Oxfordshire ADULT Antimicrobial Prescribing Guidelines For Primary Care

Oxfordshire
Clinical Commissioning Group
OXFORDSHIRE
ADULT
ANTIMICROBIAL
PRESCRIBING
GUIDELINES FOR
PRIMARY CARE
2nd Edition
May 2012
Version 2.1 (July 2012)

OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
OXFOGUIDELINES
RDSHIRE ADULT AFOR
NTIMPRIMARY
ICROBIAL PRCARE
ESCRIBING
GUIDELINES FOR PRIMARY CARE
Contents
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 UTIs 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
3
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
OXFOGUIDELINES
RDSHIRE ADULT AFOR
NTIMIPRIMARY
CROBIAL PRECARE
SCRIBING GUIDELINES FOR PRIMARY CARE
GUIDELINES FOR PRIMARY CARE INTRODUCTION
SKIN & SOFT TISSUE INFECTIONS ........................................................................23 This guidance is for Oxfordshire General Practitioners, Nurse Practitioners and members
Impetigo .................................................................................................................23 of Primary Healthcare Teams.
Eczema ..................................................................................................................23 It is also available for use within Oxford Health NHS Foundation Trust for Oxfordshire
Cellulitis..................................................................................................................23 patients that are provided with community services and specialist mental health services.
Leg Ulcers ..............................................................................................................24 Aspects of this guidance may be relevant for community hospitals, as are the secondary
Diabetic Foot Infection ...........................................................................................24 care Oxford University Hospitals NHS Trust Antimicrobial Guidelines.
http://orh.oxnet.nhs.uk/Pharmacy/Pages/abguidelines.aspx
Wound Infections (Non surgical) ............................................................................24
MRSA.....................................................................................................................24
Bites .......................................................................................................................25 Aims
Human ................................................................................................................25 1. To provide a simple, empirical approach to the treatment of common infections in adults
Cat or Dog ..........................................................................................................25 (16 years and over).
Mastitis ...................................................................................................................25 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
Acne Vulgaris .........................................................................................................26 economy.
Rosacea .................................................................................................................27 4. To reduce healthcare associated infections.
Perioral Dermatitis .................................................................................................27
Boils / Cysts/ Abscesses / Carbuncles ...................................................................27
Paronychia .............................................................................................................28 Principles of Treatment
Folliculitis ...............................................................................................................28 1. This guidance is based on the best available evidence but professional judgement should
be used and patients should be involved in the decision.
Scabies ..................................................................................................................28 2. Always document the indication for antimicrobials and the rationale behind any deviations
Head Lice ...............................................................................................................29 from these guidelines within the patient’s notes.
FUNGAL SKIN INFECTIONS ....................................................................................30 3. A dose and duration of treatment for adults is usually suggested, but may need
Fungal / Dermatophyte infection of the skin – Dermatophytes ...............................30 modification for severity of disease, age, weight and renal function.
Fungal / Dermatophyte infection of the skin - Scalp Dermatophytes......................31 4. Treatment of most infections should not exceed 7 days.
5. Have a lower threshold for antimicrobials in immunocompromised or those with co-
Fungal / Dermatophyte infection of the proximal fingernail or toenail .....................31 morbidities.
Pityriasis Versicolor ................................................................................................32 6. Prescribe an antimicrobial only when there is likely to be a clear clinical benefit.
Intertrigo .................................................................................................................32 7. Consider a no, or delayed, antimicrobial strategy for acute self-limiting upper respiratory
A+
VIRAL INFECTIONS .................................................................................................33 tract infections.
Herpes simplex ......................................................................................................33 8. Limit prescribing of antimicrobials over the telephone to exceptional cases.
9. Use simple generic antimicrobials if possible. Avoid broad spectrum antimicrobials (e.g.
Cold Sores..........................................................................................................33 co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antimicrobials
First attack genital. .............................................................................................33 remain effective, as they increase risk of Clostridium difficile, MRSA and resistant Gram
Recurrent attacks of genital herpes - intermittent therapy. .................................33 negative infections.
Recurrent attacks of genital herpes - suppressive therapy. ................................33 10. Review microbiology results regularly, and if treatment required select the most
Varicella zoster ......................................................................................................33 appropriate antimicrobial with the lowest ‘CDI or MRSA risk’
11. Avoid widespread use of topical antimicrobials (especially those agents also available as
Herpes zoster .........................................................................................................34 systemic preparations, e.g. fusidic acid).
Treatment Advice: CHICKENPOX .........................................................................34 12. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high dose metronidazole
Treatment Advice: SHINGLES ...............................................................................35 (2 g). Short-term use of nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is
Prophylaxis Advice: High Risk Contacts of Patients with Chickenpox or Shingles .35 unlikely to cause problems to the foetus. Trimethoprim also unlikely to cause problems
HEPATITIS ................................................................................................................36 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
Hepatitis B..............................................................................................................36 increased risk of necrotising enterocolitis in neonates).
Hepatitis C .............................................................................................................36 13. Whilst erythromycin remains the first line macrolide, clarithromycin is an acceptable
EYE INFECTIONS.....................................................................................................36 alternative in those who are unable to tolerate erythromycin because of side effects.
Conjunctivitis ..........................................................................................................36 Using erythromycin QDS rather than BD may reduce erythromycin side effects.
Styes ......................................................................................................................36 14. 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
MENINGITIS..............................................................................................................37 220880 or bleep 4077 via JR switchboard. Out of hours advice can be obtained by
Bacterial Meningitis and / or Suspected Meningococcal Disease .......................37 contacting the Microbiology SpR on call via the JR switchboard.
Meningococcal Meningitis Prophylaxis ...............................................................37
ASPLENIA .................................................................................................................38
Prophylaxis for Asplenia.........................................................................................38
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
Version 2.1. Approved by APCO: April 2012 (up-dated July 2012); Review Date: April 2014
4 5
GUIDELINES FOR PRIMARY CARE GUIDELINES FOR PRIMARY CARE
Healthcare Associated Infections (HCAIs) In patients with a history of clinical signs of Type I immediate hypersensitivity (life-threatening
Inappropriate use of broad-spectrum antimicrobials is associated with the acquisition of allergy) or severe non-type I reactions e.g. SJS:
3-6
Methicillin Resistant Staphylococcus aureus (MRSA) and the induction of Clostridium Drugs in RED are contra-indicated unless approved by microbiology/infectious
7-12
difficile Infection (CDI) as well as the selection of antimicrobial resistant bacteria such as diseases or Immunology in a specific patient.
13,14
Extended-Spectrum Beta-Lactamase (ESBL)-producing Gram-negative bacteria. Drugs in ORANGE are NOT for use in patients with a severe penicillin allergy, unless
at the discretion of microbiology/ID.
Whilst all antimicrobials are able to pre-dispose patients to CDI and MRSA, quinolones, Drugs in GREEN are considered safe.
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. The colour classifications below should not be confused with the Oxfordshire
15,16
Co-amoxiclav (intermediate risk) has also been associated with CDI cases both nationally Prescribing Traffic Light Classifications – for appropriate prescribing responsibility the
and locally. Therefore, the above antimicrobials have been restricted, where possible, within Oxfordshire Prescribing Traffic Lights should be consulted.
Oxfordshire primary care and secondary care antimicrobial guidelines.
In patients with a history of a mild to moderate non-type I reactions to penicillin as exemplified
Appropriate antimicrobial prescribing is a key element in the reduction of healthcare associated by an isolated rash but not drug fever or immune-complex type reactions drugs in the
17
infections . The evidence that use of antimicrobial agents (whether appropriate or not) ORANGE category can be used with caution. If in doubt, please discuss with Microbiology/ID.
18
causes resistance is overwhelming; resistance is greatest where use of antibacterial agents Drugs in GREEN are considered safe.
18
is heaviest . Prescribing a routine course of antimicrobials significantly increases the
19
likelihood of an individual carrying a resistant bacterial strain. Red Orange Green
amoxicillin, cefalexin, azithromycin, minocycline,
Establishing and maintaining ways of working which keep the level of potential cross co-amoxiclav (amoxicillin cefotaxime ciprofloxacin nitrofurantoin
contamination between patients to an absolute minimum is a major priority in Infection Control. + clavulanic acid) ceftriaxone clarithromycin oxytetracycline
20,21
The most effective way to do this is to decontaminate hands and equipment between flucloxacillin clindamycin, sodium fusidate
22
patients. penicillin V co-trimoxazole (fusidic acid)
(phenoxymethylpenicillin) (Septrin®) tetracycline
procaine benzylpenicillin doxycycline trimethoprim
Penicillin Allergy erythromycin vancomycin
Penicillins are life-saving antimicrobials and patients should not be labelled ‘penicillin-allergic’ metronidazole
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. Useful Websites
Severe allergy = all Type I reactions and some non-Type I reactions, depending on http://bnf.org/bnf/index.htm
clinical severity e.g. Stevens Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis http://prodigy.clarity.co.uk/home
(TEN). http://www.hpa.org.uk/infections/topics_az/primary_care_guidance/menu.htm
Non-severe allergy = most non-Type I reactions i.e. rash without systemic upset / http://www.nice.org.uk/
mucosal involvement. http://www.brit-thoracic.org.uk
Characteristics Type I immediate reactions Non-Type I reactions Current Version

