
Acute Prostatitis ................................................................................................................. 19
Chronic Prostatitis ............................................................................................................. 20
Urethritis .............................................................................................................................. 20
Epididymoorchitis (<35yrs or increased risk of STI) .................................................... 20
Epididymoorchitis (>35yrs or low risk of STI) ................................................................ 20
GASTRO-INTESTINAL TRACT INFECTIONS .......................................................... 21
Eradication of Helicobacter pylori ................................................................................... 21
Gastroenteritis/ Infectious Diarrhoea .............................................................................. 21
Clostridium difficile Infection (CDI) .................................................................................. 22
Traveller’s Diarrhoea ......................................................................................................... 22
Acute Diverticulitis ............................................................................................................. 22
Giardia ................................................................................................................................. 22
Threadworms ..................................................................................................................... 22
Other Worms ...................................................................................................................... 22
SKIN & SOFT TISSUE INFECTIONS .......................................................................... 23
Impetigo............................................................................................................................... 23
Eczema ............................................................................................................................... 23
Cellulitis ............................................................................................................................... 23
Leg Ulcers ........................................................................................................................... 24
Diabetic Foot Infection ...................................................................................................... 24
Wound Infections (Non surgical) ..................................................................................... 24
MRSA .................................................................................................................................. 24
Bites ..................................................................................................................................... 25
Human ............................................................................................................................. 25
Cat or Dog....................................................................................................................... 25
Mastitis ................................................................................................................................ 25
Acne Vulgaris ..................................................................................................................... 26
Rosacea .............................................................................................................................. 27
Perioral Dermatitis ............................................................................................................. 27
Boils / Cysts/ Abscesses / Carbuncles ........................................................................... 27
Paronychia .......................................................................................................................... 28
Folliculitis............................................................................................................................. 28
Scabies................................................................................................................................ 28
Head Lice ............................................................................................................................ 29
FUNGAL SKIN INFECTIONS .......................................................................................... 30
Fungal / Dermatophyte infection of the skin – Dermatophytes .................................. 30
Fungal / Dermatophyte infection of the skin - Scalp Dermatophytes ........................ 31
Fungal / Dermatophyte infection of the proximal fingernail or toenail ....................... 31
Pityriasis Versicolor ........................................................................................................... 32
Intertrigo .............................................................................................................................. 32
VIRAL INFECTIONS ......................................................................................................... 33
Herpes simplex .................................................................................................................. 33
Cold Sores ...................................................................................................................... 33
First attack genital. ........................................................................................................ 33
Recurrent attacks of genital herpes - intermittent therapy. ..................................... 33
Recurrent attacks of genital herpes - suppressive therapy. ................................... 33
Varicella zoster................................................................................................................... 33
Herpes zoster ..................................................................................................................... 34
Treatment Advice: CHICKENPOX .................................................................................. 34
Treatment Advice: SHINGLES ........................................................................................ 35
Prophylaxis Advice: High Risk Contacts of Patients with Chickenpox or Shingles 35
HEPATITIS ........................................................................................................................... 36
HEPATITIS B ..................................................................................................................... 36
HEPATITIS C ..................................................................................................................... 36
EYE INFECTIONS .............................................................................................................. 36
Conjunctivitis ...................................................................................................................... 36
Styes .................................................................................................................................... 36
MENINGITIS ....................................................................................................................... 37
Bacterial Meningitis and / or Suspected Meningococcal Disease ......................... 37
Meningococcal Meningitis Prophylaxis ...................................................................... 37
ASPLENIA ............................................................................................................................. 38
Prophylaxis for Asplenia ................................................................................................... 38
Interim Update to Guidance– Approved by APCO March 2014
1. Advice regarding use of nitrofuratoin in renal impairment has been updated in line with
MHRA guidance. Nitrofurantoin for urinary tract infections is contraindicated in
patients with <60 mL/min creatinine clearance (previously use with caution)
Sections affected:
o UTI in Men & Women (including older people)

o Recurrent UTI in Women ≥ 3 UTIs/year
o UTIs in a Person with a Catheter
o UTIs in Pregnancy
2. Update of Acne section to include more recent guidance approved by APCO in

November 2013. If oral antibiotic required: 1st line now lymecycline and 2nd line
doxycycline.
Sections affected:
o Acne Vulgaris
3. Change of preferred macrolide from erythromycin to clarithromycin (except in

pregnancy and breastfeeding in line with HPA and CKS guidance). The cost of
clarithromycin has fallen over the past year and is now more in line with
erythromycin costs. Clarithromycin is associated with a more favourable side effect
profile than erythromycin and is therefore generally better tolerated.
Sections affected:
o Acute sore throat, penicillin allergy
o Acute Otitis Media, penicillin allergy
o Dental Abscess, penicillin allergy
o Acute bronchitis, penicillin allergy
o Acute Exacerbation of COPD, penicillin allergy
o Community Acquired Pneumonia, penicillin allergy or in combination with amoxicillin
for higher CRB score
o Exacerbation of Bronchiectasis, penicillin allergy
o Gastroenteritis/ Infectious Diarrhoea, Suspected Campylobacter
o Bites, in combination with metronidazole in penicillin allergy
o Boils / Cysts/ Abscesses / Carbuncles, penicillin allergy
o Paronychia, penicillin allergy
INTRODUCTION
This guidance is for Oxfordshire General Practitioners, Nurse Practitioners and members
of Primary Healthcare Teams.
It is also available for use within Oxford Health NHS Foundation Trust for Oxfordshire
patients that are provided with community services and specialist mental health services.
Aspects of this guidance may be relevant for community hospitals, as are the secondary
care Oxford University Hospitals NHS Trust Antimicrobial Guidelines.
http://orh.oxnet.nhs.uk/Pharmacy/Pages/abguidelines.aspx
Aims
1. To provide a simple, empirical approach to the treatment of common infections in adults
(16 years and over).
2. To promote the safe, effective and economic use of antimicrobials.
3. To minimise the emergence of bacterial resistance in the community and wider health
economy.
4. To reduce healthcare associated infections.
Principles of Treatment
1. This guidance is based on the best available evidence but professional judgement should
be used and patients should be involved in the decision.
2. Always document the indication for antimicrobials and the rationale behind any deviations
from these guidelines within the patient’s notes.
3. A dose and duration of treatment for adults is usually suggested, but may need
modification for severity of disease, age, weight and renal function.
4. Treatment of most infections should not exceed 7 days.
5. Have a lower threshold for antimicrobials in immunocompromised or those with co-
morbidities.
6. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit.
7. Consider a no, or delayed, antimicrobial strategy for acute self-limiting upper respiratory
A+
tract infections.
8. Limit prescribing of antimicrobials over the telephone to exceptional cases.
9. Use simple generic antimicrobials if possible. Avoid broad spectrum antimicrobials (e.g.
co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antimicrobials
remain effective, as they increase risk of Clostridium difficile, MRSA and resistant Gram
negative infections.
10. Review microbiology results regularly, and if treatment required select the most
appropriate antimicrobial with the lowest ‘CDI or MRSA risk’
11. Avoid widespread use of topical antimicrobials (especially those agents also available as
systemic preparations, e.g. fusidic acid).
12. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole
(2 g). Short-term use of nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is
unlikely to cause problems to the foetus. Trimethoprim also unlikely to cause problems
unless poor dietary folate intake or taking another folate antagonist such as antiepileptic.
2
Avoid co-amoxiclav in patients in possible pre-term labour (may be associated with an
increased risk of necrotising enterocolitis in neonates).
13. Where a ‘best guess’ therapy has failed or special circumstances exist, advice can be
obtained during normal working hours from the OUH Duty Microbiologist on 01865
220880 or bleep 4077 via JR switchboard. Out of hours advice can be obtained by
contacting the Microbiology SpR on call via the JR switchboard.
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion.
Key: NNT = Number Needed to Treat
5
Version 2.2. Approved by APCO: April 2012 (up-dated March 2014); Review Date: April 2015
Healthcare Associated Infections (HCAIs)
Inappropriate use of broad-spectrum antimicrobials is associated with the acquisition of
3-6
Methicillin Resistant Staphylococcus aureus (MRSA) and the induction of Clostridium
7-12
difficile Infection (CDI) as well as the selection of antimicrobial resistant bacteria such as
13,14
Extended-Spectrum Beta-Lactamase (ESBL)-producing Gram-negative bacteria.
Whilst all antimicrobials are able to pre-dispose patients to CDI and MRSA, quinolones,
cephalosporins, and clindamycin are particularly associated with a high risk of causing CDI
15,16
and so should be avoided unless there are clear clinical indications for their use.
15,16
Co-amoxiclav (intermediate risk) has also been associated with CDI cases both nationally
and locally. Therefore, the above antimicrobials have been restricted, where possible, within
Oxfordshire primary care and secondary care antimicrobial guidelines.
Appropriate antimicrobial prescribing is a key element in the reduction of healthcare associated

