Greater Manchester Antimicrobial Guidelines - June 2020 Version 7.0 Planned review date: September 2020 - gmmmg
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Greater Manchester Antimicrobial Guidelines June 2020 Version 7.0 Planned review date: September 2020
Greater Manchester Antimicrobial Guidelines June 2020
DOCUMENT CONTROL
Document location
Copies of this document can be obtained from:
Name: Strategic Medicines Optimisation
Address: Greater Manchester Joint
Commissioning Team
Ellen House
Waddington Street
Oldham
OL9 6EE
Telephone: 0161 290 4905
Revision history
The latest and master version of this document is held by Greater Manchester Health and Care Commissioning Medicines
Optimisation team:
REVISION
ACTIONED BY SUMMARY OF CHANGES VERSION
DATE
27/08/2019 S Woods Final formatting 6.0
03/03/2020 S Woods Amendments made after initial feedback on proposed changes 6.1
Amendment made under UTIs in children after comments from Absar
06/03/2020 S Woods 6.2
Bajw a
28/5/2020 E Radcliffe Added CAP During COVID-19 NG 165 6.3
11/06/2020 E Radcliffe Made further amendments follow ing comments from AMS group 6.4
23/06/2020 E Radcliffe Final Formatting 7.0
Approvals
This document has been provided for information to:
NAME DATE OF ISSUE VERSION
AMSSG 01/6/2020 6.3
AMSSG 11/6/2020 6.4
GMMMG webpage 23/6/2020 7.0
Changes to version 6.0 – see end of document.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 2Greater Manchester Antimicrobial Guidelines June 2020
Aims
to provide a simple, empirical approach to the treatment of common infections
to promote the safe and effective use of antibiotics
to minimise the emergence of bacterial resistance in the community
Principles of Treatment
1. This guidance is based on the best available evidence, but use professional judgement and involve patients
in decisions.
2. Please ensure you are using the most up to date version. The latest version will be held on the GMMMG
website.
3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
4. When recommending analgesia or treatment with products available from pharmacies please follow the
guidance issued by NHS England (Conditions for which over the counter items should not routinely be
prescribed in primary care: Guidance for CCGs [Gateway approval number: 07851]). See the guidance for
exceptions to recommending self-care.
5. Consider a no, or delayed, antibiotic strategy for acute self -limiting infections e.g. upper respiratory tract
infections.
6. When prescribing an antibiotic it should be based on the severity of symptoms, risk of developing
complications, previous laboratory tests and any previous antibiotic use.
7. Limit prescribing over the telephone to exceptional cases. Except during COVID-19 pandemic where face-to-
face contact should be minimised by using telephone or video consultations
8. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight
and renal function. In severe or recurrent cases consider a larger dose or longer course.
9. Unless treatment choice is listed separately for children, then choices given are c onsidered appropriate for
adults and children; bearing in mind any specific age limitations for use listed in the BNF for Children.
10. Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; con sider culture
and seek advice.
11. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (eg co -amoxiclav, quinolones
and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium
difficile, MRSA and resistant UTIs.
12. Avoid widespread use of topical antibiotics (especially those agents also available as systemic pre parations,
e.g. fusidic acid).
13. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones and high dose metronidazole.
14. We recommend clarithromycin as the preferred macrolide as it has less side-effects than erythromycin,
greater compliance as twice rather than four times daily & generic tablets are similar cost. The syrup
formulation of clarithromycin is only slightly more expensive than erythromycin and could also be considered
for children. Erythromycin remains the drug of choice in pregnancy and should be used where
clarithromycin is indicated.
15. Always advise to seek medical help if symptoms worsen at any time or do not improve within 48 hours of
starting an antibiotic or the person becomes systemically unwell.
16. Review antibiotic choice once culture and susceptibility results are available.
17. Wh e re an empirical therapy has failed or special circumstances exist, microbiological advice can be
o b tained from your local hospital microbiology department.
18. This guidance should not be used in isolation; it should be supported with patient information about back -
up/delayed antibiotics, infection severity and usual duration, clinical staff education, and audits. Materials
are available on the RCGP TARGET website.
19. This guidance is developed alongside the NHS England Antibiotic Quality Premium (QP). In 2017/19 QP
expects: at least a 10% reduction in the number of E. coli blood stream infections across the whole health
economy; at least a 10% reduction in trimethoprim:nitrofurantoin prescribing ratio for UTI in primary care,
and at least a 10% reduction in trimethoprim items in patients > 70 years, based on CCG baseline data from
2015/16; and sustained reduction in antimicrobial items per STAR -PU.
20. This guidance should be facilitated by the adoption of Antibiotic Stewards from front line to board level
within organisations, in line with NICE NG15: Antimicrobial stewardship, August 2015 . This sets out key
activities and responsibilities for individuals and organisations in responding to the concern of antimicrobial
resistance.
21. Please note MHRA safety alert (issued 21 March 2019): Fluoroquinolone antibiotics: ciprofloxacin,
levofloxacin,moxifloxacin, ofloxacin: New restrictions and precautions due to very rare reports of disabling
and potentially long-lasting or irreversible side effects. Key details are below and referenced where the
relevant antimicrobials are advised in the guideline. Full letter can be viewed at
DDL_fluoroquinolones_March-2019_final.pdf.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 3Greater Manchester Antimicrobial Guidelines June 2020
Contents
SECTION Page
UPPER RESPIRATORY TRACT INFECTIONS 6
Influenza treatment 6
Acute sore throat 6
Acute otitis media 6
Acute otitis externa 6
Acute sinusitis 7
LOWER RESPIRATORY TRACT INFECTIONS 7
Acute cough bronchitis 7
Acute exacerbation of Bronchiectasis (non-cystic fibrosis) 7
Acute exacerbation of COPD 8
Acute exacerbation of COPD – PROPHYLAXIS 8
Community acquired pneumonia treatment in the community (Adults) DURING
9
COVID-19 pandemic
Community acquired pneumonia treatment in the community (Children & young
10
people under 18 years.
