Management of infection in primary care Brighton & Hove CCG

Adapted for local use High Weald Lewes Havens CCG

Aims:
1. To provide a simple, empirical approach to the treatment of common infections
2. To promote the safe, effective and economic use of antibiotics
3. To minimise the emergence of bacterial resistance in the community.

Principles of Treatment:
1. This guidance is based on the best available evidence but use professional judgement and involve
patients in management decisions
2. This guidance should not be used in isolation; it should be supported with patient information about
safety netting, delayed/back –up antibiotics, self-care, infection severity and usual duration, clinical staff
education, and audits. Materials are available on the RCGP TARGET website
3. Prescribe an antibiotic only when there is likely to be a clear clinical benefit, giving alternative, non-
antibiotic self-care advice, where appropriate.
4. Consider a ‘no’, or ‘delayed/back-up’, antibiotic strategy for acute self-limiting upper respiratory tract
infections and mild UTI symptoms.
5. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible,
particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information
about symptom monitoring, and how to access medical care if they are concerned.
6. Where an empirical therapy has failed or special circumstances exist, microbiology advice can be
obtained from 01273 664619
7. Limit prescribing over the telephone to exceptional cases.
8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav,
quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the
risk of Clostridium difficile, MRSA and resistant UTIs.
9. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested,
but they may need modification for age, weight, renal function, or if immunocompromised. In severe or
recurrent cases, consider a larger dose or longer course.
10. Refer to the BNF for further dosing and interaction information (e.g. the interaction between macrolides
and statins), and check for hypersensitivity.
11. Have a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities;
consider culture/specimens, and seek advice.
12. Avoid widespread use of topical antibiotics, especially in those agents also available systemically; in
most cases, topical use should be limited.
13. In pregnancy, take specimens to inform treatment, where possible, AVOID tetracyclines,
aminoglycosides, quinolones, azithromycin (except in chlamydial infection), clarithromycin and high dose
metronidazole (2g) unless the benefits outweigh the risks. Penicillins, cephalosporins and erythromycin
are safe in pregnancy. Short-term use of nitrofurantoin is not expected to cause foetal problems
(theoretical risk of neonatal haemolysis). Trimethoprim is also unlikely to cause problems unless poor
dietary folate intake, or taking another folate antagonist.
14. This guidance is developed alongside the NHS England Antibiotic Quality Premium. The required
performance in 2017/19 is: a 10% reduction (or greater) in the number of E. coli blood stream infections
across the whole health economy; a 10% reduction (or greater) in the trimethoprim: nitrofurantoin
prescribing ratio for UTI in primary care, and a 10% reduction (or greater) in the number of trimethoprim
items prescribed to patients aged 70 years or greater; sustained reduction of inappropriate prescribing in
primary care.
15. We recommend clarithromycin locally over erythromycin as it has less side-effects, and greater
compliance as twice rather than four times daily & generic tablets are similar cost.
16. Please find a Printable Self-assessment checklist for all prescribers to monitor your prescribing practice.

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
UPPER RESPIRATORY TRACT INFECTIONS
Give the TARGET ‘Manage your Infection leaflet’ when you think patients may benefit from a no or delayed antibiotic prescription.
Influenza Annual vaccinations essential for all those “at risk” of influenza. Antivirals are not recommended for healthy adults.
treatment Treat ‘at risk’ patients with 5 days oseltamivir 75mg BD, when influenza is circulating in the community, and ideally
PHE Influenza within 48 hours of onset (36 hours for zanamivir treatment in children), or in a care home where influenza is likely.
At risk: pregnant (including up to two weeks post-partum), children under 6 months, adults 65 years or over, chronic
Influenza
prophylaxis respiratory disease (including COPD and asthma) significant cardiovascular disease (not hypertension), severe
NICE Influenza immunosuppression, diabetes mellitus, chronic neurological, renal or liver disease, morbid obesity (BMI ≥40).
See the PHE Influenza guidance for the treatment of patients under 13 years of age. In severe immunosuppression or
oseltamivir resistance, use zanamivir 10mg BD (2 inhalations by Diskhaler for up to 10 days) and seek advice.
Acute sore Avoid antibiotics as 82% of cases resolve Fever PAIN 0-1:self-care
throat in 7 days, and pain is only reduced by 16
NICE RTIs hours. If Fever PAIN 2-3:
delayed prescription of:
Use Fever PAIN score: Fever in last 24
CKS
hours, purulence, rapid onset under 3 If Fever PAIN 4-5:
Fever PAIN days, severely Inflamed tonsils, No cough immediate prescription
or coryza. of:
Score 0-1: 13-18% streptococci, - NO phenoxymethylpenicillin 500mg QDS 10 days
antibiotic.
Score 2-3: 34-40% streptococci - 3 day
delayed antibiotic;
Score 4-5: 62-65% streptococci- if severe, Penicillin allergy:
immediate antibiotic or 48 hour short clarithromycin 500mg BD 5 days
delayed antibiotic
Advise paracetamol, self-care, & safety
net.
Complications are rare: antibiotics to
prevent Quinsy NNT>4000, otitis media
NNT 200.
10 days penicillin has lower relapse than 5
days in patient’s under 18 years of age.
Scarlet fever Prompt treatment with appropriate First line (mild):
(GAS) antibiotics significantly reduces the risk of analgesia
complications. and
PHE Scarlet phenoxymethylpenicillin 500mg QDS 10 days
Observe immunocompromised individuals
fever
(diabetes; women in the puerperal period; Penicillin allergy:
chickenpox) as they are at increased risk of clarithromycin 500mg BD 5 days
developing invasive infection

