RECOMMENDATION FOR THE USE OF ANTIBIOTICS FOR THE TREATMENT OF INFECTION

Aims
 to provide a simple, best guess approach to the treatment of common infections, based on known sensitivity and resistance
patterns in Cumbria
 to promote the safe, effective and economic use of antibiotics
 to minimise the emergence of bacterial resistance in the community

Principles of Treatment
1. This guidance is based on the best available evidence but its application must be modified by professional judgement in the light of
co-existing diseases and other drug therapy.
2. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
3. Limit prescribing over the telephone to exceptional cases.
4. Use simple generic antibiotics first whenever possible.
5. The use of new and more expensive antibiotics (e.g., quinolones and cephalosporins) is inappropriate when standard and less
expensive antibiotics remain effective. Antibiotics are listed in order of preference.
6. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
7. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole. Short-term use of trimethoprim
(theoretical risk in first trimester in patients with poor diet, as folate antagonist) or nitrofurantoin (at term, theoretical risk of
neonatal haemolysis) is unlikely to cause problems to the foetus.
8. Doses quoted are intended for otherwise fit adults. Doses may need to be changed in children and those with renal impairment. The
duration of therapy will vary by individual patient, disease severity and speed of resolution.
9. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from the Consultant
Microbiologists at:
West Cumberland Hospital  01946 693181
Cumberland Infirmary  01228 814641
Furness General Hospital  01229 491022
This guidance has been produced in consultation with the consultant microbiologists and the Cumbria Medicines Management team.

Published: December 2012, Review date: November 2014

Drug and dose Duration

Condition Comments
(listed in order of preference) (days)
UPPER RESPIRATORY TRACT/ENT

Delayed prescriptions are a useful strategy as most upper respiratory tract infections are viral, self-limiting and improve
without antibiotics. Regular use of analgesics such as paracetamol and ibuprofen should be encouraged.

Influenza Annual vaccination is essential for all those at OSELTAMIVIR 75mg BD or, if there 5
risk of influenza. For otherwise healthy adults is resistance to oseltamivir
antivirals not recommended. Treat ‘at risk’ patients, ZANAMIVIR 10mg BD (2 inhalations
ONLY within 48 hours of onset and when influenza is by diskhaler)
circulating in the community or in a care home where
influenza is likely. At risk: For prophylaxis, see NICE. (NICE
pregnant Influenza). Patients under 13 years
65 years or over see HPA Influenza link.
chronic respiratory disease (including COPD and
asthma)
significant cardiovascular disease (not
hypertension)
immunocompromised
diabetes mellitus
chronic neurological
renal or liver disease
Tonsillitis/pharyngitis/sore AVOID ANTIBIOTICS as 90% resolve in 7 days ANTIBIOTIC TREATMENT NOT
throat without and pain only reduced by 16 hours. If Centor ROUTINELY RECOMMENDED
score 3 to 4:
lymphadenopathy If antibiotic is required,
history of fever PHENOXYMETHYLPENICILLIN 500mg 10
tonsillar exudate QDS (severe), or
no cough CLARITHROMYCIN 250-500mg BD 5
consider 2 or 3-day delayed antibiotics or immediate
antibiotics.

Antibiotics to prevent quinsy, NNT >4000

Acute rhinosinusitis
Antibiotics to prevent otitis media, NNT 200
AVOID ANTIBIOTICS as 80% resolve in 14 days ANTIBIOTIC TREATMENT NOT
without, and they only offer marginal benefit after 7 ROUTINELY RECOMMENDED
days (NNT 15)
Use adequate analgesia If antibiotic is required,
Consider 7-day delayed or immediate antibiotic when AMOXICILLIN 500mg TDS, or 5
purulent nasal discharge (NNT 8) DOXYCYCLINE 200mg stat, then 5
In persistent infection use an agent with anti-anaerobic 100mg daily, or
activity e.g., co-amoxiclav CLARITHROMYCIN 250mg BD 5

