Southwark and Lambeth Antibiotic Guideline for Primary Care 2019

Approved by the Southwark Medicines Management Committee and Lambeth Borough Prescribing Committee: October 2019. Review date: October 2021
(or sooner if evidence changes)
These guidelines have been developed by NHS Southwark CCG, NHS Lambeth CCG, Department of Microbiology and Pharmacy Departments at King’s College Hospital NHS
Foundation Trust (KCH) and Guy’s and St Thomas’ NHS Foundation Trust (GSTFT), Southwark and Lambeth Public Health. The guideline is based on the Public Health England
Management of infection guidance for primary care, Updated September 2019

Please direct any comments or queries to Medicines Optimisation: NHS Southwark CCG (email: [email protected], tel: 020 7525 3253), NHS Lambeth
CCG (email: [email protected], tel: 020 3049 4197)

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 Aims

• To provide a simple, empirical approach to the treatment of common infections based on our local community and sensitivity patterns.
• To promote the safe, cost-effective and appropriate use of antimicrobials by targeting those who may benefit most.
• To minimise the emergence of antimicrobial resistance in the community.

Principles of Treatment
1. This guidance is based on the best available evidence at the time of development. Its application must be modified by professional judgement, based on knowledge about
individual patient co-morbidities, potential for drug interactions and involve patients in management decisions.
2. It is important to initiate antibiotic as soon as possible in severe infection or in those immunocompromised, particularly if sepsis is suspected. Refer to the NICE guideline
[NG51] Sepsis: recognition, diagnosis and early management for further information.
3. This guidance should not be used in isolation; it should be supported with patient information about safety netting, back-up/delayed antibiotics, self –care, infection severity
and usual duration, clinical staff education, and audits. The RCGP TARGET antibiotics toolkit is available via the RCGP website.
4. The majority of this guidance provides dose and duration of treatment for ADULTS. Doses may need modification for age, weight and renal function. Refer to the BNF for
Children for information on paediatric doses.
5. Refer to BNF for further dosing and interaction information (e.g. interaction between macrolides and statins), ALWAYS check for hypersensitivity/allergy.
6. Have a lower threshold for antibiotics in immunocompromised or in those with multiple co- morbidities; send samples for culture and seek advice.
7. Drugs in RED are contra-indicated in true penicillin allergy. Drugs in GREEN are considered safe in penicillin allergy.
8. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit, giving alternative, non-antibiotic self –care advice where appropriate.
9. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections (e.g. acute sore throat, acute cough and acute sinusitis) and mild UTI
symptoms
10. ‘Blind’ antibiotic prescribing for unexplained pyrexia usually leads to further difficulty in establishing the diagnosis.
11. Limit prescribing over the telephone/eConsult to exceptional cases.
12. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of all
infections, including Clostridium difficile, MRSA and resistant Urinary Tract Infections (UTIs).
13. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, in most cases, topical use should be limited).
14. If diarrhoea or vomiting occurs due to an antibiotic or the illness being treated, the efficacy of hormonal contraception may be impaired and additional precautions should be
recommended.
15. Clarithromycin is now recommended over erythromycin, except in pregnancy and breastfeeding. It has fewer side-effects and twice daily rather than four times daily dosing
promotes compliance. Statins should be withheld when macrolide antibiotics are prescribed.
16. In pregnancy, take specimens to inform treatment. Penicillins, cephalosporins and erythromycin are not associated with increased risk of spontaneous abortion. If possible,
avoid tetracyclines, quinolones, aminoglycosides, azithromycin (except in chlamydial infection), clarithromycin and high dose metronidazole (2g stat) unless the benefits
outweigh the risks. Short-term use of nitrofurantoin is not expected to cause foetal problems (theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause
problems unless poor dietary folate intake, or taking another folate antagonist. If you are unsure about a particular drug’s use in pregnancy contact the relevant
Medicines Optimisation team for further advice.
17. Annual vaccination is essential for all those at clinical risk of severe influenza. Visit Annual Flu Programme for further information. For information on Immunisation against
infectious disease refer to The Green Book.
18. For information on causative pathogens, refer to PHE guidance: Management of infection guidance for primary care for consultation and local adaptation

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 Self Care

Promote self-care where appropriate. Refer to the Self Care sections highlighted throughout the guideline. Treatments that are often available to purchase over the counter
include:

• Analgesics (painkillers) for short-term use

• Topical antifungal treatment for short-term minor ailments
• Cold sore treatment
• Colic treatment
• Cough and cold remedies
• Eye treatments/lubricating products
• Head lice treatment and scabies treatment
• Threadworm tablets
• Topical acne treatment
• Warts and verruca treatment

For further information see:

• NHS Lambeth CCG: ‘Self care with over the counter products’ leaflet
• NHS Southwark CCG: ‘Are you Self Care Aware?’ leaflet
• Self-care Forum website
• NHS Choices website

Patients who are registered with a Southwark GP and entitled to free prescriptions may be eligible to receive treatment free of charge for certain conditions under the Pharmacy
First Scheme. For further information see the Pharmacy First webpage.

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 CONTENTS PAGE
UPPER RESPIRATORY TRACT INFECTIONS LOWER RESPIRATORY TRACT INFECTIONS

• Acute sore throat • Community acquired pneumonia

• Scarlet Fever • Acute cough, bronchitis

• Influenza

• Acute rhinosinusitis • Acute exacerbation of COPD

• Acute otitis media

• Acute otitis externa

URINARY TRACT INFECTIONS SKIN INFECTIONS

• Lower UTI in adults (no fever or flank pain) • Impetigo

• Recurrent UTI in women ( ≥ 3 UTIs/year) • Cellulitis and Erysipelas

• Recurrent UTI in men • Mastitis

• Lower UTI in children • Diabetic foot infections

• Upper UTI in children • Acne

• Acute prostatitis • Eczema

• Acute pyelonephritis • Human or animal bites

• Varicella zoster (chickenpox) / Herpes zoster (shingles)

• Tick bites (Lyme disease)

