Antibiotic Guidelines for Salford Clinical Commissioning Group (CCG)
Produced July 2016
Due for review June 2017
VERSION 11
MAJOR CHANGES ARE HIGHLIGHTED IN RED
Produced by the Medicines Optimisation Team, Tel. 0161 212 4245
Aims



To provide a simple, effective, economical and empirical approach to the treatment of common infections.
To target the use of antibiotics in primary care.
To minimise the emergence of bacterial resistance in the community.
Principles of Treatment
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
This guidance is based on the best available evidence but professional judgement should be used and patients
should be involved in the decision.
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.
Lower threshold for antibiotics in immunocompromised or those with multiple morbidities; consider culture and
seek advice.
Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
Consider a ‘No’ or ‘Back-up/Delayed’ antibiotic strategy for acute self-limiting upper respiratory tract infections1A+
and mild UTI symptoms.
Limit prescribing over the telephone to exceptional cases.
Use simple generic antibiotics if possible. Avoid broad-spectrum antibiotics (e.g. co-amoxiclav, quinolones and
cephalosporins) when narrow-spectrum antibiotics remain effective, as they increase risk of Clostridium difficile,
MRSA and resistant UTIs.
Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations, e.g.
fusidic acid).
In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, high-dose metronidazole (2g) unless benefit
outweighs risk. Short-term use of nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is not expected to
cause foetal problems. Trimethoprim also unlikely to cause problems unless poor dietary folate intake or taking
another folate antagonist such as an antiepileptic.
We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather
than four times daily and generic tablets are similar cost. However, please note that children often don’t like the
taste of clarithromycin and so erythromycin may be considered as an alternative.
Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from
0161 206 5030.
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 1 of 15
ILLNESS
COMMENTS
DRUG
ADULT DOSE (oral)
(unless stated)
DURATION OF
TREATMENT
UPPER RESPIRATORY TRACT INFECTIONS
Influenza
PHE influenza
Acute sore throat
CKS
FeverPAIN
Annual vaccination is essential for all those at risk of influenza. For otherwise healthy adults, antivirals not
recommended. Treat ‘at risk’ patients, when influenza is circulating in the community and ideally within 48
hours of onset (do not wait for lab report) or in a care home where influenza is likely. At risk: pregnant
(including up to 2 weeks postpartum), 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). Use 5 days treatment with oseltamivir
75mg BD. If resistance to oseltamivir or severe immunosuppression, use zanamivir 10mg BD (2 inhalations by
diskhaler for up to 10 days) and seek advice. See PHE Influenza guidance for treatment of patients under 13
years or in severe immunosuppression (and seek advice).
For prophylaxis, see NICE (NICE Influenza).
Avoid antibiotics as 90% resolve in 7
1A+
days without, and pain only reduced
2A+
by 16 hours.
Use FeverPAIN Score (Fever in past
24h, Purulence, rapid Attendance
within 3d, Inflamed tonsils, No cough
3B+,4B+
or cold symptoms.
):
8A-
phenoxymethylpenicillin
500mg QDS
10 days
Penicillin allergy:
clarithromycin
250-500mg BD
5 days
9A+
5 days
13A+
<2 years: 125mg QDS
2-7 years: 250mg QDS
8-18 years: 250-500mg
QDS
5 days
13A+
9 years plus: 250500mg BD
5 days
5B-
Score 0-1 = 13-18% streptococci, use
NO antibiotic strategy; 2-3 = 34-40%
streptococci, use 3-day delayed
antibiotic prescription; 4 or more = 6265% streptococci, use immediate
antibiotic if symptoms are severe, or
short (48hr) delayed antibiotic
5Aprescription.
Always share self-care advice and
safety net.
Antibiotics to prevent quinsy NNT
4B>4000.
Antibiotics to prevent otitis media NNT
2A+
200.
Acute otitis media
(AOM)
(child doses)
CKS
NICE feverish
children
Optimise analgesia and target
2,3Bantibiotics.
AOM resolves in 60% in 24 hours
without antibiotics, which only reduce
pain at 2 days (NNT15) and do not
4A+
prevent deafness.
1A+
Consider 2- or 3-day delayed or
immediate antibiotics for pain relief if:
 <2 years AND bilateral AOM (NNT4)
or bulging membrane and ≥ 4 marked
5-7+
symptoms.