2nd line – CO-AMOXICLAV 625mg 5

TDS

Condition
Otitis externa (acute)
Otitis media (acute) – child
doses
LOWER RESPIRATORY TRACT
Lower respiratory tract
infection (including acute
bronchitis) in otherwise
healthy individuals
Exacerbations of COPD
Community acquired
pneumonia
Bronchiectasis
EYES
Bacterial conjunctivitis
Ocular Herpes simplex
infection
Drug and dose Duration
Comments
(listed in order of preference) (days)
First use aural toilet and analgesia. ACETIC ACID spray (EarCalm®) 1 5
Cure rates similar for topical acetic acid or antibiotic spray TDS, or
steroid PREDNISOLONE + NEOMYCIN ear
drops 3 drops TDS
Antibiotics do not reduce pain in first 24 hours, ANTIBIOTIC TREATMENT NOT
subsequent attacks or deafness. Use paracetamol or ROUTINELY RECOMMENDED
NSAID.
If antibiotic is required,
Otitis media resolves in 60% of patients in 24 hours AMOXICILLIN 40-90mg/kg/day in 3 5
without antibiotics. Antibiotics reduce pain at 2 days divided doses up to 1 gram TDS, or
(NNT 15) CLARITHROMYCIN 5
<8kg - 7.5mg/kg BD
Consider antibiotics (2 to 3 days) if: 8-11kg – 62.5mg BD
 <2 years AND bilateral otitis media (NNT 4) or 12-19kg – 125mg BD
marked otoscopic signs and ≥ 3 symptoms 20-29kg – 187.5mg BD
 All ages with otorrhea (NNT 3) 30-40kg – 250mg BD
Immediate prescribing may be appropriate for the 2nd line - CO-AMOXICLAV 5
following groups: 1-6yrs - 156mg TDS
 otorrhoea 6-12yrs - 312mg TDS
 <2 years with bilateral acute otitis media
Haemophilus is an extracellular pathogen so macrolides
(e.g., erythromycin), which concentrate intracellularly,
are less effective therapy.
Antibiotics are not routinely indicated. Consider ANTIBIOTIC TREATMENT NOT
prescribing an antibiotic if the person has a ROUTINELY RECOMMENDED
significantly impaired ability to fight infection (e.g.,
immunocompromised status, cancer, or physical If antibiotics are required,
frailty) or if acute bronchitis is likely to significantly AMOXICILLIN 500mg TDS, or 5
worsen a pre-existing condition (e.g. heart failure, DOXYCYCLINE 200mg stat, then 5
angina, or diabetes). 100mg daily
Alternative antibiotics may be used on the basis of
sputum results.
Treat exacerbations promptly with antibiotics if: AMOXICILLIN 500mg TDS, or 5
purulent sputum and DOXYCYCLINE 200mg stat, then 5
increased shortness of breath and/or 100mg daily, or
increased sputum volume CLARITHROMYCIN 500mg BD 5
Risk factors for antibiotic resistant organisms include
co-morbid disease, severe COPD, frequent
exacerbations, antibiotics in last 3 months
Assess the person's need for admission by determining If CRB65=0
CRB65 score: AMOXICILLIN 500mg TDS, or 5
Confusion (AMT<8) DOXYCYCLINE 200mg stat, then 5
Respiratory rate > 30/minute 100mg daily, or
Age >65 years CLARITHROMYCIN 500mg BD 5
BP systolic <90 or diastolic ≤60
If CRB65=1 & AT HOME
Score 0, suitable for home treatment AMOXICILLIN 500mg TDS AND 5-7
Score 1-2, hospital assessment or admission CLARITHROMYCIN 500mg BD, or
Score 3-4, urgent hospital admission DOXYCYCLINE 200mg stat, then 5-7
100mg daily
Give immediate Benzylpenicillin 1.2 grams IM or
Amoxicillin 1 gram oral if delayed admission or
life-threatening
Antibiotics should be given for exacerbations that Antibiotic choice should be based on 14
present with an acute deterioration with worsening previous culture results. Consider
symptoms (cough, increased sputum volume or need for anti-pseudomonal cover if
change in viscosity, increased sputum purulence with not responding, or Pseudomonas
or without increasing wheeze, breathlessness, growth from the sputum. If culture
haemoptysis) and/or systemic upset. negative send sample for
Aspergillus
Sputum samples should be taken to guide therapy.
Need long course of 10 to 14 days.
Treat if severe, as most are viral or self-limiting. CHLORAMPHENICOL eye drops 1 7
Bacterial conjunctivitis is unilateral and also self- drop every 2 hours for 2 days, then
limiting. It is characterised by red eye with 4 hourly (whilst awake) for up to 1
mucopurulent, not watery discharge. 65% resolve on week; eye ointment at night
placebo by day 5.
If pregnant or history of blood
dyscrasia use FUSIDIC ACID BD 7
STD: unilateral inclusion conjunctivitis usually with Chlamydial: DOXYCYCLINE 100mg 7
urethritis (causative agent: C. trachomatis). BD, or
AZITHROMYCIN 1 gram stat (treat
the sex partner as well)
Urgent ophthalmic referral necessary. Commence ACICLOVIR eye 21
ointment, applied 5 times a day
In recurrent infection treatment may be initiated but
this must be done in consultation with
ophthalmologist.
Avoid topical steroids and remove contacts lenses.
 Drug and dose Duration
Condition Comments
(listed in order of preference) (days)
Corneal abrasions If corneal ulcer - Urgent ophthalmic referral is CHLORAMPHENICOL eye ointment 5
necessary. BD
ORAL
Mucosal ulceration and Temporary pain and swelling relief can be attained with CHLORHEXIDINE 0.2% mouthwash, Until lesion
inflammation saline mouthwash(½tsp in glass of warm water) rinse mouth for 1 minute BD with resolves of
5ml diluted with equal volume of less pain
water, or allows oral
HYDROGEN PEROXIDE 6%, 15mls in hygiene
½ glass of warm water TDS
Dental abscess Advise urgent dental consultation, as repeated courses AMOXICILLIN 500mg TDS, or 5
of antibiotics for abscess are not appropriate. PHENOXYMETHYLPENICILLIN 5
Antibiotics are only recommended if there are: 500mg-1 gram QDS
signs of severe infection
systemic symptoms If penicillin allergic, or in severe
high risk of complications infection
Otherwise, regular analgesia should be first option until METRONIDAZOLE 200mg TDS 5
a dentist can be seen.
Oral thrush NYSTATIN 100,000 units QDS, or 7
MICONAZOLE gel, 5mL QDS 7
(miconazole interacts with statins and
anticoagulants)

