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 Formulary Chapter 27: Antimicrobial Guide - Full Chapter
27.12  Expand sub section  Skin Infections
 note 

Skin infections

With moderate or severe signs of infection, or failure to respond to first line treatment, consider swabbing the wound for culture and sensitivity. Review empirical antibiotic choice when culture results become available. Please include any recent antimicrobial therapy on the request.

Acne rosacea (may co-exist with acne vulgaris)
Formulary

First line: Metronidazole cream 0.75% applied daily for 8 weeks

Second line: Oxytetracycline* 500 mg BD for 3-6 months. Repeat courses if necessary
OR Doxycycline*100 mg OD. Review at 12 weeks Note unlicensed; photosensitivity reported

Alternative before oral antibiotics: Ivermectin 10 mg/g (Soolantra) cream applied daily. Review at 8 weeks

*Warning Avoid in pregnancy

Avoid topical Benzoyl peroxide

Refer to dermatology specialist patients who have failed to respond to two courses of 6 months oral treatment.

 
Link  BNFC Doxycycline
Link  BNFC Metronidazole
Link  BNFC Oxytetracycline
   
Acne vulgaris
Formulary

First line: Self care

Second line: 6 – 8 weeks single topical treatment
benzoyl peroxide 5% (Acnecide®) OD – BD
OR topical retinoid* (Differin®) thinly OD

Third line: 12 weeks dual treatment
topical benzoyl peroxide with clindamycin (Duac®) OD
OR topical benzoyl peroxide with retinoid* (Epiduo®) OD
OR topical second line treatment co-prescribed with oral antibiotics

DO NOT USE TOPICAL AND ORAL ANTIBIOTICS TOGETHER

If treatment failure/severe: add oral antibiotic, consider referral
Tetracycline* 500 mg BD for 6 - 12 weeks OR
Doxycycline* 100 mg OD for 6 - 12 weeks OR
Lymecycline* 408 mg OD for 6 - 12 weeks

*Warning Avoid in pregnancy

Self-care advice: wash with mild soap or cleanser and lukewarm water not more than twice a day; avoid vigorous scrubbing and excessive use of makeup and cosmetics; benzoyl peroxide is a useful topical over-the-counter preparation, refer to minor ailments scheme if appropriate.

If topical treatment ineffective or acne is moderate to severe, oral antibiotics are preferred. Consider swab in failure of clinical response.

Severe acne, cases unresponsive to prolonged antibiotics, the presence of scarring or psychological problems should be referred to a dermatologist.

 

 
Link  CKS Acne vulgaris
Link  BNFC Rosacea and Acne
Link  BNFC Adapalene
Link  BNFC Benzoyl peroxide
Link  BNFC Clindamycin
Link  BNFC Lymecycline
Link  BNFC Tetracycline
   
Bites  (human or animal)
(treatment and prophylaxis;
refer serious bites, especially in children, to AED
)
Formulary

Co-amoxiclav 500/125 mg TDS for 7 days

In penicillin allergy:

Human: Metronidazole 400 mg TDS plus Clarithromycin* 500 mg BD for 7 days

Animal: Doxycycline* 100 mg BD plus Metronidazole 400 mg TDS for 7 days

Children under 12 years with confirmed penicillin allergy: Azithromycin for 7 days plus Metronidazole for 7 days.

Give prophylaxis for any of the following bite or puncture wounds:

  • to the hand, foot, face, joint, tendon, ligament
  • in immunocompromised, diabetic, asplenic, or cirrhotic patients
  • in the presence of prosthetic valve or joint
  • any cat bite.

*Warning Avoid in pregnancy

Adequate wound toilet is essential and the mainstay of treatment. Consider surgical debridement if required.

Assess rabies risk for animal bites occurring abroad.

Assess tetanus immunisation status.

Assess HIV and Hepatitis B and C risk for human bites.

Penicillin allergy: review at 24 and 48 hours, as not all pathogens are covered.

Note Consider risk of blood borne virus transmission. Further guidance available from Public Health England.

 
Link  CKS Bites
Link  PHE Infectious diseses
Link  BNFC Azithromycin
Link  BNFC Co-amoxiclav
Link  BNFC Doxycycline
Link  BNFC Metronidazole
   
Boils
Formulary

If cellulitis has been excluded antibiotics not indicated.