8A+
 All ages with otorrhoea NNT3.
amoxicillin
10A+
Child doses
Neonate 7-28 days:
30mg/kg TDS
1 month - 1 year:
125mg TDS
1-4 years: 250mg TDS
5-18 years: 500mg TDS
Penicillin allergy:
11D
erythromycin
Abx to prevent mastoiditis NNT >4000.
9B-
9 years and over:
clarithromycin (tablets
only)
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 2 of 15
Acute otitis
externa (OE)
First use analgesia.
Cure rates similar at 7 days for topical
1A+
acetic acid or antibiotic +/- steroid.
CKS
If there are systemic signs of infection,
cellulitis or the infection is spreading
outside the ear canal, start oral
antibiotics and refer to exclude
2A+
malignant OE.
Acute
5C
rhinosinusitis
Avoid antibiotics as 80% resolve in 14
days without, and they only offer
marginal benefit after 7 days NNT15.
2,3A+
CKS
Use adequate analgesia.
First Line:
acetic acid 2%
Second Line:
neomycin sulphate with
3A-,4D
corticosteroid
oral flucloxacillin
1 spray TDS
7 days
3 drops TDS
7 days min to
14 days max
1A+
1g QDS
7 days
co-amoxiclav
625mg TDS
5 days
or doxycycline
200mg stat then 100mg
OD
5 days
If penicillin-allergic:
erythromycin
4B+
Consider 7-day delayed or immediate
antibiotic when purulent nasal
1,2A+
discharge NNT8.
In severe or persistent symptoms use
an agent with anti-anaerobic activity,
6B+
e.g. co-amoxiclav.
LOWER RESPIRATORY TRACT INFECTIONS
1
Note: Low doses of penicillins are more likely to select out resistance , we recommend 500mg of amoxicillin. Do not use quinolone
2B(ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven
resistant organisms.
Acute cough,
bronchitis
6
CKS
Antibiotic little benefit if no co1-4A+
morbidity.
Symptom resolution can take 3 weeks.
amoxicillin
or
doxycycline
4A+
500mg TDS
5 days
200mg stat then 100mg
OD
5 days
500mg TDS
5 days
500mg BD
5 days
doxycycline
200mg stat/100mg OD
5 days
Frequent exacerbations/
resistance and based on
sensitivity result only:
co-amoxiclav
625mg TDS
5 days
Consider 7-14 day delayed antibiotic
1,5A
with symptomatic advice/leaflet.
4A+
NICE 69
Acute
exacerbation of
COPD
Treat exacerbations promptly with
antibiotics if purulent sputum and
increased shortness of breath and/or
1-3B+
increased sputum volume.
NICE
Risk factors for antibiotic resistant
organisms include co-morbid disease,
severe COPD, frequent exacerbations,
2
antibiotics in last 3 months.
GOLD
First line:
amoxicillin
4C
or if penicillin-allergic:
clarithromycin
4A
Second line:
4C
4A
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 3 of 15
Communityacquired
pneumonia (CAP)
- treatment in the
2,3
community
BTS
NICE
Use CRB65 score to guide mortality
1
risk, place of care and antibiotics.
Each CRB65 parameter scores 1:
Confusion (abbreviated Mental Test
score 8 or less, or new disorientation
in person, place or time); Respiratory
rate 30 breaths per minute or more;
BP systolic <90 mmHg or diastolic ≤ 60
mmHg; Age 65 years or more.
Score 3-4 = high risk, urgent hospital
admission;
Score 1-2 = intermediate risk, consider
hospital assessment;
Score 0 = low risk, consider homebased care.
amoxicillin
500mg - 1g TDS
7 days
clarithromycin
500mg BD
7 days
or doxycycline
200mg stat/100mg OD
7 days
IV or IM benzylpenicillin
Age 10+ years: 1200mg
Children 1-9 yr: 600mg
Children <1 yr: 300mg
(give IM if vein
cannot be
found)
In penicillin-allergy use:
Always give safety-net advice and
likely duration of symptoms.
Give immediate IM benzylpenicillin or
amoxicillin 1G po if delayed
admission/life-threatening.
Mycoplasma infection is rare in over
1
65s.
MENINGITIS (NICE fever guidelines)
Suspected
meningococcal
disease
PHE
Transfer all patients to hospital
immediately. IF time before
admission, and non-blanching rash,
give IV benzylpenicillin or ceftriaxone
1-3B+
, unless definite history of
1Bhypersensitivity.
or
IV ceftriaxone
2g BD
Ceftriaxone
and
benzylpenicillin
are
reconstituted
with water for
injection.