The latest version of these guidelines is available on the Oxfordshire PCT Intranet. Prescribers
Timing of onset Usually 1 to 4 hours from More than 72 hours from exposure are advised to regularly visit the website to ensure they have the most up to date version of
exposure (up to 72 hours) guidelines currently held.
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
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information. 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 Studies: A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study, C = formal
combination of expert opinion. combination of expert opinion.
Key: NNT = Number Needed to Treat Key: NNT = Number Needed to Treat
Version 2.1. Approved by APCO: April 2012 (up-dated July 2012); Review Date: April 2014 Version 2.1. Approved by APCO: April 2012 (up-dated July 2012); Review Date: April 2014
6 7
CONDITION COMMENTS DRUG DOSE DURATION
RESPIRATORY TRACT INFECTIONS OF TX
UPPER RESPIRATORY TRACT INFECTIONS Acute Sore Avoid antimicrobials as the Avoid
Throat majority (over 50%) of sore antimicrobials in
Also see Oxfordshire PCT Referral Guidelines: ENT and NICE Respiratory Tract Infections and NICE
1 throats are viral; 90% resolve in 7 majority cases.
Respiratory Tract Infections - Quick Reference Guide NICE days without antimicrobials and Explain soreness will
pain is only reduced by a mean of take about 8 days to
2A+
CONDITION COMMENTS & TREATMENT Prodigy 16 hours. resolve.
1-6
Vaccination
SIGN
Annual vaccination is essential for all those at risk of influenza. For further 6A-
In patients with 3 or more Centor Phenoxymethyl- 500mg 10 days
information on patients within the ‘clinical risk groups’ please refer to ‘Immunisation 5B-
criteria (presence of tonsillar penicillin QDS
against infectious disease’ (‘The Green Book’ - Chapter 19 Influenza)
exudate, tender anterior cervical
1-6 lymphadenopathy or Avoid amoxicillin as
Treatment - NICE Guidance TA 168
lymphadenitis, history of fever and maculopapular rash
Oseltamivir and zanamivir are recommended, within their marketing authorisations, for 1,3,A-
an absence of cough consider commonly results in
the treatment of influenza in adults if ALL the following circumstances apply:
2 or 3-day delayed or immediate patients with
national surveillance schemes indicate that influenza virus A or B is circulating 1,A+
antimicrobials. glandular fever. (This
(the CCDC will advise when influenza prevalence in Oxfordshire has reached
rash is not related to
the appropriate threshold)
(Antimicrobials to prevent quinsy true penicillin allergy).
the person is in an ‘at-risk’ group as defined in NICE Guidance TA 168 and NNT >4000.
4B-
below Antimicrobials to prevent otitis Penicillin Allergy:
the person presents with an influenza-like illness and can start treatment within media NNT=200. )
2A+
erythromycin 500mg- 10 days
48 hours of the onset of symptoms as per licensed indications 1g BD or
For otherwise healthy adults, antivirals are not recommended. 250-
Influenza
500mg
Also see information for healthcare professionals from Health Protection Agency QDS
Immunisation 2,3B-
against infe Acute Otitis Optimise analgesia Avoid
At risk groups: Media Avoid antimicrobials as 60% are antimicrobials in
ctious disease People ‘at risk’ within NICE Guidance TA 168 and within HPA guidance are defined as
(‘The Green better in 24 hours without: they majority cases
those who have one of more of the following: NICE only reduce pain at 2 days
Book’) 65 years or over (NNT=15) and do not prevent
chronic respiratory disease (including asthma and chronic obstructive Prodigy deafness.
4A+
NICE pulmonary disease)
Guidance TA chronic heart disease (not hypertension) 1A+ 7A+ 9A+
168 Consider 2 or 3-day delayed or amoxicillin 500mg 5 days
chronic renal disease immediate antimicrobials for pain TDS
chronic liver disease relief if there is otorrhoea Penicillin Allergy:
NICE 5A+ 8D 9A+
Guidance TA chronic neurological conditions (NNT=3). erythromycin 500mg- 5 days
158 diabetes mellitus 1g BD or
immunosuppressed (Antimicrobials to prevent 250mg-
6B -
HPA Influenza pregnant women (including up to two weeks post partum) mastoiditis NNT >4000. ) 500mg
QDS
Therapy: - refer to current HPA recommendations for recommended treatment,
including in pregnancy. Acute Otitis First use aural toilet (if available)
Oseltamivir 75mg BD for 5 days Externa & analgesia.
Zanamivir 10mg BD (2 inhalations by diskhaler) for 5 days Cure rates similar at 7 days for acetic acid 2%* 1 spray 7 days
Prodigy topical acetic acid or antimicrobial TDS
During localised outbreaks of influenza-like illness (outside the periods when national +/- steroid.
1A+
Second line:
surveillance indicates that influenza virus is circulating in the community), oseltamivir If cellulitis or disease extending neomycin sulphate 3 drops 7 days min
and zanamivir may be offered for the treatment of influenza in ‘at-risk’ people who live in outside ear canal, start oral with corticosteroid
3A-
TDS to 14 days
long-term residential or nursing homes – however this should only be given on the antimicrobials (flucloxacillin or
,4D
max
1A+
advice from the local Health Protection Unit. erythromycin in penicillin allergy) (Betnsol-N)
2A+
and refer. *Over the counter preparation is available for
Postexposure Prophylaxis - NICE Guidance TA 158
1-6
children over 12 years.
For advice on post exposure prophylaxis, at risk groups and recommended therapy see Retail cost is £7.03 (Chemist & Druggist July 12).
NICE Guidance TA 158. Please note: if prescribed, charge to prescribing
Also see information for healthcare professionals from Health Protection Agency. budget is £4.10 (Chemist & Druggist July 12).
8 9
CONDITION COMMENTS DRUG DOSE DURATION CONDITION COMMENTS DRUG DOSE DURATION
OF TX OF TX
Acute Avoid antimicrobials as 80% Avoid ANUG (Acute GPs should not routinely be involved in dental treatment.
Rhinosinusitis resolve in 14 days without, and antimicrobials in Necrotising Where possible, advise the person to see a dental practitioner urgently. If this is
5C
they only offer marginal benefit majority cases Ulcerative not possible and treatment is required see below.
2,3A+
after 7 days NNT=15. Gingivitis) Do not routinely provide repeat prescriptions or switch antimicrobials if person
NICE fails to respond. Instead advise the person to see a dental practitioner urgently.
4B+ 4A+,7A 9A+
Use adequate analgesia. amoxicillin 500mg 7 days Prodigy Advise the person to see
Prodigy TDS a dental practitioner metronidazole 200mg- 3 days
Consider 7-day delayed or 1g TDS if urgently. AND 400mg
8D
immediate antimicrobial when severe TDS
purulent nasal discharge NNT=8. Antimicrobials are the first
1,2A+
or doxycycline 200mg 7 days line treatment.
1
chlorhexidine 0.2% or BD
stat/ hydrogen peroxide 6%
100mg Normal tooth brushing / mouth wash
OD oral hygiene measures are
In persistent infection use an For persistent very painful to carry out in Second line:
agent with anti-anaerobic activity symptoms: the acute phase of the amoxicillin 250mg- 3 days
6B+ 6B+
e.g. co-amoxiclav. co-amoxiclav 625mg 7 days infection. Therefore, the AND 500mg
TDS patient should be TDS
Dental GPs should not routinely be involved in dental treatment. encouraged to carry out
Abscess Where possible, advise the person to see a dental practitioner urgently. If this is tooth brushing with a soft chlorhexidine 0.2% or BD
not possible and treatment is required see below. toothbrush to remove food hydrogen peroxide 6%
(In the Do not routinely provide repeat prescriptions or switch antimicrobials if person detritus. mouth wash
absence of fails to respond. Instead advise the person to see a dental practitioner urgently.
immediate Antimicrobials are Avoid antimicrobials in Hydrogen peroxide
attention by a generally not indicated for majority cases mouthwashes are the most
dental otherwise healthy efficacious when proper
practitioner) individuals or when there tooth brushing is difficult to
no signs of spreading undertake.
Prodigy infection.
1-4
Only prescribe an amoxicillin alone 250mg- 5 days As well as pain, and