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
UPPER RESPIRATORY TRACT INFECTIONS continued
Acute otitis Optimise analgesia amoxicillin Child doses
media Neonate 7-28 days 5 days
children AOM resolves in 60% of cases in 24 hours 30mg/kg TDS
1 month-11 months:
without antibiotics, which only reduce pain
125mg TDS
NICE RTIs at 2 days(NNT 15) and do not prevent 1-5 years: 250mg TDS
deafness >5 years: 500mg TDS
Consider 2 or 3 day delayed or immediate
antibiotics for pain relief if: Penicillin allergy: Child 1 month-11 years
clarithromycin Body weight (BW) 5 days
<2 years AND bilateral AOM (NNT 4), <8kg:7.5mg/kg BD
bulging membrane or symptom score BW 8-11kg: 62.5mg BD
>8 for: fever; tugging ears; crying; BW 12-19kg: 125mg BD
irritability; difficulty sleeping; less BW 20-29kg: 187.5mg
playful; eating less (0 = no symptoms; BD
BW 30-40kg: 250mg BD
1 = a little; 2 = a lot)
Child 12-18 years:
All ages with otorrhoea NNT3 250mg BD
Abx to prevent mastoiditis NNT>4000
Acute otitis Optimise analgesia amoxicillin 500mg TDS 5 days
media
adults AOM resolves in 60% of patients in 24
Penicillin allergy:
hours without antibiotics, which only reduce
doxycycline 200mg stat then 100mg 5 days
pain at 2 days and do not prevent OD
deafness
Consider 2 or 3 day delayed or immediate
antibiotics for pain relief in otorrhoea
Acute otitis First line: analgesia for pain relief, and First line: see left.
externa apply localised heat (e.g. a warm flannel)
Second line:
CKS OE EarCalm spray* (acetic 1 spray TDS 7 days
Second line: topical acetic acid or topical
acid 2%) or
antibiotic +/- steroid; similar cure at 7 days Betnesol N or 3 drops TDS
Otomize spray 1 dose TDS 7 -14 days
If cellulitis or disease extends outside ear
canal, or systemic signs of infection, start
oral flucloxacillin & refer to exclude If cellulitis:flucloxacillin 500mg QDS 7 days
malignant OE
*available OTC if >12 years

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
UPPER RESPIRATORY TRACT INFECTIONS continued
Sinusitis Symptoms <10 days: do not offer No antibiotics: self-care
(acute) antibiotics as most resolve in 14 days
without, and antibiotics only offer marginal First line for delayed:
This guidance phenoxymethylpenicillin 500mg QDS
benefit after 7 days (NNT 15).
summarises
the NICE Symptoms > 10 days: no antibiotic, or Penicillin allergy;
Sinusitis back-up antibiotic if several of: purulent doxycycline 200mg stat then 100mg
(acute) nasal discharge; severe localised unilateral OR OD
guidance pain; fever; marked deterioration after initial clarithromycin 500mg BD
published in milder phase.
July 2017, and Systemically very unwell, or more First line choice if All for 5 days
the NICE RTIs systemically unwell/high
serious signs and symptoms: immediate
guidance risk of complications or
published in antibiotic. worsening after 2-3/7 first
July 2008 Suspected complications: e.g.sepsis, line(phenoxy) treatment:
intraorbital or intracranial refer to co-amoxiclav 500/125mg TDS
secondary care.
Self-care: paracetamol/ibuprofen for
pain/fever. Consider high-dose nasal
14 days
steroid if >12 years. Nasal decongestants
Mometasone nasal spray 200mcg (2 spays, each
or saline may help some. nostril) BD
ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF
TREATMENT
LOWER RESPIRATORY TRACT INFECTIONS
,
Note: Low doses of penicillins are more likely to select for resistance, we recommend 500mg of amoxicillin Do not use quinolones
(ciprofloxacin, ofloxacin) first line as there is poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven
resistant organisms.
Acute cough, Antibiotics have little benefit if no co- First line:
bronchitis morbidity Self-care and safety
Second line: 7day delayed antibiotic, safety netting advice
NICE RTIs
net, and advise that symptoms can last 3
Second line:
weeks. amoxicillin 500mg TDS 5 days