Prevention of secondary case of meningitis:
Only prescribe following advice from Health Protection Unit:  0344 225 0562 (option 3) or 0161 922 6000
URINARY TRACT INFECTIONS
People > 65 years: Do not treat asymptomatic bacteriuria; it is common but is not associated with increased morbidity.
1B+
2B+
Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis likely.
If catheter has been in place for more than 7 days consider changing it before commencing antibiotic treatment.
3B
Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma.
In catheterised patients with symptoms suggestive of a UTI (fever, flank or suprapubic discomfort, change in voiding patterns,
nausea, vomiting, malaise or confusion), send a CSU. All patients with long-term indwelling catheters have bacteriuria and therefore
urine dipsticks are not useful in making a diagnosis of catheter-associated UTI.
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 4 of 15
UTI in
adults
(no fever or flank
pain)
PHE
SIGN
CKS women
CKS men
RCGP UTI clinical
module
SAPG UTI
Women with severe or ≥ 3 symptoms:
1,2A,3C
Treat.
Women with mild or ≤ 2 symptoms:
Obtain urine sample, use dipstick to
guide treatment:
 Positive nitrite plus blood or
leucocytes (has a 92% positive
predictive value, PPV) or positive
nitrite alone: Probable UTI, treat.
 Negative nitrite and Positive
leucocytes: UTI or other diagnosis
equally likely; Treat if symptoms
are severe or consider delayed
antibiotic prescription and send
urine for culture.
 Negative nitrite, leucocytes and
blood (has a 76% negative
4Apredictive value, NPV ) or
negative nitrite and leucocytes
with positive blood or protein: UTI
unlikely, consider other
diagnosis, do not prescribe
antibiotics.
Men:
 Obtain a urine sample for culture
and microscopy before starting
1,5C
antibiotic treatment.
 Relieve symptoms with
paracetamol or ibuprofen.
 Start empirical treatment with
trimethoprim for seven days.
 Trimethoprim should not be used
for empirical treatment if the man
has a history of recurrent
infections or has taken
trimethoprim within the past
12 months.
 Follow up after 48 hours (or
according to the clinical situation)
to check response to treatment
and the urine culture results.
 If patient has symptoms of
prostatitis, treat as below.
 Refer if recurrent or fails to
respond to antibiotics.
ALWAYS safety net and consider risks
for resistance.
Women all
ages:
Women
First line:
nitrofurantoin
50mg (AS TABLETS) QDS
or 100mg M/R caps BD
Second line:
trimethoprim
200mg BD
Men: Use
trimethoprim first line
200mg BD
3 days
2,12,13A+
Men:
1,5C
7 days
Use nitrofurantoin first line as general resistance and community
multi-resistant Extended-spectrum Beta-lactamase E. coli are
increasing.
MHRA Drug Safety Update (September 2014):
 Nitrofurantoin is contraindicated in patients with an estimated
2
glomerular filtration rate (eGFR) of less than 45 ml/min/1.73m .
 A short course (3 to 7 days) may be used with caution in certain
2
patients with an eGFR of 30 to 44 ml/min/1.73m . Only
prescribe to such patients to treat lower urinary tract infection
with suspected or proven multidrug resistant pathogens when
the benefits of nitrofurantoin are considered to outweigh the
risks of side-effects.
 Nitrofurantoin should not be used to treat sepsis syndrome
secondary to urinary tract infection or suspected upper urinary
tract infections.
Amoxicillin resistance is common; only use if susceptible.
14B+
Second line: Always perform culture in all treatment failures.
1B
Risk factors for increased resistance include: care home resident,
recurrent UTI, hospitalisation >7d in the last 6 months, unresolving
urinary symptoms, recent travel to a country with increased
antimicrobial resistance (outside Northern Europe and Australasia)
especially health-related, previous known UTI resistant to
19
trimethoprim, cephalosporins or quinolones.
If increased resistance risk, consider fosfomycin on advice of
microbiologist.
FOSFOMYCIN should be prescribed by a GP only on the advice of
the duty microbiologist. (Appropriate dose for patient should be
confirmed by microbiologist.)
If the patient is unable to obtain fosfomycin from their community
pharmacist in a timely manner then they should be instructed to
take the fosfomycin prescription to the IN-Patient Pharmacy
department at SRFT who will provide the medication.
(Salford CCG will reimburse SRFT directly for the cost of the
fosfomycin.)