antimicrobial: 500mg halitosis the patient will feel
for people who are TDS significantly systemically
systemically unwell or if or combined with unwell. The patient should
there are signs of severe metronidazole 200mg- 5 days be advised not to smoke.
infection (e.g. fever, 400mg
lymphadenopathy, TDS Oral Predisposing local and For localized or mild oral
cellulitis, diffuse swelling, Penicillin Allergy: Candidiasis systemic risk factors for candidal infection, prescribe
trismus). erythromycin alone 500mg- 5 days oral candida should be topical treatment for 7 days
for high risk individuals 1g bd or Prodigy managed in conjunction (and advise the person to
1
to reduce the risk of 250mg- with antifungal treatment. continue treatment for 2 days
complications (e.g. 500mg after symptoms resolve).
people who are QDS Chlorhexidine should be
immunocompromised, or combined with used to clean dentures and nystan®* oral suspension 100,000 7 days (and
diabetic or have valvular metronidazole 200mg- 5 days may be used as an adjunct units continue for
heart disease). 400mg to topical or oral treatment. QDS 2 days after
TDS Clean and soak dentures in after food symptoms
If spreading infection chlorhexidine gluconate resolve)
(lymph node involvement, 0.2% mouthwash for 15
or systemic signs i.e. fever mins twice daily. For extensive or severe
or malaise) ADD candidiasis: fluconazole 50mg 7 days
2-4C
metronidazole. 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)
10 11
LOWER RESPIRATORY TRACT INFECTIONS CONDITION COMMENTS DRUG DOSE DURATION
OF TX
Note: 1
1, Community- Use CRB65 score to help guide and review in conjunction with clinical judgment.
Low doses of penicillins are more likely to select out resistance Acquired Post Influenza: seek specialist advice.
Do not use quinolone (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Pneumonia
Reserve all quinolones (including levofloxacin) for proven resistant organisms. - Each scores 1:
Avoid tetracyclines in pregnancy. treatment in Confusion (AMT<8);
CONDITION COMMENTS DRUG DOSE DURATION the community Respiratory rate >30/min;
OF TX 2,3,4
BP systolic <90 or diastolic ≤ 60;
Acute Antimicrobial little benefit if Avoid antimicrobials in Age >65 years
1-4A+
Bronchitis no co-morbidity. majority cases BTS 2009
Symptom resolution can Guideline If CRB65=0: may be amoxicillin
A+
500mg 7 days
NICE take 3 weeks. Adults suitable for home TDS
treatment.
Prodigy Consider 7-14 day delayed amoxicillin 500mg 5 days or erythromycin
A-
500mg 7 days
antimicrobial with TDS QDS
symptomatic advice/leaflet.
1,5A-
or doxycycline 200mg 5 days or doxycycline 200mg 7 days
stat/ stat/100
100mg mg OD
OD Score 1-2: may require If CRB65=1 & AT HOME:
hospital assessment or
or erythromycin 500mg- 5 days admission. amoxicillin
A+
500mg
1g BD or AND TDS
250mg-
500mg erythromycin
A-
500mg- 7-10 days
QDS 1g BD or
Acute Viruses may account for 250mg-
Exacerbation over 50% of these 500mg
of COPD infections. (30% viral, 30- QDS
50% bacterial, rest
NICE undetermined) or doxycycline alone 200mg 7-10 days
4c
stat/100
Prodigy Antimicrobials not amoxicillin 500mg 5 days mg OD
indicated in absence of TDS If no response in 48 hours
Management purulent/mucopurulent If ‘at home’ rescue consider admission or add
B+
of COPD in sputum. antimicrobial has been tried erythromycin first line or a
Primary Care and patient is not improving C
tetracycline to cover
Treat exacerbations change to second line ‘atypical’ organisms.
promptly with antibiotics if antimicrobial. Score 3-4: may require Give immediate IM
purulent sputum and urgent hospital benzylpenicillin 1.2g or
4c
increased shortness of or doxycycline 200mg 5 days admission. D
amoxicillin 1g po if delayed
breath and/or increased stat/ admission/life threatening.
1-3B+
sputum volume. 100 mg Start antimicrobials
OD immediately.
B-
If no response in 48 hours
4A
of antimicrobial therapy or erythromycin 500mg 5 days In severely ill give
consider admission or add QDS parenteral benzylpenicillin
erythromycin first line or a before admission.
C
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 13
OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING OXFORDSHIRE
OXFORDSHADULT
IRE ADULTANTIMICROBIAL
ANTIMICROBIAL PRESPRESCRIBING
CRIBING
OF TX URINARY TRACT INFECTIONS
Exacerbation Previous sputum People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with
of microbiology cultures, increased morbidity.
1B+
Bronchiectasis when available, may guide Catheter in situ: antimicrobials will not eradicate asymptomatic bacteriuria; only treat if systemically
antimicrobial choice. unwell or pyelonephritis likely.
2B+
Prodigy Do not use prophylactic antimicrobials for catheter changes.
When previous amoxicillin 500mg 10–14 days Refer to Local guidance on the management of UTIs.. Also see Oxfordshire PCT Referral Guidelines:
microbiology cultures are TDS Urology.
not available. Only use modified release nitrofurantoin rather than standard release if compliance is an issue.
or erythromycin 500mg 10–14 days CONDITION COMMENTS DRUG DOSE DURATION
Send sputum for culture QDS OF TX
and sensitivity testing UTI in Men & See NHS Oxfordshire trimethoprim
1B+
200mg Women 3
before starting or doxycycline 200mg 10–14 days Women Prescribing guidelines: or BD days
6-8A+
antibiotics (even if the stat and (including Men 7 days
Management of Simple
person is taking long-term then older people) nitrofurantoin*
2B+ 3C 4B+
50mg
9,10C
UTIs in Non-Pregnant
antibiotics) 100mg No fever and QDS or
Females in Primary Care
OD flank pain 100mg
Management of UTIs in
For further information see m/r BD
1 Adult Males in Primary
Prodigy HPA QRG
5C
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. Use with caution 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.
14 15
OF TX OF TX
3A- 3A-
Recurrent UTI Treatment of Infection trimethoprim 200mg 3 days Acute If admission not needed, ciprofloxacin 500mg 7 days
in Women See NHS Oxfordshire or BD Pyelonephritis send MSU for culture & or BD
≥ 3 UTIs/year Prescribing guidelines: sensitivities and start
1C 4C 4C
Management of nitrofurantoin* 50mg 3 days Prodigy antimicrobials. co-amoxiclav 625mg 14 days
HPA QRG Recurrent UTIs in Non- QDS or If no response within 24 TDS
2C
Pregnant Females in 100mg SIGN hours, admit.
Prodigy Primary Care m/r BD See NHS Oxfordshire
Second line: use MSU result to guide treatment – use Prescribing guidelines:
SIGN suitable antimicrobials with lowest risk for C. difficile or Management of Acute
MRSA infection. Pyelonephritis in Adults
in Primary Care
Amoxicillin resistance is common; only use if organism UTIs in See NHS Oxfordshire Prescribing guidelines: ‘Management of UTIs in Pregnancy in
sensitive. Pregnancy Primary Care’
7C
*Use with caution in renal impairment (eGFR less than HPA QRG Send MSU for culture & First line: nitrofurantoin* 50mg 7 days
2
60mL / min / 1.73m ). Avoid in G6PD deficiency upper sensitivity and start QDS or
1A
UTI/pyelonephritis and near term pregnancy Prodigy empirical antimicrobials. 100mg
Prophylaxis nitrofurantoin* 50– Post coital m/r BD
1,
Post-coital prophylaxis or 100mg stat (off- SIGN Short-term use of
2B+ 2B+,3C 7C
or standby antimicrobial label) nitrofurantoin in pregnancy if susceptible, amoxicillin 500mg 7 days
3B+
trimethoprim 100mg Prophylaxis is unlikely to cause TDS
2C
Nightly: reduces UTIs but OD at night problems to the foetus.
1A+ 1A+
adverse effects
7C
See NHS Oxfordshire *Use with caution in renal impairment (eGFR less than Avoid trimethoprim if low Second line: trimethoprim 200mg 7 days
2 3