Penicillin allergy;
Consider immediate antibiotics if > 80yr doxycycline 200mg stat then 100mg 5 days
and ONE of: hospitalisation in past year, OD
taking oral steroids, insulin-dependent
diabetic, congestive heart failure; serious
neurological disorder/stroke, OR > 65yrs
with 2 of above
Acute Treat with antibiotics if purulent sputum First line:
exacerbation and increased shortness of breath and/or amoxicillin 500mg TDS 5 days
of COPD increased sputum volume.
Second line:
NICE COPD doxycycline 200mg stat then 100mg 5 days
GOLD COPD Risk factors for antibiotic resistance: OD
severe COPD (MRC>3); co-morbidity; Third line:
frequent exacerbations; antibiotics in last 3 co-amoxiclav 625mg TDS 5 days
months.

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
LOWER RESPIRATORY TRACT INFECTIONS continued
Community- Use CRB65 score to guide mortality, place
acquired of care and antibiotics CRB65=0: amoxicillin 500mg TDS If CRB=0, use 5
pneumonia Each CRB65 parameter scores 1: OR days.
NICE Confusion (AMT≤8 or new disorientation in doxycycline 200mg stat then 100 mg
Pneumonia OD
person, place or time);
Respiratory rate >30/min; BP systolic <90
or diastolic ≤ 60 Age≥65; If CRB65=1-2 & AT
HOME 200mg stat then 100mg 5- 7 days
Score 0: low risk, suitable for home OD
doxycycline alone
treatment;
Score 1-2: intermediate risk, consider
hospital assessment; Score 3-4: urgent
hospital admission.
Give safety net advice and likely duration
of different symptoms, e.g. cough 6 weeks.
Mycoplasma infection is rare in >65s
ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF
TREATMENT
URINARY TRACT INFECTIONS
Note: As antimicrobial resistance and Escherichia coli bacteraemia in the community is increasing, use nitrofurantoin first line, always
give safety net and self-care advice, and consider risks for resistance.
Give TARGET Manage your infection UTI leaflet, and refer to the PHE UTI guidance for diagnostic information.
UTI in adults First line:
(lower) All patients first line antibiotic: nitrofurantoin nitrofurantoin 100mg MR BD For all treatment
if GFR ≥45mls/min; (except
PHE UTI fosfomycin)
if GFR30-44 only use if no alternative
diagnosis Due to increased resistance of If first line unsuitable
(e.g. if GFR <45mls/min) Women all ages:
trimethoprim- it is not recommended that 3 days
TARGET UTI pivmecillinam ** 400mg TDS
trimethoprim is prescribed empirically
(unlicensed)
without evidence of sensitivity Men: 7 days
RCGP UTI If penicillin allergy:
Treat women with severe/≥ 3 symptoms: fosfomycin Women: 3gr stat
Men: 3gr dose followed
SIGN UTI by another 3gr dose on
Women <65 years (mild/ ≤ 2 symptoms):
day 3 (unlicensed)
Pain relief, and consider /delayed
NHS Scotland antibiotic.
UTI ** this is a penicillin
If urine not cloudy, 97% NPV of no UTI
If urine cloudy, use dipstick to guide
NB: If increased resistance risk, send culture with FIRST
treatment:
presentation for susceptibility testing & give safety net advice.
nitrite, leukocyctes, blood all negative 76%
NPV;-nitrite plus blood or leukocytes 92%
PPV of UTI If treatment failure: always perform culture

Men < 65 years: consider prostatitis and

send pre-treatment MSU, OR if symptoms
mild or non-specific, use –ve dipstick to
exclude UTI

