Upper respiratory tract infections
Recommendations on hierarchy of national guidelines > RCTs > local practice Penicillin allergy: green safe; yellow avoid; red do not useGive oral unless only IV or IV indicated See BNFc for doses, contraindications etc Click header for link311735393428 HYPERLINK \l "Meningitis" Meningitis00 HYPERLINK \l "Meningitis" Meningitis776922598425Heart00Heart700786097790Bone00Bone626237098425Eye00Eye554799598425Skin00Skin238315587630Sepsis00Sepsis167005087630UTI00UTI83248580645Lower RTI00Lower RTI-63580645Upper RTI00Upper RTI400494599695GI00GI479107599695Genital00Genital77679552542540 HYPERLINK \l "Sickle cell disease" Fever no focusSeptic arthritisAcute chest00 HYPERLINK \l "Sickle cell disease" Fever no focusSeptic arthritisAcute chest77800202277110Sickle cell00Sickle cell77571601080770GingivitisPeri-coronitisDental abscess00GingivitisPeri-coronitisDental abscess-9525114935Sore throatInfluenzaScarlet feverOtitis mediaOtitis externaSinusitisEpiglottitis / tracheitis HYPERLINK \l "parotitis" Lymph-adenitis / parotitisMastoiditisRetro-pharyngeal abscess00Sore throatInfluenzaScarlet feverOtitis mediaOtitis externaSinusitisEpiglottitis / tracheitis HYPERLINK \l "parotitis" Lymph-adenitis / parotitisMastoiditisRetro-pharyngeal abscess800100114935CoughCommunity acquired pneumoniaHospital acquired pneumoniaAspiration pneumoniaEmpyemaPertussisBronchiectasisTB00CoughCommunity acquired pneumoniaHospital acquired pneumoniaAspiration pneumoniaEmpyemaPertussisBronchiectasisTB1619250114935Lower UTIRecurrent UTIPyelonephritisCatheter assoc UTI00Lower UTIRecurrent UTIPyelonephritisCatheter assoc UTI2362200114935Unknown originCVL assocHaem/OncProphylaxis00Unknown originCVL assocHaem/OncProphylaxis3105150114935BacterialCulture negativeOrganism specificEncephalitisNeuro-surgical 00BacterialCulture negativeOrganism specificEncephalitisNeuro-surgical 3990975114935Oral candidaInfectious diarrhoeaHelicobacter pyloriC diffTraveller’s diarrhoeaThread-wormAppendicitisPeritonitisNEC00Oral candidaInfectious diarrhoeaHelicobacter pyloriC diffTraveller’s diarrhoeaThread-wormAppendicitisPeritonitisNEC4772025114935ChlamydiaEpididymitisVaginal candida Bacterial vaginosisGenital herpesGonorrhoeaTrichomonasPIDSexual assaultBalanitisOrchitis00ChlamydiaEpididymitisVaginal candida Bacterial vaginosisGenital herpesGonorrhoeaTrichomonasPIDSexual assaultBalanitisOrchitis7000875114935Osteo-myelitisSeptic arthritis00Osteo-myelitisSeptic arthritis6257925114935ConjunctivitisBlepharitisOrbital cellulitisOphthalmia neonatorum00ConjunctivitisBlepharitisOrbital cellulitisOphthalmia neonatorum5514975114935ImpetigoPVL –SAEczemaCellulitisLeg ulcerAcneFasciitisScabies HYPERLINK \l "injury" SurgicalInjuriesBitesMRSABurnsFungalVZV / HSVTick biteHead lice00ImpetigoPVL –SAEczemaCellulitisLeg ulcerAcneFasciitisScabies HYPERLINK \l "injury" SurgicalInjuriesBitesMRSABurnsFungalVZV / HSVTick biteHead lice7750175120015Endo-carditis00Endo-carditis7773035815340Dental00DentalUpper respiratory tract infectionsSore throat / TonsillitisLast updated: June 2020Advise paracetamol, or if preferred and suitable, ibuprofen for pain Use FeverPAIN or Centor to assess symptoms> 3 years old: FeverPAIN 0-1 or Centor 0-2: no antibiotic FeverPAIN 2-3: no or back-up antibiotic FeverPAIN 4-5 or Centor 3-4: immediate or back-up antibioticSystemically very unwell or high risk of complications: immediate antibioticPhenoxymethylpenicillin (Pen V) solution unpalatable, use if can swallow tabletsFirst choice: phenoxymethylpenicillin ORamoxicillin if Pen V not tolerated ORbenzylpenicillin if unable to take oral5 to 10 daysNICE NG84NICE CG69Little P et al, BMJ 2013 HYPERLINK "" \o "SpinksA2013" \t "_blank" Spinks A et al,?Cochrane review 2013Altamimi S et al,?Cochrane review 2012Chew & Goenka Arch Dis Child 2016 HYPERLINK "" \o "LanandColford2000" \t "_blank" Lan AJ Pediatrics.?2000HYPERLINK "" \o "FalagasME2000" \t "_blank"Falagas ME Mayo Clin Proc. 2008Penicillin allergy: clarithromycin 5 days74760661044786Return to contents020000Return to contentsInfluenzaLast updated: June 2020Annual vaccination is essential for all those ‘at risk’ of influenza. Treat ‘at risk’ patients with 5?days oseltamivir, when influenza is circulating in the community, and ideally within 48?hours of onset (36?hours for zanamivir treatment in children)At risk: children under 6?months; adults 65?years or older; chronic respiratory disease (including COPD and asthma); significant cardiovascular disease (not hypertension); severe immunosuppression; chronic neurological, renal or liver disease; diabetes mellitus; morbid obesity (BMI>40). See the PHE Influenza guidance for the treatment of patients under 13?years. In severe immunosuppression, or oseltamivir resistance, use zanamivir 10mg BD (2?inhalations twice daily by diskhaler for up to 10?days) and seek advice. Uncomplicated influenza: Influenza presenting with fever, coryza, generalised symptoms (headache, malaise, myalgia, arthralgia) and sometimes gastrointestinal symptoms, but without any features of complicated plicated influenza: Influenza requiring hospital admission and/or with symptoms and signs of lower respiratory tract infection (hypoxaemia, dyspnoea, lung infiltrate), central nervous system involvement and/or a significant exacerbation of an underlying medical conditionUncomplicatedStart within 48 hours of onset5 daysPHE Guidance on use of antiviral agents for the treatment and prophylaxis of seasonal influenza Previously healthy:No treatment ORoseltamivir if serious risk complicationsCo-morbidity or <6 months old:oseltamivirComplicated, not severely immunosuppressed:oseltamivir ORzanamivir inhaled (2nd line)10 daysSeverely immunosuppressedLow risk oseltamivir resistance (e.g. A(H3N2), influenza B):Uncomplicated:oseltamivirComplicated:oseltamivir ORzanamivir inhaled (2nd line)High risk oseltamivir resistance (e.g. A(H1N1):zanamivir inhaled2nd line: poor clinical response, resistancezanamivir inhaledoseltamivir IV7476067807085Return to contents020000Return to contentsScarlet fever (GAS)Last updated: March 2020Prompt treatment with appropriate antibiotics significantly reduces the risk of complications. Vulnerable individuals (immunocompromised, the comorbid, or those with skin disease) are at increased risk of developing complications.Notify Public Health England 0344 225 0562 or Public Health Wales 0300 00 300 32 or Health Protection Scotland via local Health Board phenoxymethylpenicillin ORamoxicillin if tablets not tolerated10?days Access supporting evidence and rationales on the PHE websitePenicillin allergy: clarithromycin 5?days Optimise analgesia and give safety netting adviceOtitis mediaLast updated: March 2020Regular paracetamol or ibuprofen for pain (right dose for age or weight at the right time and maximum doses for severe pain).Otorrhoea or under 2 years with infection in both ears: no, back-up or immediate antibiotic.Otherwise: no or back-up antibiotic.Systemically very unwell or high risk of complications: immediate antibiotic. Second choice: worsening symptoms on first choice taken for at least 2 to 3 days.First choice: amoxicillin5 to 7?daysNICE NG91Hoberman A et al, NEJM 2011Ahmed W,?Arch Dis Child 2018penicillin allergy: clarithromycin Second choice: co-amoxiclav (worsening symptoms on first choice taken for at least 2 to 3 days)penicillin allergy:clarithromycin74760671972099Return to contents020000Return to contentsOtitis externaLast updated: March 2020First line: analgesia for pain relief and apply localised heat (such as a warm flannel). Second line: topical acetic acid or topical antibiotic +/- steroid: similar cure at 7?days. If cellulitis or disease extends outside ear canal, or systemic signs of infection, start oral flucloxacillin and refer to exclude malignant otitis externa. Second line:topical acetic acid 2% OR7?daysRosenfeld Otolaryngol Head Neck Surg 2014 topical neomycin sulphate with corticosteroid If perforation:ciprofloxacin ear drops7?days (min) to 14?days (max) If cellulitis: flucloxacillin OR co-amoxiclav if unable to take tablets7?days Penicillin allergy:clarithromycin OR doxycycline (not in under 12s)If severe:cefTAZidime IV PLUSciprofloxacin ear drops7 daysMalignant otitis externa:piperacillin with tazobactam IV4-6 weeksDiscuss with ENT74760662336165Return to contents020000Return to contentsSinusitisLast updated: March 2020Advise paracetamol or ibuprofen for pain. Little evidence that nasal saline or nasal decongestants help, but people may want to try them.Symptoms for 10?days or less: no antibiotic.Symptoms with no improvement for more than 10?days: no antibiotic or back-up antibiotic depending on likelihood of bacterial cause. Consider high-dose nasal corticosteroid (if over 12?years).First choice: phenoxymethylpenicillin (Pen V) ORamoxicillin (if Pen V not tolerated)5 daysNICE NG79Systemically very unwell or high risk of complications: immediate antibiotic.High risk of serious complications due to pre-existing illness (e.g. significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis and prematurely born infantsSecond choice or first choice if systemically very unwell or high risk of complications co-amoxiclav 5 dayspenicillin allergy:clarithromycinChronic sinusitisco-amoxiclav Penicillin allergy:clindamycinEpiglottitis / bacterial tracheitisLast updated: March 2020cefOTAXime OR cefTRIAXonePLUS vancomycin if MRSA colonised Oral stepdown: co-amoxiclav 5 daysPenicillin allergy:ciprofloxacin PLUS clindamycin IVPLUS vancomycin if MRSA colonised74760661827530Return to contents020000Return to contentsLymphadenitis / parotitisLast updated: March 2020Well child with few systemic symptoms or generalised lymphadenopathy: no antibioticsSystemically unwell: provide antibioticsEBV IgM: test if adolescent, pharyngitis, headache, hepatosplenomegaly, hepatitis Acute bacterial parotitis is often unilateralViral parotitis is more commonly bilateral (e.g. mumps) do not give antibioticsFirst line: co-amoxiclav 7 days minimumRCPCH p135-146 & 624Second line/penicillin allergy:clarithromycin ORclindamycinMastoiditisLast updated: March 2020Most likely causal organisms Streptococcus pneumoniaeMoraxella catarrhalisHaemophilus influenzaeGroup A StreptococcusLess common:Staph. aureusoccasionally anaerobesNo intracranial involvement:co-amoxiclav suspected intracranial:cefTRIAXone PLUSmetronidazoleOral stepdown:co-amoxiclav Penicillin allergy:not intracranial: clindamycin intracranial: ciprofloxacin PLUS metronidazole PLUS vancomycin2 weeksIf bone involvement or sinus venous thrombosis 4 weeksPsarommatis Int J Pediatr Otorhinolaryngol2012Lin. Clin Pediatr (Phila). 2010Retro-pharyngeal cellulitis / abscessLast updated: March 2020cefTRIAXone PLUSmetronidazoleOral stepdown:co-amoxiclav Penicillin allergy:clindamycin10-14 days74760671398270Return to contents020000Return to contentsLower respiratory tract infections CoughLast updated: March 2020Some people may wish to try honey (in over 1s), the herbal medicine pelargonium (in over 12s), cough medicines containing the expectorant guaifenesin (in over 12s) or cough medicines containing cough suppressants, except codeine, (in over 12s). These self-care treatments have limited evidence for the relief of cough symptoms.Acute cough with upper respiratory tract infection: no antibiotic.Acute bronchitis: no routine antibiotic.Acute cough and higher risk of complications (at face-to-face examination): immediate or back-up antibiotic.Acute cough and systemically very unwell (at face to face examination): immediate antibiotic.Higher risk of complications includes people with pre-existing comorbidity; young children born prematurely.Do not offer a mucolytic, an oral or inhaled bronchodilator, or an oral or inhaled corticosteroid unless otherwise indicated.For detailed information click on the visual summary.First choice if high risk complications or very unwell:amoxicillin5 daysNICE NG120Alternative first choices: clarithromycin ORdoxycycline (not in under 12s)74760661179618Return to contents020000Return to contentsCommunity-acquired pneumoniaLast updated: March 2020Assess severity in children based on clinical judgement.Offer an antibiotic. Start treatment as soon as possible after diagnosis, within 4 hours (within 1 hour if sepsis suspected and person meets any high risk criteria – see the NICE guideline on sepsis).When choosing an antibiotic, take account of severity, risk of complications, local antimicrobial resistance and surveillance data, recent antibiotic use and microbiological results.* Stop antibiotics after 5 days unless microbiological results suggest a longer course is needed or the person is not clinically stable.Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years and is more common in school-aged children.Chlamydia pneumoniae in under 4 months For detailed information click on the visual summary. See also the NICE guideline on pneumonia.<1 month:cefTRIAXone (if contraindications cefOTAXime) PLUSgentamicin (if severe)5 days*NICE NG138BTS HYPERLINK "" \o "Vilas-Boas AL" \t "_blank" Vilas-Boas AL J Antimicrob Chemother. 2014 HYPERLINK "" \o "Fonseca W" \t "_blank" Fonseca W Antimicrob Agents Chemother. 2003>1 month:First choice (non-severe):amoxicillinAlternative first choice (non-severe or if amoxicillin unsuitable, for example, atypical pathogens suspected):clarithromycin OR doxycycline (not in under 12s)Second line: amoxicillin PLUS clarithromycinFirst choice (severe):co-amoxiclav PLUS (if atypical pathogens suspected)clarithromycin ORPenicillin allergy (non-anaphylactic): cefUROXime +/- clarithromycinPenicillin anaphylaxis (severe): teicoplanin OR vancomycin PLUS ciprofloxacinMRSA colonised:PLUS vancomycin7476066874818Return to contents020000Return to contentsHospital-acquired pneumoniaLast updated: June 2020If symptoms or signs of pneumonia start within 48?hours of hospital admission, see community acquired pneumonia. Offer an antibiotic. Start treatment as soon as possible after diagnosis, within 4 hours (within 1 hour if sepsis suspected and person meets any high risk criteria – see the NICE guideline on sepsis).When choosing an antibiotic, take account of severity of symptoms or signs, number of days in hospital before onset of symptoms, risk of developing complications, local hospital and ward-based antimicrobial resistance data, recent antibiotic use and microbiological results, recent contact with a health or social care setting before current admission, and risk of adverse effects with broad spectrum antibiotics. No validated severity assessment tools are available. Assess severity of symptoms or signs based on clinical judgement.Higher risk of resistance includes relevant comorbidity (such as severe lung disease or immunosuppression), recent use of broad-spectrum antibiotics, colonisation with multi-drug resistant bacteria, and recent contact with health and social care settings before current admission.If symptoms or signs of pneumonia start within days 3 to 5 of hospital admission in people not at higher risk of resistance, consider following community acquired pneumonia for choice of antibiotic.Review IV antibiotics by 48 hours and consider switching to oral antibiotics as above for a total of 5 days then reviewSee BNFc for information on therapeutic drug monitoring.Age <1 month: cefTRIAXone (if contraindications cefOTAXime) PLUS gentamicin5 days then reviewNICE NG139First choice oral (non-severe and not higher risk of resistance):co-amoxiclav Alternative first choice (non-severe and not higher risk of resistance)clarithromycin OR cefUROXime if non-anaphylaxis to penicillinFirst choice IV antibiotics (severe or symptoms of sepsis, or at higher risk of resistance) piperacillin with tazobactam ORReview at 48 hours, 5 days total coursecefTAZidime PLUS teicoplanin OR vancomycincefTRIAXonePenicillin anaphylaxis (severe):ciprofloxacin PLUS clindamycinAntibiotics to be added if suspected or confirmed MRSA infection (dual therapy with an IV antibiotic listed above)teicoplanin ORvancomycin ORlinezolid (if vancomycin cannot be used; specialist advice only, not licensed in children in young people under 18 years - informed consent must be gained)Ventilator associated pneumoniaonset <5 dayscefTRIAXoneonset >5 days3451437253788Return to contents020000Return to contentspiperacillin with tazobactamAspiration pneumoniaLast updated: March 2020Organisms: Staphylococcus aureus, Streptococci, coliforms, anaerobesMild: chemical pneumonia, no antibiotic requiredModerate:co-amoxiclav Penicillin allergy: cefUROXime (oral stepdown cefALEXin) Penicillin anaphylaxis: clarithromycin PLUS metronidazole7 daysIDSA 2019RCPCH p409Severe:piperacillin with tazobactamPenicillin allergy: cefTRIAXonePenicillin anaphylaxis: clindamycinEmpyemaLast updated: July 2020Organisms: Streptococcus pneumoniae, Staphylococcus aureus, Group A Streptococcusco-amoxiclav IV ORcefUROXimePLUS clindamycin (if toxin mediated disease: haemodynamic instability, mucosal erythema, rash, diarrhoea)oral switch when fever resolving and CRP improving: co-amoxiclavPenicillin allergy: clindamycinIV until chest drains removed; minimum 2 weeks, 4 weeks if loculatedBTS 2005BTS 2010PertussisLast updated: March 2020Notify Public Health England 0344 225 0562 or Public Health Wales 0300 00 300 32Health Protection Scotland via local Health Board clarithromycinMacrolide contraindication: co-trimoxazole7 daysRCPCH p742PHE74760671437217Return to contents020000Return to contentsBronchiectasis exacerbation (non-cystic fibrosis)Last updated: March 2020Send a sputum