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 5 of 15
UTI in pregnancy
PHE
CKS
UTI in children
PHE
CKS
Send MSU for culture and start
1A
antibiotic.
Perform a second urine culture seven
days after completing antibiotic course
as a ‘test of cure’.
Treatment should be offered for
symptomatic and asymptomatic
bacteriuria detected during pregnancy.
cefalexin
Child <3 months: refer urgently for
1C
assessment.
Lower UTI:
1A
trimethoprim
1A
or nitrofurantoin
IF susceptible,
1A
amoxicillin
1C
Second line: cefalexin
Child ≥ 3 months: use positive nitrite
to guide.
1A+
Start antibiotics. Also, send pretreatment MSU for all.
Imaging: only refer if child <6 months,
1C
or recurrent or atypical UTI.
NICE
500mg BD
See BNF for dosage
Upper UTI: co1A
amoxiclav
If no response contact
microbiology for advice.
7 days
Lower UTI:
1A+
3 days
Upper UTI:
1A+
7-10 days
In young girls, consider vulvovaginitis
– the main symptoms are vaginal
discharge (which can be yellow/green
and foul-smelling) and soreness. Other
symptoms may include redness of the
vulval area, itching and pain when
passing urine.
Acute
pyelonephritis
CKS
Recurrent UTI in
non-pregnant
women ≥ 3
UTIs/year
If admission not needed, send MSU for
culture & sensitivities and start
1C
antibiotics.
If no response within 24 hours,
2C
admit.
Post-coital prophylaxis
3B+
antibiotic.
1,2B+
or standby
5A
First line: trimethoprim
200mg BD
14 days
Second line:
co-amoxiclav
625mg TDS
14 days
nitrofurantoin
or trimethoprim
50-100mg
100mg
Post coital:
stat [off-label]
Nightly prophylaxis reduces UTIs but
adverse effects and long-term
1A+
compliance is poor.
2B+,3C
Prophylaxis:
1A+
OD at night ,
review at 6
4
months.
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 6 of 15
GASTRO-INTESTINAL TRACT INFECTIONS
Eradication of
Helicobacter
pylori
NICE dyspepsia
2
1A+
Treat all positives if known DU, GU
2B+
or low grade MALToma. In Non3A+ 4B+
Ulcer dyspepsia NNT is 14.
1C
Do not offer eradication for GORD.
Do not use clarithromycin,
metronidazole or quinolone if used in
5,6A+
past year for any infection.
PHE
CKS
Penicillin allergy: use PPI plus
clarithromycin + metronidazole; If
previous clarithromycin use PPI +
bismuth salt + metronidazole +
tetracycline.
Relapse and previous metronidazole +
clarithromycin: use PPI PLUS
amoxicillin, PLUS either tetracycline
1
OR levofloxacin. Penicillin allergy:
PPI + tetracycline + levofloxacin.
Retest for H. pylori post DU/GU or
relapse after second line therapy:
using breath or stool test OR consider
endoscopy for culture and
1C
susceptibility.
Infectious
diarrhoea
CKS
Clostridium
difficile Infection
Travellers’
diarrhoea
CKS
1,8
Always use PPI.
PPI WITH amoxicillin
PLUS either
clarithromycin
OR metronidazole
Penicillin allergy and
previous
1,7
clarithromycin :
PPI WITH
bismuth subsalicylate
8C,9A+
(Pepto-Bismol®)
PLUS
metronidazole PLUS
tetracycline
8C,10
hydrochloride
Relapse and previous
metronidazole +
clarithromycin: PPI WITH
amoxicillin PLUS
tetracycline
8C
hydrochloride
1
OR levofloxacin
TWICE DAILY
1g BD
500mg BD
400mg BD
All for
7 days
1,11A+
525mg (as 2 x 262.5mg
chewable tablets) QDS
400mg BD
500mg QDS
1g BD
500mg QDS
MALToma
14 days
1C
250mg BD
1C
Refer previously healthy children with acute painful or bloody diarrhoea to exclude E. coli 0157 infection.
2C
Antibiotic therapy usually not indicated unless systemically unwell. If systemically unwell and
Campylobacter suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin 250-500mg
3C
BD for 5-7 days, if treated early (within 3 days).
Stop unnecessary antibiotics and/or
PPIs to re-establish normal flora.