>65 years: treat if fever ≥38°C or 1.5°C

above base twice in 12h AND ≥1 other
symptom

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
URINARY TRACT INFECTIONS continued
UTI patient with catheters: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell or pyelonephritis
likely.
Do not use prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma. Take sample if new
onset of delirium, or one or more symptoms of UTI.
UTI in Send MSU for culture; start empirical First line:
pregnancy antibiotics in all with significant positive nitrofurantoin (avoid at
term) 100mg MR BD All for 7 days
culture, even if asymptomatic.
SIGN UTI First line: nitrofurantoin unless at term Second line:
trimethoprim 200mg BD (off-label)
Second line: trimethoprim; avoid if low
Give folic acid 5mg OD
folate status, or on folate antagonist st
if 1 trimester
Third line: cephalosporins, as risk of C.diff Third line:
cefalexin 500mg BD
Acute Send MSU for culture and start antibiotics. First line:
prostatitis 4-wk course may prevent chronic prostatitis ciprofloxacin 500mg BD 28 days
Quinolones achieve higher prostate
CKS Second line:
concentrations
trimethoprim 200mg BD 28 days
UTI in children Child <3 months: refer urgently for Lower UTI:
assessment. First line: Lower UTI
NICE UTI in Child ≥ 3 months: use positive nitrite to trimethoprim or See BNF for doses 3 days
under 16s nitrofurantoin
guide antibiotic use: send pre-treatment
MSU. Second line:
Imaging: refer if child <6 months, or cefalexin See BNF for doses
recurrent or atypical UTI. If organism susceptible:
amoxicillin
Penicillin allergy:
ciprofloxacin if > 1year See BNF for doses
and IgE mediated
penicillin allergy

Upper UTI:
refer to paediatrics to:
obtain a urine sample for
culture; assess for signs
of systemic infection;
consider systemic
antimicrobials
Acute If admission not needed, send MSU for co-amoxiclav 500/125mg TDS 7 days
pyelonephritis culture & susceptibility testing, and start or
antibiotics. ciprofloxacin 500mg BD 7 days
CKS If no response within 24 hours, seek
advice. If ESBL risk and on advice from a De-escalate spectrum of
microbiologist, consider IV antibiotics via cover once MSU
outpatient parenteral antimicrobial therapy sensitivities known
(OPAT) service.

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
URINARY TRACT INFECTIONS continued
Recurrent UTI First line: advise simple measures, Choice should be
in non including hydration; ibuprofen for symptom driven by cultures
pregnant relief. cranberry products work for some
women (2in Antibiotic prophylaxis:
women. See TARGET UTI leaflet
6months or First line:
≥ 3 UTIs/year ) nitrofurantoin 100mg MR At night or 3-6 months, then
TARGET UTI Second line: stand-by or post-coital post- review
antibiotics Second line: coital stat recurrence rate
Third line: antibiotic prophylaxis. ciprofloxacin 500mg (off-label) and need
Ongoing prophylaxis is not encouraged
and may drive resistance. Remember to Third line:
refer for advice
review recurrence rate and need after 3-6
months
ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF
TREATMENT
MENINGITIS
Suspected Transfer all patients to hospital IV or IM benzylpenicillin Age 10+ years:
meningococcal immediately. 1200mg
disease If time before hospital admission, and non- Children 1-9 yrs: 600mg
Children <1 yr: 300mg (give IM if vein
blanching rash, give IV benzylpenicillin or
IV cefotaxime. Do not give IV antibiotics if OR cannot be found)
PHE Age 12+ years: 1gram
Meningococcal there is a definite history of anaphylaxis IV or IM cefotaxime Child < 12 yrs: 50mg/kg
disease Rash is not a contraindication
Prevention of secondary case of meningitis: Only prescribe following advice from Public Health.
Contact local HPA on 0344 225 3861 Option 1 or 0844 967 0069 out of hours.
ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF
TREATMENT
GASTRO-INTESTINAL TRACT INFECTIONS
Oral Oral candidiasis is rare in Mild-moderate 100,00units/ml 1ml 7 days or 2 days
Candidiasis immunocompetent adults; consider Nystatin suspension QDS (half a ml in each after symptoms
undiagnosed risk factors including HIV. side) cease
CKS Candida Moderate- severe
fluconazole oral capsules
50mg OD
7 days (further 7
extensive or severe
if persistent)
candidiasis, HIV or
immunosuppression
use 100mg OD

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
GASTRO-INTESTINAL TRACT INFECTIONS continued
Eradication of Treat all positives if known DU, GU, or low Always use PPI TWICE daily
Helicobacter grade MALToma First line:
pylori NNT in non-ulcer dyspepsia (14) PPI
with
Do not offer eradication for GORD
amoxicillin 1g BD 7 days
NICE GORD & Do not use clarithromycin metronidazole, plus
dyspepsia or quinolone if used in the past year for any metronidazole (MZ) 400mg BD 7 days
infection
If patient fits outside this guideline, please Second line: (unable to
PHE H.pylori refer to microbiology tolerate MZ)
PPI
with
amoxicillin 1g BD 7 days
plus
clarithromycin 500mg BD 7 days

Penicillin allergy:
PPI
plus
clarithromycin 250mg BD 7 days
and
metronidazole 400mg BD 7 days

If previous clarithromycin
use and not had
exposure to a quinolone:
PPI
with
metronidazole 400mg BD 7 days
plus
levofloxacin 250mg BD 7 days
Diverticulitis Asses the need for admission. co-amoxiclav 500/125mg TDS 5 days - 7 days