Prescribing guidelines 60mL / min / 1.73m ). Avoid in G6PD deficiency, upper folate status or on folate BD (off-
Management of UTI/pyelonephritis and near term pregnancy antagonist (e.g. label)
2
Recurrent UTIs in Non- antiepileptic or proguanil). Ensure
Pregnant Females in taking
Primary Care folic acid
6
Recurrent Discuss with urology or Do not give prophylactic antimicrobials without first 400mcg
UTIs in Men microbiology discussing with urology or microbiology/ID. if first
UTIs in a See NHS Oxfordshire trimethoprim 200mg 7-14 days trimester
1
Person with a Prescribing guidelines : or BD 4C, 5B- 7C
Catheter Management of UTIs in Third line: cefalexin 500mg 7 days
Catheterised Adults in nitrofurantoin* 50mg 7-14 days BD
HPA QRG Primary Care QDS or * Use with caution in renal impairment (eGFR less than
2
100mg 60mL / min / 1.73m ). Avoid in G6PD deficiency,
Prodigy m/r BD upper UTI/pyelonephritis and near term pregnancy
Second line: use MSU result to guide treatment – use For pyelonephritis - send Pyelonephritis:
Prodigy suitable antimicrobials with lowest risk for C. difficile or MSU for culture. cefalexin 500mg 10-14 days
MRSA infection. or TDS
SIGN Check MSU 7 days after
Amoxicillin resistance is common; only use if organism treatment co-amoxiclav
#
625mg 10-14 days
susceptible. TDS
If sensitivities known:
Community multi-resistant Extended-spectrum Beta- trimethoprim 200mg 10-14 days
lactamase E. coli are increasing: nitrofurantoin is an or BD
option.
amoxicillin 500mg 10-14 days
*Avoid if patient is febrile or clinical evidence of
TDS
prostatitis. Use with caution in renal impairment (eGFR
2
less than 60mL / min / 1.73m ). Avoid in G6PD #
Avoid co-amoxiclav in patients if possible pre-term
deficiency, upper UTI/pyelonephritis and near term
labour
pregnancy.
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.
16 17
GENITAL TRACT INFECTIONS OF TX
STI screening Bacterial Oral metronidazole is as metronidazole
1,3A+
400mg 5 -7 days
3A+
1A+
Note: Patients with risk factors for STI should be considered for referral to GUM (and screened for Vaginosis effective as topical or BD stat
1A+
chlamydia, gonorrhoea, HIV, syphilis) especially if recurrent infections. treatment but is or 2g
1,2
Risk factors are age <25, recent (<12mth)/frequent change of partner, 2 or more partners in last 6 BASHH cheaper.
1A+
months, non-use of condoms, STI or STI symptoms in partner. metronidazole 0.75% vaginal 5g 5 nights
1A+
Advice on urogenital infections is available from the Genitourinary Medicine Department, Churchill HPA Less relapse with 5-7 day gel applica-
3A+
Hospital 01865 231231 Monday to Friday 0900-1800. than 2g stat at 4 wks. or torful at
2A+
Prodigy Pregnant /breastfeeding: night
3A+ ,4B-
For further information about investigation and treatment of vaginal discharge see local guideline: avoid 2g stat.
1A+ 1A+
Investigation and Management of Vaginal Discharge in Adult Women Investigation clindamycin 2% cream 5g 7 nights
and Treating partners does not applica-
5B+
CONDITION COMMENTS DRUG DOSE DURATION Management reduce relapse torful at
OF TX of Vaginal night
Chlamydia Opportunistically screen all azithromycin
4A+
1g stat
4A+ Discharge in Failed bacterial vaginosis Examine and investigate.
trachomatis aged 15-25yrs.
1
or Adult Women
4A+ 4A+ treatment
infections doxycycline 100mg 7 days 4A+ 4A+
Treat partners and refer to BD Trichomoniasi Treat partners and refer to metronidazole 400mg 5-7 days
1B+ 4A+
SIGN, BASHH GUM service.
2,3 B+ s GUM service BD stat
HPA, Prodigy or 2 g
Pregnancy or
2C
Pregnant or breastfeeding: BASHH In pregnancy or
breastfeeding: azithromycin
5A+
1g (off- stat
5A+ breastfeeding: avoid 2g
azithromycin is the most or label HPA, single dose metronidazole
2B-
effective option.
5 A+; 6B-
use) .
3B+ 3B+
Prodigy Consider clotrimazole for clotrimazole 100mg 6 nights
Due to lower cure rate in erythromycin
5A+
500mg 10-14 days symptom relief (not cure) if pessary
3B+
pregnancy, test for cure or BD
5A+ Investigation metronidazole declined at night
6 weeks after treatment.
3C and
amoxicillin
5A+
500mg 7 days
5A+ Management
TDS of Vaginal
Vaginal All topical and oral azoles clotrimazole
1A+
500mg stat Discharge in
Candidiasis give 75% cure.
1A+
or pessary Adult Women
or 10% 3,5C
BASHH cream Pelvic Refer woman & contacts to ceftriaxone 500mg stat
1,2B+
Inflammatory GUM service AND IM
6
HPA oral fluconazole
1A+
150mg stat Disease Always culture for metronidazole 400mg 14 days
orally gonorrhoea & chlamydia AND BD
2B+ 1, 2, 4B+
Prodigy BASHH doxycycline 100mg 14 days
In pregnancy: avoid oral Pregnant or breastfeeding: BD
Investigation azole
2B-
and use clotrimazole
3A+
100mg 6 nights
5C Prodigy 28% of gonorrhoea isolates or
and intravaginal treatment for 7 or pessary now resistant to quinolones metronidazole 400mg 14 days
3B+
Management days.
3A+, 2,4B-
at night If gonorrhoea likely AND BD
1, 2, 4, 6B+
of Vaginal (partner has it, severe ofloxacin 400mg 14 days
Discharge in miconazole 2% cream
3A+
5g intra- 7 days symptoms, sex abroad) BD
Adult Women vaginally avoid ofloxacin regimen.
BD
Examine and investigate. If woman using not using erythromycin 500mg 14 days
Failed vaginal candidiasis adequate contraception. AND QDS
treatment. metronidazole 400mg 14 days
Recurrent proven candida clotrimazole 500mg for 3-6 PID during established BD
– patients experiencing or pessary months pregnancy is very
cyclical relapse that once uncommon but should be
requires suppressive weekly assessed urgently by GUM
therapy. or emergency gynae.
fluconazole 100mg for 3-6
or oral once months Acute Send MSU for culture and ciprofloxacin
1C
500mg 28 days
1C
weekly Prostatitis
1C
start antimicrobials . or BD
4-wk course may prevent
itraconazole 400mg for 3-6 BASHH chronic prostatitis
1C
ofloxacin
1C
(if STI likely 200mg 28 days
1C
oral once months Quinolones achieve higher cause) BD
monthly Prodigy prostate levels
2
at the Second line:
expected trimethoprim
1C
200mg 28 days
1C
time of BD
symptom
18 19
OF TX GASTRO-INTESTINAL TRACT INFECTIONS
Chronic Refer to GUM or urology doxycycline 100mg 3-4 weeks For further information about investigation and clinical and public health management see local guide;
1,2
Prostatitis or BD Management of Acute Diarrhoea In Primary Care – Prescribing Points 19.12. Also see Oxfordshire
Consider antimicrobials PCT Referral Guidelines: Gastroenterology.
BASHH after specialist advice. ciprofloxacin 500mg 28 days
or BD CONDITION COMMENTS DRUG DOSE DURATION
Prodigy OF TX
1A+
ofloxacin (if STI likely cause) 200mg 28 days Eradication of Eradication is beneficial in First line:
1A+
BD Helicobacter known DU, GU or low PPI (omeprazole 20mg BD
1,2 2B+
Urethritis Cause usually STI doxycycline 100mg 7 days pylori grade MALToma. or or
Refer/discuss with GUM for or BD For NUD, the NNT is 14 for lansoprazole) 30mg BD All for
3A+
BASHH contact tracing & partner NICE symptom relief. AND 7 days
treatment (See above for azithromycin 1g stat clarithromycin (C) 500mg 1,9A+
Prodigy contact details) HPA QRG Consider test and treat in BD with
Chlamydia. Refer GUM persistent uninvestigated AM or
4B+
Prodigy dyspepsia. 250mg
If gonorrhoea is BD with
suspected either due to Do not offer eradication for MTZ
1C
risk or more severe GORD. AND
symptoms refer for amoxicillin (AM) 1gram
investigation and Do not use clarithromycin or BD
treatment to GUM or metronidazole if used in metronidazole (MTZ) 400mg
because of the high the past year for any BD
5A+, 6A+ 7A+
prevalence of resistance infection. Second line: Relapse
10C
to antimicrobials. PPI (omeprazole 20mg BD or MALToma