If immunosuppressed, consider
fluconazole 50-100mg OD for 7 to
14 days
Acute necrotising ulcerative
Refer to dentist for scaling and oral hygiene advice, METRONIDAZOLE 200mg TDS 3
gingivitis after starting antibiotic
Pericoronitis Refer to dentist for irrigation and debridement. If METRONIDAZOLE 200mg TDS 3
persistent swelling or systemic symptoms, use
metronidazole
GASTRO-INTESTINAL INFECTIONS
H.pylori infection Tetracycline 500mg four times a day may be used Triple-therapy: 7
instead of amoxicillin in penicillin-allergic patients. LANSOPRAZOLE 30mg BD plus
Resistance to clarithromycin or to metronidazole is AMOXICILLIN 1 gram BD plus
much more common than to amoxicillin and can either
develop during treatment. Do not use clarithromycin CLARITHROMYCIN 500mg BD, or
or metronidazole if used for any infection in the past METRONIDAZOLE 400mg BD
year.
Giardiasis Recurrence is high even with optimal treatment, METRONIDAZOLE 200mg TDS for 7 3-7
therefore follow-up with a stool sample is advised. days is the most tolerable and depending
effective doses; 400mg TDS for 5 on the
days or 2 grams daily for 3 days doses
Threadworms Treat all household contacts at the same time PLUS MEBENDAZOLE 100mg One dose
advise hygiene measures for 2 weeks (hand hygiene, (mebendazole is not licensed for repeat in
pants at night, morning shower) PLUS wash children under 2 years, use two weeks
sleepwear, bed linen, dust and vacuum on day one. piperazine instead)
Acute gastroenteritis Antibiotics not usually indicated. Discuss any intended Antibiotic treatment not routinely
treatment with microbiologist. recommended
Fluid replacement essential
Travellers diarrhoea Limit prescription of antibacterial to be carried abroad
and taken if illness develops (ciprofloxacin 500mg
single dose, unlicensed indication) to people travelling
to remote areas in whom an episode of infective
diarrhoea could be dangerous.
C.difficile infection Stop unnecessary antibiotics and/or PPIs. 70% respond METRONIDAZOLE 400mg TDS for 1st 10-14
to metronidazole in 5 days, 92% in 14 days. and 2nd episodes
Admit if severe: VANCOMYCIN 125mg QDS for 3rd 10-14
Temperature >38.5°C episode/severe or type 027
WCC >15
Rising creatinine
Signs/symptoms of severe colitis
URINARY TRACT
Amoxicillin resistance is common, therefore ONLY use if culture confirms susceptibility. In the elderly (>65 years), do not treat asymptomatic
bacteriuria: it occurs in 25% of women and 10% of men and is not associated with increased morbidity. In the presence of a catheter,
antibiotics will not eradicate bacteriuria; only treat if systemically unwell or pyelonephritis likely.