Penicillin allergy:
ciprofloxacin 500mg BD 7 days
plus
metronidazole 400mg TDS 7 days
Infectious Refer previously healthy children with acute painful or bloody diarrhoea, to exclude Escherichia coli 0157 infection.
diarrhoea Antibiotic therapy is not indicated unless patient is systemically unwell. If systemically unwell and campylobacter
PHE Diarrhoea suspected (e.g. undercooked meat and abdominal pain), consider clarithromycin 500mg BD for 5 days if very sick.
CKS Consider recent antibiotics / hospital admission and risk of Clostridium difficile
Clostridium Stop unnecessary antibiotics, PPIs and vancomycin oral 125mg QDS 10 - 14 days
difficile antiperistaltic agents. Admit if severe: T
PHE >38.5; WCC >15, rising creatinine or
signs/symptoms of severe colitis
Prophylaxis rarely, if ever indicated. Only consider standby antimicrobial for patients at high risk of severe illness, or
Traveller’s visiting high risk areas.
diarrhoea
standby: azithromycin 500mg once daily for 3 days.
Threadworm Treat all household contacts at the same >6 months
CKS time. Advise hygiene measures for First line: mebendazole* 100mg stat dose, repeat
threadworm 2 weeks (hand hygiene, pants at night, (off-label if <2yrs) in 2 weeks if
persistent
morning shower, including perianal area).
<6 months or pregnancy
wash sleepwear, bed linen, and dust, and st
(at least in 1 trimester):
vacuum. only hygiene measures
*available OTC if >2yrs for 6 weeks
Child < 6 months, add perianal wet wiping
or washes 3 hourly

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
GENITAL TRACT INFECTIONS continued
STI screening People with risk factors should be screened for chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners to
GUM. Risk factors: < 25y, no condom use, recent (<12mth) / frequent change of partner, symptomatic partner, area of
high HIV.
Chlamydia Opportunistically screen all aged 16-24yrs
trachomatis/ Treat partners and refer to GUM. Repeat Doxycycline 100mg BD 7 days
urethritis test for cure in all at three months.
Pregnancy/breastfeeding:
SIGN
Pregnancy/breastfeeding: azithromycin is azithromycin 1g stat
Chlamydia
most effective lower cure rate in
pregnancy, test for cure at least 3 weeks
after end of treatment
Vaginal All topical and oral azoles give 70% cure clotrimazole 500mg pessary OR
stat
candidiasis OR 5gr 10% cream
Pregnancy: avoid oral azoles and use miconazole 100mg pessary 14 nights
BASHH OR
intravaginal treatment for 7 days
Vulvovaginal oral fluconazole 150mg orally stat
candidiasis
Recurrent(>4 episodes per year): 150mg
oral fluconazole every 72 hours for three Recurrent: fluconazole 150mg every 72 hours 3 doses
doses induction, followed by one dose (induction/maintenance) THEN 150mg once a 6 months
once a week for six months maintenance. week
Bacterial Oral metronidazole is as effective as oral metronidazole 400mg BD or 2gr stat 7 days/stat
vaginosis topical treatment, and is cheaper OR
BASHH Seven days results in fewer relapses than metronidazole 0.75% vag 1x 5g applicator at night 5 nights
Bacterial gel
2 gr stat at 4 weeks
vaginosis OR
Pregnant/breastfeeding: avoid 2gr dose clindamycin 2% crm 1x 5g applicator at night 7 nights
Treating partners does not reduce relapse
Genital herpes Advise: saline bathing, analgesia, or First line:
BASHH topical lidocaine for pain, and discuss oral aciclovir 400mg TDS 5 days
Anogenital transmission. 800mg TDS (if 2 days
herpes First episode: treat within five days if new OR recurrent)
lesions or systemic symptoms, and refer to valaciclovir 500mg BD 5 days
GUM.
Recurrent: self-care if mild, or immediate
short course antiviral treatment, or
suppressive therapy if more than six
episodes per year.
Gonorrhoea Antibiotic resistance is now very high. Test ceftriaxone 1gram IM Stat
of cure is essential. if chlamydia positive or
unknown
ADD
doxycycline 100mg BD 7 days