GASTROINTESTINAL INFECTIONS EYE INFECTIONS

• Infectious diarrhoea (or gastroenteritis) • Conjunctivitis

• Antibiotic-associated diarrhoea/ pseudomembranous colitis (Clostridium difficile) • Blepharitis

DENTAL INFECTIONS

SUSPECTED MENINGOCOCCAL DISEASE

SEXUALLY TRANSMITTED INFECTIONS MRSA INFECTIONS

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 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy
UPPER RESPIRATORY TRACT INFECTIONS
First Line:
AVOID ANTIBIOTICS or consider back-up/ delayed antibiotic Fever Pain 0-1: self-care see NHS Choices
prescription. Second Line: Second Line: Second Line: Second Line:
Fever pain 2-3: delayed Fever pain 2-3: Fever pain 2-3: delayed Fever pain 2-3: delayed
82% of cases resolve in 7 days without antibiotics and pain is only prescription of delayed prescription prescription of prescription of
reduced by 16 hours. phenoxymethylpenicillin of clarithromycin Phenoxymethylpenicillin erythromycin
Use FeverPAIN* Score to assess. Criteria include: Fever in last 24h, Phenoxymethylpenicillin Clarithromycin (oral) Phenoxymethylpenicillin Erythromycin (oral)
Acute sore Purulence, Attend rapidly under 3 days, severely Inflamed tonsils, No (oral) 500 mg QDS OR 250 mg BD for 5 days (oral) 500 mg QDS OR 250 mg – 500 mg QDS
cough or coryza). 1g BD (if mild) for 5-10 If severe ( refer to 1g BD (if mild) for 5-10 for 5 days.
throat
days comments): 500mg days
Score 0-1: 13-18% streptococci isolation - use NO antibiotic strategy If severe (refer to BD for 5 days If severe (refer to
PHE
comments): 500mg QDS comments): 500mg QDS
Score 2-3: 34-40% streptococci isolation - consider no antibiotic or a for 10 days for 10 days
CKS back-up antibiotic prescription;
NICE Score 4-5: 62-65% streptococci isolation. Use clinical judgement to
assess severity on baseline symptoms (difficulty swallowing, runny
FeverPAIN nose, cough, headache, muscle ache, interference with normal
activities) and use immediate antibiotic or 48 hour short delayed
Treating your antibiotic prescription.
infection
patient leaflet Always share self-care advice & safety net.

Complications are rare.

If systemically unwell, refer to emergency department.

*Centor criteria can also be used

Scarlet Prompt treatment with appropriate antibiotics significantly reduces the First line: First line: First Line: First Line:
Fever risk of complications. Vulnerable individuals (immunocompromised, the Phenoxymethylpenicillin Clarithromycin (oral) Phenoxymethylpenicillin Erythromycin (oral)
co-morbid, or those with skin disease) are at increased risk of developing (oral) 500 mg QDS for 250 mg-500mg BD for (oral) 500 mg QDS for 250 mg – 500 mg QDS
PHE Scarlet complications 10 days 5 days 10 days or 500mg – 100mg BD
Fever for 5 days.
This is a notifiable disease
See the PHE Influenza guidance for further information.
Influenza
PHE

5
 Symptoms <10 days: do not offer antibiotics as most resolve in 14 First Line: self-care see NHS Choices
days without. Antibiotics only offer marginal benefit after 7 days. Second Line: (delayed Second Line: (delayed Second Line: (delayed Second Line: (delayed
Symptoms >10 days: no antibiotic, or back-up/delayed antibiotic if antibiotic) antibiotic) antibiotic) antibiotic)
several episodes of: purulent nasal discharge; severe localised unilateral phenoxymethylpenicillin Doxycycline (oral) Phenoxymethylpenicillin Erythromycin (oral)
pain; fever; marked deterioration after initial milder phase. (oral) 500mg QDS for 5 200mg STAT then (oral) 500mg QDS for 5 250 mg – 500 mg QDS
Systemically very unwell or more serious signs and symptoms: days 100mg OD for a total days for 5 days
Acute immediate antibiotic. of 5 days
Rhino- Suspected complications: e.g. sepsis, intraorbital or intracranial OR For 2nd line choice of For 2nd line choice of
sinusitis infection, refers to secondary care. Offer as first choice if Clarithromycin (oral) antibiotic or if worsening antibiotic or if worsening
Self-care: paracetamol/ibuprofen for pain/fever. Consider high-dose systemically very unwell 500mg BD for 5 days contact local medical contact local medical
NICE nasal steroid if >12 years. Little evidence that nasal saline or nasal or high risk of infection team (refer to infection team (refer to
decongestants help, but people may want to try them (suitable for self- complications; Co- Mometasone nasal page 21 for contact page 21 for contact
CKS care) Consider prescribing a high-dose nasal corticosteroid for 14 days amoxiclav 625mg TDS spray 200mcg BD for details). details).
for adults and children aged 12 years and over with symptoms for 10 for 5 days 14 days Mometasone nasal Mometasone nasal
Treating your days or more, but being aware that nasal corticosteroids:
spray 200mcg BD for 14 spray 200mcg BD for 14
infection • may improve symptoms but are not likely to affect how long Mometasone nasal For 2nd line choice of days if benefit outweighs days if benefit outweighs
patient leaflet they last spray 200mcg BD for 14 antibiotic or worsening risk risk.
• could cause systemic effects, particularly in people already days (with or without an contact local medical
taking another corticosteroid oral antibiotic) infection team (refer to
• may be difficult for people to use correctly -consider providing page 21 for contact
patient information leaflet on usage details).