17
infections . The evidence that use of antimicrobial agents (whether appropriate or not)
18
causes resistance is overwhelming; resistance is greatest where use of antibacterial agents
18
is heaviest . Prescribing a routine course of antimicrobials significantly increases the
19
likelihood of an individual carrying a resistant bacterial strain.
Establishing and maintaining ways of working which keep the level of potential cross
contamination between patients to an absolute minimum is a major priority in Infection Control.
20,21
The most effective way to do this is to decontaminate hands and equipment between
22
patients.
Penicillin Allergy
Penicillins are life-saving antimicrobials and patients should not be labelled ‘penicillin-allergic’
23
without careful consideration.
Life-threatening adverse reactions to penicillins due to immediate hypersensitivity (IgE
mediated, Type I) are rare.
A reliable history is key.
Severe allergy = all Type I reactions and some non-Type I reactions, depending on
clinical severity e.g. Stevens Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis
(TEN).
Non-severe allergy = most non-Type I reactions i.e. rash without systemic upset /
mucosal involvement.
Characteristics Type I immediate reactions Non-Type I reactions
Timing of onset Usually 1 to 4 hours from More than 72 hours from exposure
exposure (up to 72 hours)
Maculopapular rash
Clinical signs Anaphylaxis Morbilliform rash
Laryngeal oedema Drug fever (serum sickness)
Wheezing / bronchospasm Tissue injury (immune complex)
Angioedema Contact dermatitis
Urticaria / pruritus SJS / toxic epidermal necrolysis
Diffuse erythema
6
In patients with a history of clinical signs of Type I immediate hypersensitivity (life-threatening
allergy) or severe non-type I reactions e.g. SJS:
Drugs in RED are contra-indicated unless approved by microbiology/infectious
diseases or Immunology in a specific patient.
Drugs in ORANGE are NOT for use in patients with a severe penicillin allergy, unless
at the discretion of microbiology/ID.
Drugs in GREEN are considered safe.
The colour classifications below should not be confused with the Oxfordshire
Prescribing Traffic Light Classifications – for appropriate prescribing responsibility the
Oxfordshire Prescribing Traffic Lights should be consulted.
In patients with a history of a mild to moderate non-type I reactions to penicillin as exemplified

by an isolated rash but not drug fever or immune-complex type reactions drugs in the
ORANGE category can be used with caution. If in doubt, please discuss with Microbiology/ID.
Drugs in GREEN are considered safe.
Red Orange Green

amoxicillin, cefalexin, azithromycin, minocycline,
co-amoxiclav (amoxicillin cefotaxime ciprofloxacin nitrofurantoin
+ clavulanic acid) ceftriaxone clarithromycin oxytetracycline
flucloxacillin clindamycin, sodium fusidate
penicillin V co-trimoxazole (fusidic acid)
(phenoxymethylpenicillin) (Septrin®) tetracycline
procaine benzylpenicillin doxycycline trimethoprim
erythromycin vancomycin
metronidazole
Useful Websites
http://bnf.org/bnf/index.htm
http://cks.nice.org.uk/
http://www.hpa.org.uk/infections/topics_az/primary_care_guidance/menu.htm
http://www.nice.org.uk/
http://www.brit-thoracic.org.uk
Current Version
The latest version of these guidelines is available on the Oxfordshire CCG Website.
Prescribers are advised to regularly visit the website to ensure they have the most up to date
version of guidelines currently held.
7
RESPIRATORY TRACT INFECTIONS
UPPER RESPIRATORY TRACT INFECTIONS
1
Also see Oxfordshire PCT Referral Guidelines: ENT and NICE Respiratory Tract Infections and NICE
Respiratory Tract Infections - Quick Reference Guide
CONDITION COMMENTS & TREATMENT
1-6
Vaccination
Annual vaccination is essential for all those at risk of influenza. For further
information on patients within the ‘clinical risk groups’ please refer to ‘Immunisation
against infectious disease’ (‘The Green Book’ - Chapter 19 Influenza)
1-6
Treatment - NICE Guidance TA 168
Oseltamivir and zanamivir are recommended, within their marketing authorisations, for
the treatment of influenza in adults if ALL the following circumstances apply:
national surveillance schemes indicate that influenza virus A or B is circulating
(the CCDC will advise when influenza prevalence in Oxfordshire has reached
the appropriate threshold)
the person is in an ‘at-risk’ group as defined in NICE Guidance TA 168 and
below
the person presents with an influenza-like illness and can start treatment within
48 hours of the onset of symptoms as per licensed indications
For otherwise healthy adults, antivirals are not recommended.
Influenza
Also see information for healthcare professionals from Health Protection Agency
Immunisation
against infe At risk groups:
ctious disease People ‘at risk’ within NICE Guidance TA 168 and within HPA guidance are defined as
(‘The Green those who have one of more of the following:
Book’) 65 years or over
chronic respiratory disease (including asthma and chronic obstructive
NICE pulmonary disease)
Guidance TA chronic heart disease (not hypertension)
168
chronic renal disease
chronic liver disease
NICE
Guidance TA chronic neurological conditions
158 diabetes mellitus
immunosuppressed
HPA Influenza pregnant women (including up to two weeks post partum)
Therapy: - refer to current HPA recommendations for recommended treatment,

including in pregnancy.
Oseltamivir 75mg BD for 5 days
Zanamivir 10mg BD (2 inhalations by diskhaler) for 5 days
During localised outbreaks of influenza-like illness (outside the periods when national
surveillance indicates that influenza virus is circulating in the community), oseltamivir
and zanamivir may be offered for the treatment of influenza in ‘at-risk’ people who live in
long-term residential or nursing homes – however this should only be given on the
advice from the local Health Protection Unit.
1-6
Postexposure Prophylaxis - NICE Guidance TA 158
For advice on post exposure prophylaxis, at risk groups and recommended therapy see
NICE Guidance TA 158.
Also see information for healthcare professionals from Health Protection Agency.
8
CONDITION COMMENTS DRUG DOSE DURATION
OF TX
Acute Sore Avoid antimicrobials as the Avoid
Throat majority (over 50%) of sore antimicrobials in
throats are viral; 90% resolve in 7 majority cases.
NICE days without antimicrobials and Explain soreness will
pain is only reduced by a mean of take about 8 days to
2A+
Prodigy 16 hours. resolve.
SIGN
6A-
In patients with 3 or more Centor Phenoxymethyl- 500mg 10 days
5B-
criteria (presence of tonsillar penicillin QDS
exudate, tender anterior cervical
lymphadenopathy or Avoid amoxicillin as
lymphadenitis, history of fever and maculopapular rash
1,3,A-
an absence of cough consider commonly results in
2 or 3-day delayed or immediate patients with
1,A
antimicrobials. + glandular fever. (This
rash is not related to
(Antimicrobials to prevent quinsy true penicillin allergy).
4B-
NNT >4000.
Antimicrobials to prevent otitis Penicillin Allergy:
2A+ 9A+
media NNT=200. ) Clarithromycin 250mg – 5 days
500mg
BD
2,3B-
Acute Otitis Optimise analgesia Avoid
Media Avoid antimicrobials as 60% are antimicrobials in
better in 24 hours without: they majority cases
NICE only reduce pain at 2 days
(NNT=15) and do not prevent
4A+
Prodigy deafness.
1A+ 7A+ 9A+
Consider 2 or 3-day delayed or amoxicillin 500mg 5 days
immediate antimicrobials for pain TDS
relief if there is otorrhoea Penicillin Allergy:
5A+ 8D 9A+
(NNT=3). Clarithromycin 250mg- 5 days
500mg
(Antimicrobials to prevent BD
6B -
mastoiditis NNT >4000. )
Acute Otitis First use aural toilet (if available)
Externa & analgesia.
Cure rates similar at 7 days for acetic acid 2%* 1 spray 7 days
Prodigy topical acetic acid or antimicrobial TDS
1A+
+/- steroid. Second line:
If cellulitis or disease extending neomycin sulphate 3 drops 7 days min
3A-
outside ear canal, start oral with corticosteroid TDS to 14 days
,4D 1A+
antimicrobials (flucloxacillin or max
clarithromycin in penicillin allergy) (Betnsol-N)
2A+
and refer. *Over the counter preparation is available for
children over 12 years.
Retail cost is £7.03 (Chemist & Druggist July 12).
Please note: if prescribed, charge to prescribing
budget is £4.10 (Chemist & Druggist July 12).
9
OF TX
Acute Avoid antimicrobials as 80% Avoid
Rhinosinusitis resolve in 14 days without, and antimicrobials in
5C
they only offer marginal benefit majority cases
2,3A+
after 7 days NNT=15.
NICE
4B+ 4A+,7A 9A+
Use adequate analgesia. amoxicillin 500mg 7 days
Prodigy TDS
Consider 7-day delayed or 1g TDS if
8D
immediate antimicrobial when severe
purulent nasal discharge NNT=8.
1,2A+
or doxycycline 200mg 7 days
stat/
100mg
OD
In persistent infection use an For persistent
agent with anti-anaerobic activity symptoms:
6B+ 6B+
e.g. co-amoxiclav. co-amoxiclav 625mg 7 days
TDS
Dental GPs should not routinely be involved in dental treatment.
Abscess Where possible, advise the person to see a dental practitioner urgently. If this is
not possible and treatment is required see below.
(In the Do not routinely provide repeat prescriptions or switch antimicrobials if person
absence of fails to respond. Instead advise the person to see a dental practitioner urgently.
immediate Antimicrobials are Avoid antimicrobials in
attention by a generally not indicated for majority cases
dental otherwise healthy
practitioner) individuals or when there
no signs of spreading
Prodigy infection.
1-4
Only prescribe an amoxicillin alone 250mg- 5 days