1,2
Epididymoorch Cause usually STI Refer/discuss with GUM for Symptomatic DU/GU relapse: retest for or or 1C
itis (<35yrs or contact tracing & partner relapse H. pylori using breath or lansoprazole) 30mg BD 14 days
increased risk If gonorrhoea is treatment. stool test OR consider AND
®
of STI) suspected either due to endoscopy for culture & bismuthate (De-nol tab ) 120mg
1C
risk or more severe doxycycline 100mg 14 days susceptibility. AND 2 previously unused QDS
BASHH symptoms refer for BD antimicrobials:
investigation and NUD: Do not retest, offer amoxicillin 1gram
1C, 3A+
Prodigy treatment to GUM PPI or H2RA. BD
because of the high metronidazole 400mg
prevalence of resistance TDS
8C
to antimicrobials. tetracycline 500mg
QDS
For epididymo-orchitis ofloxacin 200mg 14 days Gastroenteritis Most self-limiting and antimicrobial treatment is rarely required. Antimicrobial
B+
most probably due to BD / Infectious therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and
B+
enteric organisms Diarrhoea can cause antimicrobial resistance or increased incidence of C.difficile.
Epididymoorch E.coli trimethoprim 200mg 14 days
itis (>35yrs or Obtain a urine sample for or BD Prodigy Empirical treatment with ciprofloxacin may be given to those with dysenteric symptoms
low risk of STI) culture before starting i.e. if bloody diarrhoea is present and considered in the elderly and others at high risk
1,2
antimicrobial treatment. ciprofloxacin 500mg 14 days of serious complications of gastroenteritis if systemically unwell (see ‘High Risk’
BASHH A dipstick test should be BD patients in Prescribing Points 19.12).
used to evaluate
Prodigy significance of symptoms. Only consider empirical
therapy if the patient is
1c
systemically unwell.
Usually wait for culture
result to reassess
whether antimicrobials
are indicated.
Suspected Campylobacter erythromycin 500mg- 3-5 days