First episode:
vancomycin
Patients with severe disease at any
episode [ T >38.5°C and/or WBC >15
9
x 10 /L and/or acutely rising serum
creatinine (increased by >50% above
baseline) and/or >5 stools per
day and/or signs/symptoms of
severe colitis]: REFER FOR HOSPITAL
ASSESSMENT
Second episode
(i.e. First relapse):
fidaxomicin (ONLY on
the advice of
microbiologist)
125mg QDS
14 days
200mg BD
10 days
Third episode:
Discuss with
microbiologist
Only consider standby antibiotics for remote areas or people at high-risk of severe illness with travellers’
1,2C
diarrhoea.
2C, 3B+
If standby treatment appropriate give ciprofloxacin 500mg twice a day for 3 days (private prescription).
If
quinolone resistance high (e.g. south Asia): consider bismuth subsalicylate (Pepto-Bismol®) 2 tablets QDS as
2B+
4B+
prophylaxis or for 2 days treatment.
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 7 of 15
Threadworm
CKS
Treat all household contacts at the
same time PLUS advise hygiene
measures for 2 weeks (hand hygiene,
pants at night, morning shower –
include perianal area) PLUS wash
sleepwear, bed linen and dust,
1C
vacuum on day one. Child <6 mths
add perianal wet wiping or washes 3
hourly during day.
All patients over 6
months: mebendazole
1C
[off-label if <2yrs]
100mg
1C
Child <6 months:
mebendazole is
unlicensed, use hygiene
measures alone for 6
1C
weeks.
stat dose, but
repeat in 2
weeks if
infestation
persists
GENITAL TRACT INFECTIONS
STI screening
People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and
partners to GUM service. Risk factors: <25yr, no condom use, recent (<12mth)/frequent change of partner,
1,2
symptomatic partner, area of high HIV.
Chlamydia
trachomatis /
urethritis
Opportunistically screen all aged 151
25 years.
Treat partners and refer to GUM
2,3 B+
service.
2C
Pregnancy or breastfeeding:
azithromycin is the most effective
5A+
option.
Due to lower cure rate in pregnancy,
test for cure 6 weeks after treatment.
SIGN
BASHH
PHE
CKS
3C
Epididymoorchitis
4A+
4A+
azithromycin
4A+
or doxycycline
1g
100mg BD
stat
4A+
7 days
Pregnant or
breastfeeding:
5A+
azithromycin
5A+
or erythromycin
1g [off-label use]
500mg QDS
stat
5A+
7 days
500mg TDS
7 days
or amoxicillin
5A+
5A+
5A+
If thought due to sexually transmitted pathogen, refer to sexual health.
For epididymo-orchitis most probably due to enteric organisms:

Ciprofloxacin 500mg orally twice daily for 10 days.
If swelling has worsened or has not started to improve within 3 days of commencing antibiotics, reassess and
consider a change of antibiotics according to laboratory results (no causative organism is found in 30–40% of
men with epididymitis), or consider urology referral.
Vaginal
candidiasis
BASHH
PHE
CKS
All topical and oral azoles give 75%
1A+
cure.
clotrimazole
1A+
150mg orally
stat
applied BD for
7 days
stat
Pregnant: clotrimazole
100mg pessary at night
6 nights
or
3A+
miconazole 2% cream
5g intravaginally BD
7 days
or oral fluconazole
500mg pessary plus
1% clotrimazole cream
1A+
2B-
In pregnancy: avoid oral azoles and
use intravaginal treatment for 7 days.
3A+, 2,4B-
3A+
5C
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 8 of 15
Bacterial
vaginosis
BASHH
Oral metronidazole is as effective as
1A+
topical treatment but is cheaper.
5g applicatorful at night
5 nights
1A+
5g applicatorful at night
7 nights
1A+
400mg BD
or 2g
7 days
4A+
stat
100mg pessary at night
6 nights
metronidazole PLUS
1, 2, 4, 6B+
ofloxacin
1, 2, 4B+
or doxycycline
400mg BD
400mg BD
100mg BD
14 days
14 days
14 days
If gonorrhea suspected /
moderate PID:
3,5C
ADD ceftriaxone
500mg IM
stat
Send MSU for culture and start
1C
antibiotics.
Quinolones achieve higher prostate
2
levels.
4-week course may prevent chronic
1C
prostatitis.
Review at 4 weeks.
First line:
1C
ciprofloxacin
500mg BD
28 days
1C
Second line (in patients
unsuitable or allergic to
quinolones):
1C
trimethoprim
200mg BD
28 days
1C
Antibiotic resistance is now very
1C
high.
ceftriaxone
500mg deep IM
stat
1g oral
stat
2A+
PHE
CKS
Treating partners does not reduce
5B+
relapse.