antimicrobial: 500mg
for people who are TDS
systemically unwell or if or combined with
there are signs of severe metronidazole 200mg- 5 days
infection (e.g. fever, 400mg
lymphadenopathy, TDS
cellulitis, diffuse swelling, Penicillin Allergy:
trismus). Clarithromycin alone 500mg 5 days
for high risk individuals bd
to reduce the risk of
complications (e.g.
people who are
immunocompromised, or combined with 200mg-
diabetic or have valvular metronidazole 400mg 5 days
heart disease). TDS
If spreading infection
(lymph node involvement,
or systemic signs i.e. fever
or malaise) ADD
2-4C
metronidazole.
10
OF TX
ANUG (Acute GPs should not routinely be involved in dental treatment.
Necrotising Where possible, advise the person to see a dental practitioner urgently. If this is
Ulcerative not possible and treatment is required see below.
Gingivitis) Do not routinely provide repeat prescriptions or switch antimicrobials if person
fails to respond. Instead advise the person to see a dental practitioner urgently.
Prodigy Advise the person to see
a dental practitioner metronidazole 200mg- 3 days
urgently. AND 400mg
TDS
Antimicrobials are the first
1
line treatment. chlorhexidine 0.2% or BD
hydrogen peroxide 6%
Normal tooth brushing / mouth wash
oral hygiene measures are
very painful to carry out in Second line:
the acute phase of the amoxicillin 250mg- 3 days
infection. Therefore, the AND 500mg
patient should be TDS
encouraged to carry out
tooth brushing with a soft chlorhexidine 0.2% or BD
toothbrush to remove food hydrogen peroxide 6%
detritus. mouth wash
Hydrogen peroxide
mouthwashes are the most
efficacious when proper
tooth brushing is difficult to
undertake.
As well as pain, and

halitosis the patient will feel
significantly systemically
unwell. The patient should
be advised not to smoke.
Oral Predisposing local and For localized or mild oral

Candidiasis systemic risk factors for candidal infection, prescribe
oral candida should be topical treatment for 7 days
Prodigy managed in conjunction (and advise the person to
1
with antifungal treatment. continue treatment for 2 days
after symptoms resolve).
Chlorhexidine should be
used to clean dentures and nystan®* oral suspension 100,000 7 days (and
may be used as an adjunct units continue for
to topical or oral treatment. QDS 2 days after
Clean and soak dentures in after food symptoms
chlorhexidine gluconate resolve)
0.2% mouthwash for 15
mins twice daily. For extensive or severe
candidiasis: fluconazole 50mg 7 days
Advise to see dental daily
practitioner if ill-fitting * Nystan® oral suspension is significantly more cost
dentures. effective than generic nystatin oral suspension (March
2012: £1.80 vs. £20.80)
11
LOWER RESPIRATORY TRACT INFECTIONS
Note:
1,
Low doses of penicillins are more likely to select out resistance
Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity.
Reserve all quinolones (including levofloxacin) for proven resistant organisms.
Avoid tetracyclines in pregnancy.
OF TX
Acute Antimicrobial little benefit if Avoid antimicrobials in
1-4A+
Bronchitis no co-morbidity. majority cases
Symptom resolution can
NICE take 3 weeks.
Prodigy Consider 7-14 day delayed amoxicillin 500mg 5 days

antimicrobial with TDS
symptomatic advice/leaflet.
1,5A-
stat/
100mg
OD
or clarithromycin 250mg- 5 days

500mg
BD
Acute Viruses may account for
Exacerbation over 50% of these
of COPD infections. (30% viral, 30-
50% bacterial, rest
NICE undetermined)
4c
Prodigy Antimicrobials not amoxicillin 500mg 5 days
indicated in absence of TDS
Management purulent/mucopurulent If ‘at home’ rescue
B+
of COPD in sputum. antimicrobial has been tried
Primary Care and patient is not improving
Treat exacerbations change to second line
promptly with antibiotics if antimicrobial.
purulent sputum and
4c
increased shortness of or doxycycline 200mg 5 days
breath and/or increased stat/
1-3B+
sputum volume. 100 mg
OD
If no response in 48 hours
4A
of antimicrobial therapy or clarithromycin 500mg 5 days
consider admission or add BD
erythromycin first line or a
C
tetracycline to cover
‘atypical’ organisms.
Risk factors for If resistance risk factors:

4A
antimicrobial resistant co-amoxiclav 625 mg 5 days
organisms include: co- TDS
morbid disease, severe
COPD, frequent
exacerbations,
antimicrobials in last 3
2
months.
12
OF TX
1
Community- Use CRB65 score to help guide and review in conjunction with clinical judgment.
Acquired Post Influenza: seek specialist advice.
Pneumonia
- Each scores 1:
treatment in Confusion (AMT<8);
the community Respiratory rate >30/min;
2,3,4
BP systolic <90 or diastolic ≤ 60;
Age >65 years
BTS 2009
A+
Guideline If CRB65=0: may be amoxicillin 500mg 7 days
Adults suitable for home TDS
treatment.
A-
or clarithromycin 500mg 7 days
BD

stat/100
mg OD
Score 1-2: may require If CRB65=1 & AT HOME:
hospital assessment or
A+
admission. amoxicillin 500mg
AND TDS
7-10 days
-
clarithromycin 500mg
BD
or doxycycline alone 200mg 7-10 days

stat/100
mg OD
If no response in 48 hours
consider admission or add
clarithromycin first line or a
C
tetracycline to cover
‘atypical’ organisms.
Score 3-4: may require Give immediate IM
urgent hospital benzylpenicillin 1.2g or
D
admission. amoxicillin 1g po if delayed
admission/life threatening.
Start antimicrobials
B-
immediately.
In severely ill give

parenteral benzylpenicillin
C
before admission.
13
OF TX
Exacerbation Previous sputum
of microbiology cultures,
Bronchiectasis when available, may guide
antimicrobial choice.
Prodigy
When previous amoxicillin 500mg 10–14 days
microbiology cultures are TDS
not available.
or clarithromycin 500mg 10–14 days
Send sputum for culture BD
and sensitivity testing
before starting or doxycycline 200mg 10–14 days
antibiotics (even if the stat and
person is taking long-term then
antibiotics) 100mg
OD
For further information see
1
Prodigy
14
URINARY TRACT INFECTIONS
People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with
1B+
increased morbidity.
Catheter in situ: antimicrobials will not eradicate asymptomatic bacteriuria; only treat if systemically
2B+
unwell or pyelonephritis likely.
Do not use prophylactic antimicrobials for catheter changes.
Refer to Local guidance on the management of UTIs.. Also see Oxfordshire PCT Referral Guidelines:
Urology.
Only use modified release nitrofurantoin rather than standard release if compliance is an issue.
OF TX
1B+
UTI in Men & See NHS Oxfordshire trimethoprim 200mg Women 3
6-8A+
Women Prescribing guidelines: or BD days
(including Management of Simple Men 7 days
2B+ 3C 4B+ 9,10C
older people) UTIs in Non-Pregnant nitrofurantoin* 50mg
No fever and Females in Primary Care QDS or
flank pain Management of UTIs in 100mg
Adult Males in Primary m/r BD
5C
HPA QRG Care
Management of UTIs in Second line: use MSU result to guide treatment – use
SIGN Older People in Primary suitable antimicrobials with lowest risk for C. difficile or
Care MRSA infection.
Prodigy,
Amoxicillin resistance is common; only use if sensitive.
Prodigy 11B+
*Avoid if patient is febrile or clinical evidence of

prostatitis. Contraindicated in renal impairment (eGFR
2
less than 60mL / min / 1.73m ). Avoid in G6PD
deficiency upper UTI/pyelonephritis and near term
pregnancy.
In older patients, community multi-resistant Extended-

spectrum Beta-lactamase E. coli are increasing:
nitrofurantoin is an option.
15
OF TX
Recurrent UTI Treatment of Infection trimethoprim 200mg 3 days
in Women See NHS Oxfordshire or BD
≥ 3 UTIs/year Prescribing guidelines:
Management of nitrofurantoin* 50mg 3 days
HPA QRG Recurrent UTIs in Non- QDS or
Pregnant Females in 100mg
Prodigy Primary Care m/r BD
Second line: use MSU result to guide treatment – use
SIGN suitable antimicrobials with lowest risk for C. difficile or
MRSA infection.
Amoxicillin resistance is common; only use if organism