MENINGITIS 11
Suspected meningococcal disease 11
URINARY TRACT INFECTIONS 11
Lower UTI in non-pregnant women 11
Catheter associated UTI 12
Lower UTI in pregnancy 12
Lower UTI in men 12
Recurrent UTI in non-pregnant women 3 or more UTIs per year 13
Acute prostatitis 13
Acute pyelonephritis in adults (Upper UTI) 13
Lower UTI in children 14
Acute Pyelonephritis in children (Upper UTI) 14
GASTRO INTESTINAL TRACT INFECTIONS 14
Oral candidiasis 14
Eradication of Helicobacter pylori 14
Infectious diarrhoea 14
Clostridium difficile 15
Acute diverticulitis 15
Traveller’s diarrhoea 15
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 4Greater Manchester Antimicrobial Guidelines June 2020
SECTION Page
GENITAL TRACT INFECTIONS 16
STI screening 16
Chlamydia trachomatis/ urethritis 16
Epididymitis 16
Vaginal candidiasis 16
Bacterial vaginosis 16
Gonorrhoea 16
Trichomoniasis 16
Pelvic inflammatory disease 17
SKIN INFECTIONS 17
MRSA 17
Impetigo 17
Eczema 17
Leg ulcer 18
Diabetic Foot 18
Cellulitis 19
Mastitis - Lactational 19
Mastitis – Non-Lactational 19
Bites - Human 20
Bites - Cat or dog 20
Lyme disease – Tick bite 20
Dermatophyte infection - skin 20
Dermatophyte infection - nail 20
Varicella zoster/chicken pox 21
Herpes zoster/shingles 21
Scarlet Fever (GAS) 21
Cold sores 21
Acne & Rosacea 21
PARASITES 22
Scabies 22
Head lice 22
Threadworms 22
EYE INFECTIONS 22
Conjunctivitis 22
Changes to version 6.0 23
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 5Greater Manchester Antimicrobial Guidelines June 2020
Greater Manchester Antimicrobial Guidelines
UPPER RESPIRATORY TRACT INFECTIONS
Annual vaccination is essential for all those at risk of influenza. For otherw ise healthy adults antivirals not
Influenza recommended.
treatment Treat ‘at risk’ patients, w hen influenza is circulating in the community and ideally w ithin 48 hours of onset (do
not w ait for lab report) or in a care home w here influenza is likely. At risk: pregnant (including up to tw o w eeks
Back to Contents post-partum), 65 years or over, chronic respiratory disease (including COPD and asthma) significant
cardiovascular disease (not hypertension), immunocompromised, diabetes mellitus, chronic neurological, renal
or liver disease, morbid obesity (BMI 40 or greater). See PHE seasonal influenza guidance for current
treatment advice and: GMMMG: GP guide - Influenza outbreak in an adult care hom es, January 2019
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Avoid antibiotics as 90% resolve in 7 days w ithout, and pain only reduced by 16 hours .
Acute sore Advise self-care in line w ith NHS England guidance.
throat Use FeverPAIN Score Phenoxymethylpenicillin 500mg Penicillin Allergy:
(this has replaced CENTOR): four times a day or Clarithromycin 500mg tw ice a
Fever in last 24 hours 1g tw ice a day day
Purulence
Attend rapidly under 3days Duration: 10 days Duration: 5 days
severely Inflamed tonsils
NICE Visual Summary No cough or coryza Phenoxymethylpenicillin is first
Back to Contents Score: choice due to a significantly
low er rate of resistance in Group
0 to 1: 13 to 18% streptococci. Do not
A streptococcus compared w ith
offer an antibiotic.
clarithromycin.
2 to 3: 34 to 40% streptococci.
Consider* no antibiotic or a back -up
antibiotic prescription.
Greater than 4: 62 to 65% streptococci.
Consider* an im m ediate antibiotic or
a back-up antibiotic prescription.
See NICE NG84 (Sore throat (acute):
antimicrobial prescribing).
No antibiotics – 80% resolve w ithout antibiotics. Advise self-care in line w ith NHS England guidance.
Acute otitis
Recom m end appropriate analgesia. Amoxicillin 500mg to 1g three Penicillin Allergy:
media times a day Clarithromycin 500mg tw ice a
60% are better in 24hrs w ithout
antibiotics, w hich only reduce pain at day
2 days and do not prevent deafness. Duration: 5 days
Duration: 5 days
Consider 2 or 3-day delayed or
immediate antibiotics for pain relief if:
NICE Visual Summary Less than 2 years AND bilateral
Back to Contents acute otitis media or
any age w ith otorrhoea
See NICE NG91 (Otitis media (acute):
antimicrobial prescribing).
Mild infection: No antibiotics. Advis e self-care in line w ith NHS England guidance.
Acute otitis
First recom mend analgesia. Moderate infection: Moderate infection:
externa
Cure rates similar at 7 days for topical Acetic acid 2% Neomycin sulphate w ith
Back to Contents acetic acid or antibiotic plus or minus a 1 spray three times a day corticosteroid
steroid. 3 drops three times a day
Duration: 7 days
Duration: 7 to 14 days
If cellulitis or disease extends outside Severe infection:
ear canal, or system ic signs of Flucloxacillin 250mg/ 500mg four times a day
infection.
Duration: 7 days
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 6Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
No antibiotics – 80% resolve in 14 days and only 2% are com plicated by bacterial infection.
Acute Sinusitis Advise self-care in line w ith NHS England guidance.
Sym ptom s less than 10 days: No Amoxicillin Penicillin allergy:
antibiotics. Recom m end self-care. 500mg to 1g three times a day Doxycycline (not for under 12
Paracetamol / ibuprofen for pain / fever. years) 200mg stat then 100mg
Nasal decongestant may help. Duration: 5 days
daily
Sym ptom s greater than 10days: Only
Duration: 5 days
consider back-up antibiotics if no
NICE Visual summary improvement in symptoms.
Back to Contents Consider* high dose nasal steroid if Mometasone 50microgram
older than 12 years. nasal spray.
Tw o actuations (100mcg) in For children under 12 years:
At any tim e if the person is: each nostril tw ice a day for 14
days (off-label use) Clarithromycin
systemically very unw ell,
Duration 5 days
or has symptoms and signs of a more Preferred choice if
serious illness or condition, systemically very unwell,
or has high risk of complications symptoms and signs of a
Offer* immediate antibiotic or investigate more serious illness or
and manage in line w ith NICE guidance condition, or at high risk of
on respiratory tract infections (self - complications:
limiting) Co-amoxiclav 625mg three
See NICE NG79 (Sinusitis (acute): times a day
antimicrobial prescribing)
Duration: 5 days
LOWER RESPIRATORY TRACT INFECTIONS
Low doses of penicillins are more likely to select out resistance, we recommend at least 500mg of amoxicillin. Do not use quinolone
(ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones for proven resistant organis ms.
Only offer* / consider* treatm ent if:
Acute cough $
Acute cough and higher risk of com plications (at face-to-face exam ination): consider* immediate or
bronchitis back-up antibiotic.
Acute cough and system ically very unw ell (at face to face exam ination): offer* immediate antibiotic.
Acute cough w ith upper respiratory Doxycycline 200mg stat then Amoxicillin 500mg three times
tract infection: no antibiotic. 100mg daily a day.
Acute bronchitis: no routine antibiotic. Duration: 5 days Duration: 5 days
NICE Visual summary Advise self-care in line w ith NHS England
Back to Contents guidance. Preferred choice for children For children less than 12
less than 12 years: years w ith Penicillin allergy:
Do not offer a mucolytic, an oral or
inhaled bronchodilator, or an oral or Amoxicillin Clarithromycin
inhaled corticosteroid unless otherw ise
indicated. Duration 5 days Duration 5 days
$
Higher risk of complications includes people w ith pre-existing comorbidity; young children born prematurely;
people over 65 w ith 2 or more of, or over 80 w ith 1 or more of: hospitalisation in previous year, type 1 or 2
diabetes, history of congestive heart failure, current use of oral corticosteroids.