sample for culture and susceptibility testing. Offer an antibiotic. When choosing an antibiotic, take account of severity of symptoms and risk of treatment failure. People who may be at higher risk of treatment failure include people who’ve had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.Course length is based on severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment.Do not routinely offer antibiotic prophylaxis to prevent exacerbations.Seek specialist advice for preventing exacerbations in people with repeated acute exacerbations. This may include a trial of antibiotic prophylaxis after a discussion of the possible benefits and harms, and the need for regular review.See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), and avoiding coadministration with a corticosteroid (March 2019).First choice empirical treatment:(guided by most recent sputum culture and susceptibilities where possible)amoxicillin OR7 to 14 daysNICE NG117clarithromycin) ORdoxycycline (not in under 12s)Alternative choice (if person at higher risk of treatment failure) empirical treatment:co-amoxiclav OR7 to 14 daysciprofloxacin (with specialist advice if co-amoxiclav cannot be used; consider safety issues)IV antibiotics co-amoxiclav ORReview by 48 hours and consider stepping down to oral antibiotics where possible for a total antibiotic course of 7 to 14 dayspiperacillin with tazobactam OR ciprofloxacin (with specialist advice if co-amoxiclav cannot be used; consider safety issues) PLUSteicoplanin OR vancomycin74760675726006Return to contents020000Return to contentsTuberculosisTBLast updated: March 2020Referral all cases of suspected or proven TB to Paeds ID/TB specialistLiquid formulations:Rifampicin 100mg/5mlIsoniazid 50mg/5ml or tablets as below +(ethambutol 100mg tab)mg/kgrange (mg)maxLatent TBRH 3 months ORH 6 months2 months RHZE +non-CNS TB4 months RHCNS TB10 months RHWHONICE NG33Isoniazid (H)1010-15300 mgRifampicin (R)1510-20450 mg (body weight <50kg)600 mg (body weight >50kg)Pyrazinamide (Z)3530-401.5 g (body weight <50kg)2 g (body weight >50kg)Ethambutol (E)2015-25Active TB 1st 2 monthsBody weight (kg)Rifinah 150/100VoractivIsoniazid 50Pyrazinamide 500Ethambutol 400Total tablets15-20?112 ?20-2521 ?14 ?25-3012330-35121?4 ?35-4013440-4513445-5044>5044Active TB continuation phase and Latent TBBody weight (kg)Rifinah 150/100Rifinah 300/150Total tablets10-151115-201 ?1 ?20-252225-302 ?2 ?30-353335-401 ?12 ?40-452245-5022>50227467600228600Return to contents00Return to contentsUrinary tract infectionsLower urinary tract infection Last updated: March 2020Advise paracetamol or ibuprofen for pain.When considering antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data.A lower risk of resistance is likely if not used in the past 3?months, previous urine culture suggests susceptibility (but this was not used), and in areas where local epidemiology data suggest resistance is low. A higher risk of resistance is likely with recent useFor detailed information click on the visual summary. See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management and the Public Health England urinary tract infection: diagnostic tools for primary care.First choice: trimethoprim (if low risk of resistance) OR3 days NICE NG109Kaufman?J 2015nitrofurantoin (if able to take tablets/capsules) ORamoxicillin (only if culture results available and susceptible) ORcefALEXinRecurrent urinary tract infectionLast updated: March 2020First advise about behavioural and personal hygiene measures, and self-care (with D-mannose or cranberry products) to reduce the risk of UTI.With specialist advice consider a trial of daily antibiotic prophylaxis (review within 6?months).For detailed information click on the visual summary. See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management and the Public Health England urinary tract infection: diagnostic tools for primary care.First choice antibiotic prophylaxis: trimethoprim ORReview at least every 6 monthsNICE NG112nitrofurantoin (if able to take tablets/capsules)Second choice antibiotic prophylaxis: cefALEXin ORamoxicillin(not licensed)7477548612352Return to contents020000Return to contentsPyelonephritis (upper urinary tract)Last updated: March 2020Advise paracetamol (+/- low-dose weak opioid) for pain for people over 12.Offer an antibiotic.When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data.For detailed information click on the visual summary. See also the NICE guideline on urinary tract infection in under 16s: diagnosis and management and the Public Health England urinary tract infection: diagnostic tools for primary care.Age <3 month: cefTRIAXone (if contra-indications cefOTAXime) +/- gentamicin7 to 10 daysNICE NG111Age >3?months first choice oral: cefALEXin ORco-amoxiclav (only if culture results available and susceptible)ciprofloxacin (penicillin anaphylaxis)Age >3 months IV antibiotics (if vomiting, unable to take oral antibiotics or severe unwell)co-amoxiclav (only in combination or if culture results available and susceptible) ORReview IV antibiotics by 48 hours and consider stepping down to oral where possible for a total of 10 dayscefUROXime ORcefTRIAXone PLUS gentamicin (penicillin allergy or stat dose if severe sepsis) Previous renal pathology:gentamicin ORpiperacillin with tazobactam (if gentamicin contra-indicated)Penicillin allergy:ciprofloxacin PLUS gentamicin (stat dose if severe sepsis)74845341442085Return to contents020000Return to contentsCatheter-associated urinary tract infectionLast updated: March 2020Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a urinary catheter. Consider removing or, if not possible, changing the catheter if it has been in place for more than 7 days. But do not delay antibiotic treatment.Advise paracetamol for pain.Advise drinking enough fluids to avoid dehydration.Offer an antibiotic for a symptomatic infection. When prescribing antibiotics, take account of severity of symptoms, risk of complications, previous urine culture and susceptibility results, previous antibiotic use which may have led to resistant bacteria and local antimicrobial resistance data. Do not routinely offer antibiotic prophylaxis to people with a short-term or long-term catheter.For detailed information click on the visual summary. See also the Public Health England urinary tract infection: diagnostic tools for primary care.First choice: trimethoprim (if low risk of resistance) OR7 to 10 daysNICE NG113amoxicillin (only if culture results available and susceptible) ORcefALEXin ORco-amoxiclav (only if culture results available and susceptible)IV antibiotics (if vomiting, unable to take oral antibiotics or severely unwell)co-amoxiclav (only in combination with aminoglycosides below unless culture results confirm susceptibility) ORReview IV antibiotics by 48 hours and consider stepping down to oral where possible for a total of 10 dayscefUROXime ORcefTRIAXone (if sepsis) OR gentamicin (include if severe sepsis) ORamikacin (if high rates of gentamicin resistance)Peritoneal dialysis associated peritonitisLast updated: March 2020vancomycin PLUSciprofloxacinadded to dialysis fluid14 days74760662379133Return to contents020000Return to contentsSepsis74760675727065Return to contents020000Return to contentsSepsis of unknown origin Last updated: June 2020Fever <1 month without focus treat as sepsisFever 1-3 months without focus treat if unwell or WBC <5 or >15 x 109/LFever >3 months without focus treat if ‘red’ flag (see NICE guideline)If focus, treat as per localised infectionObtain appropriate cultures before starting antibiotic (including blood culture, urine (catheter if necessary), lumbar puncture)Start treatment within 1 hour of presentation Check previous microbiology results to determine if recent antibiotic-resistant organisms have been identified and contact the Infectious Diseases / Microbiology if: Patient has a previous history of carriage or infection with antibiotic-resistant organisms (e.g. Extended Spectrum Beta-Lactamase (ESBL) expressing organisms) amoxicillin/co-trimoxazole: Stop once Listeria infection is excluded (very rare >1 month)Neonatal Units follow Neonatal Guidelines, usually benzylpenicillin and gentamicinImmunosuppression: use febrile neutropenia guidance<72 hours old benzylpenicillin and gentamicin<3 monthcefTRIAXone (if contra-indications cefOTAXime)PLUS amoxicillin IV+/- aciclovir IV>3 monthcefTRIAXone +/- clindamycin; +/- gentamicinHistory of cephalosporin anaphylaxischloramphenicol PLUS vancomycin +/- gentamicin +/- acicloviraciclovir if <2 months, raised ALT, coagulopathy, maternal primary herpes simplex, vesicles, seizure or suspected meningitis/encephalitis, haemodynamically unstablegentamicinif severe sepsis requiring inotropes/critical care OR likely resistant