sensitive.
*Contraindicated in renal impairment (eGFR less than

2
60mL / min / 1.73m ). Avoid in G6PD deficiency upper
UTI/pyelonephritis and near term pregnancy
Prophylaxis nitrofurantoin* 50– Post coital
1,
Post-coital prophylaxis or 100mg stat (off-
2B+ 2B+,3C
or standby antimicrobial label)
3B+
trimethoprim 100mg Prophylaxis
Nightly: reduces UTIs but OD at night
1A+ 1A+
adverse effects
See NHS Oxfordshire *Contraindicated in renal impairment (eGFR less than
2
Prescribing guidelines 60mL / min / 1.73m ). Avoid in G6PD deficiency, upper
Management of UTI/pyelonephritis and near term pregnancy
Recurrent UTIs in Non-
Pregnant Females in
Primary Care
Recurrent Discuss with urology or Do not give prophylactic antimicrobials without first
UTIs in Men microbiology discussing with urology or microbiology/ID.
UTIs in a See NHS Oxfordshire trimethoprim 200mg 7-14 days
1
Person with a Prescribing guidelines : or BD
Catheter Management of UTIs in
Catheterised Adults in nitrofurantoin* 50mg 7-14 days
HPA QRG Primary Care QDS or
100mg
Prodigy m/r BD
Second line: use MSU result to guide treatment – use
Prodigy suitable antimicrobials with lowest risk for C. difficile or
MRSA infection.
SIGN
Amoxicillin resistance is common; only use if organism
susceptible.
Community multi-resistant Extended-spectrum Beta-

lactamase E. coli are increasing: nitrofurantoin is an
option.
*Avoid if patient is febrile or clinical evidence of

prostatitis. Contraindicated in renal impairment (eGFR
2
less than 60mL / min / 1.73m ). Avoid in G6PD
deficiency, upper UTI/pyelonephritis and near term
pregnancy.
16
OF TX
3A- 3A-
Acute If admission not needed, ciprofloxacin 500mg 7 days
Pyelonephritis send MSU for culture & or BD
sensitivities and start
1C 4C 4C
Prodigy antimicrobials. co-amoxiclav 625mg 14 days
If no response within 24 TDS
2C
SIGN hours, admit.
See NHS Oxfordshire
Prescribing guidelines:
Management of Acute
Pyelonephritis in Adults
in Primary Care
UTIs in See NHS Oxfordshire Prescribing guidelines: ‘Management of UTIs in Pregnancy in
Pregnancy Primary Care’
7C
HPA QRG Send MSU for culture & First line: nitrofurantoin* 50mg 7 days
sensitivity and start QDS or
1A
Prodigy empirical antimicrobials. 100mg
m/r BD
SIGN Short-term use of
7C
nitrofurantoin in pregnancy if susceptible, amoxicillin 500mg 7 days
is unlikely to cause TDS
2C
problems to the foetus.
7C
Avoid trimethoprim if low Second line: trimethoprim 200mg 7 days
3
folate status or on folate BD (off-
antagonist (e.g. label)
2
antiepileptic or proguanil). Ensure
taking
folic acid
6
400mcg
if first
trimester
4C, 5B- 7C
Third line: cefalexin 500mg 7 days
BD
* Contraindicated in renal impairment (eGFR less than
2
60mL / min / 1.73m ). Avoid in G6PD deficiency,
upper UTI/pyelonephritis and near term pregnancy
For pyelonephritis - send Pyelonephritis:
MSU for culture. cefalexin 500mg 10-14 days
or TDS
Check MSU 7 days after
#
treatment co-amoxiclav 625mg 10-14 days
TDS
If sensitivities known:
trimethoprim 200mg 10-14 days
or BD
amoxicillin 500mg 10-14 days

TDS
#
Avoid co-amoxiclav in patients if possible pre-term
labour
For asymptomatic bacteruria in pregnancy – treat as per sensitivities with antimicrobial
with lowest risk for C.difficile or MRSA infection that is suitable in pregnancy for 7 days.
Refer to ‘Management of UTIs in Pregnancy in Primary Care’ for further details.
17
GENITAL TRACT INFECTIONS
STI screening
Note: Patients with risk factors for STI should be considered for referral to GUM (and screened for
chlamydia, gonorrhoea, HIV, syphilis) especially if recurrent infections.
1,2
Risk factors are age <25, recent (<12mth)/frequent change of partner, 2 or more partners in last 6
months, non-use of condoms, STI or STI symptoms in partner.
Advice on urogenital infections is available from the Genitourinary Medicine Department, Churchill
Hospital 01865 231231 Monday to Friday 0900-1800.
For further information about investigation and treatment of vaginal discharge see local guideline:
Investigation and Management of Vaginal Discharge in Adult Women

OF TX
4A+ 4A+
Chlamydia Opportunistically screen all azithromycin 1g stat
1
trachomatis aged 15-25yrs. or
4A+ 4A+
infections doxycycline 100mg 7 days
Treat partners and refer to BD
2,3 B+
SIGN, BASHH GUM service.
HPA, Prodigy
2C
Pregnancy or Pregnant or breastfeeding:
5A+ 5A+
breastfeeding: azithromycin 1g (off- stat
azithromycin is the most or label
5 A+; 6B-
effective option. use)
5A+
Due to lower cure rate in erythromycin 500mg 10-14 days
5A+
pregnancy, test for cure or BD
3C
6 weeks after treatment.
5A+ 5A+
amoxicillin 500mg 7 days
TDS
1A+
Vaginal All topical and oral azoles clotrimazole 500mg stat
1A+
Candidiasis give 75% cure. or pessary
or 10%
BASHH cream
1A+
HPA oral fluconazole 150mg stat
orally
Prodigy
In pregnancy: avoid oral Pregnant or breastfeeding:
2B- 3A+ 5C
Investigation azole and use clotrimazole 100mg 6 nights
and intravaginal treatment for 7 or pessary
3A+, 2,4B-
Management days. at night
of Vaginal
3A+
Discharge in miconazole 2% cream 5g intra- 7 days
Adult Women vaginally
BD
Failed vaginal candidiasis Examine and investigate.
treatment.
Recurrent proven candida clotrimazole 500mg for 3-6
– patients experiencing or pessary months
cyclical relapse that once
requires suppressive weekly
therapy.
fluconazole 100mg for 3-6
or oral once months
weekly
itraconazole 400mg for 3-6

oral once months
monthly
at the
expected
time of
symptom
18
OF TX
1,3A+ 1A+
Bacterial Oral metronidazole is as metronidazole 400mg 5 -7 days
3A+
Vaginosis effective as topical or BD stat
1A+
treatment but is or 2g
BASHH cheaper.
1A+
metronidazole 0.75% vaginal 5g 5 nights
1A+
HPA Less relapse with 5-7 day gel applica-
3A+
than 2g stat at 4 wks. or torful at
2A+
Prodigy Pregnant /breastfeeding: night
3A+ ,4B-
avoid 2g stat.
1A+ 1A+
Investigation clindamycin 2% cream 5g 7 nights
and Treating partners does not applica-
5B+
Management reduce relapse torful at
of Vaginal night
Discharge in Failed bacterial vaginosis Examine and investigate.
Adult Women
treatment
4A+ 4A+
Trichomoniasi Treat partners and refer to metronidazole 400mg 5-7 days
1B+ 4A+
s GUM service BD stat
or 2 g
BASHH In pregnancy or
breastfeeding: avoid 2g
HPA, single dose metronidazole
2B-
.
3B+ 3B+
Prodigy Consider clotrimazole for clotrimazole 100mg 6 nights
symptom relief (not cure) if pessary
3B+
Investigation metronidazole declined at night
and
Management
of Vaginal
Discharge in
Adult Women
3,5C
Pelvic Refer woman & contacts to ceftriaxone 500mg stat
1,2B+
Inflammatory GUM service AND IM
6
Disease Always culture for metronidazole 400mg 14 days
gonorrhoea & chlamydia AND BD
2B+ 1, 2, 4B+
BASHH doxycycline 100mg 14 days
BD
Prodigy 28% of gonorrhoea isolates or
now resistant to quinolones metronidazole 400mg 14 days
3B+
If gonorrhoea likely AND BD
1, 2, 4, 6B+
(partner has it, severe ofloxacin 400mg 14 days
symptoms, sex abroad) BD
avoid ofloxacin regimen.
If woman using not using erythromycin 500mg 14 days

adequate contraception. AND QDS
metronidazole 400mg 14 days
PID during established BD
pregnancy is very
uncommon but should be
assessed urgently by GUM
or emergency gynae.
1C 1C
Acute Send MSU for culture and ciprofloxacin 500mg 28 days
1C
Prostatitis start antimicrobials . or BD
4-wk course may prevent
1C 1C 1C
BASHH chronic prostatitis ofloxacin (if STI likely 200mg 28 days
Quinolones achieve higher cause) BD
2
Prodigy prostate levels
Second line:
1C 1C
trimethoprim 200mg 28 days
BD
19
OF TX
Chronic Refer to GUM or urology doxycycline 100mg 3-4 weeks
1,2
Prostatitis or BD
Consider antimicrobials
BASHH after specialist advice. ciprofloxacin 500mg 28 days
or BD
Prodigy
ofloxacin (if STI likely cause) 200mg 28 days
BD
1,2
Urethritis Cause usually STI doxycycline 100mg 7 days
Refer/discuss with GUM for or BD
BASHH contact tracing & partner
treatment (See above for azithromycin 1g stat
Prodigy contact details)
Chlamydia. Refer GUM
If gonorrhoea is
suspected either due to
risk or more severe
symptoms refer for
investigation and
treatment to GUM
because of the high
prevalence of resistance
to antimicrobials.
1,2
Epididymoorch Cause usually STI Refer/discuss with GUM for
itis (<35yrs or contact tracing & partner
increased risk If gonorrhoea is treatment.
of STI) suspected either due to
risk or more severe doxycycline 100mg 14 days
BASHH symptoms refer for BD
investigation and
Prodigy treatment to GUM
because of the high
prevalence of resistance
to antimicrobials.
For epididymo-orchitis ofloxacin 200mg 14 days

most probably due to BD
enteric organisms
Epididymoorch E.coli trimethoprim 200mg 14 days
itis (>35yrs or Obtain a urine sample for or BD
low risk of STI) culture before starting
1,2
antimicrobial treatment. ciprofloxacin 500mg 14 days
BASHH A dipstick test should be BD
used to evaluate
Prodigy significance of symptoms.
20
GASTRO-INTESTINAL TRACT INFECTIONS
For further information about investigation and clinical and public health management see local guide;
Management of Acute Diarrhoea In Primary Care – Prescribing Points 19.12. Also see Oxfordshire
PCT Referral Guidelines: Gastroenterology.