2
1g BD or
250mg-
500mg
QDS
Suspected Salmonella / ciprofloxacin 500mg 3-5 days

Shigella BD
20 21
OXFORDSHIRE
OXFORDSHADULT
IRE ADULANTIMICROBIAL
T ANTIMICROBIAL PREPRESCRIBING
SCRIBING OXFORDSHIRE ADULT ANTIMICROBIAL PRESCRIBING
OF TX SKIN & SOFT TISSUE INFECTIONS
st nd
Clostridium STOP unnecessary 1 /2 episode (whether Also see Oxfordshire PCT Referral Guidelines: Dermatology and Guidelines for the effective diagnosis
difficile antimicrobials and/or recurrence or relapse): and management of local wound bed infection and bacterial colonisation in primary care.
1,2B+ 1C
Infection (CDI) PPIs. vancomycin (oral) 125mg 14 days
QDS CONDITION COMMENTS DRUG DOSE DURATION
rd
DH & HPA If continued antimicrobial 3 episode/or severe OF TX
2C
treatment necessary seek disease: Impetigo For extensive, severe, or flucloxacillin (oral) 500mg 7 days
microbiology/infectious Seek gastroenterology or bullous impetigo, use oral QDS
1C
disease advice. microbiology /infectious Prodigy antimicrobials. Penicillin Allergy:
2C
disease advice erythromycin (oral) 500mg- 7 days
Admit if severe: T >38.5; 1g BD or
WCC >15, rising creatinine 250mg-
or signs/symptoms of 500mg
1C
severe colitis. QDS
1C Reserve topical 3B+
If patient is unable to metronidazole 400mg 14 days antimicrobials for very topical fusidic acid TDS 5 days
swallow solid dosage forms TDS localised lesions to reduce
give metronidazole the risk of resistance.
1,5C,
suspension. 4B+
Only consider standby antimicrobials for remote areas or people at high-risk of
Traveller’s 1,2C 3A+
severe illness with travellers’ diarrhoea. . Reserve mupirocin for MRSA only mupirocin TDS 5 days
Diarrhoea 3
If standby treatment appropriate give: ciprofloxacin 500 mg stat (private Rx). MRSA.
1C
If quinolone resistance high (e.g. south Asia) and standby treatment appropriate: Eczema If no visible signs of infection, use of antimicrobials (alone or with steroids) encourages
Prodigy
consider azithromycin 1g stat (private Rx). Prodigy resistance and does not improve healing.
1B
In eczema with visible signs of infection,
2C
use treatment as in impetigo for treatment of infection, also ensure treatment of
Acute Antimicrobials for acute eczema.
Diverticulitis diverticulitis should only
be used in patients with a Cellulitis If patient afebrile and flucloxacillin
1,2,3C
500mg All for
Prodigy confirmed diagnosis of healthy other than cellulitis, QDS 7 days.
diverticulosis unless Prodigy use oral flucloxacillin alone.
under specialist advice. 1,2C
Facial: co-amoxiclav
4C
625mg If slow
If febrile and ill, admit for IV TDS response
For people managed at treatment.
1C
Penicillin Allergy: continue for
1
home: clindamycin
1,2C
450mg a further 7
Prescribe broad-spectrum co-amoxiclav 625mg 7 days If failure of first line therapy TDS days
1C
antimicrobials to cover TDS seek microbiology
anaerobes and Gram- Penicillin Allergy (non-severe /infectious disease advice.
negative rods. allergy):
metronidazole 400mg If river, sea or flood water
Review within 48 hours or AND TDS exposure, discuss with
sooner if symptoms cefalexin 500mg 7 days microbiologist.
deteriorate. Arrange TDS Note: Control of oedema, good skin emollient therapy and elevation of the affected limb
admission if symptoms Penicillin Allergy (severe is a key part of treatment.
persist or deteriorate. allergy): 400mg Discontinue compression therapy during the acute phase of cellulitis.
metronidazole TDS Dermatitis is often misdiagnosed as cellulitis: Review diagnosis if it appears bilateral.
AND 500mg 7 days
ciprofloxacin BD 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.
Giardia metronidazole 400mg 5 days phenoxymethylpenicillin 250mg BD (500mg BD if weight > 75kg) or erythromycin
TDS 500mg daily if penicillin allergic is recommended.
1
Prodigy Dosage may be reduced to 250mg daily after 1 year of successful prophylaxis.
5
1C
Threadworms Treat all household mebendazole 100mg stat
contacts at the same time
Prodigy PLUS advise hygiene
measures for 2 weeks
Lavender (hand hygiene, pants at
Statement night, morning shower)
PLUS wash sleepwear,
bed linen, dust, and
1C
vacuum on day one.
Other Worms As per BNF Guidelines
22 23
OXFORDSHADULT
T ANTIMICROBIAL PRESPRESCRIBING
CRIBING
OF TX OF TX
1A+
Leg Ulcers Bacteria will always be present. Antimicrobials do not improve healing. Bites Thorough irrigation is Prophylaxis or treatment:
1C
Culture swabs and antimicrobials are only indicated if there is evidence of clinical important. co-amoxiclav 375mg -
Prodigy - infection such as inflammation/redness/cellulitis; increased pain; purulent exudate; rapid Prodigy Consider need for surgical 625mg
2,3c 4C
Venous deterioration of ulcer or pyrexia. If these signs are present: treat as for Cellulitis (see debridement. TDS
section above). Review antibiotics after culture result available; select most suitable Penicillin Allergy:
antibiotic with lowest risk for C.difficile or MRSA infection. Human Assess risk of tetanus, metronidazole 400mg
1C
HIV, hepatitis B&C. AND TDS
Diabetic Foot Ensure vascular assessment and podiatry review. The Health Protection Unit doxycycline (cat/dog/human) 100mg
5C
Infection and ‘On Call’ Public Health BD All for 7 days
4,5,6C
Mild diabetic foot flucloxacillin 500mg 7-14 team are available to help
Prodigy QDS days; may on risk assessment. 9am– metronidazole 400mg
Penicillin Allergy: extend to 28 5pm: 0845 2799879. Out AND TDS
IDSA cefalexin 500mg days if slow of hours: 0844 967 0083. erythromycin (human bite) 500mg -
TDS to resolve* Antimicrobial prophylaxis is 1g BD or
3B-
advised. 250mg -
Moderate diabetic foot If IV antimicrobials NOT 500mg
6C
infection (moderate required: Cat or Dog Assess risk of tetanus and QDS
2C
diabetic foot infection - e.g. rabies. AND review at 24 and
3 7C
gangrene or deep tissue co-amoxiclav oral 625mg Give prophylaxis if cat 48hrs
1-3
involvement). AND TDS bite/puncture wound; bite
14 -28 days* to hand, foot, face, joint,
metronidazole 400mg tendon, ligament;
If IV antimicrobials TDS immunocompromised/
required refer to Penicillin Allergy: diabetic/asplenic/
specialist. ciprofloxacin oral 500mg cirrhotic.
AND BD
14 -28 days* For animals not covered in
clindamycin 450mg this guidance (for example
TDS monkeys, pigs, exotic pets
Severe diabetic foot Refer to specialist etc), seek microbiology/
infection i.e., causing infectious diseases advice.
1-3
systemic illness.
* Review the patient regularly for signs of improvement – if no / limited response to Mastitis Antimicrobials only flucloxacillin 500mg 14 days
1
antibiotics within 2 weeks seek specialist advice. required if: QDS
Prodigy Symptoms have not Penicillin Allergy:
Wound Swabbing not normally necessary. improved or are erythromycin alone 500mg- 14 days
Infections worsening after 12– 1g BD or
(Non surgical) Treat as per cellulitis and leg ulcers. 24 hours despite 250mg-
effective milk removal 500mg
For surgical wound infections – seek microbiology/infectious disease advice. The woman has a nipple QDS
fissure that is infected
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 25
OF TX OF TX
Acne Vulgaris Topical treatments - advise to treat all areas ever affected to help prevent new Rosacea Ensure steroids are not being used on the face; ensure inhaled steroids, steroid eye
outbreaks. drops etc are not inadvertently contacting the face.
1
Prodigy Topical retinoids are the first line agent for ALL acne, unless contraindicated (topical
1 Mild & localised metronidazole 0.75% BD Review after
retinoids are contra-indicated in pregnancy; women of child-bearing age should use Prodigy papulopustular cream * 7-8 weeks.
Lavender effective contraception).
Statement If patient unable to tolerate retinoids daily, specialists advise using twice weekly to Dermatology If not responding after 8
reduce irritation (unlicensed). Referral weeks:
Dermatology Topical antimicrobials are generally not used first line. Guidelines
Referral azelaic acid 15% BD
Guidelines Mild or moderate & Topical retinoid first line OD Follow up
localised. (see above). after 6-8 * some gel preparations are ~3 times the cost of the
weeks to cream.
If unable to tolerate topical assess
retinoid or not responding, compliance. Moderate or severe doxycycline * 100mg Review after
add in benzoyl peroxide: benzoyl peroxide 2.5% OD-BD papulopustular (unlicensed) OD 3-4 weeks
50% and if
If unable to tolerate retinoid improvement Consider adding in topical If compliance is an issue: improving
& benzoyl peroxide, or not is usually treatment for patients lymecycline (unlicensed) 408mg review 6
responding, STOP benzoyl seen at 6 receiving oral antimicrobial OD monthly.
peroxide and add in topical clindamycin 1% BD month; therapy that have not
antimicrobial. 80% at 8 responded at review, or Pregnant or breastfeeding:
months. seek specialist advice. erythromycin 500mg
Moderate widespread. Ensure on topical retinoid Follow up BD