An acute exacerbation of bronchiectasis Amoxicillin 500mg three times a Doxycycline 200mg stat, then
Acute is sustained w orsening of symptoms from day 100mg daily
exacerbation of a person’s stable state. #
Duration : 7 to 14 days
# OR
Bronchiectasis Send a sputum sample for culture and
Clarithromycin 500mg tw ice a
(non-cystic susceptibility testing. When results
day
available, review choice of antibiotic.
fibrosis) Offer* an antibiotic
#
Duration : 7 to 14 days
#
When choosing antibiotics, take account
of:
the severity of symptoms
previous exacerbations,hospitalisations
NICE Visual summary
and risk of complications
Back to Contents previous sputum culture and
susceptibility results
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 7Greater Manchester Antimicrobial Guidelines June 2020
#
Course length based on an assessment of the person’s severity
of bronchiectasis, exacerbation history, severity of exacerbation
symptoms, previous culture and susceptibility results, and
response to treatment.
Where a person is receiving antibiotic prophylaxis, treatment
should be w ith an antibiotic from a different class.
Prophylaxis should only be offered on specialist advice.
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Many exacerbations (including som e severe exacerbations) are not caused by bacterial infections so
Acute w ill not respond to antibiotics.
exacerbation of
Sending sputum samples for culture is Doxycycline 200mg stat, then In severe infection:
COPD not recommended in routine practice. 100mg daily
Consider* an antibiotic: Doxycycline 200mg stat, then
or 100mg tw ice a day
Based on the severity of symptoms,
particularly sputum colour changes Amoxicillin 500mg three times a or
and increases in volume or thickness day
from the patient’s normal. Amoxicillin 1g three times a
NICE Visual summary Previous exacerbations and hospital Duration: 5 days. day
Back to Contents admission history, and the risk of Duration 5 days
developing complications
Previous sputum culture and
susceptibility results w here available.
The risk of AMR w ith repeated
courses of antibiotics.
Patients identified as suitable for having ‘rescue packs’ should normally only be provided w ith steroids, as
these have been show n to improve lung function alone, w ith advice to seek medical attention if symptoms
suddenly w orsen or do not improve w ithin 48 hours of starting treatment. Any decision to include antibiotics
should be based on clinical need, do not use the higher dose in ‘rescue packs’. Patients w ill need to notify
prescribers w hen they use their ‘rescue pack’ medication, and to ask for replacements.
Refer to a respiratory specialist for a Duration: Review treatment after the first 3 months and then at
Acute decision to prescribe oral prophylactic least every 6 months. Only continue treatment if continued
exacerbation of antibiotic therapy in patients w ith COPD. benefits outw eigh the risks.
COPD – Consider* treatment only for people if Before starting prophylactic antibiotics, ensure that the person has
PROPHYLAXIS they: had:
do not sm oke and
Back to Contents sputum culture and sensitivity (including tuberculosis culture),
have optimised non-pharmacological
to identify other possible causes of persistent or recurrent
management and inhaled therapies,
infection that may need specific treatment
relevant vaccinations and (if
training in airw ay clearance techniques to optimise sputum
appropriate) have been referred for
clearance
pulmonary rehabilitation and
a CT scan of the thorax to rule out bronchiectasis and other
continue to have 1 or more of the
lung pathologies.
follow ing, particularly if they have
Also carry out the follow ing:
significant daily sputum production:
an electrocardiogram (ECG) to rule out prolonged QT interval
frequent (typically 4 or more per
and
year) exacerbations w ith sputum
production baseline liver function tests.
For people w ho are still at risk of exacerbations, provide an
prolonged exacerbations w ith
antibiotic from a different class. to keep at home as part of their
sputum production ‘rescue pack’
exacerbations resulting in Be aw are that it is not necessary to stop prophylactic treatment
hospitalisation. during an acute exacerbation of COPD.
NICE guidance - Chronic obstructive Monitoring for long-term therapy: See BNF
pulmonary disease in over 16s: diagnosis
and management (NG115)
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 8Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
If a patient show s typical COVID 19 As COVID-19 pneumonia is Alternative :
COVID-19 symptoms, follow UK government caused by a virus, antibiotics are
Community guidance on investigation and initial ineffective. Amoxicillin 500mg three times
acquired clinical management of possible cases. Do not offer an antibiotic for a day
This includes information on testing and Duration: 5 days
pneumonia isolating patients.
treatment or prevention of
pneumonia if:
treatment in the For patients w ith know or suspected
COVID-19 is likely to be the
community COVID-19 follow UK guidance on
cause and
If atypical pathogens
suspected AND moderately
(Adults) infection prevention and control
symptoms are mild. severe symptoms based on
Minimise face-to-face contact. Use the
clinical judgement (or CRB =1
BMJ remote assessment tools.
or 2):
[DURING Amoxicillin
Offer an oral antibiotic for
COVID-19 The clinical diagnosis of community- treatment of pneumonia in 500 mg 3 times a day (higher
pandemic] acquired pneumonia of any people w ho can or w ish to be doses can be used – see BNF)
cause in an adult can be treated in the community if: Duration: 5 days
informed by clinical signs or PLUS
Back to Contents symptoms such as:temperature the likely cause is bacterial or Clarithromycin
>38°C 500 mg tw ice a day
it is unclear w hether the cause Duration: 5 days
respiratory rate >20 breaths per minute is bacterial or viral and
heart rate >100 beats per minute symptoms are more
concerning or
new confusion If high severity based on
Assessing shortness of breath they are at high risk of clinincal judgement (or CRB65
(dyspnoea) is important but may be complications because, for
= 3 or 4) & patient able to take
difficult via remote consultation. Use example, they are older or
oral medicines and safe to
online tools such as dyspnoea scale, or frail, or have a pre-existing
remain at home
CEBM review . comorbidity such as
Co-amoxiclav 500/125mg
immunosuppression or
three times a day
significant heart or lung
Duration: 5 days
Where pulse oximetry is available use disease (for example AND
oxygen saturation levels below 92% bronchiectasis or COPD), or Clarithromycin 500mg tw ice a
(below 88% in people w ith COPD) on have a history of severe day
room air at rest to identify seriously ill illness follow ing previous lung
Duration 5 days
patients. infection.
OR
Erythromycin (in pregnancy)
Use of the NEWS2 tool in the community 500 mg 4 times a day orally
for predicting the risk of clinical Doxycycline 200m g stat then Duration: 5 days
deterioration may be useful. How ever a 100m g daily
face to face consultation should not be Duration: 5 days If penicillin allergy AND high
arranged solely to calculate a NEWS2 severity
score. Levofloxacin (consider safety
issues)
Doxycycline is preferred
because it has a broader 500 mg tw ice a day orally
spectrum of cover than Duration: 5 days
amoxicillin, particularly
against Mycoplasma
If preferred choice not suitable
pneumoniae and Staphylococcu
consult microbiology or
s aureus, w hich are more likely
consider* urgent referral to
to be secondary bacterial
hospital.
causes of pneumonia during the
COVID-19 pandemic. If unable to take oral
medication refer urgently to
hospital.