OF TX
1A+
Eradication of Eradication is beneficial in First line:
1A+
Helicobacter known DU, GU or low PPI (omeprazole 20mg BD
2B+
pylori grade MALToma. or or
For NUD, the NNT is 14 for lansoprazole) 30mg BD All for
3A+
NICE symptom relief. AND 7 days
clarithromycin (C) 500mg 1,9A+
HPA QRG Consider test and treat in BD with
persistent uninvestigated AM or
4B+
Prodigy dyspepsia. 250mg
BD with
Do not offer eradication for MTZ
1C
GORD. AND
amoxicillin (AM) 1gram
Do not use clarithromycin or BD
or metronidazole if used in metronidazole (MTZ) 400mg
the past year for any BD
5A+, 6A+ 7A+
infection. Second line: Relapse
10C
PPI (omeprazole 20mg BD or MALToma
Symptomatic DU/GU relapse: retest for or or 1C
relapse H. pylori using breath or lansoprazole) 30mg BD 14 days
stool test OR consider AND
®
endoscopy for culture & bismuthate (De-nol tab ) 120mg
1C
susceptibility. AND 2 previously unused QDS
antimicrobials:
NUD: Do not retest, offer amoxicillin 1gram
1C, 3A+
PPI or H2RA. BD
metronidazole 400mg
TDS
8C
tetracycline 500mg
QDS
Gastroenteritis Most self-limiting and antimicrobial treatment is rarely required. Antimicrobial
B+
/ Infectious therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and
B+
Diarrhoea can cause antimicrobial resistance or increased incidence of C.difficile.
Prodigy Empirical treatment with ciprofloxacin may be given to those with dysenteric symptoms
i.e. if bloody diarrhoea is present and considered in the elderly and others at high risk
of serious complications of gastroenteritis if systemically unwell (see ‘High Risk’
patients in Prescribing Points 19.12).
Only consider empirical

therapy if the patient is
1c
systemically unwell.
Usually wait for culture
result to reassess
whether antimicrobials
are indicated.
Suspected Campylobacter clarithromycin 250mg- 3-5 days

2
500mg
BD
Suspected Salmonella / ciprofloxacin 500mg 3-5 days

Shigella BD
21
OF TX
st nd
Clostridium STOP unnecessary 1 /2 episode (whether
difficile antimicrobials and/or recurrence or relapse):
1,2B+ 1C
Infection (CDI) PPIs. vancomycin (oral) 125mg 14 days
QDS
rd
DH & HPA If continued antimicrobial 3 episode/or severe
treatment necessary seek disease:
microbiology/infectious Seek gastroenterology or
disease advice. microbiology /infectious
disease advice
Admit if severe: T >38.5;
WCC >15, rising creatinine
or signs/symptoms of
1C
severe colitis.
1C
If patient is unable to metronidazole 400mg 14 days
swallow solid dosage forms TDS
give metronidazole
suspension.
Only consider standby antimicrobials for remote areas or people at high-risk of
Traveller’s 1,2C
severe illness with travellers’ diarrhoea. .
Diarrhoea 3
If standby treatment appropriate give: ciprofloxacin 500 mg stat (private Rx).
If quinolone resistance high (e.g. south Asia) and standby treatment appropriate:
Prodigy
consider azithromycin 1g stat (private Rx).
Acute Antimicrobials for acute

Diverticulitis diverticulitis should only
be used in patients with a
Prodigy confirmed diagnosis of
diverticulosis unless
under specialist advice.
For people managed at

1
home:
Prescribe broad-spectrum co-amoxiclav 625mg 7 days
antimicrobials to cover TDS
anaerobes and Gram- Penicillin Allergy (non-severe
negative rods. allergy):
metronidazole 400mg
Review within 48 hours or AND TDS
sooner if symptoms cefalexin 500mg 7 days
deteriorate. Arrange TDS
admission if symptoms Penicillin Allergy (severe
persist or deteriorate. allergy): 400mg
metronidazole TDS
AND 500mg 7 days
ciprofloxacin BD
Giardia metronidazole 400mg 5 days

TDS
1
Prodigy
1C
Threadworms Treat all household mebendazole 100mg stat
contacts at the same time
Prodigy PLUS advise hygiene
measures for 2 weeks
(hand hygiene, pants at
night, morning shower)
PLUS wash sleepwear,
bed linen, dust, and
1C
vacuum on day one.
Other Worms As per BNF Guidelines
22
SKIN & SOFT TISSUE INFECTIONS
Also see Guidelines for the effective diagnosis and management of local wound bed infection and
bacterial colonisation in primary care.

OF TX
2C
Impetigo For extensive, severe, or flucloxacillin (oral) 500mg 7 days
bullous impetigo, use oral QDS
1C
Prodigy antimicrobials. Penicillin Allergy:
2C
Clarithromycin (oral) 250mg- 7 days
500mg
BD
Reserve topical 3B+

antimicrobials for very topical fusidic acid TDS 5 days
localised lesions to reduce
1,5C,
the risk of resistance.
4B+
3A+
Reserve mupirocin for MRSA only mupirocin TDS 5 days
1C
MRSA.
Eczema If no visible signs of infection, use of antimicrobials (alone or with steroids) encourages
1B
Prodigy resistance and does not improve healing. In eczema with visible signs of infection,
2C
use treatment as in impetigo for treatment of infection, also ensure treatment of
eczema.
1,2,3C
Cellulitis If patient afebrile and flucloxacillin 500mg All for
healthy other than cellulitis, QDS 7 days.
Prodigy use oral flucloxacillin alone.
1,2C 4C
Facial: co-amoxiclav 625mg If slow
If febrile and ill, admit for IV TDS response
1C
treatment. Penicillin Allergy: continue for
1,2C
clindamycin 450mg a further 7
1C
If failure of first line therapy TDS days
seek microbiology
/infectious disease advice.
If river, sea or flood water

exposure, discuss with
microbiologist.
Note: Control of oedema, good skin emollient therapy and elevation of the affected limb
is a key part of treatment.
Discontinue compression therapy during the acute phase of cellulitis.
Dermatitis is often misdiagnosed as cellulitis: Review diagnosis if it appears bilateral.
Recurrent cellulitis in lymphoedema is a common problem: Consider prophylactic

treatment if patients have had 2 or more attacks of cellulitis (in lymphoedema) in a year.
phenoxymethylpenicillin 250mg BD (500mg BD if weight > 75kg) or erythromycin
500mg daily if penicillin allergic is recommended.
5
Dosage may be reduced to 250mg daily after 1 year of successful prophylaxis.
23
OF TX
1A+
Leg Ulcers Bacteria will always be present. Antimicrobials do not improve healing.
Culture swabs and antimicrobials are only indicated if there is evidence of clinical
Prodigy - infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid
2,3c
Venous deterioration of ulcer or pyrexia. If these signs are present: treat as for Cellulitis (see
section above). Review antibiotics after culture result available; select most suitable
antibiotic with lowest risk for C.difficile or MRSA infection.
Diabetic Foot Ensure vascular assessment and podiatry review.

Infection
Mild diabetic foot flucloxacillin 500mg 7-14
Prodigy QDS days; may
Penicillin Allergy: extend to 28
IDSA cefalexin 500mg days if slow
TDS to resolve*
Moderate diabetic foot If IV antimicrobials NOT

infection (moderate required:
diabetic foot infection - e.g.
gangrene or deep tissue co-amoxiclav oral 625mg
1-3
involvement). AND TDS
14 -28 days*
metronidazole 400mg
If IV antimicrobials TDS
required refer to Penicillin Allergy:
specialist. ciprofloxacin oral 500mg
AND BD
14 -28 days*
clindamycin 450mg
TDS
Severe diabetic foot Refer to specialist
infection i.e., causing
1-3
systemic illness.
* Review the patient regularly for signs of improvement – if no / limited response to
antibiotics within 2 weeks seek specialist advice.
Wound Swabbing not normally necessary.