and benzoyl peroxide. after 6-8 Switching to an alternative * 40mg capsules are licensed for papulopustular facial
weeks to oral antimicrobial (unless roseacea (without ocular involvement) but are ~4 times
If topical treatment cannot First line oral antibacterial: assess compliance issues) is the cost of the 100mg capsules.
be tolerated, moderate doxycycline 100mg compliance. unlikely to be of benefit.
acne on back or shoulders OD Severe & resistant / not Seek specialist advice.
or significant risk of 50% responding.
scarring or substantial If compliance is an issue: improvement
Perioral Aggravated by steroids. oxytetracycline 500mg 4 weeks
pigment change, consider lymecycline 408mg is usually
Dermatitis BD
oral therapy. OD seen at 6
month;
Pregnant or breastfeeding: 80% at 8 Boils / Cysts/ Antimicrobials treatment Antimicrobial treatment
erythromycin 500mg months Abscesses / not required unless not usually indicated
1
BD Carbuncles person has:
Severe acne &/or if acne is scarring significantly: make specialist referral for fever flucloxacillin 500mg 7 days
consideration of isotretinoin (specialist prescribing only). Prodigy cellulitis QDS
Ensure fasting lipids and liver function results are available; all women of child lesion is on the face Penicillin Allergy:
bearing age are on established contraception and are prepared to use 2 forms of lesion is a carbuncle erythromycin 500mg- 7 days
contraception; any past history or vulnerability to psychological disease is highlighted person is in pain or 1g BD or
to the specialist; women of child bearing age should be advised to anticipate having a severe discomfort 250mg-
pregnancy test done on a fresh urine sample at the initial outpatient appointment. there are other 500mg
Consider prescribing an oral antimicrobial in combination with a topical drug whilst comorbidities (such as QDS
waiting for an appointment. diabetes or
Refer to Dermatology Referral Guidelines for further advice. 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.
26 27
OF TX OF TX
Paronychia Consider antimicrobials if flucloxacillin 250mg- 7 days Head Lice Treatment is not necessary Wet combing: sole Treat- 4 sessions
1
incision and drainage: 500mg unless a live louse is treatment of regular wet ment over 2
Prodigy is not required (because QDS Prodigy found. Ensure all combing with conditioner, or involves weeks
the lesion is non- Penicillin Allergy: affected individuals in a combine with below. Wet method-
fluctuant). erythromycin 500mg- 7 days Lavender household are treated combing should be ically
1,2
was performed, but the 1g BD or Statement simultaneously. continued until no full-grown combing
person has signs of 250mg- lice have been seen for 3 wet hair
cellulitis or fever, or has 500mg MHRA consecutive sessions. with a
other comorbidities (such QDS Offer a choice of treatment fine-
as diabetes or strategies: wet combing, toothed
immunosuppression). dimeticone lotion or an comb to
Folliculitis Antimicrobials not required insecticide. remove
lice
Scabies Treat all members of the permethrin
3A+
5% 2 No treatment is 100%
Prodigy household, close contacts cream applications effective. Consider dimeticone Rub 2
& sexual contacts within If allergy: 1 week apart (physical insecticide) lotion applications
24h.
1C
malathion
3C
0.5%
1C Choice of treatment especially if resistance to onto dry 7 days apart
Treat whole body from aqueous depends on the preference other treatments. hair and
ear/chin downwards and liquid of the individual/parent and scalp.
under nails. If under on the treatment history. Allow to
2/elderly, also face/scalp.
2 dry
Ensure appropriate Use lotions or liquids naturally.
management of ‘itch’ and formulations; shampoos Shampoo
any associated eczema. 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.
28 29
FUNGAL SKIN INFECTIONS OF TX
1
CONDITION COMMENTS DRUG DOSE DURATION Fungal / Scalp Ringworm. Adults: terbinafine oral (off 250mg 4 weeks
OF TX Dermatophyte license) OD
4A+
Fungal / Athletes Foot/ Fungal Topical 1% terbinafine OD-BD 2 week* infection of the Take scalp scrapings – this
Dermatophyte Groin Infection / or skin - Scalp often pulls out infected hair selenium shampoo in severe Twice a 2 - 4 weeks
infection of the Ringworm. Dermatophyte stumps which are critical cases may be appropriate in week
skin – topical 1% imidazole e.g. OD-BD 4 – 6 weeks* s for successful culture & addition. This reduces the
1 4A+
Dermatophyte Terbinafine is fungicidal , clotrimazole / miconazole microscopy. Hair plucking risk of spreading the
s so treatment time shorter (Not nystatin as is NOT Prodigy does not produce the best infection to others.
than with fungistatic effective against samples. A soft toothbrush
4A+
Prodigy imidazole. dermatophytes ) HPA can be used if scrapings Also ketoconazole shampoo
2
are not possible. and povidone iodine
Prodigy 1 week terbinafine is as or (athletes foot only)
effective as 4 weeks azole. topical undecanoates BD 4 – 6 weeks* Scalp scrapings for
A- ® 4B+
HPA (Mycota ) culture are essential as
choice of treatment is
Lavender If inflammation is marked, species dependent: M
Statement consider prescribing a canis responds well to
topical antifungal combined griseofulvin whereas T.
with a mildly potent tonsurans (greater recent
corticosteroid for a prevalence especially in
maximum of seven days. cities) responds well to
terbinafine. Dermatologists
Use a combination advise initiating treatment
preparation with caution on with terbinafine and being
fungal infection of the prepared to switch
groin, because of the treatment to griseofulvin if
increased risk of adverse culture shows M canis.
effects with topical
corticosteroids in occluded Fungal / Unsightly nails due to Prescribe only in line with
areas. Dermatophyte fungal infection are Priorities Committee
infection of the primarily a cosmetic Lavender Statement
If intractable: send skin terbinafine oral 250mg proximal problem.
2C 2A+
scrapings If infection OD fingernail or Therefore the Priorities terbinafine oral 250 mg
confirmed, use oral ringworm 4 weeks* toenail Committees considers the OD
3B+
terbinafine/itraconazole groin 2-4 weeks* treatment of finger- 6-12 weeks
* duration of treatment is given as an approximation. Lavender onychomycosis (fungal nail nails
Treatment should be continued for 1-2 weeks after the Statement infection) with terbinafine to
disappearance of all signs of infection. 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.
30 31
OXFORDSHADULT
T ANTIMICROBIAL PRESPRESCRIBING
CRIBING
OF TX VIRAL INFECTIONS
Pityriasis Caused by an overgrowth First Line: CONDITION COMMENTS DRUG DOSE DURATION
Versicolor of Pityrosporum orbiculare selenium shampoo Apply 7 days OF TX
(Malassezia furfur).
1
DAILY to Herpes Cold Sores Cold sores resolve after 7–10d without treatment.
Prodigy the simplex Topical over the counter antivirals (aciclovir) can be
Most adults have affected bought. If applied prodromally (early) reduce duration by
1,2,3B+,4
Pityrosporum orbiculare on or area – Prodigy 12-24hrs.
their skin; however, in a leave on First attack genital. aciclovir
#
200mg 5 days
few people its presence for 10 Prodigy FIVE x
results in a harmless skin mins Recurrent attacks of genital Specific treatments usually daily
disease. before Lavender herpes - intermittent not beneficial as recurrences
rinsing. Statement therapy. are self-limiting and
Pityrosporum orbiculare (Diluting generally cause minor
also plays a role in the with a symptoms.
5
development of small
seborrhoeic dermatitis amount Recurrent attacks of genital aciclovir
#
400 mg Interrupt
(including cradle cap). of water herpes - suppressive BD therapy
can therapy. every 6-12
Poorly responsive to reduce months for
terbinafine and completely irritation) Only indicated if at least six reassess-
unresponsive to nystatin recurrences per annum. ment of
and griseofulvin. ketoconazole shampoo Apply Max 5 days disease
once #
Use normal oral dose every 12 hours if eGFR less than
If initial therapy fails, verify daily – 10mL/minute/1.73m .
2
that the treatment regimen leave
has been followed prepara- Varicella If pregnant/ neonate /
adequately. Consider a tion on zoster immunocompromised seek
second topical therapy for 3- / Chickenpox advice re treatment and
before considering 5mins prophylaxis from
systemic treatment. before Prodigy microbiology or infectious
1B+
rinsing disease.
Third line (adults): Immunisatio
itraconazole (only in severe 200mg 7 days n against Chickenpox: Use aciclovir If indicated:
3B+, 6A+ 3B+
unresponsive cases due to daily Infectious if less than <24h of rash aciclovir* 800 mg 7 days
benefit risk ratio) Disease and >14 years or severe five times
2006 (‘The pain or dense/oral rash or a day
o
Intertrigo Combination preparations clotrimazole 1% cream Apply Continue for Green 2 household case or * use normal oral dosage every 8 hours if eGFR 10-25