Drainage is advised.

Also, see recurrent boils

 
   
Boils, recurrent (associated with carriage of Staph. aureus)
Formulary

Topical antiseptic for one week, see MRSA bacteraemia

Mupirocin 2% nasal ointment BD for 5 days

Swabs to confirm nasal carriage of Staphylococcus aureus. Ask for PVL testing to be carried out. Mupirocin resistance should be discussed with a specialist.

 
Link  BNFC Mupirocin
   
Cellulitis and Erysipelas
Formulary

Erysipelas or Class I cellulitis - patient afebrile and healthy other than cellulitis: Flucloxacillin 500 mg QDS for 7 days

Severe infection: Flucloxacillin 1 g QDS for 7 days (unlicensed)

Known colonisation with MRSA: Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

Penicillin allergy and on statins: Doxycycline* 200 mg STAT then 100 mg OD for 7 days in total

If unresolving: Clindamycin 300 mg QDS for 7 days

*Warning Avoid in pregnancy

Class II cellulitis – patient febrile and ill, or comorbidity, admit for intravenous treatment, or use OPAT: consider admission if febrile and unwell. Outpatient Parenteral Antimicrobial Therapy may be available for those assessed for suitability for the service according to strict criteria. See OPAT

Class III cellulitis – if toxic appearance, admit.

If river or sea water exposure, discuss with a microbiologist.

Review response to treatment after 7 days. If slow response, continue for further 7 days.

 

 
Link  BLS Cellulitis
Link  CREST Cellulitis
Link  BNFC Clarithromycin
Link  BNFC Flucloxacillin
   
Cellulitis, facial (non-dental)
Formulary

Co-amoxiclav 500/125 mg TDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

*Warning Avoid in pregnancy

Review response to treatment after 7 days. If slow response, continue for further 7 days.

Orbital cellulitis: urgent referral to hospital

 

 
Link  BNFC Clarithromycin
Link  BNFC Co-amoxiclav
   
Chickenpox (Varicella zoster)
Formulary

Children: antiviral treatment not recommended if < 14 years.

Adults and adolescents ≥14 years: consider prescribing valaciclovir 1 g TDS for 7 days if within 24 hours of rash onset, particularly for people with severe chickenpox (severe pain, dense rash, oral rash, secondary household case) or those at increased risk of complications, such as smokers, pregnant women, chronic diseases (neurological, hepatic, renal, pulmonary, cardiac, diabetes mellitus), morbid obesity (BMI = 40).

Varicella zoster virus (VZV) is highly communicable.

Admit patient urgently if immunocompromised.

Seek urgent advice from obstetrician for pregnant women with chickenpox.

Contacts of VZV (chickenpox or shingles): for babies under one month of age, non-immune pregnant women and immunocompromised contacts maybe offered immunoglobulin - contact virologist or microbiologist urgently for advice.

 
Link  PHE Varicella
Link  BNFC Valaciclovir
   
Herpes, genital
Formulary
 
See Genital Tract infections
 
   
Herpes, oral
Formulary

Cold sores do not normally require antiviral treatment. The mainstay for primary acute oral herpes stomatitis is oral fluids.

If frequent, severe, and predictable triggers: consider oral prophylaxis: aciclovir 400 mg BD for 5 - 7 days

Most cold sores resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12 - 18 hrs.

Encourage self-care with over the counter medicines for self limiting conditions

 
Link  CKS Herpes simplex, oral
Link  BNFC Aciclovir
   
Impetigo or eczema with visible signs of infection
Formulary

As resistance is increasing, topical treatment should only be used when a few localised lesions are present:
Fusidic acid cream TDS for 5 days OR for MRSA lesions only: topical Mupirocin 2% ointment TDS for 5 days.

For more extensive infection: Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days OR for MRSA only: Doxycycline* 200 mg OD on day 1 followed by 100 mg OD for another 6 days (i.e. 7 days in total)

*Warning Avoid in pregnancy

Advise on the importance of personal hygiene e.g. not to share communal items such as towels, flannels etc. Avoid topical steroids or long-term topical antibiotic use. Further advice may be obtained from the community infection control nurse.