Infections
(Non surgical) Treat as per cellulitis and leg ulcers.
For surgical wound infections – seek microbiology/infectious disease advice.
MRSA For MRSA screening and suppression, see HPA MRSA quick reference guide.
Prodigy If active infection, MRSA confirmed by lab results,

1,2B+
For active MRSA infection infection not severe and admission not required : Use
antimicrobial sensitivities to guide treatment, selecting
most suitable antimicrobial with lowest risk for C. difficile
or MRSA infection e.g. doxycycline 100mg BD for 7 days
if tetracycline sensitive
If severe infection or no response to monotherapy after

24-48 hours, seek advice from microbiologist on
combination therapy.
24
OF TX
Bites Thorough irrigation is Prophylaxis or treatment:
1C
important. co-amoxiclav 375mg -
Prodigy Consider need for surgical 625mg
4C
debridement. TDS
Penicillin Allergy:
Human Assess risk of tetanus, metronidazole 400mg
1C
HIV, hepatitis B&C. AND TDS
The Health Protection Unit doxycycline (cat/dog/human) 100mg
5C
and ‘On Call’ Public Health BD All for 7 days
4,5,6C
team are available to help
on risk assessment. 9am– metronidazole 400mg
5pm: 0845 2799879. Out AND TDS
of hours: 0844 967 0083. clarithromycin(human bite)
Antimicrobial prophylaxis is
3B-
advised.
Cat or Dog Assess risk of tetanus and

2C
rabies. AND review at 24 and 250mg -
3 7C
Give prophylaxis if cat 48hrs 500mg
6C
bite/puncture wound; bite BD
to hand, foot, face, joint,
tendon, ligament;
immunocompromised/
diabetic/asplenic/
cirrhotic.
For animals not covered in

this guidance (for example
monkeys, pigs, exotic pets
etc), seek microbiology/
infectious diseases advice.
Mastitis Antimicrobials only flucloxacillin 500mg 14 days

1
required if: QDS
Prodigy Symptoms have not Penicillin Allergy:
improved or are erythromycin alone 500mg- 14 days
worsening after 12– 1g BD or
24 hours despite 250mg-
effective milk removal 500mg
The woman has a nipple QDS
fissure that is infected
25
CONDITION
Acne Vulgaris OCCG Acne Prescribing Guidelines November 2013
1
Prodigy
Lavender
Statement
OCCG Acne
Primary Care
Prescribing
Guidelines
26
OF TX
Rosacea Ensure steroids are not being used on the face; ensure inhaled steroids, steroid eye
drops etc are not inadvertently contacting the face.
1 Mild & localised metronidazole 0.75% BD Review after
Prodigy papulopustular cream * 7-8 weeks.
If not responding after 8

weeks:
azelaic acid 15% BD
* some gel preparations are ~3 times the cost of the

cream.
Moderate or severe doxycycline * 100mg Review after
papulopustular (unlicensed) OD 3-4 weeks
and if
Consider adding in topical If compliance is an issue: improving
treatment for patients lymecycline (unlicensed) 408mg review 6
receiving oral antimicrobial OD monthly.
therapy that have not
responded at review, or Pregnant or breastfeeding:
seek specialist advice. erythromycin 500mg
BD
Switching to an alternative * 40mg capsules are licensed for papulopustular facial
oral antimicrobial (unless roseacea (without ocular involvement) but are ~4 times
compliance issues) is the cost of the 100mg capsules.
unlikely to be of benefit.
Severe & resistant / not Seek specialist advice.
responding.
Perioral Aggravated by steroids. oxytetracycline 500mg 4 weeks
Dermatitis BD
Boils / Cysts/ Antimicrobials treatment Antimicrobial treatment

Abscesses / not required unless not usually indicated
1
Carbuncles person has:
fever flucloxacillin 500mg 7 days
Prodigy cellulitis QDS
lesion is on the face Penicillin Allergy:
lesion is a carbuncle clarithromycin 250mg- 7 days
person is in pain or 500mg
severe discomfort BD
there are other
comorbidities (such as
diabetes or
immunosuppression
Recurrent boils may need

incision and drainage.
Check for diabetes.
Consider diagnosis of
hidradenitis suppurativa if
axillae and groin involved.
If a boil is drained then a

sample should be taken.
27
OF TX
Paronychia Consider antimicrobials if flucloxacillin 250mg- 7 days
1
incision and drainage: 500mg
Prodigy is not required (because QDS
the lesion is non- Penicillin Allergy:
fluctuant). clarithromycin 250mg- 7 days
was performed, but the 500mg
person has signs of BD
cellulitis or fever, or has
other comorbidities (such
as diabetes or
immunosuppression).
Folliculitis Antimicrobials not required
3A+
Scabies Treat all members of the permethrin 5% 2
Prodigy household, close contacts cream applications
& sexual contacts within If allergy: 1 week apart
1C 3C 1C
24h. malathion 0.5%
Treat whole body from aqueous
ear/chin downwards and liquid
under nails. If under
2
2/elderly, also face/scalp.
Ensure appropriate
management of ‘itch’ and
any associated eczema.
28
OF TX
Head Lice Treatment is not necessary Wet combing: sole Treat- 4 sessions
unless a live louse is treatment of regular wet ment over 2
Prodigy found. Ensure all combing with conditioner, or involves weeks
affected individuals in a combine with below. Wet method-
Lavender household are treated combing should be ically
1,2
Statement simultaneously. continued until no full-grown combing
lice have been seen for 3 wet hair
MHRA consecutive sessions. with a
Offer a choice of treatment fine-
strategies: wet combing, toothed
dimeticone lotion or an comb to
insecticide. remove
lice
No treatment is 100%
effective. Consider dimeticone Rub 2
(physical insecticide) lotion applications
Choice of treatment especially if resistance to onto dry 7 days apart
depends on the preference other treatments. hair and
of the individual/parent and scalp.
on the treatment history. Allow to
dry
Use lotions or liquids naturally.
formulations; shampoos Shampoo
are diluted too much in use after
to be effective. minimum
of 8
Preparations with a contact hours or
time of 8-12 hours or overnight
overnight are
recommended; a 2 hour Another option is malathion Rub 2
treatment is not sufficient (traditional insecticide) lotion into applications
to kill eggs. dry hair 7 days apart
and scalp
Do not use insecticide allow to
lotion more than once for dry
three consecutive weeks naturally.
Remove
by
washing
after 12
hours
Pregnant or breastfeeding Wet combing or dimeticone

If a traditional insecticide is required as an alternative in
treatment failure, malathion is recommended.
29
FUNGAL SKIN INFECTIONS
OF TX
4A+
Fungal / Athletes Foot/ Fungal Topical 1% terbinafine OD-BD 2 week*
Dermatophyte Groin Infection / or
infection of the Ringworm.
skin – topical 1% imidazole e.g. OD-BD 4 – 6 weeks*
1 4A+
Dermatophyte Terbinafine is fungicidal , clotrimazole / miconazole
s so treatment time shorter (Not nystatin as is NOT
than with fungistatic effective against
4A+
Prodigy imidazole. dermatophytes )
Prodigy 1 week terbinafine is as or (athletes foot only)

effective as 4 weeks azole. topical undecanoates BD 4 – 6 weeks*
A- ® 4B+
HPA (Mycota )
If inflammation is marked,
consider prescribing a
topical antifungal combined
with a mildly potent
corticosteroid for a
maximum of seven days.
Use a combination
preparation with caution on
fungal infection of the
groin, because of the
increased risk of adverse
effects with topical
corticosteroids in occluded
areas.
If intractable: send skin terbinafine oral 250mg

2C
scrapings If infection OD
confirmed, use oral ringworm 4 weeks*
3B+
terbinafine/itraconazole groin 2-4 weeks*
* duration of treatment is given as an approximation.
Treatment should be continued for 1-2 weeks after the
disappearance of all signs of infection.
30
OF TX
1
Fungal / Scalp Ringworm. Adults: terbinafine oral (off 250mg 4 weeks
Dermatophyte license) OD
infection of the Take scalp scrapings – this
skin - Scalp often pulls out infected hair selenium shampoo in severe Twice a 2 - 4 weeks
Dermatophyte stumps which are critical cases may be appropriate in week
s for successful culture & addition. This reduces the
microscopy. Hair plucking risk of spreading the
Prodigy does not produce the best infection to others.
samples. A soft toothbrush
HPA can be used if scrapings Also ketoconazole shampoo
2
are not possible. and povidone iodine
Scalp scrapings for

culture are essential as
choice of treatment is
species dependent: M
canis responds well to
griseofulvin whereas T.
tonsurans (greater recent
prevalence especially in
cities) responds well to
terbinafine. Dermatologists
advise initiating treatment
with terbinafine and being
prepared to switch
treatment to griseofulvin if
culture shows M canis.
Fungal / Unsightly nails due to Prescribe only in line with