Doxycycline should not be
used in pregnancy
In Pregnancy
Erythromycin
500 mg 4 times a day
Duration: 5 days
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 9Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Offer an antibiotic(s) w ithin 4 hours of Children aged 1 m onth and Children aged 1 m onth and
Community establishing a diagnosis. over - if non-severe symptoms over - if non-severe symptoms
acquired Severity is assessed by clinical or signs (based on clinical or signs (based on clinical
pneumonia judgement. judgement) judgement)
treatment in the Amoxicillin Clarithromycin
community Give advice about: Duration: 5 days Duration: 5 days
(Children and possible adverse effects of antibiotics If severe symptoms or signs
young people seeking medical help if symptoms (based on clinical judgement);
w orsen rapidly or significantly, or do guided by microbiological results Alternative choice for
under 18 years) not improve w ithin 3 days, or the w hen available: children aged 12 years to 17
years.
person becomes systemically very Co-amoxiclav
unw ell. PLUS (if atypical pathogen Doxycycline 200mg on first
suspected) day, then 100mg once a day.
Stop antibiotic treatment after 5 days Clarithromycin Duration: 5 days
unless microbiological results suggest a
Duration: 5 days
longer course length is needed or the
person is not clinically stable.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 10Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
MENINGITIS
Transfer all patients to hospital Benzylpenicillin by intravenous or intramuscular injection
Suspected im m ediately. Age 10 plus years: 1200mg
meningococcal If time before hospital admission and if Children 1 to 9 years: 600mg
disease suspected meningococcal septicaemia or Children less than1 years: 300mg
non-blanching rash, give intravenous or Stat doses
Back to Contents intramuscular benzylpenicillin as soon as Give by intramuscular injection if vein cannot be found.
possible.
Do not give antibiotics if there is a definite
history of anaphylaxis; rash is not a
contraindication.
Prevention of secondary case of m eningitis.
Only prescribe follow ing advice from Public Health England North West: 03442250562 option 3 (9 to 5 Mon to Fri)
Out of hours contact 0151 434 4819 and ask for PHE on call.
URINARY TRACT INFECTIONS
As antimicrobial resistance and E. coli bacteraemia is increasing use nitrofurantoin first line. Always give safety net and self -care advice
and consider risks for resistance. Give the appropriate TARGET Treat Your Infection UTI leaflet.
Do not perform urine dipsticks – For men and women over 65 years
Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have
bacteria present in the bladder/urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it c auses a positive
urine dipstick, antibiotics are not beneficial and may cause harm.
For guidance on diagnosing UTIs and the need for dipsticks , in all ages, see PHE’s quick reference tool for primary care.
Treat w om en with severe/or 3 or m ore Nitrofurantoin MR (if eGFR 45 If preferred choice
Lower UTI in sym ptom s. ml/minute or greater) 100mg unsuitable:
Non-pregnant Wom en m ild/or 2 or less sym ptoms tw ice a day Pivmecillinam
400mg initial dose then 200mg
Women advise self-care in line w ith NHS Duration: 3 days three times a day
England guidance and consider * back +
up / delayed prescription. If low risk of resistance and
preferably if susceptibility Duration: 3 days
People over 65 years: do not treat
asym ptom atic bacteriuria; it is demonstrated & no risk CHECK AVAILABILITY AS
£
common but is not associated w ith factors (below): NOT ALL PHARMACIES
NICE Visual summary increased morbidity. Treat if fever AND Trimethoprim 200mg tw ice a day HOLD STOCK.
dysuria OR 2 or more other symptoms.
Back to Contents Duration: 3 days
In treatment failure: always perform
culture.
+
Sym ptom s: A low er risk of resistance may be more likely if not used in the
Increased need to urinate. past 3 months, previous urine culture suggests susceptibility (but
Pain or discomfort w hen urinating. this w as not used) or it is the first presentation of a UTI, and in
Sudden urges to urinate. younger w omen.
Feeling unable to empty bladder fully. £
Risk factors for increased resistance include: care home
Pain low dow n in your tummy. resident, recurrent UTI, hospitalisation for greater than 7 days in
Urine is cloudy, foul-smelling or contains the last 6 months, unresolving urinary symptoms, recent travel to a
blood. country w ith increased resistance, previous know n UTI resistant to
Feeling unw ell, achy and tired. trimethoprim, cephalosporins or quinolones.
If risk of resistance send urine for culture for susceptibility testing
& give safety net advice.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 11Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
DO NOT DIPSTICK Low er UTI sym ptom s
Catheter Do not treat asymptomatic bacteriuria in Nitrofurantoin MR (if eGFR 45 Pivmecillinam
associated UTI people w ith a catheter. ml/minute or greater) 100mg 400mg initial dose, then
Advise paracetamol for pain. tw ice a day 200mg three times a day
Advise drinking enough fluids to avoid Duration: 7 days Duration: 7 days
dehydration.
Advise seeking medical help if symptoms OR
w orsen at any time or do not start to Trimethoprim (if low risk of
NICE Visual summary improve w ithin 48 hours, or the person resistance) 200mg tw ice a day
Back to Contents becomes systemically very unw ell
Duration: 7 days
Consider* removing or, if not possible,
changing the catheter if it has been in Upper UTI sym ptom s
place for more than 7 days. But do not
delay antibiotic treatment if considered Cefalexin 500mg tw ice or three Ciprofloxacin 500mg tw ice a
appropriate. times a day (up to 1g to 1.5g day
three times a day or four times a
Send a urine sample for culture and Duration: 7 days
day for severe infections)
susceptibility testing.
(See MHRA Safety Alert - note
When results of urine culture are Duration: 7 to 10 days
21 page 3)
available:
review choice of antibiotic Pregnant w om en aged 12 years and over
change antibiotic according to Cefalexin 500mg tw ice or three If vomiting, unable to take oral
susceptibility results if bacteria are times a day (up to 1g to 1.5g antibiotics or severely unw ell
resistant, using narrow spectrum three times a day or four times a refer to hospital.
antibiotics w hen possible day for severe infections)
Duration: 7 to 10 days
Low risk of resistance is likely if not used in the past 3 months and previous urine culture suggests
susceptibility (but this w as not used) or it is the first presentation of a UTI . Higher risk of resistance is likely w ith
recent use.
Send MSU for culture and start Up to 34 weeks Amoxicillin (only if culture
Lower UTI in antibiotics. Nitrofurantoin MR (if eGFR 45 results available and
pregnancy Short-term use of nitrofurantoin in
ml/minute or greater) 100mg susceptible)
tw ice a day 500mg to 1g three times a day
pregnancy is unlikely to cause problems
to the foetus but avoid at term (from 34 OR
Duration: 7 days
w eeks onw ards). Cefalexin 500mg tw ice a day
After 34 w eeks use alternative Duration: All for 7 days
Treatment of asymptomatic bacteriuria in
NICE Visual summary pregnant w omen: choose from
Back to Contents nitrofurantoin (avoid at term), amoxicillin
or cefalexin based on recent culture and
susceptibility results.