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
GENITAL TRACT INFECTIONS continued
Trichomoniasis Oral treatment needed as extravaginal metronidazole 400mg BD 5 - 7 days
infection common. Treat partners, and 2g stat (more adverse stat
refer to GUM for other STI’s effects)
BASHH
Trichomoniasis Pregnancy/breastfeeding: avoid 2gr single
Pregnancy for symptoms:
dose metronidazole, clotrimazole for clotrimazole 100mg pessary ON 6 nights
symptom relief (not cure) if metronidazole
declined
Pelvic Refer woman & sexual contacts to GUM. metronidazole 400mg BD 5 days
Inflammatory plus
Always culture for gonorrhoea & chlamydia
Disease ofloxacin 400mg BD 14 days
If gonorrhoea likely (partner has it; sex
abroad; severe symptoms,) use regimen If high risk of G&C:
BASHH PID
with ceftriaxone, as resistance to ceftriaxone 500mg IM stat
quinolones is high plus
metronidazole 400mg BD 5 days
If pregnant, do not prescribe, refer to GUM
plus
doxycycline 100mg BD 14 days
Epididymitis Usually due to gram- negative enteric ofloxacin 200mg BD 14 days
and bacteria in men over 35 years with low risk OR
Epididymo- of STI. doxycycline 100mg BD 14 days
orchitis If under 35 years or STI risk refer to GUM
For suspected epididymitis and epididymo-
orchitis in men over 35 years with low risk
of STI (high risk refer to GUM).

Exclude testicular torsion.

Obtain an MSU for sensitivity and culture

and send urine for gonorrhoea
and chlamydia NAAT.
ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF
TREATMENT
SKIN INFECTIONS
Note: refer to RCGP Skin infections online training for MRSA, discuss therapy with microbiologist.
Impetigo Reserve topical antibiotics for very topical fusidic acid Thinly TDS 5 days
PHE Impetigo localised lesions to reduce risk of bacteria
becoming resistant. MRSA: topical mupirocin 2% ointment TDS 5 days
Only use mupirocin if caused by MRSA.
oral flucloxacillin 500mg QDS 7 days
Extensive, severe, or bullous impetigo:oral
antibiotics Penicillin Allergy:
oral clarithromycin 500mg BD 7 days
Cold sore Most resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12-18 hours.
CKS cold If frequent, severe, and predictable triggers: consider oral prophylaxis: aciclovir 400mg, twice daily, for 5-7 days.
sores
Eczema If no visible signs of infection use of antibiotics (alone or with steroids) encourages resistance and does not improve
NICE eczema healing. In eczema with visible signs of infection, use treatment as in impetigo.

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
SKIN INFECTIONS continued
Acne vulgaris Treatment is dependent on severity, mild First line
moderate or severe (treat and refer) Self-care
CKS Mild (open and closed comedones) or
moderate (inflammatory lesions) Second line
First-line: self-care (wash with mild soap; topical retinoid Apply OD 6-8 weeks
OR
do not scrub; avoid make-up)
benzoyl peroxide 5% gel OD - BD 6-8 weeks
Second-line: topical retinoid or benzoyl
peroxide Third line
Third line: add topical antibiotic, or topical clindamycin 1% gel/solution/lotion 12 weeks
consider addition or oral antibiotic. If failure/severe thinly BD
Severe (nodules and cysts): add oral
antibiotic (for 3 months max) and refer oral lymecycline 408mg OD 8-12 weeks
OR
oral doxycycline 100mg OD 6-12 weeks
Do not combine a topical antibiotic with
oral antibiotic treatment
Cellulitisand Class I: patient afebrile and healthy other flucloxacillin 500mg QDS All for 7 days.
erysipelas than cellulitis, use oral flucloxacillin alone. If slow response
If river or sea water exposure: discuss with Penicillin allergy: continue for a
CREST clarithromycin 500mg BD further 7 days
microbiologist.
Cellulitis Penicillin allergic and on
Class II: patient febrile and ill, or statins:
BLS Cellulitis comorbidity, consider admit for IV doxycycline 200mg stat then 100mg
treatment or use OPAT. OD
Class III: toxic appearance, admit. If unresolving
Erysipelas: Often facial and unilateral. Use clindamycin 300-450mg QDS
flucloxacillin for non-facial erysipelas
If facial(non-dental):
co-amoxiclav 500/125mg TDS
Admission avoidance Cellulitis pathway
Leg ulcer Ulcers are always colonized. Antibiotics do
not improve healing unless active infection
PHE Venous (prurulent exudate/odour; increased pain;
Leg ulcers
cellulitis; pyrexia)..
If active infection:
If active infection, send pre-treatment flucloxacillin 500mg QDS As for cellulitis
swab. OR
Review antibiotics after culture results clarithromycin 500mg BD
Bites Human: Thorough irrigation is important. prophylaxis / treatment
Assess risk of tetanus, rabies, HIV, all:
hepatitis B&C. co-amoxiclav 625mg TDS 7 days