BASHH
PHE
/ breastfeeding: avoid 2g
Treat partners and refer to GUM
1B+
service.
In pregnancy / breastfeeding: avoid 2g
single dose metronidazole (use 400mg
BD for 7 days). Consider clotrimazole
for symptom relief (not cure) if
3B+
metronidazole declined.
Review: Test of cure in 2 weeks posttreatment.
Pelvic
inflammatory
disease (PID)
Refer woman and contacts to GUM
1,2B+
service.
CKS
or metronidazole 0.75%
1A+
vaginal gel
or
clindamycin 2% vaginal
1A+
cream
metronidazole
CKS
BASHH
1A+
7 days
3A+
stat
Pregnant
3A+
stat.
Trichomoniasis
1,3A+
400mg BD
or 2g stat
Less relapse with 7 days than 2g stat
3A+
at 4 weeks.
oral metronidazole
Always culture for gonorrhoea and
2B+
chlamydia.
If gonorrhoea likely (partner has it, sex
abroad, severe symptoms), resistance
to quinolones is high, use ceftriaxone
3B+
regimen or refer to GUM.
clotrimazole
4A+
3B+
4A+
3B+
If severe PID or ectopic, refer to
Gynaecology / Emergency Dept.
Acute prostatitis
BASHH
CKS
Uncomplicated
anogenital
gonorrhoea
2,3B
Refer to GUM clinic for treatment.
Gonorrhoea cultures MUST be taken
before antibiotics are administered.
BASHH
CKS
Treat partners simultaneously.
Infection must have been confirmed
by laboratory results.
Possible co-infection with
Trichomonas vaginalis, Candida
albicans and Chlamydia trachomatis.
2B+,3B+
PLUS
azithromycin
2B+,3B+
(Avoid ceftriaxone in
patients with severe
penicillin hypersensitivity
in case of reaction with
cephalosporins.)
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 9 of 15
SKIN INFECTIONS
Impetigo
CKS
For extensive, severe or bullous
1C
impetigo, use oral antibiotics.
Reserve topical antibiotics for very
localised lesions to reduce the risk of
1,5C,4B+
resistance.
Reserve mupirocin for MRSA.
Acne
CKS
1C
oral flucloxacillin
2C
If penicillin-allergic:
2C
oral clarithromycin
3B+
topical fusidic acid
MRSA only mupirocin
Topical preparations should be used to
treat mild to moderate acne.
3A+
Lymecycline
500mg QDS
7 days
250-500mg BD
TDS
7 days
5 days
TDS
5 days
408mg OD
Supply
monthly with
frequent
review.
Oral antibiotics should be used for
moderate or severe acne or where
topical preparations are not tolerated
or are ineffective or where application
to the site is difficult.
Severe acne should be referred to the
dermatology service.
Eczema
CKS
Cellulitis
CKS
If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not
1B
improve healing.
2C
In eczema with visible signs of infection, use treatment as in impetigo.
1,2,3,5C
Class I: patient afebrile and healthy
other than cellulitis: use oral
1,2,5C
flucloxacillin alone.
flucloxacillin
500mg QDS
(For patients ≥80kg, 1g
QDS may be needed.)
Class II: febrile and ill, or comorbidity:
admit for intravenous treatment.
If penicillin-allergic:
1,2,3,5C
clarithromycin
If on statins: doxycycline
All for 7 days.
1
Class III: toxic appearance: admit.
If river or sea water exposure, discuss
with microbiologist.
500mg BD
200mg stat then 100mg
OD
If slow
response,
continue for a
further 7 days.
1C
If unresolving:
1,2
clindamycin
(Stop if diarrhoea occurs
and seek advice.)
If facial: co-amoxiclav
4C
300-450mg QDS
625mg TDS
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 10 of 15
Leg ulcers
PHE
CKS
Ulcers always colonized. Antibiotics
do not improve healing unless active
1A+
infection.
If active infection, send pre-treatment
3C
swab.
Review antibiotics after culture
results.
Active infection if cellulitis/increased pain/pyrexia/purulent
2C
exudate/odour.
If active infection:
flucloxacillin
500mg QDS
As for cellulitis
or clarithromycin
500mg BD
Diabetic Foot Ulcers
Mild infection:
flucloxacillin
All diabetic patients with foot
ulceration should be referred for a
podiatry review.