Consider prostatitis and send pre- Trimethoprim 200mg tw ice a day Consider alternative diagnoses
Lower UTI in treatment MSU basing antibiotic choice on
Duration: 7 days
Men Consider STIs. recent culture and
Or susceptibility results
Nitrofurantoin MR (if eGFR 45
ml/minute or greater and no
prostate involvement) 100mg
tw ice a day
NICE Visual summary
Duration: 7 days
Back to Contents
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 12Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
First advise about behavioural and Choice should be based on culture and susceptibility results.
Recurrent UTI personal hygiene measures, and self -
in non pregnant care (w ith D-mannose or cranberry
Single dose when exposed to a Single dose when exposed to
products) to reduce the risk of UTI.
women having 3 trigger a trigger
or more UTIs For postmenopausal w omen, if no Trimethoprim 200mg (off label) Amoxicillin 500 mg (off label)
improvement, consider vaginal oestrogen
per year (review w ithin 12 months).
Or Or
Nitrofurantoin MR (if eGFR 45 Cefalexin 500 mg (off label)
If no improvement, consider single-dose ml/minute or greater) 100mg (off
antibiotic prophylaxis for exposure to a label)
trigger (review w ithin 6 months).
If no improvement or no identifiable Continuous prophylaxis
NICE Visual summary
trigger consider a trial of daily antibiotic Continuous prophylaxis
prophylaxis (review w ithin 6 months). Trimethoprim 100mg at night
Back to Contents Amoxicillin 250mg at night (off
Or
Advice to be given: label)
Nitrofurantoin MR (if eGFR 45
how to use (in particular for single ml/minute or greater) 50mg to Or
dose prophylaxis) 100mg at night Cefalexin 125mg at night (off
possible adverse effects of antibiotics, label)
Duration for all: 3 to 6 months
particularly diarrhoea and nausea then review Duration for all: 3 to 6 months
returning for review w ithin 3 to 6 then review
months Monitoring for long-term therapy: See BNF
seeking medical help if symptoms of
an acute UTI develop
Send MSU for culture and start Ciprofloxacin (See MHRA Safety If unable to take quinolone:
Acute antibiotics. Alert – note 21 page 3) Trimethoprim 200mg tw ice a
prostatitis Review antibiotic treatment after 14 days 500mg tw ice a day day
and either stop antibiotics or continue for Duration: up to 28 days
a further 14 days if needed (based on Duration: up to 28 days
assessment of history, symptoms, clinical
examination, urine and blood tests).
NICE Visual summary
Back to Contents
Send MSU for culture & susceptibility. Cefalexin 500mg tw ice a day or Co-amoxiclav (only if culture
Acute Offer an antibiotic. three times a day (up to 1g to results available and
pyelonephritis in When prescribing antibiotics, take
1.5g three times a day or four susceptible) 500/125mg three
adults times a day for severe times a day
account of severity of symptoms, risk of
infections)
(Upper UTI) complications, previous urine culture and Duration: 7 to 10 days
susceptibility results, previous antibiotic Duration: 7 to 10 days
Or
use w hich may have led to resistant If know n ESBL positive in urine,
Trimethoprim (only if culture
bacteria. please discuss w ith
results available and
If no response w ithin 24 hours, admit for microbiologist.
susceptible)
IV antibiotics. 200mg tw ice a day
Pregnant w om en:
NICE Visual summary Consider referral. Duration: 14 days
Back to Contents If cefalexin contraindicated or Or
not tolerated consult
microbiologist. Ciprofloxacin (See MHRA
Safety Alert – note 21 page 3)
500mg tw ice a day
Duration: 7 days
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 13Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Child under 3 m ths: refer urgently for assessm ent.
Lower UTI in
Child ≥ 3 m ths: use positive nitrite to 3 m onths and over 3 m onths and over
children
guide. Start antibiotics, also send pre- Nitrofurantoin (if eGFR 45 Amoxicillin (only if culture
treatment MSU. ml/minute or greater) results available and
If recurrent UTI, refer to paediatrics. If [If children can swallow them, susceptible)
antibiotics required in recurrent UTI, 100mg M/R capsules (older than OR
seek specialist advice. 12yrs) should be used in preference
to the liquid formulation. 50mg Cefalexin
NICE Visual summary tablets can be considered for lower Duration: 3 days
doses. Do not crush tablets or
Back to Contents
open capsules]
OR
Trimethoprim (if low risk of
Ω
resistance )
Duration: 3 days
Ω
A low er risk of resistance may be more likely if not used in the past 3 months and previous urine culture
suggests susceptibility (but this w as not used) or it is the first presentation of a UTI . A higher risk of resistance
may be more likely w ith recent use.
Refer children under 3 m onths to paediatric specialist
Acute
Send a urine sample for culture and Cefalexin Co-amoxiclav (only if culture
pyelonephritis susceptibility testing in line w ith the NICE results available and
in children guideline, Urinary tract infection in under
Duration: 7 to 10 days
susceptible)
under 16 years 16s: diagnosis and management (CG54).
Duration: 7 to 10 days
(Upper UTI) Offer* an antibiotic.
When prescribing antibiotics, take
account of severity of symptoms, risk of
complications, previous urine culture and
susceptibility results, previous antibiotic
NICE Visual summary use w hich may have led to resistant
bacteria. Assess and manage fever in under 5s in line w ith NICE guidance -
Back to Contents Fever in under 5s: assessment and initial management (CG160)
If no response w ithin 24 hours, admit for
intravenous antibiotics.
GASTRO INTESTINAL TRACT INFECTIONS
Oral candidiasis is a m inor condition that can be treated w ithout the need for a GP consultation or
Oral candidiasis prescription in the first instance.
Advise self-care in line w ith NHS England guidance.
Back to Contents
Topical azoles are more effective than Fluconazole capsules If miconazole not tolerated:
topical nystatin. 50mg to 100mg daily Nystatin suspension
100,000 units four times a day
Oral candidiasis rare in Duration: 7 days & further 7 after meals
immunocompetent adults. days if persistent
Or Duration: 7 days or until 2
days after symptoms
Miconazole oral gel
2.5ml four times a day after
meals
Duration: 7 days or until 2 days
after symptoms.
Refer to BNF or GMMMG
Eradication of Do not offer eradication for GORD. (PPI for 4 w eeks).
Helicobacter Do not use clarithromycin, metronidazole or quinolone if used in past year for any infection.
pylori Retest for H.pylori post DU/GU or relapse after second line therapy: using breath or stool test OR consider
Back to Contents endoscopy for culture and susceptibility.