organisms e.g. hospital acquiredvancomycin if travel outside UK or recent prolonged antibiotic exposure in last 3 monthsclindamycinif toxic shock (discuss IVIG with PID/micro)Minimum 5 days if rapid response; usually 7-10 days GBS 7 daysMeningococcus 7 daysLonger if S aureus, slow response, undrainable foci, immune deficiency cefTRIAXone: 2nd dose can be given 12-24hrs after 1st dose for OPAT HYPERLINK "" NICE NG51546036529845Return to contents00Return to contentsRCPCH p340 HYPERLINK "" Surviving Sepsis CampaignSepsis TrustCentral line associated blood-stream infectionLast updated: March 2020Cultures: take repeat blood cultures from CVC when the laboratory calls to say there is a positive blood culture. Two positive blood cultures with the same organism are highly suggestive of CVC infection. Repeat blood cultures (both CVC and peripheral) if fever persists and the child is not improving clinicallyRemove: all non-tunnelled venous catheters associated with confirmed blood stream infection is recommended promptly. Remove line if Staphylococcus aureus, Pseudomonas aeruginosa or Candida CVC infection, or if persistently positive blood cultures, despite treatment.Line lock: improves the chance of saving the Central Venous Catheter (CVC). Line locks are not useful in CVCs which have been inserted <14 days previously. Antibiotic line-lock should be locked into the catheter lumen for as long as possible (up to 48 hours), during periods when the catheter is not being used. The antibiotic lock should be aspirated before the line is used for other infusions. The amount instilled should be equivalent to the priming volumes printed on the catheter or clamp, but as a guide, the volume of antibiotic line locks prescribed should be no more than 1 ml for children under 2 years, and 2 ml for children 2 years and above. Suitable antibiotics for line locks; vancomycin (for Gram positive infections), aminoglycosides (for Gram negative infections) – discuss sensitivities with microbiology. Refer to local guidelines. Empiric treatment:teicoplanin OR vancomycinPLUS cefTRIAXone if septic+/- gentamicin if history of pseudomonasPenicillin allergy: teicoplanin OR vancomycin PLUS gentamicinIf line removed duration of antibiotics from 1st negative culture after line removal: - coagulase negative staphylococci 5-7 days- Staph aureus 14 days- enterococcus 7-14 days- Gram-negative bacilli 7-14 days- Candida 14 daysOther organisms discuss with microbiology/ infectious diseasesIf line stays in situ: - Coagulase negative staphylococci 10-14 days- Enterococcus 7-14 daysRCPCH p97HYPERLINK ""IDSA 2009Coagulase negative staphylococcus:teicoplanin OR vancomycinStaphylococcus aureus:flucloxacillin IVPenicillin allergy: teicoplanin OR vancomycinEnterococcus:amoxicillin IV (if sensitive) or teicoplanin OR vancomycin if amoxicillin resistantPenicillin allergy: teicoplanin OR vancomycinCandida spp (except C krusei/glabrata/lusitaneae):Liposomal amphotericin ORechinocandin (e.g. caspofungin)On parenteral nutrition (TPN)teicoplanin OR vancomycinPLUS gentamicinPLUS metronidazoleConsider piperacillin with tazobactam if severe sepsisConsider echinocandin (eg caspofungin) if unresponsive after 48 hrs74760675727700Return to contents020000Return to contentsHaematology /Oncology neutropenia <0.5 x 109/L and other immune-compromised sepsisLast updated: March 2020Organisms: Staphylococcus aureus, Streptococci, coliforms, Pseudomonas aeruginosaSee patient’s previous organisms cultured and empiric treatment should cover recent isolatesFollow local oncology protocolsNon-neutropenic:piperacillin with tazobactamNeutropenic:piperacillin with tazobactam PLUSgentamicin (if patient specific or local microbiological indications) ORamikacin (if high rates of gentamicin resistance)Neutropenic 2nd line:meropenem PLUS amikacinNon-anaphylactic penicillin allergy: meropenemAnaphylactic cephalosporin allergy: chloramphenicol OR ciprofloxacinPLUS gentamicin OR amikacin PLUS vancomycin HYPERLINK "" NICE CG151 Local resistance English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) Meningo-coccal disease prophylaxis Last updated: June 2020Expert advice is available for managing clusters of meningitis. Please alert the appropriate organisation to any cluster situation. Public Health England 0344 225 0562AWARe (all Wales Acute Response team) (tel: 0300 003 0032)Health Protection Scotland via local Health Board PHE7476067660400Return to contents020000Return to contentsMeningitis Bacterial meningitis(suspected or confirmed)Last updated: June 2020Start antimicrobial therapy <1 hour of presentationAfter lumbar puncture unless contraindicated Amoxicillin / co-trimoxazole: stop if Listeria not grown after 48 hours, Listeria rare >1-month-old Aciclovir: if <2 months, raised ALT, coagulopathy, maternal primary herpes simplex, vesicles, seizure or suspected meningitis/encephalitis, haemodynamically unstableVancomycin: If recent travel outside UK or recent prolonged antibiotic exposure in last 3 monthsClarithromycin: add if severely unwell or high suspicion of mycoplasmaDexamethasone 0.15 mg/kg to a maximum dose of 10 mg, four times daily for 4 days for children >3-month-old if ≤12 hours from first antibiotics and LP shows:· Frankly purulent CSF· CSF WBC count >1000/microlitre· Raised CSF WBC + protein >1 g/L· Bacteria on Gram stainNotify Public Health England 0344 225 0562 or Public Health Wales 0300 00 300 32Health Protection Scotland via local Health Board . < 3 months:cefTRIAXone (high dose) (if contraindications cefOTAXime) PLUSamoxicillin +/- aciclovir< 3 months14-21 days> 3 months10 daysNICE NG102 RCPCH p49BIA> 3 months:cefTRIAXone (high dose)+/- aciclovirHospital acquired:meropenemPenicillin allergy non-anaphylactic:cefTRIAXone (high dose) PLUS co-trimoxazole if <3 months old+/- aciclovirPenicillin/cephalosporin anaphylaxis:chloramphenicol (<1 month old)OR ciprofloxacinPLUS co-trimoxazole (if <3 months old)+/- aciclovir74760675384800Return to contents020000Return to contentsCulture negative suspected bacterial meningitisLast updated: March 2020cefTRIAXone Penicillin/cephalosporin anaphylaxis:chloramphenicol OR ciprofloxacin IV PLUSvancomycin(seek urgent PID/micro advice)< 3 months14 days> 3 months10 days74760665736166Return to contents00Return to contentsMeningitis organism specific guidanceOrganism AntibioticNon-anaphylactic penicillin allergyPenicillin/ cephalosporin anaphylaxisDurationGroup B streptococcuscefOTAXime or cefTRIAXonechloramphenicol OR vancomycin IVMinimum 14 daysListeria monocytogenes amoxicillin IV +gentamicin co-trimoxazole +gentamicinamoxicillin 21 days, gentamicin 7 daysGram negative bacillicefOTAXime or cefTRIAXonechloramphenicol OR ciprofloxacin IVMinimum 21 daysHaemophilus influenzae type bcefTRIAXone chloramphenicol OR ciprofloxacin IVTotal 10 daysStreptococcus pneumoniaecefTRIAXone chloramphenicol OR vancomycinTotal 14 daysNeisseria meningitidis (confirmed OR suspected)cefTRIAXone Meningococcal chemoprophylaxis ciprofloxacin single dose (see Sepsis above)chloramphenicol OR ciprofloxacin IVTotal 7 days Mycobacterium tuberculosisDiscuss with paediatric ID/TB specialistFungal meningitisDiscuss with Paediatric Infectious DiseasesEncephalitisLast updated: March 2020Meningo-encephalitis: treat for Meningitis (see above) PLUS EncephalitisRepeat LP after recommended duration and only stop IV aciclovir when PCR negative aciclovir PLUSclarithromycin (if respiratory symptoms)oseltamivir (in flu season)< 12 years old or immunosuppressed21 days then repeat LP> 12 years old14 days then repeat LPBPAIIG5436870100965Return to contents00Return to contentsRCPCH p596Then prophylaxis if < 3 months old OR immune deficiencyaciclovir or valaciclovir6-12 monthsNeuro-surgical infectionsLast updated: June 2020Ventricular shunt infectionVentriculitis with extraventricular/lumbar draincefOTAXime OR cefTRIAXone PLUSvancomycin 10 daysIDSABrain abscess / subdural empyemaPenetrating intracranial injurycefTRIAXone PLUSmetronidazoleCollection: 4-8 weeksInjury: 5 daysPost-operative meningitis1st linecefTRIAXone PLUS vancomycin if device or MRSA2nd linemeropenem PLUS vancomycin 10 daysPenicillin anaphylaxis for all neurosurgical infectionschloramphenicol OR ciprofloxacin IV PLUS vancomycin PLUS metronidazole if collection74760671205018Return to contents020000Return to contentsGastrointestinal tract infectionsOral candidiasisLast updated: March 2020Topical azoles are more effective than topical nystatin.Oral candidiasis is rare in immunocompetent adults; consider undiagnosed risk factors, including HIV. miconazole oral gel7?days; continue for 7?days after resolvedIf not tolerated: nystatin suspension7?days; continue for 2?days after resolvedfluconazole capsules7?to?14?daysInfectious diarrhoeaLast updated: March 