For detailed information click on the visual summary contained within the
NICE hyperlink
Consider no or back up/delayed antibiotics First-line: self-care analgesia for pain relief
Amoxicillin (oral) for 5 Clarithromycin (oral)
Regular paracetamol or ibuprofen for pain (ensure correct dose Amoxicillin (oral) Erythromycin (oral)
Acute otitis days for 5 days
for age or weight at the right time and maximum doses for severe 500 mg 250 mg – 500 mg QDS
media pain) AOM resolves in 60% of cases in 24hrs without antibiotics, which TDS for 5 days for 5 days
500mg TDS 250 mg BD, increased
(AOM) only reduce pain at 2 days and does not prevent deafness. if necessary in severe
Otorrhoea or under 2 years with infection in both ears: no, back-up Second Line: infections to 500 mg
CKS or immediate antibiotic. (if symptoms worsen on BD
Otherwise: no or back-up antibiotic. first choice antibiotic
NICE Systemically very unwell or high risk of complications: immediate taken for at least 2-3
antibiotic days): Co-amoxiclav
NICE: Fever in 625mg TDS for 5 days
Under 5s

Treating your
infection If systemically unwell, refer to emergency department.
patient leaflet

NHS Choices

6
 If cellulitis/disease extending outside ear canal, take a swab for culture, First-line: self-care analgesia for pain relief and advice to apply localised heat (e.g. a warm
start oral flucloxacillin & refer to exclude malignant OE. Malignant OE flannel).
can be caused by Pseudomonas aeruginosa and therefore may not Second Line:
respond to flucloxacillin. Topical acetic acid 2% spray: 1 spray TDS for 7
Acute Otitis days (Available OTC as EarCalm®)
If patient presents with symptoms of longer than 2 weeks, in particular OR neomycin sulphate with corticosteroid ear
Externa (OE) patients with diabetes, refer to exclude malignant OE. drops: 3 drops TDS for 7 days minimum to 14
days maximum.
CKS Cure rates similar at 7 days for topical acetic acid
or antibiotic +/- steroid.
If cellulitis: flucloxacillin (oral) 250mg QDS for 7
days
If severe: 500mg QDS for 7 days

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 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy

LOWER RESPIRATORY TRACT INFECTIONS

Refer to hospital if CRB65≥3 Refer to hospital if CRB65 ≥ 1

If CRB65=1,2 & AT If CRB65=1, 2 and at If CRB65=0: If CRB65=0:

HOME, clinically assess home: Amoxicillin(oral) Erythromycin (oral)
need for antibiotic cover Clarithromycin(oral) 500 mg TDS for 7 days 250 mg – 500 mg QDS
for atypicals: 500 mg BD for 7 days for 7 days.
Amoxicillin (oral) depending on severity To return for review at 3
500 mg TDS days; if not improving or To return for review at 3
Use CRB65 score in conjunction with clinical judgement to help guide worsening refer to
AND Clarithromycin OR days; if not improving or
and review: Each parameter scores 1: hospital
(oral) 500 mg BD for 7 Doxycycline(oral) worsening refer to
Confusion (AMT≤8); Respiratory rate >30/min;
Community days depending on 200 mg STAT on day hospital
BP systolic <90mmHg or diastolic ≤ 60mmHg, Age ≥65.
Acquired severity 1 then 100 mg OD for
Score 3-4: urgent hospital admission
Pneumonia a total of 7 days
Score 1-2: intermediate risk consider hospital assessment
OR Doxycycline alone
(treatment Score 0: low risk consider home based care
(oral) 200 mg STAT on If CRB65=0:
in the day 1 then 100 mg OD Clarithromycin (oral)
community) Provide safety net advice and likely duration of symptoms: fever
for a total of 7 days 500mg BD 5 days
for 1 week, sputum production for up to 4 weeks, cough up to 6
with safety netting
BTS weeks, most symptoms resolve with 3 months and may take up
If CRB65=0: advice; to return for
to 6 months to get back to normal.
Amoxicillin (oral) review within 3 days;
NICE: 500 mg TDS for 5 days continue for a total of
Pneumonia in Atypical mycoplasma infection is rare in > 65 years.
with safety netting 7 days if no
Adults Failure to improve or worsening within 48 hours, consider hospital
advice; to return for improvement or
treatment or chest X-ray. 'When life threatening infection, GP
review at within 3 days; worsening.
should administer antibiotics. Benzylpenicillin 1.2 gram IV or
continue for a total of 7 OR
amoxicillin 1 gram orally are preferred agents5.
days if no improvement Doxycycline
or worsening. (oral)200mg STAT on
day 1, then 100mg
OD for 4 days; review
at 3 days; total 7 days
if poor response

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 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy
Acute Consider no or 7 day back up/delayed antibiotic with self-care and First line: Self Care and safety netting advice, see NHS Choices
cough, safety netting and advise that symptoms can last 3 weeks. Second line: Second line: Second line: Second line:
bronchitis Antibiotics are of little benefit if no co-morbidity. Doxycycline (adults and Doxycycline (adults Amoxicillin(oral) 500 mg Erythromycin(oral)
Symptom resolution can take up to 3 weeks. children over 12 years) and children over 12 TDS for 5 days 250 mg – 500 mg QDS
Consider immediate antibiotics if >80years of age and ONE of: (oral)200 mg STAT, years) (oral)200 mg for 5 days
CKS-cough
hospitalisation in past year; taking oral steroids; insulin dependent then 100 mg OD (total STAT, then 100 mg
diabetic; congestive heart failure, serious neurological disorder/stroke 5 days treatment) OD (total 5 days
CKS-
OR >65 years with TWO of the above. treatment) OR
Bronchitis
Consider CRP testing if antibiotic treatment is being considered. No Third line:
antibiotics if CRP<20mg/L and symptoms for >24 hours; delayed Amoxicillin(oral) 500 mg Clarithromycin (in
NICE: RTI
antibiotics if CRP 20-100mg mg/L; immediate antibiotics if TDS for 5 days children < 12 years
>100mg/L. old) 250mg-500mg
Treating your
infection BD for 5 days
patient leaflet

Rescue Pack (for initial management of exacerbation)