Refer previously healthy children w ith acute painful or bloody diarrhoea to exclude E. coli 0157 infection.
Infectious Antibiotic therapy usually not indicated unless systemically unw ell.
diarrhoea If systemically unw ell and campylobacter suspected consider Clarithromycin 250 to 500mg tw ice a day for 7
Back to Contents days, if treated w ithin 3 days of onset.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 14Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Consult microbiology for all cases. First episode: If recurrent or severe then
Clostridium Stop unnecessary antibiotics and/or seek microbiology advice.
Vancomycin
difficile PPIs. 125mg four times a day
Back to Contents If severe symptoms or signs (below )
should treat, review progress closely Duration: 10 to 14 days
and/or consider hospital referral. CHECK AVAILABILITY AS
Definition of severe: Temperature NOT ALL PHARMACIES HOLD
o
greater than 38.5 C, or WCC greater STOCK.
than 15, or rising creatinine or
signs/symptoms of severe colitis.
Consider w atchful w aiting if person: For patients who do not Ciprofloxacin (See MHRA
Acute Systemically w ell require urgent hospital Safety Alert – note 21 page 3)
Diverticulitis No co-morbidities admission and infection is 500mg tw ice a day
Back to Contents No suspected infection. suspected: PLUS
Advise analgesia (avoid NSAIDs and Co-amoxiclav 625mg three Metronidazole 400mg three
opioids), clear liquids w ith gradual times a day times a day
reintroduction of solid food if symptoms
improve. Consider checking for raised Duration: 7 days Duration: 7days
w hite cell count and CRP, w hich may
suggest infection.
Patients should be review ed after 72 Arrange im m ediate urgent hospital adm ission for those w ith:
hours and if there is no improvement, Rectal bleeding
and/or fever and leukocytosis persist, Unmanageable abdominal pain
urgent hospital admission is advised. Dehydrated or at risk of dehydration
Unable to take or tolerate oral antibiotics (if needed) at home
Frail / significant co-morbidities and or / is immunocompromised.
Prophylaxis rarely, if ever indicated. If standby treatment appropriate If prophylaxis / treatment
Traveller’s Only consider standby antibiotics for give azithromycin 500mg each consider bismuth subsalicylate
diarrhoea high risk areas for people at high-risk of day for 3 days on a private (Pepto Bismol) (Private
severe illness. prescription. purchase)
Back to Contents 2 tablets four times a day for 2
days.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 15Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
GENITAL TRACT INFECTIONS
People w ith risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and
STI screening partners to GUM service.
Risk factors: less than 25 years, no condom use, recent (less than 12momths)/frequent change of partner,
Back to Contents
symptomatic partner, area of high HIV.
Opportunistically screen all sexually Doxycycline 100mg tw ice a day Pregnant, breastfeeding,
Chlamydia active patients aged 15 to 24 years for Duration: 7 days allergy, or intolerance:
trachomatis/ chlamydia annually and on change of Azithromycin 1g stat, then
sexual partner.
urethritis 500mg daily for the follow ing 2
If positive, treat index case, refer to GUM days.
Back to Contents and initiate partner notification, testing
and treatment. Advise patient w ith chlamydia to abstain from sexual intercourse
until doxycycline is completed or for 7 days after treatment w ith
As single dose azithromycin has led to azithromycin (14 days after azithromycin started and until
increased resistance in GU infections, symptoms resolved if urethritis).
doxycycline should be used first line f or
chlamydia and urethritis. If chlamydia, test for reinfection at 3 to 6 months follow ing
treatment if under 25 years; or consider if over 25 years and high
Consider referring all patients w ith risk of re-infection.
symptomatic urethritis to GUM as testing
should include Mycoplasma genitalium As low er cure rate in pregnancy, test for cure at least 3 w eeks
and Gonorrhoea. after end of treatment.
If M.genitalium is proven, use
doxycycline follow ed by azithromycin
using the same dosing regimen and
advise to avoid sex for 14 days after start
of treatment and until symptoms have
resolved.
For suspected epididymitis in men over Ofloxacin 200mg tw ice a day Doxycycline 100mg tw ice a
Epididymitis 35 years w ith low risk of STI. (See MHRA Safety Alert – note day
(High risk, refer to GUM) 21 page 3)
Back to Contents Duration: 14 days
Duration : 14 days
All topical and oral azoles give 75% Clotrimazole 500mg pessary Fluconazole 150mg orally
Vaginal cure. or 10% cream stat stat
candidiasis Pregnant: Pregnant:
Back to Contents In pregnancy: avoid oral azoles and
Clotrimazole 100mg pessary Miconazole 2% cream, 5g
use intravaginal treatment for 7 days.
at night intravaginally twice a day
Duration: 6 nights Duration: 7 days
Oral metronidazole is as effective as Metronidazole 400mg tw ice a Metronidazole 0.75% vaginal
Bacterial topical treatment and is cheaper. day gel 5g applicator at night
vaginosis Less relapse w ith 7 day than 2g stat. Duration: 7 days Duration: 5 nights
Back to Contents Pregnant/breastfeeding: avoid 2g stat. Or or
Treating partners does not reduce Metronidazole 2g stat (use 5 x Clindamycin 2% cream 5g
relapse. 400mg tablets) applicator at night.
Duration: 7 nights
Refer to GUM for treatm ent.
Gonorrhoea
Antibiotic resistance is now very high. Ceftriaxone 1g stat, by Ciprofloxacin 500mg stat
Back to Contents intramuscular injection [ONLY IF KNOWN TO BE
SENSITIVE]
(See MHRA Safety Alert –
note 21 page 3)
Treat partners and refer to GUM service. Metronidazole 400mg tw ice a Clotrimazole
In pregnancy or breastfeeding: avoid 2g day 100mg pessary at night
Trichomoniasis single dose metronidazole.
Duration: 7 days Duration: 6 nights
Consider clotrimazole for symptom relief
Back to Contents (not cure) if metronidazole declined. OR
Metronidazole 2g stat (use 5 x
400mg tablets)
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 16Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Children under 12 years m ust be referred to a paediatrician.
Pelvic
Refer w om an and contacts to GUM Ceftriaxone 1g stat by These treatment choices
inflammatory service for treatment. intramuscular injection [This is should only be used for true
disease Raised CRP supports diagnosis, absent an essential part of treatm ent cephalosporin allergy and a
pus cells in HVS smear good negative – refer patients to local low risk of gonococcal PID.
Back to Contents services if injection not
predictive value. Metronidazole 400mg tw ice a
available via GP practice] day
Exclude: ectopic pregnancy,
appendicitis, endometriosis, UTI, irritable PLUS PLUS
bow el, complicated ovarian cyst, Metronidazole 400mg tw ice a Ofloxacin 400mg tw ice a day
functional pain. day
Or
Moxifloxacin has greater activity against PLUS
likely pathogens, but alw ays test for Moxifloxacin 400mg daily
Doxycycline 100mg tw ice a day alone.
gonorrhoea, chlamydia, and
M. genitalium. Duration : 14 days (If M. genitalium tests positive
use moxifloxacin as an
Ofloxacin and m oxifloxacin should be alternative.)
avoided in patients w ho are at high
(See MHRA Safety Alert –
risk of gonococcal PID.
note 21 page 3)
Duration : 14 days
SKIN INFECTIONS
For active MRSA infection, refer to microbiology and only treat according to antibiotic susceptibilities confirmed
MRSA by lab results.