Intravenous antibiotics may be
required, only oral doses and drug
choices are listed here.
For further information consult the
Salford ‘Management of Diabetic Foot
Infections’ guideline.
1g QDS
500mg QDS if frail,
elderly or poorly
tolerant
7-14 days
Second line and
penicillin-allergic:
clarithromycin
500mg BD
or
doxycycline
7-14 days
200mg stat then 100mg
OD or BD
Moderate infection:
Oral therapy
co-amoxiclav
625mg TDS
2-6 weeks
or
clindamycin plus
ciprofloxacin
300-450mg QDS
500mg BD
(caution patient about
risk of diarrhoea with
clindamycin)
Severe infection:
IV antibiotics required
MRSA
See PHE MRSA quick reference guide
PVL S. aureus
Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from boils/abscesses. This bacteria
1C
can rarely cause severe invasive infections in healthy people; if found suppression therapy should be given.
1C
Send swabs if recurrent boils/abscesses. At risk: close contact in communities or sport, poor hygiene.
PHE
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 11 of 15
Bites
Thorough irrigation is important.
CKS
Assess risk of tetanus, rabies, HIV,
1
hepatitis B/C.
Human:
Antibiotic prophylaxis is advised.
Cat or dog:
2B-
Give prophylaxis if cat bite/puncture
2
wound ; bite to hand, foot, face, joint,
tendon, ligament;
immunocompromised/diabetic/
asplenic/cirrhotic/presence of
prosthetic valve or prosthetic joint.
Prophylaxis or
treatment:
co-amoxiclav
375-625mg TDS
If penicillin-allergic:
metronidazole PLUS
doxycycline
(cat/dog/man)
or metronidazole PLUS
clarithromycin (human
bite)
3C
400mg TDS
4C
100mg BD
All for 7 days
3,4,5C
200-400mg TDS
5C
250-500mg BD
AND review at 24 and 48
6C
hours.
Wound infection
(surgical or
traumatic)
In general, infected wounds can be
managed as per recommendations for
cellulitis.
Exclude any underlying collection
which may require drainage.
flucloxacillin
1,2,3C
500mg QDS
If penicillin‐allergic:
clarithromycin
or clindamycin
1,2C
facial: co‐amoxiclav
300–450mg QDS
If slow
response,
continue for a
further 7
625mg TDS
days.
500mg BD
1,2,3C
4C
All for 7 days.
1C
If wound likely to be
contaminated by faecal
flora, e.g. stoma
site/perianal wound/
gynaecological surgery:
co-amoxiclav
625mg TDS
If penicillin-allergic,
discuss with
microbiology.
Scabies
CKS
Treat whole body from ear/chin
downwards and under nails. If under
2
2/elderly, also face/scalp.
Treat all home and sexual contacts
1C
within 24 hours.
permethrin
3A+
If allergy:
3C
malathion
5% cream
2 applications
1C
1 week apart
0.5% aqueous liquid
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 12 of 15
Fungal infection –
skin
1
Terbinafine is fungicidal , so treatment
time shorter than with fungistatic
imidazoles.
1
If candida possible, use imidazole.
CKS body & groin
CKS foot
CKS scalp
2C
If intractable: send skin scrapings.
If infection confirmed, use oral
terbinafine/itraconazole (see BNF for
3B+,5C
doses).
Regarding oral
terbinafine, ensure LFTs are monitored
before treatment and then every 4–6
weeks during treatment.
Topical terbinafine
4A+,5C
BD
1-2 weeks
4A+
BD
for 1-2 weeks
after healing
(i.e. 4-6
4A
weeks)
or topical imidazole
or (athlete’s foot only):
topical undecanoates
(Mycota®)
BD
4A+
Scalp: discuss with specialist, oral
therapy indicated.
Fungal infection –
nail
CKS
Take nail clippings: start therapy only
if infection is confirmed by
1C
laboratory.
Oral terbinafine is more effective than
6
oral azole.
Liver reactions rare with oral
2A+
antifungals.
If candida or non-dermatophyte
infection confirmed, use oral
3B+ 4C
itraconazole.
3C
For children, seek specialist advice.
6A+
First line: terbinafine
Regarding oral
terbinafine, ensure LFTs
are monitored before
treatment and then
every 4–6 weeks during
treatment.