Prescribe prednisolone 5mg tablets - Take SIX tablets in the morning for 5 days and Doxycycline
100mg capsules (unless allergic/pregnant/breastfeeding – see below for antibiotic choice) - Take
Treat exacerbations promptly with antibiotics if purulent sputum and TWO capsules on the first day, then 100mg daily for a further 4 days, if no improvement in symptoms or
increased shortness of breath and/or increased sputum volume. doxycycline allergy refer to Visual Summary for choice of antibiotics and prescribing considerations
If a patient is using two or more packs in a year they need a specialist review. Consider referral
Consider risk factors for antibiotic resistance: severe COPD to the Integrated Respiratory Team who can be contacted 7 days a week 9am-5pm on 07796
(MRC>3), co-morbidity, frequent exacerbations, antibiotics in the last 178719 (St Thomas’) or 0203 299 6531 (Kings). Single Point of Referral can be accessed via
Acute 3 months [email protected] (Lambeth) [email protected] (Southwark)
exacerbation Previous microbiology should be reviewed if at risk of resistance.14
of COPD For access to the South East London integrated guideline for the management of COPD, click here:
Antibiotics should be used to treat exacerbations of COPD South East London integrated guideline for the management of COPD
NICE: COPD associated with a history of more purulent sputum. Patients with Doxycycline(oral) Doxycycline (oral) Amoxicillin (oral) Erythromycin(oral)
in over 16s exacerbations without more purulent sputum do not need antibiotic 200 mg OD for 1 day 200 mg OD for 1 day 500 mg TDS for 5 days 250 mg – 500 mg QDS
therapy unless there is consolidation on a chest radiograph or clinical then 100mg for a further then 100mg for a for 7 days
GOLD COPD signs of pneumonia7 - in which case follow treatment guidance for 4 days further 4 days OR
pneumonia. Clarithromycin (oral) If risk factors present,
500 mg BD for 5 days contact microbiology If risk factors present,
Oral corticosteroids should be considered in patients with a contact microbiology
significant increase in breathlessness which interferes with daily If risk factors
activities7. present, contact
If at risk of resistance: microbiology for
Co-amoxiclav (oral) advice on antibiotic
625mg TDS for 5days choice in
recurrent/resistant
cases

9
 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy

URINARY TRACT INFECTIONS

Women treat empirically if ≥ 2 symptoms First line for women and men: Nitrofurantoin
(oral) 100mg MR twice daily if eGFR over
a) Send urine culture if risk of antibiotic resistance. If not 45ml/min. Use nitrofurantoin 1st line as resistance
pregnant and mild symptoms, watch & wait with back-up and community multi-resistant Extended-spectrum
antibiotic OR consider immediate antibiotic Beta-lactamase E. coli are increasing.
b) Advise paracetamol or ibuprofen for pain
Nitrofurantoin is contraindicated if eGFR <
Men: Consider prostatitis and send pre-treatment Mid-stream 45 mL/min or if known G6PD deficiency or in
urine (MSU OR if symptoms mild/non-specific, use negative acute porphyria.
Lower UTI in adults dipstick to exclude UTI.
(no fever or flank Alternative 1st line agents for women and men: Prompt treatment for seven days to prevent
pain) Always provide safety net advice. Trimethoprim (oral) 200 mg BD (local resistance is progression to pyelonephritis. Send MSU for culture
high, therefore only recommend if patient has low and review antibiotics already prescribed based on
PHE UTI quick In treatment failure: always perform culture risk factors for resistance or if sensitivity of this is results.
reference guide known). OR
Low risk of resistance: younger women with acute UTI and For non-pregnant women >16y
SIGN no risk. Pivmecillinam (oral) 400mg STAT then 200mg Short-term use of nitrofurantoin in pregnancy is
Risk factors for increased resistance include: care home TDS unlikely to cause problems to the foetus.
resident, recurrent UTI, hospitalisation anywhere >7days within
CKS women the last 12 months unresolving urinary symptoms, recent travel
to a country with increased antimicrobial resistance (outside If eGFR<45ml/min or elderly consider
CKS men Northern Europe and Australasia), previous known UTI resistant pivmecillinam or fosfomycin (3g stat in women). Do not prescribe trimethoprim for pregnant
to trimethoprim, cephalosporins or quinolones (consider safety NOTE: Fosfomycin should only be prescribed on women with established folate deficiency, or low
TARGET Antibiotic issues) the advice of a microbiologist following culture dietary folate intake, or those taking folate
Toolkit If increased resistance risk send culture for susceptibility testing sensitivity results for the treatment of complicated antagonists (e.g. antiepileptics or proguanil)
& give safety net advice. ESBL producing UTI
SAPG UTI
>65 years: treat if fever >38°C, or 1.5°C above base twice in 12 For men >16y: Second-choice: If no
hours, and >1 other symptom improvement in UTI symptoms on first-choice
taken for at least 48 hours or when first-choice not
People > 65 years: do not treat suitable, consider alternative diagnoses and
asymptomatic bacteriuria; it is common but is follow recommendations in the NICE guidelines on
not associated with increased morbidity pyelonephritis (acute): antimicrobial prescribing or
prostatitis (acute): antimicrobial prescribing,
basing antibiotic choice on recent culture and
susceptibility results.

10
 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy

Treat for 7 days: Treat for 7 days:

1st line: Nitrofurantoin (oral) Nitrofurantoin (oral)
100mg m/r BD, unless at 100mg m/r BD OR
Treatment duration: Women: 3 days
term
Men: 7 days. Referral to hospital may be
2nd line: 2nd line: Contact
indicated in non-responding, severe or recurrent
Cefalexin (oral) 500 mg BD local medical
infection or suspicion of underlying UT abnormality
Risk of C.difficile infection team (refer
to contact details on
page 21)

First line: Advise simple measures, including

hydration & ibuprofen for symptom relief.
Cranberry products, which can be purchased from
pharmacies and health food stores, work for some
women, but good evidence is lacking. For
postmenopausal women, if no improvement,
consider vaginal oestrogen (review with 12
Recurrent UTI in months).
women ( 2 in 6 Second line:
Standby: for those with recurrent UTIs consider a
months or ≥ 3 Contact local medical infection team (refer to
course at home to start as soon as symptoms
proven UTIs/year) occur. Base choice on past sensitivity. contact details on page 21) for advice on treating
Consider STI screen and Urology referral where necessary.
ORPost-coital (off label) take STAT recurrent UTIs in pregnant, breastfeeding women
PHE UTI diagnosis and women trying to conceive.
guide for primary care Third line:
Prophylaxis once daily at night and review at 3
TARGET UTI months.