2020Antibiotic therapy is not usually indicated unless patient is systemically unwell. If systemically unwell and campylobacter suspected (such as undercooked meat and abdominal pain), consider clarithromycin for 5 to 7?days, if treated early (within 3?days) If giardia is confirmed or suspected: metronidazole 3 daysBloody diarrhoea and septic: cefTRIAXone 5 daysBloody diarrhoea and known IBD consider ciprofloxacin IV/PO PLUS metronidazole IV/PO and discuss with GastroenterologySalmonella (non-typhoidal): self-limiting unless chronic GI tract disease, haemoglobinopathy, malignancy or immunocompromised: azithromycin oral 5 days (or amoxicillin if sensitive). If bacteraemic or enteric fever (typhoid bacteraemia) cefTRIAXone IV 10 – 14 days; oral stepdown azithromycin or ciprofloxacin if sensitiveListeria: amoxicillin (penicillin allergy: co-trimoxazole) 7 daysCryptosporidium: self-limiting, if immunosuppressed seek specialist adviceE. coli 0157: do not give antibiotics, consult PID/Micro7476066561551Return to contents020000Return to contentsHelico-bacter pyloriLast updated: March 2020Always test for H.pylori before giving antibiotics. Treat all positives if known DU or GU. NNT in non-ulcer dyspepsia: 14. Do not offer eradication for GORD. Do not use clarithromycin, metronidazole or quinolone if used in the past year for any infection. Always use PPI First line and first relapse and no penicillin allergy PPI PLUS 2 antibiotics7?days See PHE quick reference guide for diagnostic advice: PHE H.?pyloriamoxicillin PLUSclarithromycin ORmetronidazolePenicillin allergy clarithromycin PLUSmetronidazole with PPI Clostridioides difficile toxinLast updated: July 2020Review need for antibiotics, PPIs, and antiperistaltic agents and discontinue use where possible. Mild cases (<4 episodes of stool/day) may respond without metronidazole; 70% respond to metronidazole in 5?days; 92% respond to metronidazole in 14?days. If severe (T>38.5 or WCC>15, rising creatinine, or signs/symptoms of severe colitis): treat with oral vancomycin, review progress closely, and consider hospital referral. Discontinue antibiotics, PPI, anti-peristaltic agent where possibleConsider faecal microbiota transplantFirst episode: metronidazole 10 to 14?days Wolf J CID 2019Severe, type?027 or recurrent:oral vancomycin 10 to 14?days, then taper Recurrent or second line: fidaxomicin 10?days 74760674246033Return to contents020000Return to contentsTraveller’s diarrhoeaLast updated: March 2020Prophylaxis rarely, if ever, indicated. Consider standby antimicrobial only for patients at high risk of severe illness or visiting high-risk areas(see Infectious diarrhoea above)Standby: azithromycin 1 to 3?days Prophylaxis/treatment: bismuth subsalicylate2?days Shigella: self-limiting, if severe: azithromycin OR cefTRIAXone if systemically unwell5 daysGiardia: metronidazole3 daysThreadwormLast updated: March 2020Treat all household contacts at the same time. Advise hygiene measures for 2?weeks (hand hygiene; pants at night; morning shower, including perianal area). Wash sleepwear, bed linen, and dust and vacuum. Child <6?months, add perianal wet wiping or washes 3?hourly Child >6?months: mebendazole 1?dose; repeat in 2?weeks if persistent Child <6?months: only hygiene measure for 6?weeks AppendicitisLast updated: July 2020Surgical prophylaxiscefUROXime PLUS metronidazoleoral stepdown: co-amoxiclavPenicillin anaphylaxis:metronidazole PLUS ciprofloxacin IVIV pre-op, stop immediately post opIf gangrenous or perforated IV 72 hours post op then reviewRCPCH p409, 452, 495, 808, 820JAMA 2018;320(12):1259-1265Pediatrics 2017; 139: e2 0163003Ann Surg 2019;270:1028–1040Conservative managementamoxicillin PLUS gentamicin PLUS metronidazoleTHEN amoxicillin oralPenicillin allergy non-anaphylactic: cefUROXime PLUS metronidazolePenicillin/cephalosporin anaphylaxis:ciprofloxacin IV PLUS metronidazoleTHEN ciprofloxacin oral PLUS metronidazoleIV 24 hoursOral 7 days74760663765550Return to contents020000Return to contentsPeritonitis Last updated: March 2020Perforated appendicitis /abscess,First line: cefUROXime PLUS metronidazoleOR co-amoxiclav IV if not septicSecond line: amoxicillin PLUS gentamicin PLUS metronidazoleAssociated with underlying pathology: piperacillin with tazobactam PLUS gentamicinPenicillin anaphylaxis:gentamicin PLUS clindamycin3-7 dayslonger if non-drainable abscessIDSA 2010Necrotising enterocolitisLast updated: March 2020amoxicillin PLUSgentamicin PLUSmetronidazole5 daysIDSA 2010CholangitisLast updated: March 2020cefTRIAXone PLUSmetronidazole5 daysIDSA 201074760673092450Return to contents020000Return to contentsGenital tract infectionsChlamydia trachomatis/ urethritisLast updated: March 2020Opportunistically screen all sexually active patients for chlamydia annually and on change of sexual partner. If positive, treat index case, refer to GUM and initiate partner notification, testing and treatment. Consider safeguarding As single dose azithromycin has led to increased resistance in GU infections, doxycycline should be used first line for chlamydia and urethritis. Advise patient with chlamydia to abstain from sexual intercourse until doxycycline is completed or for 7 days after treatment with azithromycin (14?days after azithromycin started and until symptoms resolved if urethritis). If chlamydia, test for reinfection at 3 to 6?months following treatment Consider referring all patients with symptomatic urethritis to GUM as testing should include Mycoplasma genitalium and Gonorrhoea. If M.genitalium is proven, use doxycycline followed by azithromycin using the same dosing regimen and avoid sex for 14?days after start of treatment and until symptoms resolved. First line:doxycycline (not in under 12s) 7?days Second line/allergy/intolerance: azithromycin Stat Then 2?days (total 3?days) EpididymitisLast updated: March 2020Refer to GUMdoxycycline (not in under 12s) OR10 to 14?daysofloxacin OR14?daysciprofloxacin 10?daysHigh risk of STI: cefTRIAXone Single dosePLUS doxycycline (not in under 12s)10 daysVaginal candidiasisLast updated: March 2020All topical and oral azoles give over 80% cure. Recurrent (>4 episodes per year): oral fluconazole every 72?hours for 3 doses induction, followed by 1 dose once a week for 6?months maintenance. clotrimazole ORStat fenticonazole ORStat oral fluconazole Stat If recurrent: fluconazole (induction/maintenance) 3?doses – once every 72 hours then weekly for 6?months 74760671390650Return to contents020000Return to contentsBacterial vaginosisLast updated: March 2020Oral metronidazole is as effective as topical treatment, and is cheaper. 7?days results in fewer relapses than 2g stat at 4?weeks. oral metronidazole OR7?days metronidazole 0.75% vaginal gel OR 5?nights clindamycin 2% cream 7?nights Genital herpesLast updated: March 2020Advise: saline bathing, analgesia, or topical lidocaine for pain, and discuss transmission. First episode: treat within 5?days if new lesions or systemic symptoms, and refer to GUM, consider safeguardingRecurrent: self-care if mild or immediate short course antiviral treatment, or suppressive therapy if more than 6 episodes per year. oral aciclovir OR5?days valaciclovir (licensed >12 yrs) OR5?days famciclovir (licensed >12 yrs)5?days GonorrhoeaLast updated: March 2020Antibiotic resistance is now very high. Use IM cefTRIAXone if susceptibility not known prior to treatment Use ciprofloxacin only If susceptibility is known prior to treatment and the isolate is sensitive to ciprofloxacin at all sites of infection Refer to GUM. Test of cure is essential. Consider safeguardingcefTRIAXone ORStat ciprofloxacin (only if known to be sensitive)Stat TrichomoniasisLast updated: March 2020Oral treatment needed as extra-vaginal infection common. Treat partners and refer to GUM for other STIs. Consider safeguardingmetronidazole 5 to 7 day 7476066494454Return to contents020000Return to contentsPelvic inflammatory diseaseLast updated: March 2020Refer women and sexual contacts to GUM, consider safeguarding. Raised CRP supports diagnosis, absent pus cells in HVS smear good negative predictive value. Exclude: ectopic pregnancy, appendicitis, endometriosis, UTI, irritable bowel, complicated ovarian cyst, functional pain. Moxifloxacin has greater activity against likely pathogens, but always test for gonorrhoea, chlamydia, and M. genitalium. If M. genitalium tests positive use moxifloxacin. First line therapy: cefTRIAXone PLUSStatBASHHmetronidazole PLUS14?days doxycycline (not in under 12s) OR azithromycin if <12 yrs old14?days Second line therapy:metronidazole PLUS14?days ofloxacin OR14?days moxifloxacin alone (first line for M. genitalium associated PID)14?days Penicillin allergy:gentamicin PLUS clindamycin IV 24 hoursOral: metronidazole PLUS doxycycline (not