Dermatophyte fungal infection are Priorities Committee
infection of the primarily a cosmetic Lavender Statement
proximal problem.
2A+
fingernail or Therefore the Priorities terbinafine oral 250 mg
toenail Committees considers the OD
treatment of finger- 6-12 weeks
Lavender onychomycosis (fungal nail nails
Statement infection) with terbinafine to
be a Low Priority and toenails 3-6 months
HPA recommends that it is not
normally prescribed, with Second line:
2A+
Prodigy the exception of patients itraconazole 200mg
1
with : BD
peripheral vascular finger- 2 courses of
disease nails 7 days per
diabetes or month
other
immunocompromised toenails 3 courses of
patients. 7 days per
month
In these patients,
mycological confirmation
should always be sought
prior to treatment.
When treatment is
indicated, only oral
terbinafine should be
prescribed as topical
terbinafine has inferior
efficacy.
31
OF TX
Pityriasis Caused by an overgrowth First Line:
Versicolor of Pityrosporum orbiculare selenium shampoo Apply 7 days
1
(Malassezia furfur). DAILY to
Prodigy the
Most adults have affected
Pityrosporum orbiculare on or area –
their skin; however, in a leave on
few people its presence for 10
results in a harmless skin mins
disease. before
rinsing.
Pityrosporum orbiculare (Diluting
also plays a role in the with a
development of small
seborrhoeic dermatitis amount
(including cradle cap). of water
can
Poorly responsive to reduce
terbinafine and completely irritation)
unresponsive to nystatin
and griseofulvin. ketoconazole shampoo Apply Max 5 days
once
If initial therapy fails, verify daily –
that the treatment regimen leave
has been followed prepara-
adequately. Consider a tion on
second topical therapy for 3-
before considering 5mins
systemic treatment. before
rinsing
Third line (adults):
itraconazole (only in severe 200mg 7 days
unresponsive cases due to daily
benefit risk ratio)
Intertrigo Combination preparations clotrimazole 1% cream Apply Continue for

containing corticosteroids BD-TDS at least 2
Prodigy e.g. trimovate cream weeks after
should only be applied if the affected
there is marked area has
1
inflammation. healed
They should be applied
sparingly to avoid skin
atrophy on areas of thin
skin (e.g. facial areas) and
for a maximum of 1 week.
32
VIRAL INFECTIONS
OF TX
Herpes Cold Sores Cold sores resolve after 7–10d without treatment.
simplex Topical over the counter antivirals (aciclovir) can be
bought. If applied prodromally (early) reduce duration by
1,2,3B+,4
Prodigy 12-24hrs.
#
First attack genital. aciclovir 200mg 5 days
Prodigy FIVE x
Recurrent attacks of genital Specific treatments usually daily
herpes - intermittent not beneficial as recurrences
therapy. are self-limiting and
generally cause minor
5
symptoms.
#
Recurrent attacks of genital aciclovir 400 mg Interrupt
herpes - suppressive BD therapy
therapy. every 6-12
months for
Only indicated if at least six reassess-
recurrences per annum. ment of
disease
#
Use normal oral dose every 12 hours if eGFR less than
2
10mL/minute/1.73m .
Varicella If pregnant/ neonate /
zoster immunocompromised seek
/ Chickenpox advice re treatment and
prophylaxis from
Prodigy microbiology or infectious
1B+
disease.
Immunisatio
n against Chickenpox: Use aciclovir If indicated:
3B+, 6A+ 3B+
Infectious if less than <24h of rash aciclovir* 800 mg 7 days
Disease and >14 years or severe five times
2006 (‘The pain or dense/oral rash or a day
o
Green 2 household case or * use normal oral dosage every 8 hours if eGFR 10-25
-5 2
Book’) steroids or smoker. mL/minute/1.73m (every 12 hours if eGFR less than 10
2
(Chapter 34) mL/minute/1.73m ).
See below for additional
Chickenpox advice on treatment and
in adults – prophylaxis.
Clinical
management
33
OF TX
Herpes If pregnant/ neonate /
zoster immunocompromised seek
/ Shingles advice re treatment and
prophylaxis from
Prodigy microbiology or infectious
1B+
disease.
Immunisatio If indicated:
3B+, 6A+ 3B+
n against Shingles: treat if >50 aciclovir* 800 mg 7 days
6A+
Infectious yrs and within 72 hrs of five times
7B+
Disease rash (PHN rare if <50yrs Second line if compliance a a day
8B-
2006 ); or if active ophthalmic problem, as ten times cost.
9B+ 10C
(‘The Green or Ramsey Hunt or Consult BNF if renal
Book’) eczema. impairment:
11B+ 11B+
(Chapter 34) valaciclovir 1gram 7 days
See below for additional or TDS
advice on treatment and
12B+ 12B+
prophylaxis. famciclovir 250mg 7 days
TDS or
750mg
OD
* use normal oral dosage every 8 hours if eGFR 10-25
2
mL/minute/1.73m (every 12 hours if eGFR less than 10
2
mL/minute/1.73m ).
Treatment Advice: CHICKENPOX
Immunocompromised Patients: (Immunisation against Infectious Disease 2006 (‘The Green Book’) –
for definition of immunosuppressed patients see Chapter 6 & 34)
 Refer urgently to a specialist for intravenous aciclovir.
Immunocompetent Patients: (Also see: Chickenpox in adults – Clinical management).

 Treatment is indicated for all persons over 14 years of age.
 Treatment should start as soon as possible, preferably within 24 hours and certainly within 72
hours of the onset of the rash.
 Treat adults for 7 days as for shingles above.
 Pregnant women may have more serious disease and the benefits of treatment should be
balanced against any potential harm to the foetus. (NB: Chickenpox in adults – Clinical
management).
 Chickenpox in pregnancy should be treated with aciclovir 800 mg 5 times daily for 7 days. There is
no evidence so far that aciclovir causes congenital abnormalities in humans.
 Additional risk factors for Chickenpox pneumonitis include smoking, chronic lung disease,
underlying immunosuppression and > 36 weeks gestation.
 Symptoms/signs of more severe Chickenpox include respiratory symptoms, haemorrhagic rash,
bleeding, densely cropping vesicles, any neurological changes, and persisting fever with new
vesicles erupting more than 6 days after onset.
 Individuals with additional risk factors or symptoms/signs of more severe disease should be
referred to the local infectious diseases unit for consideration of IV aciclovir.
 These management guidelines also apply to pregnant women who develop Chickenpox despite
being given VZIG.
34
Treatment Advice: SHINGLES
Immunocompromised: (Immunisation against Infectious Disease 2006 (‘The Green Book’) – for
definition of immunosuppressed patients see Chapter 6 & 34).
 Refer to specialist as intravenous therapy may be required.
Immunocompetent including pregnancy:

 Refer all patients with eye involvement to an Ophthalmologist.
 Treat all patients > 50 years old with aciclovir 800 mg 5 times daily for 7 days. If compliance is an
issue consider valaciclovir 1gram TDS or famciclovir 250 mg TDS or 750 mg once daily for 7 days
as valaciclovir and famiciclovir are ten times the cost. Commence within 72 hours of onset of rash
or up to one week after onset for ophthalmic zoster.
Prophylaxis Advice: High Risk Contacts of Patients with Chickenpox or Shingles
High risk contacts are patients without a definite history of Chickenpox or Shingles and a negative test
for varicella antibody, and who have had a significant contact with Chickenpox or Shingles
(Immunisation against Infectious Disease 2006 (‘The Green Book’) – Chapter 34 Varicella) and are at
high risk of serious disease.
These include:
1. Immunocompromised patients (see Immunisation against Infectious Disease 2006 ) (‘The Green
Book’).
2. Pregnant women.
3. Neonates of non-immune mothers who:
develop Chickenpox between 7 days before and 7 days after delivery
are exposed to Chickenpox or Herpes zoster (other than in the mother) in the first seven days of
life.
4. Infants of any age, exposed to Chickenpox or Herpes zoster while still requiring intensive or
prolonged special care nursing.
Contact the Microbiology SpR/Consultant 01865-220880 or Bleep 4077 (in hours) or via JR switchboard
(out of hours) for specific advice, to arrange urgent antibody testing and for supplies of VZIG if
required.
If patient is eligible for varicella-zoster immune globulin (VZIG) this will prescribed by the Microbiology
SpR/consultant. Give varicella-zoster immune globulin (VZIG) 250 mg (1 vial) to 1000mg (4 vials)
intramuscularly depending on age. Give preferably within 96 hours of contact, but may be efficacious up
to 10 days post exposure.
VZIG will need to be collected from the JR pharmacy site by the patient or representative. VZIG does
not prevent infection but may reduce severity.
35
HEPATITIS
HEPATITIS B
 All patients with hepatitis B not previously assessed by a hepatologist should be referred for
assessment and consideration of treatment.
 Contact Follow Up has a significant role to play. All household and sexual contacts of HbSAg+ve
patients should be screened offered HBV vaccine and advice on minimising risk of spread. Further
guidance is available from the Health Protection Unit 9am–5pm: 0845 2799879. Out of hours:
0844 967 0083.
 Also see Antenatal screening Hepatitis B flowchart.
HEPATITIS C
 Patients who are both hepatitis C antibody and Hepatitis C RNA positive should be referred for
assessment and consideration of treatment by a hepatologist.
 Also see Hepatitis C: diagnosis and referral flowchart.
EYE INFECTIONS
Also see Oxfordshire PCT Referral Guidelines: Ophthalmology
OF TX
Conjunctiviti Treat if severe; most are viral Treatment often not
s or self-limiting. required.
Prodigy
4,5B+,6B-
Bacterial conjunctivitis is If severe:
usually unilateral and also chloramphenicol 0.5% 2 hourly
2C
self-limiting; it is drops for
characterised by red eye with 2 days
mucopurulent, not watery, then
discharge; and 4 hourly
65% resolve on placebo by (whilst All for 48
1A+
day five. awake) hours after
resolution
Fusidic acid has less Gram- chloramphenicol 1% at night
3
negative activity. ointment
Second line:
fusidic acid 1% gel BD
Styes See Prodigy for advice on for Systemic or topical antimicrobials not required.
1
Prodigy management.
36
MENINGITIS
OF TX
Bacterial Suspected bacterial
Meningitis meningitis without non-
1,2,3,4
and / or blanching rash
Suspected transfer directly to
Meningococ secondary care as an
cal Disease emergency via ambulance
without giving parenteral
HPA antibiotics.
IV or IM benzylpenicillin* (give IM if
HPA if urgent transfer to hospital 1200mg
vein cannot
is not possible (for example,
be found)
NICE remote locations or adverse
weather conditions),
antibiotics should be
administered to someone
with suspected bacterial
meningitis.
Suspected meningococcal IV or IM benzylpenicillin* 1200mg (give IM if