First line choice (if eGFR≥45ml/min):

Nitrofurantoin M/R 100mg

Second line choice: Ciprofloxacin (oral) 500mg

If recent culture sensitive: Trimethoprim (oral)
100mg

11
 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy
Recurrent UTI in Refer to hospital
men
Urgently refer children < 3 months old for assessment See BNF-C for doses See BNF-C for doses Trimethoprim(oral)
If ≥ 3 months old: First Line: OR
• If nitrate positive and fresh sample, start antibiotics Trimethoprim (oral) OR if eGFR≥45ml/min Nitrofurantoin(oral)
Lower UTI in and send for microscopy, culture and sensitivity Nitrofurantoin (oral)
children (MC+S). If susceptible, amoxicillin (oral) For 2nd line choice of antibiotic contact local trust
• If leucocyte only positive, may be indicative of medical infection team (see contact details on
PHE UTI infection outside urinary tract, send MSU for MC+S, Second line: Cefalexin(oral) page 20).
initiate antibiotics if there is good clinical evidence of
CKS UTI. 3 days treatment 3 days treatment
• If nitrate and leucocyte negative, consider another
NICE: UTI in under 16s cause for illness.
Imaging: only refer if child <6 months, or recurrent or atypical
UTI

Upper UTI in
children
PHE UTI
CKS Refer to paediatrics to obtain a urine sample for culture; assess signs of systemic infection , consider systemic antimicrobials
NICE: UTI in under 16s
If no upper UTI
Antibiotic treatment is not routinely needed for symptoms
asymptomatic bacteriuria in people with a urinary catheter. First line: If no upper UTI First line:
Cefalexin 500mg BD or Contact local
Consider removing or, if not possible, changing the catheter if it symptoms medical infection
has been in place for more than 7 days. But do not delay Nitrofurantoin (if First line: TDS (up to 1g-1.5g TDS or
QDS for severe infections) team (refer to
antibiotic treatment. Advise paracetamol for pain. Advise eGFR≥45ml/min) 100mg contact details on
drinking enough fluids to avoid dehydration. Offer an antibiotic M/R 100mg BD Nitrofurantoin (if page 21)
for a symptomatic infection. When prescribing antibiotics, take OR Trimethoprim (if low eGFR≥45ml/min) 7-10 days treatment
account of severity of symptoms, risk of complications, previous risk of resistance) 200mg 100mg M/R 100mg Second line:
Catheter associated urine culture and susceptibility results, previous antibiotic use BD BD Seek advice from the local
UTI which may have led to resistant bacteria and local antimicrobial OR Amoxicillin (only if Microbiologist
resistance data. Do not routinely offer antibiotic prophylaxis to culture results available OR Trimethoprim (if
people with a short-term or long-term catheter. KCH and and susceptible) 500mg low risk of resistance)
GSTFT (Including community services) launched “My Catheter TDS 200mg BD
Passport” to improve the care for people with catheters. You
can view My Catheter Passport here Second line 7 days treatment
Pivmecillinam 400mg
STAT then 200mg TDS

7 days treatment

12
 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy
If upper UTI symptoms
present
Cefalexin 500mg BD or
TDS (up to 1g-1.5g TDS
or QDS for severe
infections) OR If upper UTI
Co-amoxiclav (only if symptoms present
culture results available Trimethoprim (only if
and susceptible) 625mg culture results
TDS available and
7-10 days treatment susceptible) 200mg
BD
OR Trimethoprim (only if 14 days treatment
culture results available
and susceptible) 200mg OR Ciprofloxacin
BD (oral) 500mg BD
14 days treatment (consider safety
issues)
OR Ciprofloxacin (oral) 7 days treatment
500mg BD (consider
safety issues)
7 days treatment

Advise paracetamol (+/- low-dose weak opioid) for pain, or Treatment duration: 14 days then review
ibuprofen if preferred and suitable. Frist line (guided susceptibilities when available:
Offer antibiotic. Ciprofloxacin (oral) 500mg BD (consider safety
Review antibiotic treatment after 14 days and either stop issues) or ofloxacin 200mg BD (consider safety
antibiotics or continue for a further 14 days if needed (based on issues) or trimethoprim (oral) 200mg BD (if unable
assessment of history, symptoms, clinical examination, urine to take quinolone
Acute prostatitis and blood tests). Second line (after discussion with specialist) 14
Send MSU for culture and start antibiotics. days then review: Levofloxacin 500mg OD
Consider STI screen and urology referral where necessary. Not applicable
BASHH (consider safety issues) OR co-trimoxazole 960mg
BD
CKS 4 week course may prevent chronic prostatitis
Quinolones (consider safety issues) achieve higher prostate
levels

13
 First Choice Antibiotics Pregnancy and Breastfeeding
Infection Comments
No allergy Penicillin allergy No allergy Penicillin allergy
Advise paracetamol (+/- low-dose weak opioid) for pain, or Cefalexin (oral) for 7
ibuprofen if preferred and suitable. days
≥16 years: 500mg BD or
If admission not needed, send MSU for culture & susceptibility TDS
for people aged ≥16 years and start empirical antibiotics. For severe infections: Up
to 1-1.5g TDS - QDS OR
Review MSU result once available and adjust treatment If susceptible,
appropriately if necessary. Arrange if there is any clinical Co-amoxiclav (oral) for 7 Trimethoprim (oral)
deterioration or the person does not respond to treatment days 200 mg BD for 14
Cefalexin (oral) 500mg BD-
Acute within 24 hours. ≥16 years: 625mg TDS days OR Contact local
TDS (upto 1-1.5g TDS-
Ciprofloxacin (oral) medical infection
pyelonephritis QDS for severe infections
If extended-spectrum beta-lactamases (ESBL) risk and with OR if MSU results show 500 mg BD for 7 days team for advice(see
microbiology advice consider intravenous (IV) antibiotic via the susceptibility consider contact details on
CKS Outpatient Parenteral Antimicrobial Therapy (OPAT) service. switch to: Refer to hospital if page 21)
7-10 days treatment
This service is managed by the acute trust and GPs would not Trimethoprim (oral) 2nd line agent
be expected to prescribe intravenous antibiotics. 200 mg BD for 14 days required.
OR Ciprofloxacin
For children: Ensure sample is taken and referral is made to (consider safety issues)
paediatrics 500mg BD for 7 days