If identified as part of pre-op screening, treatment should be provided at that time by secondary care.
Back to Contents
Advise people w ith impetigo, and their Localised non-bullous im petigo (not systemically unw ell or at
Impetigo parents or carers if appropriate, about high risk of com plications)
good hygiene measures to reduce the
spread of impetigo to other areas of the Consider*: If hydrogen peroxide unsuitable
body and to other people. (e.g., if impetigo is around
Hydrogen peroxide 1% cream eyes) or ineffective:
Do not prescribe mupirocin (reserved Apply tw o or three times a day
NICE Visual summary for MRSA), unless advised by Fusidic acid 2% cream
§
Back to Contents microbiology. Duration: 5 days Apply thinly three times a day
Do not offer combination treatment w ith a §
Duration: 5 days
topical and oral antibiotic to treat
impetigo. Widespread non‑ bullous im petigo w ho are not system ically
unw ell or at high risk of com plications.
Advise people w ith impetigo, and their
parents or carers if appropriate, to seek Fusidic acid 2% cream Penicillin allergy or
medical help if symptoms w orsen rapidly flucloxacillin unsuitable:
Apply thinly three times a day
or significantly at any time, or have not ¥
§ Clarithromycin 250mg tw ice a
improved after completing a course of Duration: 5 days day
treatment.
Or: Duration: 5 days
§
See NICE NG153 (Impetigo:
Flucloxacillin 500mg four times
antimicrobial prescribing) for further
a day
guidance. §
Duration: 5 days
§
A 5-day course is appropriate for most
Bullous im petigo or im petigo in people w ho are system ically
people w ith impetigo but can be
unw ell or at high risk of com plications
increased to 7 days based on clinical
judgement, depending on the severity Flucloxacillin 500mg four times Penicillin allergy or
and number of lesions. a day flucloxacillin unsuitable:
¥ § ¥
Dosage can be increased to 500 mg Duration: 5 days Clarithromycin 250mg tw ice a
tw ice a day, if needed for severe day
infections. §
Duration: 5 days
If no visible signs of infection, do not use antibiotics (alone or w ith steroids) as this encourages resistance and
Eczema does not improve healing.
Back to Contents If visible signs of infection, treat as for impetigo.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 17Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Background: If active infection
Leg ulcer There are many causes of leg ulcer;
Flucloxacillin 500mg to 1g four If penicillin allergic:
any underlying conditions, such as times a day
#
Clarithromycin 500mg tw ice a
venous insufficiency and oedema,
Duration: 7 days day
should be managed to promote
or
healing
Doxycycline 200mg stat then
NICE Visual summary Few leg ulcers are clinically infected
100mg tw ice a day
Most leg ulcers are colonised by
Back to Contents Duration: All 7 days
bacteria
Antibiotics don't promote healing Do not take a sam ple for m icrobiological testing at initial
w hen a leg ulcer is not clinically presentation, even if the ulcer m ight be infected.
infected
Refer to hospital if there are symptoms or signs of a more serious
Symptoms and signs of an
illness or condition such as sepsis, necrotising fasciitis or
infected leg ulcer include: osteomyelitis
redness or sw elling spreading beyond
the ulcer Consider* referring or seeking specialist advice if the person:
localised w armth has a higher risk of complications because of comorbidities
increased pain such as diabetes or immunosuppression
fever has lymphangitis
When choosing an antibiotic, has spreading infection not responding to oral antibiotics
take account of: cannot take oral antibiotics (to explore possible options for
the severity of symptoms or signs intravenous or intramuscular antibiotics at home or in the
the risk of complications community)
previous antibiotic use
A longer course (up to a further 7 days) may be needed based on
clinical assessment. How ever, skin does take some time to return
Reassess if symptoms w orsen rapidly or
to normal, and full resolution of symptoms at 7 days is not
significantly at any time, do not start to
expected.
improve w ithin 2 to 3 days, or the person
becomes systemically unw ell or has
severe pain out of proportion to the
infection.
#
The upper dose of 1 g four times a day w ould be off -label. Prescribers should follow relevant professional
guidance, taking full responsibility for the decision, and obtaining and documenting informed consent. See the
GMC's Good practice in prescribing and managing medicines for more information.
In diabetes, all foot w ounds are likely to Flucloxacillin 500mg to 1g four If penicillin allergic:
Diabetic Foot be colonised w ith bacteria. times a day
#
Clarithromycin 500mg tw ice a
Diabetic foot infection has at least 2 of: Duration: 7 days day
local sw elling or induration or
erythema Doxycycline 200mg stat then
local tenderness or pain 100mg tw ice a day
NICE Visual summary local w armth Duration: All 7 days
Back to Contents purulent discharge
Severity is classified as: Refer to hospital immediately and inform multidisciplinary foot care
Mild - local infection w ith 0.5 to less service if there are limb- or life-threatening problems such as:
than 2 cm erythema ulceration w ith fever or any signs of sepsis, or
Refer the follow ing to hospital: ulceration w ith limb ischaemia, or
suspected deep-seated soft tissue or bone infection, or
Moderate - local infection w ithmore
gangrene
than 2 cm erythema or involving
For all other active diabetic foot problems, refer to foot service
deeper structures (such as abscess,
w ithin 1 w orking day
osteomyelitis, septic arthritis or
A longer course (up to a further 7 days) may be needed based on
fasciitis)
clinical assessment. How ever, skin does take some time to return
Severe - local infection w ith signs of a
to normal, and full resolution of symptoms at 7 days is not
systemic inflammatory response. expected.
#
The upper dose of 1 g four times a day w ould be off -label. Prescribers should follow relevant professional
guidance, taking full responsibility for the decision, and obtaining and documenting informed consent. See the
GMC's Good practice in prescribing and managing medicines for more information.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 18Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Exclude other causes of skin redness Flucloxacillin 500mg to 1g four If penicillin allergic:
Cellulitis (inflammatory reactions or non-infectious times a day
#
Clarithromycin 500mg tw ice a
causes). If infection near eyes or nose day
Consider marking extent of infection w ith (consider seeking specialist or
a single-use surgical marker pen. advice):
Doxycycline 200mg stat then
Offer an antibiotic. Take account of Co-amoxiclav 625mg three 100mg tw ice a day
severity, site of infection, risk of times a day
NICE Visual summary uncommon pathogens, any If infection near eyes or
Duration: All 7 days . nose (Consider seeking
Back to Contents microbiological results and MRSA status.
specialist advice):
Infection around eyes or nose is more
concerning because of serious Clarithromycin 500mg tw ice a
day AND
intracranial complications.