in under 12s) OR azithromycin if <12 yrs oldSexual assaultLast updated: July 2020GU/SARC needs assessmentSee BASHH/BHIVA guidelines for HIV post exposure prophylaxis and hepatitis B vaccineFirst line:cefTRIAXone IV/IM single dose PLUSazithromycin 3 doses PLUSmetronidazole oral single doseBASHHPenicillin allergy:azithromycin 3 doses PLUSmetronidazole single doseBalanitisLast updated: June 2020Do not attempt to retract the foreskinDo not use soapBacterial: painful redness of the glans penis, oedema, erosions, purulent exudateNon-specific:clotrimazole 1% cream 8-12 hrly PLUS hydrocortisone 1% cream or ointment daily14 daysNICE CKSBacterial:flucloxacillin7 days74760671350856Return to contents020000Return to contentsOrchitisLast updated: June 2020Aetiology:ViralAutoimmuneUTISTINot-sexually active:ciprofloxacin10-14 daysEAU Guidelines on Urological Infections 2016Sexually active: cefTRIAXone PLUSSingle dosedoxycycline10-14 days74760675729605Return to contents020000Return to contentsSkin and soft tissue infectionsImpetigoLast updated: July 2020Consider first line: hydrogen peroxide 1% topical.Reserve topical antibiotics for very localised lesions to reduce risk of bacteria becoming resistant. Only use mupirocin if caused by MRSA. Extensive, severe, or bullous: oral antibiotics. Topical fusidic acid 5?days NICE NG153Francis NA NIHR 2016 If MRSA: topical mupirocin 5?days More severe: oral flucloxacillin OR if not tolerated co-amoxiclav suspension OR7?days oral clarithromycin if penicillin allergy7?days PVL-Staph aureusLast updated: July 2020Panton-Valentine Leukocidin (PVL) is a toxin produced by 20.8?to?46% of S. aureus from boils/abscesses. PVL strains are rare in healthy people, but severe. Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking. Risk factors for PVL: recurrent skin infections; invasive infections; MSM; if there is more than one case in a home or close community (school children; household contacts). Follow local antibiotic guidelines for the specific type of infection ADD clindamycin if there are any features suggestive of PVL-SA ADD linezolid if MRSA is suspected based on contact history, travel history or failure to respond to treatment, or once PVL status is confirmedBone/Joint: Initial Phase of treatment: Intravenous clindamycin plus linezolid plus rifampicin until inflammatory markers return to normal and infection is controlled (absolute maximum of 4-weeks of linezolid treatment, ideally only 2-3 weeks) Continuation phase of treatment: IV / Oral clindamycin plus rifampicin, duration & route directed by a specialist in Paediatric Infectious DiseasesSevere sepsis/Pneumonia: If clindamycin sensitive, use clindamycin plus rifampicin +/- linezolid; if resistant, use linezolid plus rifampicinGuidance on the diagnosis and management of PVL-associated Staphylococcus aureus infections (PVL-SA) in EnglandEczemaLast updated: July 2020No visible signs of infection: antibiotic use (alone or with steroids) encourages resistance and does not improve healing. With visible signs of infection: use oral flucloxacillin OR if not tolerated co-amoxiclav suspension OR oral clarithromycin if penicillin allergy OR topical treatment (as in impetigo). Eczema herpeticum: aciclovir 5 daysNICE CG575 days7476066361315Return to contents020000Return to contentsCellulitis and erysipelasLast updated: July 2020Exclude other causes of skin redness (inflammatory reactions or non-infectious causes).Consider marking extent of infection with a single-use surgical marker pen.Offer an antibiotic. Take account of severity, site of infection, risk of uncommon pathogens, any microbiological results and MRSA status. Infection around eyes or nose is more concerning because of serious intracranial complications.*A longer course (up to 14 days in total) may be needed but skin takes time to return to normal, and full resolution at 5 to 7 days is not expected.Do not routinely offer antibiotics to prevent recurrent cellulitis or erysipelas.For detailed information click on the visual summary.First choice:flucloxacillin (IV if severe)5 to 7 days*NICE NG141Moran GJ JAMA. 2017 Aboltins CA J Antimicrob Chemother. 2015 Chen AE et al.? Pediatrics. 2011 Parish LC,?Int?J?Clin?Pract?2000Mallory SB Am J Med 1991Dillon HC Jr. J Am Acad Dermatol. 1983 or if flucloxacillin unsuitable/not tolerated:co-amoxiclav ORIf penicillin allergyclarithromycin ORIf infection near eyes or nose:co-amoxiclav 7 daysIf infection near eyes or nose (penicillin allergy):clarithromycin PLUS5 to 7 daysmetronidazole (only add in children if anaerobes suspected)7 daysAlternative choice antibiotics for severe infectionco-amoxiclav OR7 daysIf penicllin allergycefUROXime ORIf penicillin anaphylaxisclindamycin ORteicoplaninFor suspected or confirmed MRSA infectionvancomycin ORteicoplanin ORlinezolid (specialist use only)7476066683683Return to contents020000Return to contentsLeg ulcerLast updated: March 2020Ulcers are always colonisedAntibiotics do not improve healing unless active infection (only consider if purulent exudate/odour; increased pain; cellulitis; pyrexia). flucloxacillin OR7?days If slow response continue for another 7?days clarithromycin Non-healing ulcers: antimicrobialreactive oxygen gel may reduce bacterial load. AcneLast updated: July 2020Mild (open and closed comedones) or moderate (inflammatory lesions): First line: self-care (wash with mild soap; do not scrub; avoid make-up). Second line: topical retinoid or benzoyl peroxide. Third-line: add topical antibiotic, or consider addition of oral antibiotic. Severe (nodules and cysts): add oral antibiotic (for 3 months max) and refer.Second line: topical retinoid (e.g. adapalene) OR6 to 8?weeks benzoyl peroxide Third line: topical clindamycin 12?weeks If treatment failure/severe: oral tetracycline (not in under 12s) OR6 to 12?weeks oral doxycycline (not in under 12s)clarithromycin (under 12s)Soft tissue injuryLast updated: March 2020Clean: no antibioticsContaminated: prophylaxisInfected: treat and review after 3 daysCheck tetanus immunisation statusco-amoxiclavPenicillin allergy:clindamycin3 days 74760671383453Return to contents020000Return to contentsNecrotising fasciitisLast updated: March 2020Discuss all suspected cases with intensive care, surgeons and micro/IDUrgent surgical debridement essential and send specimens for cultureLocal authorisation required for IVIGpiperacillin with tazobactam ORmeropenem (if high risk ESBL or non-anaphylactic penicillin allergy)PLUSclindamycin IVPenicillin anaphylaxis:teicoplanin OR vancomycin PLUSclindamycin PLUSciprofloxacin PLUSgentamicin single doseScabiesLast updated: July 2020First choice permethrin: Treat whole body from ear/chin downwards, and under nails. If using permethrin and patient is under 2?years, elderly or immunosuppressed, or if treating with malathion: also treat face and scalp. Home/sexual contacts: treat within 24?hours. permethrin 5% cream2 applications, 1?week apart Permethrin allergy: Malathion 0.5% aqueous liquid Surgical site infectionLast updated: March 2020Not all infections require treatment with antibiotics, minor infections may respond to drainage of pus (for example by removal of sutures) and topical antiseptics. Deep seated infections may need surgical debridement and prosthetic material should be removed where possible. If systemic antibiotics required:flucloxacillin IVif risk of faecal contaminationco-amoxiclav IV (oral stepdown)if MRSA or penicillin anaphylaxisvancomycin PLUS gentamicin if faecal contamination orPLUS ciprofloxacin if not improving5 days(longer for deep surgical infection; very long courses for prosthetic material in situ)74760671604433Return to contents020000Return to contentsBitesLast updated: March 2020Human: thorough irrigation is important. Antibiotic prophylaxis is advised. Assess risk of tetanus, rabies, HIV, and hepatitis B and C. Cat: always give prophylaxis. , Dog: give prophylaxis if: puncture wound, bite to hand, foot, face, joint, tendon, or ligament; immunocompromised; cirrhotic; asplenic; or presence of prosthetic valve/joint. Penicillin allergy: Review all at 24 and 48?hours, as not all pathogens are covered. Tetanus: ask about immunisation status and administer vaccine if not received within past 10 yearsRabies: consider for animal bites overseas (discuss risk assessment with PHE)Other animals discuss with ID/MicroProphylaxis/treatment all: co-amoxiclav Human bite and penicillin allergy:metronidazole PLUS clarithromycin Animal and penicillin allergy: metronidazole PLUS doxycycline (not in under 12s) OR azithromycin <12 yrs old7?days NICE: Human and animal bites: antimicrobial prescribingPHE SummaryPHE Rabies: risk assessment, post-exposure treatment, management Deep bites:co-amoxiclav IVDeep bites with penicillin allergy:cefUROXime