Penicillin allergy:
Cat: Always give prophylaxis
 cat/dog
Dog: Give prophylaxis if: puncture wound, metronidazole 400mg TDS 7 days
CKS Bites bite to hand, foot, face, joint, tendon or plus
ligament, immunocompromised, cirrhotic, doxycycline 100mg BD 7 days
asplenic or presence of prosthetic
valve/joint  human bite
ciprofloxacin 500mg BD 7 days
Penicillin allergy: Review all at 24 and 48
plus
hours, as not all pathogens are covered 300mg QDS 7 days
clindamycin
AND review at 24 & 48
hours

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
SKIN INFECTIONS continued
Post-operative For the majority of cases, flucloxacillin is flucloxacillin 500mg QDS 7 days
wound sufficient.
infection Ensure prosthetic patients have a culture Penicillin allergy: 500mg BD 7 days
taken first before treatment is chosen. clarithromycin

If infection is severe, or fails to respond,

contact microbiology for advice.
Scabies Treat all home & sexual contacts within permethrin 5% cream
24h 2 applications
NHS Scabies Treat whole body from ear/chin downwards If allergy: 1 week apart
malathion 0.5% aqueous liquid
and under nails.
If under 2/elderly: also treat face/scalp
Home /sexual contacts: treat within 24h
Mastitis S. aureus is the most common infecting flucloxacillin 500mg QDS 10 - 14 days
CKS Mastitis pathogen. Suspect if woman has: a painful
and breast breast; fever and/or general malaise; a penicillin allergy:
abscess erythromycin 500mg QDS
tender, red breast.
OR
Breastfeeding: oral antibiotics are clarithromycin 500mg BD
appropriate, where indicated.
Women should continue feeding, including
from the affected breast.
Dermatophyte Most cases: Terbinafine is fungicidal; topical terbinafine 1% apply OD - BD 1 - 4 weeks
infection – skin treatment time shorter than with fungistatic OR
PHE Fungal imidazoles. topical clotrimazole 1% apply OD - BD
skin and nail
If candida possible, use imidazole. 4 - 6 weeks
infections
For athlete’s foot: apply OD - BD
If intractable, or scalp: send skin scrapings topical undecanoates
If infection confirmed: use oral terbinafine (e.g. Mycota)*
or itraconazole
Scalp: oral therapy and discuss with
dermatology
*available OTC
Dermatophyte Take nail clippings; start therapy only if First line:
infection –nail infection is confirmed by laboratory. terbinafine 250mg OD fingers 6 weeks
Oral terbinafine is more effective than oral toes 12 weeks
CKS Fungal
azole. Liver reactions 0.1 to 1% with oral
nail infection
antifungals. Second line:
itraconazole 200mg BD fingers 2 courses
If candida or non-dermatophyte infection is toes 3 courses
confirmed, use oral itraconazole (1 course = 7
Topical nail lacquer is not as effective. consecutive
To prevent reoccurrence: apply weekly 1% Stop treatment when days treatment
continual, new healthy, per month)
topical antifungal cream to entire toe area
proximal nail growth
Children: seek specialist advice

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
SKIN INFECTIONS continued
Varicella Pregnant/ immunocompromised/ neonate:
zoster/chicken seek urgent specialist advice
pox Chicken pox: consider aciclovir If: onset of First line:
PHE Varicella aciclovir 800mg five times a day 7 days
rash <24h, & one of the following :> 14yrs;
severe pain; dense/oral rash; taking
steroids; smoker. For shingles:
Second line: if
Herpes Shingles: treat if >50 yrs and within 72 hrs compliance a problem,
zoster/shingles of rash (PHN rare if <50yrs); or if one of the valaciclovir 1g TDS 7 days
following: active ophthalmic; Ramsey
PCDS Herpes
Hunt, eczema, non-truncal involvement,
zoster
moderate or severe pain, moderate or
severe rash
Shingles treatment if not within 72 hours:
consider starting antiviral drug up to one
week after rash onset, if high risk of severe
shingles or complications (continued
vesicle formation; older age;
immunocompromised; severe pain).
ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF
TREATMENT
EYE INFECTIONS
Conjunctivitis First line: bath/clean eyelids with cotton First line: self-care (see
wool dipped in sterile saline or boiled left)
AAO (cooled) water, to remove crusting.
Conjunctivitis Second line: 2 hourly for 2 days then
Treat only if severe, as most cases are
chloramphenicol 0.5% reduce frequency
viral or self-limiting. drops* All:
Bacterial conjunctivitis: usually unilateral OR Continue for 48
and also self-limiting; It is characterised by chloramphenicol 1% 3 - 4 times daily, or just hours after
red eye with mucopurulent, not watery ointment* at night if using eye resolution
discharge. 65% and 74% resolve on drops
placebo by day five and 7. Third line:
fusidic acid 1% gel Apply BD
Second line: Fusidic acid as it has less
gram negative activity
*available OTC if >2 years
Blepharitis First line: lid hygiene for symptom control, First line: self-care
CKS including: warm compresses; lid massage
Blepharitis and scrubs; gentle washing; avoiding Second line:
chloramphenicol 1% BD 6 week trial
cosmetics.
ointment
Second line: topical antibiotics if hygiene
measures are ineffective after 2 weeks. Third line:
Signs of Meibomian gland dysfunction or oral doxycycline 100mg OD 4 weeks (initial)
acne rosacea: consider oral antibiotics 50mg OD 8 weeks (maint.)