 
Link  PHE Childcare settings
Link  BNFC Clarithromycin
Link  BNFC Doxycycline
Link  BNFC Flucloxacillin
Link  BNFC Fusidic acid
Link  BNFC Mupirocin
   
Ingrowing toenail infection
Formulary

Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

*Warning Avoid in pregnancy

Wound debridement and swab.

Lateral nail ablation recommended when infection settled if the problem is recurrent.

 
Link  BNFC Clarithromycin
Link  BNFC Flucloxacillin
   
Lice, body
Formulary

Malathion 0.5% aqueous solution

Hot wash (50°C) all clothes and bedding or dry clean following first treatment.

 
Link  BNFC Malathion
   
Lice, crab or pubic
Formulary

Malathion 0.5% aqueous solution

Apply to all hairy parts of the body. Repeat after 7 days. Consider other sexually transmitted infections.

 
Link  BNFC Malathion
   
Lice, head
(Only treat if live moving lice are found or black or brown eggs, not empty white egg cases)
Formulary

Wet combing AND
Dimeticone 4% OR Malathion 0.5% aqueous solution

Encourage self-care of this condition

A course involves two treatments one week apart.

Reinfection is more probable than treatment failure. Combs should be thoroughly cleaned after each use.

Use different insecticides for subsequent course following treatment failure. Avoid shampoos and do not use insecticides as prophylaxis

 
Link  CKS Head Lice
Link  BNFC Dimeticone
Link  BNFC Malathion
   
Lyme disease
Formulary

First line: Doxycycline* 100 mg BD for 21 days

Alternative: Amoxicillin 1 g TDS for 21 days

Prophylaxis, low risk: antibiotic not recommended, give safety netting advice

Prophylaxis, high risk: Doxycycline* 200 mg STAT

*Warning Avoid in pregnancy

Treat erythema migrans. Suspected Lyme disease with focal symptoms, uveitis, or cardiac complications should be disused with a specialist.

Prophylaxis is not routinely recommended in Europe. Risk increased if high prevalence area and the longer tick is attached to the skin. Only give prophylaxis within 72 hours of tick removal. Give safety netting advice about erythema migrans and other possible symptoms that may occur within one month of tick removal.

 
Link  BMJ (2018) Infographic
Link  NICE (2018) NG95
Link  BNFC Amoxicillin
Link  BNFC Doxycycline
   
Mastitis
Formulary

Flucloxacillin 500 mg QDS for 14 days if clinical evidence of infection.

In penicillin allergy: Erythromycin 500 mg QDS for 14 days

The most common cause of mastitis is an ineffective attachment at the breast. It is essential that this is corrected otherwise the problem will persist and secondary problems may result despite antibiotic treatment

 
Link  CKS Mastitis and breast abscess
   
Post-operative wound infections
Formulary

Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

*Warning Avoid in pregnancy

Infection within 30 days of surgery should be referred back to the responsible Trust.

Swab wound for culture and sensitivity. Consider nature of the operation and likely pathogens including MRSA status.

Consider hospital admission and discuss with a medical microbiologist.

Post-operative infections involving a prosthetic implant avoid prescribing antibiotics and refer urgently back to the surgeon.

 
Link  BNFC Flucloxacillin
Link  BNFC Clarithromycin
   
Scabies
Formulary

Permethrin 5% dermal cream applied for 12 hours.

Apply to the whole body from ear and chin downwards and under nails. Do not apply after a hot bath.

It is important that ALL household and sexual contacts (previous 2 months) should also be treated at the same time (within 24hrs).

Apply 2 treatments 1 week apart

If allergic to permethrin, Malathion 0.5% aqueous solution, 2 applications 1 week apart

Infants aged less than 2 years and the elderly aged over 65 years require head and face application (avoiding eyes) initially. Unlicensed use in less than 2 months of age, refer to paediatric dermatologist.

Itch may persist for 4-6 weeks following effective treatment; crotamiton or aqueous cream may be beneficial. Sedative antihistamines may help with nocturnal itch.

Hot wash (50°C) all clothes and bedding or dry clean following first treatment.

If patient institutionalised refer to Community Infection Prevention and Control Team

 
Link  NHS Scabies
Link  BNFC Malathion
Link  BNFC Permethrin
   
Scabies, crusted (Norwegian)
Formulary

Rare. Treat as for scabies but include head and neck.

Refer to Dermatology for specialist advice including prescribing oral ivermectin (unlicensed).