OR cefTRIAXone if septic PLUSmetronidazolePenicillin anaphylaxis: clindamycin PLUS ciprofloxacinMRSA de-colonisationLast updated: March 2020mupirocin nasalPLUS octenidine (Octenisan?) ORchlorhexidine body wash5 days74760661947333Return to contents020000Return to contentsBurns (secondary infection)Last updated: March 2020Only treat if signs of clinical infection, prophylaxis is not requiredMild-moderate infection:flucloxacillinSecond lineco-amoxiclavpenicillin allergy:clarithromycin7 daysSevere infection:cefTRIAXoneif known Pseudomonas colonised:piperacillin with tazobactampenicillin allergy:clindamycinDermato-phyte infection: skinLast updated: July 2020Most cases: use terbinafine as fungicidal, treatment time shorter and more effective than with fungistatic imidazoles or undecenoates. If candida possible, use imidazole. If intractable, or scalp: send skin scrapings, and if infection confirmed: use oral terbinafine or itraconazole. Scalp: oral therapy, and discuss with specialist. topical terbinafine OR1 to 4?weeks NICE CKS bodyNICE CKS scalpNICE CKS foottopical imidazole4 to 6?weeks Alternative in athlete’s foot:topical undecenoates (such as Mycota?)74760673259667Return to contents020000Return to contentsDermato-phyte infection: nailLast updated: July 2020Take nail clippings; start therapy only if infection is confirmed. Oral terbinafine is more effective than oral azole. Liver reactions 0.1?to?1% with oral antifungals. If candida or non-dermatophyte infection is confirmed, use oral itraconazole. Topical nail lacquer is not as effective. , To prevent recurrence: apply weekly 1% topical antifungal cream to entire toe area. Children: seek specialist advice. First line: terbinafine oralFingers: 6?weeksToes: 12?weeksNICE CKSSecond line: itraconazole oral1?week a month Fingers: 2?coursesToes: 3?courses Stop treatment when continual, new, healthy, proximal nail growth. Varicella zoster/ chickenpoxHerpes zoster/ shinglesLast updated: June 2020Immunocompromised/neonate: seek urgent specialist advice. Chickenpox: consider aciclovir if: onset of rash <24?hours, and 1 of the following: >14?years of age; severe pain; dense/oral rash; taking steroids; smoker. Give paracetamol for pain relief. See Cellulitis Shingles: treat if >50?years (PHN rare if <50?years) and within 72?hours of rash, or if 1 of the following: active ophthalmic; Ramsey Hunt; eczema; non-truncal involvement; moderate or severe pain; moderate or severe rash.Shingles treatment if not within 72?hours: consider starting antiviral drug up to 1?week after rash onset, if high risk of severe shingles or continued vesicle formation; older age; immunocompromised; or severe painFirst line for chicken pox and shingles: aciclovir IV OR if >12 years old: valaciclovir7 daysSecond line for shingles if poor compliance: valaciclovir if >12 years oldHerpes simplexLast updated: March 2020Skin lesions (cold sore, whitlow): start treatment if <48 hours from onset if severeNeonatal skin-eye-mouth:Treatment: IV aciclovir high doseProphylaxis: oral aciclovir or valaciclovir14 days minimum (treatment)6 months (prophylaxis with follow up)NICE CG57RCPCH p594Gingivostomatitis (if <72h from onset):aciclovir oral or IV5 daysIf new lesions during treatment, then continue until 3 days after lesions heal overEczema herpeticum / immunocompromised:aciclovir IVSkin lesions:aciclovir oral if severe7476066578485Return to contents020000Return to contentsTick bites (Lyme disease)Last updated: March 2020Prophylaxis: not routinely recommended If immunocompromised, consider prophylactic doxycycline. 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 net advice about erythema migrans and other possible symptoms that may occur within 1 month of tick removal. Prophylaxis: doxycycline (not in under 12s)amoxicillin (<12 years old)Penicillin allergy:azithromycinStatNICE NG95Treatment: Treat erythema migrans empirically; serology is often negative early in infection. For other suspected Lyme disease such as neuroborreliosis (CN palsy, radiculopathy) seek advice.Treatment:doxycycline (not in under 12s)21?days Alternative: amoxicillin (<12 years old)Penicillin allergy:azithromycinHead liceLast updated: June 2020Wet combing or dimeticone 4% lotion is recommended first-line for pregnant or breastfeeding women, young children aged 6 months to 2 years, and people with asthma or eczema.All?affected family members should be treated on the same day to avoid reinfectionPhysical insecticide:dimeticone 4%?gel, lotion, or spray (Hedrin??Once or Lotion; Chemists' Own??Head Lice Spray)?dimeticone 92% spray (NYDA?) dimeticone > 95% lotion (Linicin??Lotion)?isopropyl myristate and cyclomethicone solution (Full Marks Solution?) isopropyl myristrate and isopropyl alcohol aerosol (Vamousse?Head Lice Treatment)NICE CKSChemical Insecticide:Malathion 0.5% aqueous liquid (Derbac-M?)Wet combing:Bug Buster?74760663129915Return to contents020000Return to contentsEye infectionsConjunctivitisLast updated: July 2020First line: bath/clean eyelids with cotton wool dipped in sterile saline or boiled (cooled) water, to remove crusting.Treat only if severe as most cases are viral or self-limiting.Bacterial conjunctivitis: usually unilateral and also self-limiting. It is characterised by red eye with mucopurulent, not watery discharge. 65% and 74% resolve on placebo by days 5 and 7.Third line: fusidic acid as it has less Gram-negative activity.Neonates: see Ophthalmia neonatorum below Second line:chloramphenicol 0.5% eye drop OR1% ointment48?hours after resolution RCPCH p501College of Optometrists, Clinical Management GuidelinesBASHHThird line:fusidic acid 1% gelHerpes simplex: same day Eye Casualty<1 month: aciclovir IV>1 month: aciclovir oralOlder children: ganciclovir 0.15% eye gel14 daysSevere: aciclovir IV THEN valaciclovir PO7-14 daysChlamydiaerythromycin14 daysBlepharitisLast updated: July 2020First line: lid hygiene for symptom control, including: warm compresses; lid massage and scrubs; gentle washing; avoiding cosmetics. Second line: topical antibiotics if hygiene measures are ineffective after 2?weeks. Signs of meibomian gland dysfunction, or acne rosacea: consider oral antibiotics.Second line:topical chloramphenicol6-week trial Third line: oral oxytetracycline OR oral doxycycline (not in under 12s)4?weeks (high dose) 8?weeks (low dose) (<12 years old)erythromycin2 weeks 7476067508000Return to contents020000Return to contentsPre-septal/ peri-orbital and orbital cellulitisLast updated: July 2020Treat as orbital cellulitis if: Cannot see eye movementsEye movements restricted Conditions worsens after 24 hrs therapyUnsure if pre-septal or orbital cellulitis or <2 years oldIf pre-septal or uncomplicated orbital cellulitis step down to co-amoxiclav when afebrile and clinical improvementMild pre-septal:co-amoxiclav penicillin allergy:clarithromycin5 daysRCPCH p156-159Oral not toleratedco-amoxiclav IVpenicillin allergy:clindamycin PLUS ciprofloxacinIV 24-48 hours then oral 7 daysOrbital cellulitis:cefTRIAXone PLUS metronidazole PLUSvancomycin (if MRSA colonised)Penicillin anaphylaxis:chloramphenicol PLUS metronidazole ORciprofloxacin IV PLUS vancomycin PLUS metronidazole Oral stepdown if no intracranial involvement: co-amoxiclavPenicillin allergy:clindamycin14 days minimumOphthalmia neonatorumLast updated: March 2020Urgent ophthalmology reviewSwab for chlamydia and gonococcusConsider HSV is vesiclescefOTAXime single dose IV immediately PLUSgentamicin 0.3% eye drops PLUSaciclovir if concern HSV PLUSazithromycin after discussion with PID/GU3 days7476067324485Return to contents020000Return to contentsBone and Joint infectionsOsteomyelitis Septic ArthritisLast updated: July 2020Unifocal disease indicates “simple” disease at a single site. Complex disease includes multifocal, significant bone destruction, resistant or unusual pathogen, immunosuppression, sepsis or shock<3 months:cefOTAXime ORcefTRIAXone IVOral after 14-21 days:co-amoxiclav OR cefALEXinIF: afebrile, pain free >24 hours, CRP <20 or reduced by 2/3 highest value3-4 weeks in septic arthritis4-6 weeks in osteomyelitisComplex disease IV to oral switch after 14 days; may require >6 weeks of treatment. Consult Orthopaedics and micro/IDRCPCH p65Managing bone and joint infection in children Arch Dis Child 2012;97:545-553 >3 months – ≤5 years:cefUROXime IVOral after 72 hours:co-amoxiclav OR cefALEXinIF: afebrile, pain free >24 hours, CRP <20 or reduced by 2/3 highest value≥6yearsflucloxacillin IVOral after 72 hours:6-8 years: flucloxacillin OR co-amoxiclav 8-19 years: flucloxacillin OR clindamycinPenicillin allergy:cefUROXime OR cefTRIAXone oral step down to clindamycinPenicillin anaphylaxis: clindamycin Staph. aureus: flucloxacillinMRSA: teicoplanin OR vancomycinMetal work:teicoplanin OR vancomycin