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
OTHER INFECTIONS
Prevention of ’At risk’ patients:- amoxicillin 2g stat dose one hour pre-
infective  Prosthetic valve or prosthetic OR procedure
endocarditis in material used for cardiac repair clindamycin orally 600mg stat dose
dental
procedures  Previous endocarditis
 Cyanotic heart disease
Antibiotic prophylaxis against infective
endocarditis is not routinely
recommended except in the ‘at risk’
patients listed above

Suspected dental infections in primary care (outside dental setting)

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
Derived from the Scottish Dental Clinical Effectiveness Programme (SDCEP) 2013 Guidelines
This guidance is not designed to be a definitive guide to oral conditions, as GPs should not be involved in dental treatment. Patients
presenting to non-dental primary care 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.
Note: Antibiotics do not cure toothache. First line treatment is with paracetamol and/or ibuprofen; codeine is not effective for toothache.
Mucosal Temporary pain and swelling relief can be saline mouthwash ½ tsp salt dissolved in All:
ulceration and attained with saline mouthwash warm water Always spit out
inflammation after use.
Use antiseptic mouthwash If more severe,
(simple chlorhexidine 0.12-0.2% 1 minute BD with 10ml Use until lesions
gingivitis) & if pain limits oral hygiene to treat or (Do not use within resolve/less pain
SDCEP Dental prevent secondary infection. The primary 30 mins of toothpaste) allows for oral
problems cause for mucosal ulceration or hygiene
inflammation (aphthous ulcers; oral lichen
planus; herpes simplex infection; oral
cancer) needs to be evaluated and treated.
Acute Refer to dentist for scaling and oral chlorhexidine 0.12-0.2% see above dosing in Until pain allows
necrotising hygiene advice. mucosal ulceration for oral hygiene
ulcerative Antiseptic mouthwash if pain limits oral
gingivitis
hygiene.
metronidazole 400mg TDS 3 days
Commence metronidazole in the presence
of systemic signs and symptoms.
Pericoronitis Refer to dentist for irrigation and
SDCEP Dental debridement. metronidazole 400mg TDS 3 days
problems If persistent swelling or systemic OR
amoxicillin 500mg TDS 3 days
symptoms, use metronidazole or
amoxicillin. chlorhexidine 0.2% See above dosing for Until pain allows
Use antiseptic mouthwash if pain and mucosal ulceration for oral hygiene
trismus limit oral hygiene.

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted
Management of infection in primary care Brighton & Hove CCG
Adapted for local use High Weald Lewes Havens CCG

ILLNESS GOOD PRACTICE POINTS TREATMENT ADULT DOSE DURATION OF

TREATMENT
This guidance is not designed to be a definitive guide to oral conditions. It is for GPs for the management of acute oral conditions
pending being seen by a dentist or dental specialist. GPs should not routinely be involved in dental treatment and, if possible, advice
should be sought from the patient’s dentist
Dental  Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of
abscess antibiotics for abscess are not appropriate. Repeated antibiotics alone, without drainage, are ineffective in
SDCEP Dental preventing the spread of infection.
problems
 Antibiotics are only recommended if there are signs of severe infection, systemic symptoms or 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 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 first line drugs.

If pus is present, refer for drainage, tooth amoxicillin 500mg - 1gr TDS
extraction, or root canal. Send pus for Up to 5 days
investigation Penicillin allergy: review at 3 days
If spreading infection: (lymph node clarithromycin 500mg BD
involvement or systemic signs, i.e. fever or
malaise) ADD metronidazole.
Severe, spreading
Use clarithromycin in true penicillin allergy
infection
If severe: refer to hospital.
add
metronidazole 400mg TDS

REFERENCES

Adapted from PHE guidance: Management of infection guidance for primary care for consultation and local adaption
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/664740/Managing_common_infections_guidan
ce_for_consultation_and_adaptation.pdf last updated November 2017

Author Fionnuala Plumart, Ellen Mason, Sam Lippett Issue date Feb 19 Version 9
Editor Kristina Fowlie Expiry date 2years Supersedes 8
Reviewer Jade Tomes To be reviewed before expiry date if warranted