Co-amoxiclav is alternative in patients with low GFR. Nitrofurantoin should not be used if GFR is <60mL/min/1.73m2 or trimethoprim if GFR is
<15mL/min/1.73m2.
Cystitis in women
UTI in men
Routine urine culture unnecessary for simple cystitis in TRIMETHOPRIM 200mg BD, or 3
adult women. NITROFURANTOIN MR 100mg BD 3
Further diagnosis should be made on basis of (Note that trimethoprim may cause a rise in
serum creatinine especially in pre-existing
symptoms and dipstick analysis (see HPA guidance).
renal impairment due to competition for
renal excretion)
Co-amoxiclav is alternative in
patients with low GFR (see above)
TRIMETHOPRIM 200mg BD, or 7
NITROFURANTOIN MR 100mg BD 7
Co-amoxiclav is alternative in
patients with low GFR (see above)
 Drug and dose Duration
Condition Comments
(listed in order of preference) (days)
UTI or confirmed Screening requires a urine sample to be sent to AMOXICILLIN 500mg TDS, or 7
asymptomatic bacteriuria in microbiology for microscopy and culture, dip stick NITROFURANTOIN MR 100mg BD, 7
pregnant women testing alone is not adequate or
CEFALEXIN 500mg TDS for 7 days, 7
or
TRIMETHOPRIM 200mg BD for 7 7
days (unless folate deficient or
taking folate antagonist [e.g.
antiepileptic or proguanil])
UTI in children < 3 months, immediate paediatric referral TRIMETHOPRIM 4mg/kg BD (max 3 (lower)
> 3 months with acute pyelonephritis/upper UTI, 200mg), or
consider referral to paediatric specialist, treat with CEFALEXIN 7-10 if
antibiotics 1 month-1 year - 125mg BD upper UTI
> 3 months with cystitis/lower UTI, treat. If still 1 – 5 years - 125mg TDS
unwell after 24 to 48 hours, child should be 5 - 12years - 250mg TDS
reassessed
Pyelonephritis Culture required. CO-AMOXICLAV 625mg TDS, or 7-10
CIPROFLOXACIN 500mg BD
Epididymo-orchitis Screen for chlamydia. DOXYCYCLINE 100mg BD 10-14