Consider referring to hospital or seeking Metronidazole 400mg three
specialist advice if the person: times a day (only add in
children if anaerobes
is severely unw ell or has lymphangitis suspected).
has infection near the eyes or nose
Duration: All 7 days .
may have uncommon pathogens e.g.
after a penetrating injury, exposure to
A longer course (up to 14 days in total) may be needed but skin
w ater-borne organisms, or an infection takes time to return to normal, and full resolution at 5 to 7 days is
acquired outside the UK not expected.
has spreading infection not responding If not responding after 14 days of antibiotic therapy then a holistic
to oral antibiotics review of the w ound and prescribing to date should be undertaken.
cannot take oral antibiotics (to explore Consider:
giving IV antibiotics at home or in the other possible diagnoses, such as an inflammatory reaction to
community if appropriate) an immunisation or an insect bite, gout, superficial
Refer people to hospital if they have any thrombophlebitis, eczema, allergic dermatitis or deep vein
symptoms or signs suggesting a more thrombosis
serious illness or condition, such as
any underlying condition that may predispose to cellulitis or
orbital cellulitis, osteomyelitis, septic
arthritis, necrotising fasciitis or sepsis. erysipelas, such as oedema, diabetes, venous insufficiency or
#
The upper dose of 1 g four times a day eczema
w ould be off-label. Prescribers should any symptoms or signs suggesting a more serious illness or
follow relevant professional guidance, condition, such as lymphangitis, orbital cellulitis, osteomyelitis,
taking full responsibility for the decision, septic arthritis, necrotising fasciitis or sepsis
and obtaining and documenting informed
any results from microbiological testing
consent. See the GMC's Good practice in
prescribing and managing medicines for any previous antibiotic use, w hich may have led to resistant
more information. bacteria.
Most cases of lactational m astitis are Flucloxacillin 500mg to 1g four If penicillin allergic:
Mastitis – not caused by an infection and do not times a day ♦
Clarithromycin 500mg tw ice a
Lactational require antibiotics.
Duration: 7 to 14 days day
Advice is to take paracetamol or
Back to Contents ibuprofen to reduce pain and fever, drink Duration: 7 to 14 days
plenty of fluids, rest and apply a w arm
compress. ♦
Epidemiologic evidence indicates that the risk of hypertrophic
Breastfeeding: oral antibiotics are safe pyloric stenosis in infants might be increased by use of maternal
and appropriate, w here indicated. macrolides, especially in infants exposed in the first 2 w eeks after
Women should continue feeding, birth. The risk may be greater w ith erythromycin, w hich is w hy
including from the affected breast and be clarithromycin is recommended here.
advised to monitor the child for adverse
drug reactions e.g. diarrhoea and thrush.
If immediate admission or referral is not Co-amoxiclav 500/125mg three Clarithromycin 500 mg tw ice a
Mastitis – indicated then prescribe an oral antibiotic times a day day
Non-Lactational for all w omen w ith non-lactational
Duration: 10 to 14 days
PLUS
mastitis. Metronidazole 400 mg three
Back to Contents Advise the w oman to seek immediate times a day
medical advice if symptoms w orsen or fail Duration: 10 to 14 days.
to settle after 48 hours of antibiotic
treatment.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 19Greater Manchester Antimicrobial Guidelines June 2020
ILLNESS GOOD PRACTICE POINTS PREFERRED CHOICE ALTERNATIVE
Thorough irrigation is im portant. Prophylaxis or treatment: If penicillin allergic:
Bites - Human Assess risk of tetanus, rabies, HIV, Co-amoxiclav 625mg three Metronidazole 400mg three
hepatitis B/C. times a day times a day
Back to Contents
Antibiotic prophylaxis is advised. PLUS
Duration: 7 days
Clarithromycin
500mg tw ice a day
Duration: 7 days
AND review at 24 and 48
hours, as not all pathogens
covered
For children under 12 years of age, w ho are penicillin allergic, consult m icrobiology.
Bites - Cat or
Cat: alw ays give prophylaxis. Prophylaxis or treatment: If penicillin allergic:
dog Dog: give prophylaxis if: puncture w ound; Co-amoxiclav 625mg three times Metronidazole 400mg three
Back to Contents bite to hand, foot, face, joint, tendon, or a day times a day
ligament; immunocompromised; cirrhotic; PLUS
asplenic; or presence of prosthetic Duration: 7 days
valve/joint. Doxycycline 100mg tw ice a
day
Duration: 7 days
AND review at 24 and 48
hours, as not all pathogens
covered.
Most tick bites do not transm it Lym e disease and prom pt, correct removal of the tick reduces the risk
Lyme disease – of transm ission. For correct tick rem oval and how to do this see the Public Health England w ebsite for
Tick bites inform ation on rem oving ticks and supporting information .
Treat erythema migrans empirically; Doxycycline Where preferred option is
serology is often negative early in 100mg tw ice a day contraindicated or not
infection. licensed:
Duration: 21 days
For other suspected Lyme disease such Amoxicillin
NICE Visual summary as neuroborreliosis (CN palsy, 1g three times a day
radiculopathy) seek advice.
Back to Contents Duration: 21 days
See NICE guideline [NG95]
Athlete’s foot and ringw orm are not serious fungal infections and are usually easily treated w ith over
Dermatophyte the counter treatm ents. Advise self-care and good hygiene in line w ith NHS England guidance.
infection - skin Most cases: use terbinafine as Terbinafine cream 1% tw ice a Imidazole:
Back to Contents fungicidal, so treatment time shorter and day Clotrimazole cream 1% or
more effective than w ith fungistatic Miconazole cream 2% tw ice a
imidazoles or undecanoates. Duration: 1 to 2 w eeks plus 2
w eeks after healing day
If candida possible, use imidazole. or (athlete’s foot only):
If intractable or scalp: send skin topical undecanoates tw ice a
®
scrapings and if infection confirmed, use day (Mycota )
oral terbinafine/itraconazole. Duration: 1 to 2 w ks plus 2
Scalp: discuss w ith specialist, oral w eeks after healing
therapy indicated.
Take nail clippings: start therapy only if First line: Second line:
Dermatophyte infection is confirmed by laboratory. Terbinafine 250mg daily Itraconazole 200mg tw ice a
infection - nail Oral terbinafine is more effective than day
oral azole. Duration:
Back to Contents Fingers: 6 to 12 w eeks Duration: 7 days per month
Liver reactions rare w ith oral antifungals. Toes: 3 to 6 months Fingers: 2 courses
If candida or non-dermatophyte infection Toes: 3 courses
confirmed, use oral itraconazole.
For children, seek specialist advice.
Do not prescribe am orolfine 5% nail
lacquer as very lim ited evidence of
effectiveness.
Version 7.0 *NICE uses ‘offer’ w hen there is more certainty of benefit and ‘consider’ w hen evidence of benefit is less clear. 20You can also read