-5 2
containing corticosteroids BD-TDS at least 2 Book’) steroids or smoker. mL/minute/1.73m (every 12 hours if eGFR less than 10
2
Prodigy e.g. trimovate cream weeks after (Chapter 34) mL/minute/1.73m ).
should only be applied if the affected See below for additional
Chickenpox advice on treatment and
there is marked area has
1 in adults – prophylaxis.
inflammation. healed
They should be applied Clinical
sparingly to avoid skin management
atrophy on areas of thin
skin (e.g. facial areas) and
for a maximum of 1 week.
32 33
CONDITION COMMENTS DRUG DOSE DURATION Treatment Advice: SHINGLES
OF TX
Herpes If pregnant/ neonate / Immunocompromised: (Immunisation against Infectious Disease 2006 (‘The Green Book’) – for
zoster immunocompromised seek definition of immunosuppressed patients see Chapter 6 & 34).
/ Shingles advice re treatment and  Refer to specialist as intravenous therapy may be required.
prophylaxis from
Prodigy microbiology or infectious Immunocompetent including pregnancy:
1B+
disease.  Refer all patients with eye involvement to an Ophthalmologist.
Immunisatio If indicated:  Treat all patients > 50 years old with aciclovir 800 mg 5 times daily for 7 days. If compliance is an
3B+, 6A+ 3B+
n against Shingles: treat if >50 aciclovir* 800 mg 7 days issue consider valaciclovir 1gram TDS or famciclovir 250 mg TDS or 750 mg once daily for 7 days
6A+
Infectious yrs and within 72 hrs of five times as valaciclovir and famiciclovir are ten times the cost. Commence within 72 hours of onset of rash
7B+
Disease rash (PHN rare if <50yrs Second line if compliance a a day or up to one week after onset for ophthalmic zoster.
8B-
2006 ); or if active ophthalmic problem, as ten times cost.
9B+ 10C
(‘The Green or Ramsey Hunt or Consult BNF if renal Prophylaxis Advice: High Risk Contacts of Patients with Chickenpox or Shingles
Book’) eczema. impairment:
11B+ 11B+
(Chapter 34) valaciclovir 1gram 7 days High risk contacts are patients without a definite history of Chickenpox or Shingles and a negative test
See below for additional or TDS for varicella antibody, and who have had a significant contact with Chickenpox or Shingles
advice on treatment and (Immunisation against Infectious Disease 2006 (‘The Green Book’) – Chapter 34 Varicella) and are at
prophylaxis. famciclovir
12B+
250mg 7 days
12B+
high risk of serious disease.
TDS or
750mg These include:
OD 1. Immunocompromised patients (see Immunisation against Infectious Disease 2006 ) (‘The Green
* use normal oral dosage every 8 hours if eGFR 10-25 Book’).
2
mL/minute/1.73m (every 12 hours if eGFR less than 10 2. Pregnant women.
2
mL/minute/1.73m ). 3. Neonates of non-immune mothers who:
Treatment Advice: CHICKENPOX 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
Immunocompromised Patients: (Immunisation against Infectious Disease 2006 (‘The Green Book’) – life.
for definition of immunosuppressed patients see Chapter 6 & 34) 4. Infants of any age, exposed to Chickenpox or Herpes zoster while still requiring intensive or
 Refer urgently to a specialist for intravenous aciclovir. prolonged special care nursing.
Immunocompetent Patients: (Also see: Chickenpox in adults – Clinical management). Contact the Microbiology SpR/Consultant 01865-220880 or Bleep 4077 (in hours) or via JR switchboard
 Treatment is indicated for all persons over 14 years of age. (out of hours) for specific advice, to arrange urgent antibody testing and for supplies of VZIG if
 Treatment should start as soon as possible, preferably within 24 hours and certainly within 72 required.
hours of the onset of the rash.
 Treat adults for 7 days as for shingles above. If patient is eligible for varicella-zoster immune globulin (VZIG) this will prescribed by the Microbiology
 Pregnant women may have more serious disease and the benefits of treatment should be SpR/consultant. Give varicella-zoster immune globulin (VZIG) 250 mg (1 vial) to 1000mg (4 vials)
balanced against any potential harm to the foetus. (NB: Chickenpox in adults – Clinical intramuscularly depending on age. Give preferably within 96 hours of contact, but may be efficacious up
management). to 10 days post exposure.
 Chickenpox in pregnancy should be treated with aciclovir 800 mg 5 times daily for 7 days. There is
VZIG will need to be collected from the JR pharmacy site by the patient or representative. VZIG does
no evidence so far that aciclovir causes congenital abnormalities in humans.
not prevent infection but may reduce severity.
 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 35
OXFORDSHADULT
IRE ADULTANTIMICROBIAL
ANTIMICROBIAL PRESPRESCRIBING
CRIBING
HEPATITIS MENINGITIS
HEPATITIS B CONDITION COMMENTS DRUG DOSE DURATION
 All patients with hepatitis B not previously assessed by a hepatologist should be referred for OF TX
assessment and consideration of treatment. Bacterial Suspected bacterial
Meningitis meningitis without non-
1,2,3,4
 Contact Follow Up has a significant role to play. All household and sexual contacts of HbSAg+ve and / or blanching rash
patients should be screened offered HBV vaccine and advice on minimising risk of spread. Further Suspected transfer directly to
guidance is available from the Health Protection Unit 9am–5pm: 0845 2799879. Out of hours: Meningococ secondary care as an
0844 967 0083. cal Disease emergency via ambulance
without giving parenteral
 Also see Antenatal screening Hepatitis B flowchart. HPA antibiotics.
IV or IM benzylpenicillin* (give IM if
HPA if urgent transfer to hospital 1200mg
vein cannot
HEPATITIS C is not possible (for example,
be found)
 Patients who are both hepatitis C antibody and Hepatitis C RNA positive should be referred for NICE remote locations or adverse
assessment and consideration of treatment by a hepatologist. weather conditions),
antibiotics should be
 Also see Hepatitis C: diagnosis and referral flowchart. administered to someone
with suspected bacterial
meningitis.
EYE INFECTIONS
Also see Oxfordshire PCT Referral Guidelines: Ophthalmology Suspected meningococcal IV or IM benzylpenicillin* 1200mg (give IM if
disease (meningitis with vein cannot
CONDITION COMMENTS DRUG DOSE DURATION non-blanching rash or be found)
OF TX meningococcal
1,2,3,4
Conjunctiviti Treat if severe; most are viral Treatment often not septicaemia).
s or self-limiting. required. transfer directly to
Prodigy secondary care as an
4,5B+,6B-
Bacterial conjunctivitis is If severe: emergency via ambulance.
Lavender usually unilateral and also chloramphenicol 0.5% 2 hourly
2C
Statement self-limiting; it is drops for parenteral antibiotics should
characterised by red eye with 2 days be given at the earliest
mucopurulent, not watery, then opportunity, either in
discharge; and 4 hourly primary or secondary care,
65% resolve on placebo by (whilst All for 48 but urgent transfer to
1A+
day five. awake) hours after hospital by emergency
resolution ambulance should not be
Fusidic acid has less Gram- chloramphenicol 1% at night delayed in order to give
3
negative activity. ointment the parenteral antibiotics.
Second line: *Withhold benzylpenicillin only in adults who have a history of significant allergic response
fusidic acid 1% gel BD to penicillin; a history of a rash is not considered as significant in this context.
Styes See Prodigy for advice on for Systemic or topical antimicrobials not required. *An alternative for adults who have a significant allergic response to penicillin is not given
1
Prodigy management. 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)
36 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.
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
Version 2.1. Approved by APCO: April 2012 (up-dated July 2012); Review Date: April 2014
38

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Clinical Commissioning Group

Version 2.1 (July 2012)

Characteristics Type I immediate reactions Non-Type I reactions Current Version

Only prescribe an amoxicillin alone 250mg- 5 days As well as pain, and

Risk factors for If resistance risk factors:

*Avoid if patient is febrile or clinical evidence of

In older patients, community multi-resistant Extended-

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

to antimicrobials. PPI (omeprazole 20mg BD or MALToma

Suspected Campylobacter erythromycin 500mg- 3-5 days

Suspected Salmonella / ciprofloxacin 500mg 3-5 days

Prodigy If active infection, MRSA confirmed by lab results,

If severe infection or no response to monotherapy after

Recurrent boils may need

If a boil is drained then a

Pregnant or breastfeeding Wet combing or dimeticone

HPA Adults (alternative) rifampicin 600mg oral BD for 2 days

Pregnant women ciprofloxacin 500mg oral single dose

Further advise on vaccination

Specialist advice from:

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