PLUS rifampicin if Staph aureusSickle cell or no Hib vaccine:cefTRIAXone oral step down to ciprofloxacin Open fractureLast updated: March 2020On presentation to Emergency Deptco-amoxiclav Penicillin allergy:cefTRIAXone Penicillin anaphylaxis: clindamycin PLUS ciprofloxacin3 daysEndocarditis74760665737013Return to contents020000Return to contentsEndocarditisLast updated: March 2020Empiric treatmentNative valveamoxicillin (high dose) IV PLUSflucloxacillin (high dose) IV PLUSgentamicin IV (low dose)Penicillin allergy:vancomycin IV PLUS gentamicinUntil pathogen identificationgentamicin 7 days2015 Guidelines for the management of infective endocarditis. European Heart Journal, 36(44), 3075-3128Native valve + severe sepsis and risk factors for ESBLvancomycin IV PLUSmeropenem IV (high dose)Prosthetic valveteicoplanin OR vancomycin IV PLUSgentamicin IV PLUS rifampicin PONative ValvesStrep. bovis and oral strep with penicillin MIC <0.125mg/Lbenzylpenicillin 25 mg/kg 4 hrly IVOR cefTRIAXone 100 mg/kg daily ORbenzylpenicillin 25 mg/kg 4 hrly IVOR cefTRIAXone 100 mg/kg daily PLUS gentamicin 3 mg/kg daily IVPenicillin anaphylaxis: teicoplanin OR vancomycin 4 weeks2 weeks6 weeksStrep. bovis and oral strep with penicillin MIC 0.25-2 mg/Lbenzylpenicillin 50 mg/kg 4 hrly IVOR cefTRIAXone 100 mg/kg daily PLUS gentamicinPenicillin allergy:teicoplanin OR vancomycin PLUS gentamicin4 weeks IV course:2 weeks of gentamicin onlyStaphylococcus (MSSA)flucloxacillin 50 mg/kg 6 hrly IV penicillin allergy:co-trimoxazole 1 week IV and 5 weeks PO PLUSclindamycin 1 week 4-6 weeksMethicillin resistant Staphylococcus aureusvancomycin IV OR daptomycin IV4-6 weeksEnterococciamoxicillin IV PLUSgentamicin IVPenicillin allergy:teicoplanin OR vancomycin IV PLUSgentamicin IV4-6 weeks2-6 weeks of gentamicinProsthetic valvesStaphylococcus (MSSA)flucloxacillin IV PLUSrifampicin PO PLUSgentamicin IVPenicillin allergy: see MRSA>6 weeks>6 weeks2 weeksMethicillin resistant Staphylococcus aureusteicoplanin OR vancomycin IV PLUSrifampicin PO PLUSgentamicin IV>6 weeks>6 weeks2 weeks74760672201334Return to contents020000Return to contents77101705758815 HYPERLINK \l "Header" Return to contents(control click)020000 HYPERLINK \l "Header" Return to contents(control click)Suspected dental infections (outside dental settings)Derived from the Scottish Dental Clinical Effectiveness Programme (SDCEP) 2013 Guidelines. This guidance is not designed to be a definitive guide to oral conditions. Patients presenting to non-dental services with dental problems should be directed to their regular dentist, or if this is not possible, to the NHS 111 service (in England), who will be able to provide details of how to access emergency dental care.Mucosal ulceration and inflammation (simple gingivitis)Last updated: March 2020Temporary pain and swelling relief can be attained with saline mouthwash (? tsp salt in warm water). Use antiseptic mouthwash if more severe, and if pain limits oral hygiene to treat or prevent secondary infection. The primary cause for mucosal ulceration or inflammation (aphthous ulcers; oral lichen planus; herpes simplex infection; oral cancer) needs to be evaluated and treated.chlorhexidine 0.12?to?0.2% (do not use within 30?minutes of toothpaste) ORAlways spit out after use. Use until lesions resolve orless pain allows for oral hygieneDiscourage use of whitening toothpaste hydrogen peroxide 6% Gingivitis necrotising ulcerative Last updated: March 2020Refer to dentist for scaling and hygiene advice. Antiseptic mouthwash if pain limits oral hygiene. Commence metronidazole if systemic signs and symptoms.chlorhexidine 0.12?to?0.2% (do not use within 30 minutes of toothpaste) ORUntil pain allows for oral hygiene hydrogen peroxide 6%metronidazole 3?daysPericoronitisLast updated: March 2020Refer to dentist for irrigation and debridement. If persistent swelling or systemic symptoms, use metronidazole or amoxicillin. Use antiseptic mouthwash if pain and trismus limit oral hygiene. metronidazole OR3?days amoxicillinchlorhexidine 0.2% (do not use within 30 minutes of toothpaste) ORUntil less pain allows for oral hygiene hydrogen peroxide 6%74760662061845Return to contents020000Return to contentsDental abscessLast updated: March 2020Regular analgesia should be the first option until a dentist can be seen for urgent drainage, as repeated courses of antibiotics for abscesses are not appropriate. Repeated antibiotics alone, without drainage, are ineffective in preventing the spread of infection. Antibiotics are only recommended if there are signs of severe infection, systemic symptoms, or a high risk of complications. Patients with severe odontogenic infections (cellulitis, plus signs of sepsis; difficulty in swallowing; impending airway obstruction) should be referred urgently for hospital admission to protect airway, for surgical drainage and for IV antibiotics. The empirical use of cephalosporins, co-amoxiclav, clarithromycin, and clindamycin do not offer any advantage for most dental patients and should only be used if there is no response to firstline drugs. If pus is present, refer for drainage, tooth extraction, or root canal. Send pus for investigation. If spreading infection (lymph node involvement or systemic signs, that is, fever or malaise) ADD metronidazole. Use clarithromycin in true penicillin allergy and, if severe, refer to hospital. amoxicillin ORUp to 5?days; review at 3?days phenoxymethylpenicillinmetronidazolePenicillin allergy: clarithromycinSickle cell diseaseFever with no focus cefTRIAXonePLUS clarithromycin (if chest involvement)If no bacterial focus identified and clinically improving consider stopping antibioticSeptic arthritis / osteomyelitiscefTRIAXoneSeek urgent PID/Orthopaedic inputPneumonia (acute chest syndrome)cefTRIAXonePLUS clarithromycin5-7 daysProphylaxisLast updated: June 2020phenoxymethylpenicillin (penicillin V)Penicillin allergy: erythromycin After completing treatmentTo continue 75184002547832Return to contents020000Return to contentsAbbreviationsBASHH: British Association of Sexual Health and HIVBPAIIG: British Paediatric Allergy Immunology Infection GroupBTS: British Thoracic SocietyIDSA: Infectious Disease Society of AmericaNICE: National Institute for Health and Care ExcellencePHE: Public Health EnglandPID: Paediatric Infectious DiseasesRCPCH: Manual of Childhood Infections 2016 4th edition72898003344334Return to contents020000Return to contentsSARC: Sexual Assault Referral CentreContributorsELCH: Evelina Children’s Hospital, Antibiotic Use in Paediatrics, Clinical GuidelineNWPAIG: North West Paediatric Allergy Infection Group Hospitals & Trusts: Royal Manchester Children’s, Manchester Foundation Trust, Alder Hey, Northern Care Alliance, Royal Blackburn, Arrowe Park, Royal Bolton, Stepping Hill, Royal Albert Edward Infirmary, Royal Preston, Ysbyty Gwynedd (Bangor), PHE North West, Warrington and Halton, Stockport, Macclesfield, Countess of Chester, Tameside and Glossop, Blackpool Victoria, Lancashire Teaching Hospitals, East Cheshire, Wirral University Teaching Hospital RACH: Royal Alexandra Children’s Hospital, Brighton and Sussex University HospitalsSouthampton: University Hospital of Southampton NHS Foundation (Microguide) Sheffield: Sheffield Children’s NHS Foundation Trust74760663505200Return to contents020000Return to contentsSt George’s: St George’s University Hospital NHS Foundation Trust (Microguide)Appendix 1: PHE Antimicrobial Stewardship72136005672031Return to contents020000Return to contentsAppendix 2: Prescribing in penicillin allergyDO NOT USEContra-indicatedAVOIDUnless no safe alternativeSAFEExamples includeLists are not exhaustive – see current BNF for full detailsAmoxicillinBenzylpenicillinCo-amoxiclavFlucloxacillinPenicillin GPenicillin VPhenoxymethylpenicillinPiperacillin+TazobactamTazocin?TemocillinTicarcillin+Clavulanic AcidTimentin?Cefalexin (1st Generation)Cefuroxime (2nd Generation)Cefixime (3rd Generation)Cefotaxime (3rd Generation)Ceftazidime (3rd Generation)Ceftriaxone (3rd Generation)ErtapenemImipenem+CilastatinMeropenemAmikacinCiprofloxacinClarithromycinClindamycinDaptomycinDoxycyclineFosfomycinGentamicinLevofloxacinMetronidazoleNitrofurantoinTeicoplaninTrimethoprimVancomycinContraindications to cefTRIAXone: give cefOTAXimeConcomitant treatment with intravenous calcium (including total parenteral nutrition containing calcium) in premature and full-term neonatesFull-term neonates with jaundice, hypoalbuminaemia, acidosis, unconjugated hyperbilirubinaemia, or impaired bilirubin binding<41 weeks corrected gestational age74760671498600Return to contents020000Return to contentsCefTRIAXone: 2nd dose can be given 12-24hrs after 1st dose for ease of OPAT ................
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