Add IM CEFTRIAXONE 500mg stat if

GENITAL SYSTEM
Vaginal candidiasis
Bacterial vaginosis
Chlamydia
Trichomoniasis
Gonorrhoea - uncomplicated
Pelvic inflammatory disease
Acute prostatitis
Genital herpes
Bartholins gland infection
Genital warts
WOUND AND SKIN INFECTION
Cellulitis If afebrile and well other than cellulitis oral therapy is
- limb adequate.
If febrile and unwell admit or arrange for IV antibiotics
(flucloxacillin or clarithromycin, as approved under
PCT Cellulitis pathway).
there likelihood of sexually
transmitted pathogen
Clotrimazole and fluconazole are available over-the- CLOTRIMAZOLE pessaries 500mg, 1
counter. or
7 day course recommended during pregnancy. 200mg 3
Fluconazole is contra-indicated in pregnancy.
FLUCONAZOLE 150mg Stat dose
Usually associated with anaerobes, recurrence is METRONIDAZOLE 400mg BD, or 2 7
frequent, but is not a sexually transmissible infection grams stat, or
(STI). METRONIDAZOLE vaginal gel, 5
Do not retest if symptoms resolve. 0.75% daily – apply at night
In pregnancy 7 days of clindamycin gel recommended.
In pregnancy testing should be repeated after 1 CLINDAMYCIN vaginal gel, 7
month to ensure cure achieved. 2% daily – apply at night
Advise sexual abstinence until the infected woman and DOXYCYCLINE 100mg BD, or 7
her partner(s) have both completed the course of AZITHROMYCIN 1 gram (not stat
treatment. If treatment with single-dose azithromycin licensed for use in pregnancy, see
is given, then sexual abstinence for the following 7 comments)
days is advised.
(Azithromycin has been used for 20 years, during which time a
number of studies have shown that there is no increased risk of
adverse effects associated with using the drug during pregnancy. It
is significantly more effective and better tolerated than the
alternative agents (erythromycin and amoxicillin), but its use is
more limited).
Pregnant woman must be retested after 5 weeks after
completing therapy (6 weeks if azithromycin used).
Refer to GUM clinic for contact tracing.
Refer to GUM – may be associated with other STDs. METRONIDAZOLE 400mg BD 7
Increasing resistance Refer to GUM clinic for contact CEFTRIAXONE IM 500mg stat and stat
tracing and screening for other sexually transmitted AZITHROMYCIN 1 gram stat
diseases.
Refer to GUM. CEFTRIAXONE IM 500mg stat 14
followed by DOXYCYCLINE 100mg
Tests essential for gonococcus and chlamydia. BD and METRONIDAZOLE 400mg
BD or
OFLOXACIN 400mg BD and 14
METRONIDAZOLE 400mg BD
Send MSU for culture and start antibiotics. 2 week CIPROFLOXACIN 500mg BD, or 14
course may prevent chronic prostatitis. TRIMETHOPRIM 200mg BD 14
Screening for low risk patients may be done in practice. ACICLOVIR 200mg five times a day 5
Higher risk should be referred to GUM.
May be associated with STD – consider screening. Antibiotics not indicated for
uncomplicated disease
Screening for co-existent STD indicated. PODOPHYLLOTOXIN applied twice
daily for three consecutive days,
Podophyllotoxin is contra-indicated in pregnancy. repeated at weekly intervals if
necessary for a total of 4 to 5
courses
Liquid nitrogen if small number of
low volume warts or keratinized
FLUCLOXACILLIN 500mg QDS, or 5
CLARITHROMYCIN 500mg BD 5

If river or seawater exposure discuss with

microbiologist.
- facial Early referral necessary if not responding to treatment. CO-AMOXICLAV 625mg TDS 7