Refer to hospital if 2nd

line agent required

14
 Infection Comments First Choice Antibiotics Pregnancy and Breastfeeding
No allergy Penicillin allergy No allergy Penicillin allergy

SKIN INFECTIONS

Refer to local infection department for all patients with known or suspected MRSA where oral antibiotics are required
A systematic review indicates topical and oral treatment Flucloxacillin oral) 250- Clarithromycin (oral) Flucloxacillin (oral) 250- Erythromycin (oral)
produces similar results. 500 mg QDS for 7 days 250 mg – 500 mg BD 500 mg QDS for 7 days 250 mg – 500 mg QDS
for 7 days for 7 days
Reserve topical antibiotics for very localised lesions to Topical
reduce the risk of resistance. Treatment for 7 days is Fusidic acid 2% TDS
Impetigo usually adequate; max. duration of topical treatment 10 (thinly) for 5 days
days.
CKS Mupirocin TDS for 5 days
Reserve mupirocin for MRSA (if MRSA)

For extensive, severe, or bullous impetigo, use oral

antibiotics for 7 days.
If river or sea water exposure, discuss with Non facial
microbiologist cellulitis/erysipelas Clarithromycin oral) Flucloxacillin oral) 500 mg Erythromycin oral)
Flucloxacillin oral) 500 mg BD for 7days QDS for 7days 250 mg – 500 mg QDS
Class I: patient afebrile and healthy other than cellulitis, 500 mg QDS for 7 days for 7days – be
use oral flucloxacillin alone. If on statins: particularly alert to
If unresolving, Doxycycline oral) deteriorating disease,
If river or sea water exposure: seek advice. Clindamycin oral) 300- 200mg stat on day 1, carry out an early
450mg QDS for 7 days then 100mg daily for review
Cellulitis and Class II febrile & ill, or unstable comorbidity, admit for 6 days
intravenous treatment, or use OPAT (if available). Facial
Erysipelas cellulitis/erysipelas (non OR
Class III toxic appearance: admit. dental): Clindamycin oral)
CKS Deep pain may indicate severe streptococcal sepsis Co-amoxiclav (oral) 300mg-450 mg QDS
and will require IV therapy. Admit patients urgently in 625 mg TDS for 7days for 7days
British Lymphology such circumstances for early surgical review. Do not
Society prescribe topical antibiotics. There is no published Stop clindamycin if
evidence to support their use, and widespread use is diarrhoea occurs
likely to increase antibiotic resistance.
If slow response, continue treatment for a further 7 days. Skin changes (such as discolouration)
Erysipelas: often facial and unilateral. may persist for months or longer following severe cellulitis and do not necessarily require
Use flucloxacillin for non-facial erysipelas. ongoing antibiotics.
Arrange a review after 48 hours by telephone or
face-to-face, depending on clinical judgement.

15
 Infection Comments First Choice Antibiotics Pregnancy and Breastfeeding
No allergy Penicillin allergy No allergy Penicillin allergy

S. aureus is the most common infecting pathogen. Flucloxacillin 500mg QDS Erythromycin 250- Flucloxacillin 500mg QDS for Erythromycin 250-
Suspect if woman has: a painful breast; fever and/or for 10-14 days 500mg QDS for 10-14 10-14 days days 500mg QDS for 10-14
general malaise; a tender, red breast. days days
OR
Breastfeeding: oral antibiotics are appropriate, where Clarithromycin 500mg
indicated. Women should continue feeding, including BD for 10-14 days
from the affected breast
Mastitis
Treat all non-lactating women with oral antibiotics;
CKS
consider 24-48 hours of effective breast milk removal by
expressing milk/breastfeeding from affected breast
before starting antibiotics for lactating women.

If a breast abscess is suspected, the woman should

be referred urgently to a general surgeon for
confirmation of the diagnosis and management.
Diabetic foot Refer for specialist (e.g. microbiologist, diabetes foot specialist) opinion unless mild, superficial wound margins. If diagnosis of mild cellulitis is suspected, treat as above.
infections Check microbiology results in those who may have been previously treated. Refer MRSA and treatment failure cases
First-line: Self-care NHS Choices
Second-line: topical retinoid thinly OD OR over the
counter (OTC) benzoyl peroxide 5% gel OD-BD
Mild (open and closed comedones) or moderate
(inflammatory lesions): (especially if papules and pustules are present) for
First-line: self-care (wash with mild soap; do not scrub; 6-8 weeks
Acne avoid make-up). Third-line: topical clindamycin 1% cream, thinly
Second-line: topical retinoid or benzoyl peroxide. Third- BD for 12 weeks
Fourth- line:If treatment failure/severe: oral Erythromycin (oral) 500 mg BD for 6-12 weeks
CKS line: add topical antibiotic, or consider addition of oral
antibiotic. tetracycline 500mg BD OR oral doxycycline 100mg
Severe (nodules and cysts): add oral antibiotic (for 3 OD for 6-12 weeks
months max) and refer to a dermatologist.
Lymecycline 408mg OD should ONLY be
considered in patients experiencing
photosensitivity/ADRs/contraindication/intolerance/i
nefficacy with doxycycline.
If no visible signs of infection use of antibiotics (alone or with steroids) encourages resistance and does not improve healing. In eczema with visible signs of infection, use
treatment as in impetigo (see page 12).