 
   
Shingles (Varicella zoster)
Formulary

Antiviral treatment not recommended if < 50 years

Treat if ≥ 50 years (PHN rare if < 50 years) or one or more of the following: active ophthalmic lesions, Ramsey Hunt, eczema, non-truncal involvement (e.g. meningitis), moderate or severe pain, moderate or severe rash if within 72 hours of rash.

First line: Valaciclovir 1 g TDS for 7 days

Alternative (expensive): Famciclovir 500 mg TDS for 7 days OR Famciclovir 750 mg BD for 7 days

Refer to ophthalmologist urgently if ocular involvement.

Antiviral treatment if not within 72 hours of rash: consider up to one week after rash onset if high risk of severe shingles or complications (continued vesicle formation, older age, immunocompromised, severe pain).

 
Link  PCDS Herpes zoster
   
Superficial skin and soft tissue infections, Paronychia
Formulary

Flucloxacillin 500 mg QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

If infection due to MRSA, use Doxycycline* 100 mg BD for 7 days
Use sensitivity results to guide therapy.

In children (mild)

< 1 month: Cefalexin

> 1 month and older: Flucloxacillin capsules (depending on age and ability to swallow) OR Cefalexin.

*Warning Avoid in pregnancy

Wound debridement if suspected foreign body and swab.

Empirical antibiotic treatment

 
Link  BNFC Clarithromycin
Link  BNFC Cefalexin
Link  BNFC Flucloxacillin
Link  BNFC Doxycycline
   
Ulcer, diabetic foot
(grade 0 or 1)
Formulary

Mild infection in patients previously untreated with antibiotics: Flucloxacillin 1 g QDS for 7 days

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

If MRSA-positive: Doxycycline* 100 mg BD

Consider adding Metronidazole 400 mg TDS if anaerobic infection is suspected.

If treatment failure or chronic infection

Consider referral to secondary care (see decision triggers)

Co-amoxiclav 520/125 mg TDS

In penicillin allergy or MRSA carriage: seek advice from a Medical Microbiologist

*Warning Avoid in pregnancy

Refer all patients immediately to the community podiatry team as per local guidance stating clearly that the patient has diabetes and a new ulcer.

Decision triggers for referral

  1. New foot ulceration
  2. Recurrent foot ulceration
  3. Unexplained foot pain, swelling and deformity
  4. Cellulitis of the foot
  5. Suspected osteomyelitis of the toes
  6. Suspected Charcot neuroarthropathy
  7. Severe neuropathic pain
  8. Deteriorating foot ulcer, despite earlier assessment by MDT

Clinical emergency

  1. Critical limb ischaemia
  2. Acute Charcot suspected
  3. Spreading cellulitis
  4. Gangrene
  5. Significantly deteriorating foot ulceration

This list is not exhaustive, use clinical judgement

 
Link  NWCSCN Foot care
Link  BNFC Clarithromycin
Link  BNFC Co-amoxiclav
Link  BNFC Doxycycline
Link  BNFC Flucloxacillin
Link  BNFC Metronidazole
   
Ulcer, leg
Formulary

Flucloxacillin 500 mg QDS for 7 days

Severe infection: Flucloxacillin 1 g QDS for 7 days (unlicensed)

In penicillin allergy: Clarithromycin* 500 mg BD for 7 days

If slow response, continue for a further 7 days

*Warning Avoid in pregnancy

Ulcers are always colonised. Check MRSA status. Antibiotics do not improve healing unless active infection. If active infection, send pre treatment swab. Review antibiotics after culture results.

Signs of active infection: cellulitis, increased pain, pyrexia, purulent exudate, odour

Refer to local district nurse team as per local guidance.

 
Link  PHE Venous leg ulcer
Link  BNFC Clarithromycin
Link  BNFC Flucloxacillin
   
 ....
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

Requires specialist assessment to enable patient selection. †Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care.  

Amber Initiated

Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable   

Amber Retained

Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria: (1)Requires specialist assessment to enable patient selection (2)Medicine is suitable for on-going prescribing in Primary Care (3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patientís dose and condition is stable (4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care   

Amber

Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained.  

Purple

Shared Care. Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care. Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber. A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients. A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care. All drugs to be included in this category must meet Shared Care criteria 1 to 3: SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition. SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care. SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year). Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available.  

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