Condition
Surgical wounds, abscesses,
mastitis, wound infection
Leg ulcers and pressure
sores
Herpes zoster
Animal and human bites
Tick bite
Impetigo
Fungal nail infections
Fungal skin infections
- dermatophyte (ringworm)
- candida
Varicella zoster/chickenpox
CENTRAL NERVOUS SYSTEM
Meningitis
Drug and dose Duration
Comments
(listed in order of preference) (days)
Abscesses should be drained. FLUCLOXACILLIN 500mg QDS, or 5
CLARITHROMYCIN 500mg BD 5
If wound could be contaminated with soil, faeces or CO-AMOXICLAV 625mg TDS, or 5
bodily fluids or if infection area has poor vascular CLARITHROMYCIN 500mg BD and 5
supply. METRONIDAZOLE 400mg TDS, or
CLINDAMYCIN 300mg QDS 5
Bacteria will always be present. Antibiotics do not improve healing, unless active infection. Culture swabs and
antibiotics are only indicated if diabetic or there is evidence of clinical infection such as
inflammation/redness/cellulitis, increased pain, purulent exudate, rapid deterioration of ulcer or pyrexia.
ACICLOVIR 800mg five times a day, 5
started within 72 hours of onset of
rash
Human bites should generally be treated with CO-AMOXICLAV 625mg TDS 5
antibiotics if the skin is broken, and consideration
given to tetanus, hepatitis B and HIV prophylaxis. If 2nd line
the skin is broken following an animal bite, consider Cat, dog and human bites - 5
antibiotics if puncture wound, bite to hand, foot, face, DOXYCYCLINE 100mg BD and
joint, tendon, ligament or immunocompromised, METRONIDAZOLE 400mg TDS
diabetic, asplenic or cirrhotic. Cat bites carry a high Human bites - CLARITHROMYCIN 5
risk of infection and should be treated. 250-500mg BD and
Consider tetanus, and, if the bite occurred abroad, METRONIDAZOLE 400mg TDS
rabies.
Lyme disease prophylaxis is indicated if tick is likely to DOXYCYCLINE 200mg single dose
have been attached for >24 hours, or it is obviously
engorged.
Prophylaxis not indicated if the bite occurred more than
72 hours ago, or if the patient is continually exposed
to ticks.
Treatment of localised erythema migrans: DOXYCYCLINE 100mg BD, or 14
AMOXICILLIN 500mg TDS; children
Treatment of later stages of Lyme disease - discuss <8 years Amoxicillin 50mg/kg/day
with Microbiologist. in divided doses for 2 weeks or
Erythromycin
For extensive, severe or bullous impetigo, use oral FLUCLOXACILLIN 500mg QDS, or 5
antibiotics CLARITHROMYCIN 250mg to 500mg 5
BD
Reserve topical antibiotics for very localised lesions to FUSIDIC ACID, topical TDS 5
reduce the risk of resistance.
Reserve mupirocin (local) for MRSA infections. MUPIROCIN, topical TDS 5
Take nail clippings. TERBINAFINE 250mg daily;
Treatment must only be commenced after mycological fingernails, 6 to 12
confirmation of infection. weeks;
toenails, 3 to 6
Topical amorolfine should only be used where infection months
is confined to the distal edge of the nail in the very ITRACONAZOLE 200mg BD
early stages of distal and lateral subungual fingernails, (2 courses) 7 days
onychomycosis or in superficial white onychomycosis. monthly
toenails, (3 courses)
Terbinafine not licensed in children but listed in BNFc.
Clotrimazole is an alternative. TERBINAFINE cream twice a day 10-14
CLOTRIMAZOLE cream BD/TDS, Continue 1-
2 weeks
after
affected
area has
healed
Pregnant/immunocompromised/neonate, seek urgent
specialist advice
Chicken pox: If started < 24 hours of rash and > 14 ACICLOVIR 800mg five times day 7
years or severe pain or dense/oral rash or 2 household
case or smoker
Shingles: treat if > 50 years and within 72 hours of
rash or if active ophthalmic or Ramsey Hunt or
eczema.
Urgent hospital transfer is primary consideration. Only BENZYLPENICILLIN, preferably IV, stat
contra-indication to benzylpenicillin if true penicillin but IM if access difficult
anaphylaxis; use of alternate antibiotics is not Over 10 years, 1.2 grams
recommended. 1 to 9 years, 600mg
Under 1 year, 300mg