250mg OD
fingers
toes
6-12 weeks
3-6 months
Second line: itraconazole
200mg BD
fingers
toes
7 days
monthly
2 courses
3 courses
fingers
toes
6 months
12 months
6A+
Third line for very
superficial as limited
evidence of
effectiveness:
amorolfine 5% nail
5-8Blacquer.
1-2x/weekly
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 13 of 15
Varicella zoster/
chickenpox
Pregnant/immunocompromised/
neonate: seek urgent specialist advice.
If indicated:
3B+, 5A+
aciclovir
Chickenpox: If onset of rash <24hrs
and >14yrs or severe pain or
o
dense/oral rash or 2 household case
or steroids or smoker consider
2-4
aciclovir.
Second line for shingles
if compliance a problem,
as ten times cost:
10B+
valaciclovir
11B+
or famciclovir
1B+
CKS
&
Herpes zoster/
shingles
CKS
5A+
Shingles: Treat if >50 yrs and within
6B+
72 hrs of rash (PHN rare if
7B8B+
<50yrs ); or if active ophthalmic or
9C
Ramsey Hunt or eczema.
Ophthalmic treatment:
aciclovir 3% eye
ointment
For herpes labialis:
aciclovir 5% cream
or
penciclovir 1% cream
Dental abscess
CKS
Cold sores
Regular analgesia should be first
option until a dentist can be seen for
urgent drainage, as repeated courses
of antibiotics for abscess are not
1
appropriate. Repeated antibiotics
alone, without drainage are ineffective
in preventing spread of infection.
Antibiotics are only recommended if
there are signs of severe infection (e.g.
fever, lymphadenopathy, cellulitis,
diffuse swelling), systemic symptoms
(e.g. fever or malaise) or a high-risk of
complications (e.g. people who are
immunocompromised or diabetic or
2,3
have valvular heart disease).
Initiate antibiotic therapy if necessary,
refer to a Dentist.
2
Amoxicillin
or
phenoxymethylpenicillin
3B+
800mg FIVE times a day
7 days
1g TDS
500mg TDS or 750mg
BD
7 days
11B+
7 days
Apply FIVE times a day
until 3 days
after healing
Apply to lesions every 4
hours (5 times daily)
Apply every 2 hours
during waking hours
10B+
5-10 days
4 days
500mg TDS
500mg – 1g QDS
All for 5 days
True penicillin allergy:
clarithromycin
500mg BD
If infection is spreading
(lymph node
involvement, or
systemic signs, i.e. fever
or malaise), ADD
8-10C
metronidazole
400mg TDS
(review at 3
days)
Cold sores resolve after 7-10 days without treatment. Topical antivirals applied prodromally reduce duration
1,2,3B+,4
by 12-24 hours.
EYE INFECTIONS
Conjunctivitis
CKS
Treat if severe, as most viral or selflimiting.
Bacterial conjunctivitis is usually
2C
unilateral and also self-limiting ; it is
characterised by red eye with
mucopurulent, not watery, discharge;
1A+
65% resolve on placebo by day five.
Fusidic acid has less Gram-negative
3
activity.
4,5B+,6B-
If severe:
chloramphenicol 0.5%
drops
2-hourly for 2 days
then 4-hourly (whilst
awake)
and 1% ointment
at night
Second line:
fusidic acid 1% gel
BD
For all,
continue for
another 48
hours after
resolution
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 14 of 15
The following references were used when developing these guidelines:

Public Health England ‘Management of infection guidance for primary care for consultation and local adaptation’ (last
updated May 2016).
This guidance has been produced in consultation with GPs and specialists in the field. It is in agreement with other
guidance, including CKS, SIGN and NICE.
Please see full document for complete References with supporting information.

Salford Royal NHS Foundation Trust (SRFT) Antibiotic Guidelines
Please see SRFT website for most-up-to-date guidelines.
Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.
Study design
Recommendation
grade
Good recent systematic review and meta-analysis of studies
A+
One or more rigorous studies; randomised controlled trials
A-
One or more prospective studies
B+
One or more retrospective studies
B-
Non-analytic studies, e.g. case reports or case series
C
Formal combination of expert opinion
D
Note: Doses are oral and for adults unless otherwise stated. Please refer to latest BNF for further information.
Letters indicate strength of evidence:
Developed from guidance issued by Public Health England and aligned with SRFT policies July 2016.
A+ = good recent systematic review and meta-analysis of studies; D = formal combination of expert opinion
Next Review: June 2017
Page 15 of 15