Eczema
CKS

16
 Infection Comments First Choice Antibiotics Pregnancy and Breastfeeding
No allergy Penicillin allergy No allergy Penicillin allergy

Ensure thorough cleaning of wound and check tetanus First line

status. For further information and advice on tetanus prophylaxis or
schedule refer to Immunisation against Infectious treatment for:
Disease(The Green Book): Animal bite:
Metronidazole 400
Assess rabies risk. mg TDS
For advice on rabies prophylaxis, contact South East First line animal or PLUS doxycycline
London Health Protection Team (HPT). human prophylaxis and 100 mg BD for 7 days
Surgical toilet most important. treatment: Animal or human
Contact the South London HPT on 0344 326 2052 or Co-amoxiclav 625 mg Human bite: prophylaxis/treatment:
via [email protected]; [email protected]. TDS for 7 days Metronidazole 400 Co-amoxiclav 625 mg TDS for If pregnancy and rash
Children with bites should mg TDS 7 days after penicillin, refer to
Human bites: Assess HIV/hepatitis B/hepatitis C risk. also be treated with: PLUS ambulatory.
Human or Thorough irrigation. Antibiotic prophylaxis is Co-amoxiclav. See BNF- Clarithromycin 250 – The use of a combination of
animal bites recommended. C for doses. 500 mg BD for 7 co-amoxiclav is NOT
Animal bites: Cat bite: always give antibiotic days recommended for women with
CKS prophylaxis, other animal give antibiotic prophylaxis if Preterm Prelabour Rupture of
puncture wound; bite involving hand, foot, face, joint, Membranes or 4 weeks before
tendon, ligament; immunocompromised, diabetics, term.
elderly, asplenic, cirrhotic, presence of prosthetic valve Animal or human
or prosthetic joint Seek advice from the local bites in children
Review at 24 and 48 hours. Microbiologist if necessary under 12 years:
(see contact details on Metronidazole AND
People with severely infected wounds or who are page 21). clarithromycin. See
systemically unwell may require referral to A&E for IV BNF-C for doses.
antibiotics. Seek advice from the
local Microbiologist if
necessary (see
contact details on
page 20).
Pregnant/immunocompromised/ neonate: seek urgent
specialist advice. Chickenpox: consider aciclovir if:
Varicella zoster/ onset of rash > 14 years of age; severe pain; dense/oral
chickenpox rash; taking steroids; smoker.
CKS First Line:
Aciclovir 800mg, 5 TDS for 7 days
Give paracetamol for pain relief.
Seek urgent specialist advice
Herpes zoster/ Shingles: treat if >50 years (Postherpetic neuralgia rare
if, <50 years) and within 72 hours of rash, or if 1 of the Second line for shingles if poor compliance:
shingles Valaciclovir 1g TDS for 7 days
CKS following: active ophthalmic; Ramsey Hunt, eczema,
non-truncal involvement, moderate/severe pain or rash
Shingles treatment if not within 72 hours; consider
starting antiviral drug up to 1 week after rash onset, if

17
 Infection Comments First Choice Antibiotics Pregnancy and Breastfeeding
No allergy Penicillin allergy No allergy Penicillin allergy

high risk of severe shingles or continued vesicle

formation, older age, immunocompromised or severe
pain
Prophylaxis: Not routinely recommended. If Prophylaxis:
immunocompromised, consider prophylactic Doxycycline 200mg
doxycycline. High-risk areas include grassy and Prophylaxis:
STAT
wooded areas in southern England and the Scottish Doxycycline 200mg
Tick bites Contact local medical
Highlands. STAT
Treatment infection team for
(Lyme disease) Amoxicillin 1g TDS for 21 days advice (see contact
Doxycycline 100mg BD
CKS Only give prophylaxis within 72 hours of tick removal. Treatment
for 21 days details on page 21)
Doxycycline 100mg BD
Give safety net advice about erythema migrans and for 21 days
First alternative:
other possible symptoms that may occur within 1 month Amoxicillin 1g TDS for
of tick removal. 21 days

18
 Infection Comments Antibiotic treatment

SEXUALLY TRANSMITTED INFECTIONS (STIs): For guidance, refer to Southwark and Lambeth STI Management in Primary Care

GASTROINTESTINAL INFECTIONS
Refer previously healthy children with acute painful or bloody Antibiotic therapy usually not indicated unless systemically unwell as it only reduces diarrhoea by 1-2 days
diarrhoea to exclude E. coli 0157 infection. and can cause resistance.
Initiate treatment, on advice of Microbiologist (see contact details on page 20).
Infectious Normal feeding should be restarted as soon as possible; there is If systemically unwell and campylobacter suspected (e.g. undercooked meat and abdominal pain), consider
diarrhoea no evidence that fasting will have any benefit. clarithromycin 250–500mg BD for 5–7 days if treated early (within 3 days).
If giardia is confirmed or suspected – tinidazole 2g single dose is the treatment of choice
CKS Fluid replacement is essential.
Notify suspected cases of food poisoning to, and seek advice on exclusion of patients from, South London HPT
Travel history should be reported if stool sample sent. on 0344 326 2052, or email [email protected] ; [email protected] . Send stool samples in these
cases.
Stop unnecessary antibiotics and/or PPIs to re-establish Some patients with recurrent C. difficile infections (CDI) may continue their treatment in a primary care setting, due
normal flora. Stop any antidiarrhoeal agents in patients who to long-duration and/or tapering courses of vancomycin and attempts to avoid long hospital stays.
are proven CD toxin positive.
1st episode: Oral metronidazole 400 mg TDS for 10-14 days
2nd episode/Severe CDI/ type 027: Oral vancomycin 125 mg QDS for 10-14 days
Clostridium difficile (CD) has been identified as a causative
If severe symptoms or signs (see below) should treat with oral vancomycin, review progress closely
organism in pseudomembranous colitis/antibiotic-associated
and/or consider hospital referral
diarrhoea.
Severe if T > 38.50C; WCC > 15 x109/L, rising creatinine (> 50% increase above baseline) or signs/symptoms of
Fluids and electrolytes should be replaced. severe colitis (abdominal or radiological).
Clostridium Fidaxomicin (200mg PO BD for 10 days)- Treatment can be initiated in primary care after a
recommendation from a Consultant Microbiologist.
difficile
Restricted to treatment of laboratory-confirmed clostridium difficile
infection (CDI) in the following groups:
• Recurrence following vancomycin treatment
• Patients who require ongoing concomitant antibiotic treatment
• Patients who are immunocompromised and at risk of further recurrence
Subsequent recurrences and all cases of severe CDI will require admission. If the patient is well enough to avoid
admission to hospital, but has diarrhoea and there is a suspicion of CDI, for the first and second episodes, send a
stool sample, rehydrate and consider treatment as above.