disease (meningitis with vein cannot
non-blanching rash or be found)
meningococcal
1,2,3,4
septicaemia).
transfer directly to
secondary care as an
emergency via ambulance.
parenteral antibiotics should

be given at the earliest
opportunity, either in
primary or secondary care,
but urgent transfer to
hospital by emergency
ambulance should not be
delayed in order to give
the parenteral antibiotics.
*Withhold benzylpenicillin only in adults who have a history of significant allergic response
to penicillin; a history of a rash is not considered as significant in this context.
*An alternative for adults who have a significant allergic response to penicillin is not given
as the most important aspect of care is to transfer urgently to hospital – transfer should
not be delayed in order to administer an antimicrobial in the community.
1,2,3,5
Meningococ Only prescribe following advice from HPA:
cal 9am–5pm: 0845 2799879
Meningitis Out of hours: 0844 967 0083
st
Prophylaxis Adults (1 choice) ciprofloxacin 500mg oral single dose
HPA Adults (alternative) rifampicin 600mg oral BD for 2 days
Pregnant women ciprofloxacin 500mg oral single dose

or
ceftriaxone 250mg IM or IV
(unlicensed)
37
ASPLENIA
OF TX
Prophylaxis Lifelong antimicrobial phenoxymethylpenicillin 500 mg See below
for Asplenia prophylaxis is recommended, (Adult dosage) BD
especially for patients with
Immunisatio functional hyposplenism and Penicillin Allergy:
n against those whose splenectomy was erythromycin 500 mg See below
1
Infectious for underlying disease. (Adult dosage) BD
Disease
2006 It is recognised that many
(‘The Green patients are unable to comply
Book’) and the value is less certain
1
(Chapter 7) after the first two years.
Note: Antimicrobial
prophylaxis is not fully
reliable and vaccines
should be considered.
Further advise on vaccination

for asplenics is available via;
Immunisation against
Infectious Disease 2006 (‘The
Green Book’).
1. Patients should keep a supply of appropriate antimicrobials (e.g. amoxicillin) at home to be used
should infective symptoms of raised temperature, malaise or shivering develop. This is particularly
important for those not taking prophylaxis.
2. Patients taking prophylactic erythromycin should increase their dose to therapeutic range (500mg
QDS) at first symptom of infection.
3. Patients with such symptoms should also seek immediate medical help.
4. Severe sepsis can occur despite the use of antibacterial prophylaxis
Adults should receive pneumococcal vaccine, Hib vaccine, MenACWY vaccine and influenza vaccine
(DOH recommendations). When possible, the first doses (or booster doses) of the vaccines should be
given simultaneously at different sites, at least four weeks before splenectomy. Refer to Immunisation
against Infectious Disease 2006 for further information. An NHS ‘Splenectomy Information for Patients’
leaflet is also available.
Based on the Health Protection Agency and British Infection Association; ‘Management of Infection Guidance
for Primary Care for Consultation and Local Adaptation’.
Editors / Authors: Dr Bridget Atkins, Consultant Microbiologist; Dr Andrew Woodhouse, Consultant in
Infectious Diseases; Jo Stanney, Interface Medicines Management Lead, OCCG; Julie Dandridge, Chief
Pharmacist, OCCG.
Specialist advice from:

OUH: Dr Katie Jeffery & Dr Ian Bowler Consultant Microbiologists; Dr Chris Conlon, Consultant in Infectious
Diseases; Dr Jackie Sherrard, GUM Consultant; Dr Roger Chapman & Dr Jonathan Marshall, Consultant
Gastroenterologists; Dr Steve Chapman, Respiratory Consultant; Dr Simon Brewster, Consultant Urologist; Dr
Graham Ogg, Dr Vanessa Venning, Dr Sue Burge, Dr John Reed, Dr Jonathan Bowling & Dr Richard Turner,
Consultant Dermatologists; Dr Penny Lennox, ENT Consultant; Mel Snelling, Lead HIV/Infectious Diseases
Pharmacist.
HPA: Dr Noel McCarthy, Consultant Communicable Disease Control.
OCCG: Dr Nick Elwig & Dr Lucy Jenkins, GPs; Dr George Moncrieff GP with Special Interest.
Buckinghamshire & Oxfordshire Cluster: Amanda Le Conte, Infection Control Manager; Chris Evans &
Mandy Crosse, Dentists.
Oxford Health: Neil Oastler, Dentist; Sarah Gardner & Julie Hewish, Tissue Viability Nurses.
38

Oxfordshire-Antimicrobial-ADULT-Guidelines-Primary-Care - 2014

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Oxfordshire-Antimicrobial-ADULT-Guidelines-Primary-Care - 2014

Uploaded by

Copyright:

Available Formats

OXFORDSHIRE

Version 2.2 (March 2014)

Interim Update to Guidance– Approved by APCO March 2014

o UTI in Men & Women (including older people)

2. Update of Acne section to include more recent guidance approved by APCO in

3. Change of preferred macrolide from erythromycin to clarithromycin (except in

Appropriate antimicrobial prescribing is a key element in the reduction of healthcare associated

Characteristics Type I immediate reactions Non-Type I reactions

In patients with a history of a mild to moderate non-type I reactions to penicillin as exemplified

Red Orange Green

Therapy: - refer to current HPA recommendations for recommended treatment,

Only prescribe an amoxicillin alone 250mg- 5 days

As well as pain, and

Oral Predisposing local and For localized or mild oral

Prodigy Consider 7-14 day delayed amoxicillin 500mg 5 days

or clarithromycin 250mg- 5 days

Risk factors for If resistance risk factors:

or doxycycline 200mg 7 days

or doxycycline alone 200mg 7-10 days

In severely ill give

*Avoid if patient is febrile or clinical evidence of

In older patients, community multi-resistant Extended-

Amoxicillin resistance is common; only use if organism

*Contraindicated in renal impairment (eGFR less than

Community multi-resistant Extended-spectrum Beta-

*Avoid if patient is febrile or clinical evidence of

amoxicillin 500mg 10-14 days

Refer to ‘Management of UTIs in Pregnancy in Primary Care’ for further details.

CONDITION COMMENTS DRUG DOSE DURATION

itraconazole 400mg for 3-6

If woman using not using erythromycin 500mg 14 days

For epididymo-orchitis ofloxacin 200mg 14 days

CONDITION COMMENTS DRUG DOSE DURATION

Only consider empirical

Suspected Campylobacter clarithromycin 250mg- 3-5 days

Suspected Salmonella / ciprofloxacin 500mg 3-5 days

Acute Antimicrobials for acute

For people managed at

Giardia metronidazole 400mg 5 days

CONDITION COMMENTS DRUG DOSE DURATION

Reserve topical 3B+

If river, sea or flood water

Recurrent cellulitis in lymphoedema is a common problem: Consider prophylactic

Diabetic Foot Ensure vascular assessment and podiatry review.

Moderate diabetic foot If IV antimicrobials NOT

Wound Swabbing not normally necessary.

For surgical wound infections – seek microbiology/infectious disease advice.

Prodigy If active infection, MRSA confirmed by lab results,

If severe infection or no response to monotherapy after

Cat or Dog Assess risk of tetanus and

For animals not covered in

Mastitis Antimicrobials only flucloxacillin 500mg 14 days

If not responding after 8

azelaic acid 15% BD

* some gel preparations are ~3 times the cost of the

Boils / Cysts/ Antimicrobials treatment Antimicrobial treatment

Recurrent boils may need

If a boil is drained then a

Pregnant or breastfeeding Wet combing or dimeticone

Prodigy 1 week terbinafine is as or (athletes foot only)

If intractable: send skin terbinafine oral 250mg

Scalp scrapings for

Fungal / Unsightly nails due to Prescribe only in line with