19
 Infection Comments Antibiotic treatment
MENINGITIS

Transfer all patients to hospital immediately.

If time before hospital admission, and non-blanching rash, administer benzylpenicillin prior to
admission, unless history of true anaphylaxis reaction to previous penicillin;
Keep supply of benzylpenicillin and check expiry dates.
Ideally administer IV bolus but IM if a vein cannot be found.
Suspected ARRANGE URGENT Adults and children:
meningococcal TRANSFER TO HOSPITAL 10 yr and over: 1200 mg (1.2grams)
disease Children 1 - 9 yr: 600 mg
Children <1 yr: 300 mg
PHE Past history of allergic responses other than anaphylaxis, such as a rash is not a contraindication
to an urgent penicillin injection in this situation.
No alternative antibiotic is indicated in patients with anaphylactic reactions to penicillin.
Prevention of secondary case of meningitis (prophylaxis): prescribe only on advice of South London HPT:
on 0344 326 2052 or via [email protected]; [email protected].
METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)

MRSA
For support in prophylaxis and treatment of MRSA infections contact the local Medical Infection team (refer to page 21 for contact details).
infections
CKS For advice on infection control, contact the local Infection Prevention and Control Team (IPCT) (refer to page 21 for contact details).
Severe MRSA infections would be better treated in secondary care, on an individual case basis, working closely with the IPCT.
EYE CONDITIONS

First line:
Self-care and OTC lubricant eye drops. Children rarely require treatment or exclusion (PHE)
Bathe/clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water, to remove crusting
Second line:
Chloramphenicol 0.5% eye drops (available OTC to patients aged 2 years and above) 2 hourly for 2 days,
Conjunctivitis then reduce frequency to 3-4 times a day OR
Treat only if severe, as most cases are viral or self-limiting
1% ointment (available OTC to patients aged 2 years and above) 3-4 times daily,or just at night if using
especially in children.
NHS Choices eye drops
Bacterial conjunctivitis: usually unilateral and also self-
Third line (as less gram-negative activity):
limiting. It is characterised by red eye with mucopurulent, not
CKS (Infective) Topical fusidic acid 1% gel BD
watery discharge. 65% and 74% resolve on placebo by days 5
and 7.
CKS (Allergic) Treatment should continue for 48 hours after resolution

20
 Infection Comments Antibiotic treatment
First line: Self-care
First line: Self Care-Lid hygiene for symptom control, Second line:
Blepharitis
including: warm compresses; lid massage and scrubs; gentle Topical chloramphenicol 1% ointment (available OTC only patients aged 2 years and above) BD 6 week
washing; avoiding cosmetics. trial
CKS (Blepharitis)
Second line: topical antibiotics if hygiene measures are Third line (excluding pregnancy and breastfeeding):
ineffective after 2 weeks. Oral oxytetracycline 500mg BD 4 weeks (initial) then 250mg BD 8 weeks (maintance)
NHS Choices
Signs of Meibomian gland dysfunction, or acne rosacea: OR
consider oral antibiotics. Oral doxycycline 100mg OD 4 weeks (initial) then 50mg OD 8 weeks (maintance)

DENTAL INFECTIONS
GPs should not be involved in prescribing antibiotics for dental treatment. Patients should be directed to their regular dentist or if this is not possible 111.
Most dental conditions require dental input rather than antibiotics. Advise regular analgesia until a dentist can be seen. Also refer to:
• NHS choices topic on Dental Abscess
• British Dental Association Patient Information Leaflet

Contact Details
Guy’s and St Medical Infection team:
Thomas’ NHS During working hours: (Monday – Friday, 9am – 5pm) Tel: 0207 188 3100 or call 0207 188 7188 (switchboard)
Foundation Out of hours: Call switchboard on 0207 188 7188 and ask to speak to the Microbiology Registrar on call.
Trust Infection Prevention and Control Team(IPCT)
Tel: 020 7188 3153
Email: [email protected]
King’s College Medical Infection team:
Hospital NHS During working hours: (Monday – Friday, 9am – 5pm) Tel. 020 3299 9000 followed by extensions:34360/34358/34356
Foundation Out of hours: Call switchboard on 020 3299 9000 and ask to speak to the Microbiology Registrar on call.
Trust Infection Prevention and Control Team(IPCT)
Tel: 020 3299 4374
Email: [email protected]

21
 References
1. Public Health England: Managing common infections: guidance for primary care Updated September 2019
2. British National Formulary. Available online via https://bnf.nice.org.uk/
3. British National Formulary for Children. Available online via https://bnfc.nice.org.uk/
4. South East London Integrated Guideline for the Management of Asthma in adults (18 years old and over). April 2019. Available online via: https://www.lambethccg.nhs.uk/news-and-publications/meeting-papers/south-
east-london-area-prescribing-committee/Documents/Clinical%20guidelines%20and%20pathways/SEL%20Asthma%20Guideline%20Apr%202019.pdf
5. South East London Integrated Guideline for the Management of COPD. April 2019. Available online via: https://www.lambethccg.nhs.uk/news-and-publications/meeting-papers/south-east-london-area-prescribing-
committee/Documents/Clinical%20guidelines%20and%20pathways/SEL%20COPD%20guideline%20Apr%202019.pdf
6. BTS Guidelines for the Management of Community Acquired Pneumonia in Adults, 2009 update. Available online via www.brit-thoracic.org.uk
7. NICE Guideline 69: Respiratory Tract Infections (self-limiting): prescribing antibiotics (July 2008).
8. NICE Guideline 115 : Chronic obstructive pulmonary disease in over 16s: diagnosis and management (June 2010)
9. NICE Guideline 102: Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management (updated February 2015)
10. SIGN Guideline 88: Management of suspected bacterial urinary tract infections in adults. Updated July 2012
11. European Association of Urology Guideline on Urological Infections (2016)
12. Public Health England and Department of Health Guidance: Clostridium difficile infection: How to deal with the problem Updated June 2013
13. NICE Clinical Knowledge Summaries. Available online via www.evidence.nhs.uk
14. Public Health England. Guidance for public health management of meningococcal disease in the UK. Updated March 2012
All resources last accessed on 22/08/2019

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