Summary of antimicrobial prescribing guidance – managing common infections

• For all PHE guidance, follow PHE’s principles of treatment.

• See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.

Key: Click to access doses for children Click to access NICE’s printable visual summary
Jump to section on:
Upper RTI Lower RTI UTI Meningitis GI Genital Skin Eye Dental

Doses Visual
Infection Key points Medicine Length
Adult Child summary
Upper respiratory tract infections
Acute sore Advise paracetamol, or if preferred and suitable, First choice: 500mg QDS or 5 to 10 days*
throat ibuprofen for pain. phenoxymethylpenicillin 1000mg BD
Medicated lozenges may help pain in adults. Penicillin allergy: 250mg to 500mg 5 days
Use FeverPAIN or Centor to assess symptoms: clarithromycin OR BD
FeverPAIN 0-1 or Centor 0-2: no antibiotic; erythromycin (preferred if 250mg to 500mg 5 days
FeverPAIN 2-3: no or back-up antibiotic; pregnant) QDS or
FeverPAIN 4-5 or Centor 3-4: immediate or
back-up antibiotic. 500mg to 1000mg
Public Health BD
Systemically very unwell or high risk of
England complications: immediate antibiotic.
*5 days of phenoxymethylpenicillin may be
enough for symptomatic cure; but a 10-day
Last updated: course may increase the chance of
Jan 2018 microbiological cure.
For detailed information click the visual summary
icon.

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 1

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Influenza Annual vaccination is essential for all those ‘at risk’ of influenza.1D Antivirals are not recommended for healthy adults.1D,2A+
Treat ‘at risk’ patients with 5 days oseltamivir 75mg BD,1D when influenza is circulating in the community, and ideally within 48 hours of onset
(36 hours for zanamivir treatment in children),1D,3D or in a care home where influenza is likely.1D,2A+
Public Health
England At risk: pregnant (and up to 2 weeks post-partum); 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).4D See the PHE Influenza guidance for the treatment of patients under 13 years.4D In severe
Last updated: immunosuppression, or oseltamivir resistance, use zanamivir 10mg BD5A+,6A+ (2 inhalations twice daily by diskhaler for up to 10 days) and seek
Feb 2019
advice.4D
Access supporting evidence and rationales on the PHE website.
Scarlet fever Prompt treatment with appropriate antibiotics Phenoxymethylpenicillin2D 500mg QDS2D 10 days3A+,4A+,5A+ Not available.
(GAS) significantly reduces the risk of complications.1D Access
Vulnerable individuals (immunocompromised, supporting
Public Health Penicillin allergy: 250mg to 500mg 5 days2D,5A+
the comorbid, or those with skin disease) are at evidence and
England clarithromycin2D BD2D rationales on
Last updated:
increased risk of developing complications.1D Optimise analgesia2D and give safety netting advice the PHE
Oct 2018 website
Acute otitis Regular paracetamol or ibuprofen for pain (right First choice: amoxicillin - 5 to 7 days
media dose for age or weight at the right time and Penicillin allergy: - 5 to 7 days
maximum doses for severe pain). clarithromycin OR
Otorrhoea or under 2 years with infection in erythromycin (preferred if -
both ears: no, back-up or immediate antibiotic. pregnant)
Otherwise: no or back-up antibiotic. Second choice: co- - 5 to 7 days
Public Health
Systemically very unwell or high risk of amoxiclav
England
complications: immediate antibiotic.
For detailed information click on the visual summary.
Last updated: Feb
2018
Acute otitis First line: analgesia for pain relief,1D,2D and Second line: 1 spray TDS5A- 7 days5A
externa apply localised heat (such as a warm flannel).2D topical acetic acid 2%2D,4B-
Second line: topical acetic acid or topical OR
Not available.
Public Health antibiotic +/- steroid: similar cure at topical neomycin sulphate 3 drops TDS5A- 7 days (min) to Access
England 7 days.2D,3A+,4B- with corticosteroid2D,5A- 14 days (max)3A+ supporting
If cellulitis or disease extends outside ear (consider safety issues if evidence and
canal, or systemic signs of infection, start oral perforated tympanic rationales on
Last updated: the PHE
Nov 2017 flucloxacillin and refer to exclude malignant otitis membrane)6B-
externa.1D website
If cellulitis: 250mg QDS2D
flucloxacillin7B+ If severe: 500mg 7 days2D
QDS2D

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 2

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Sinusitis Advise paracetamol or ibuprofen for pain. Little First choice: 500mg QDS
5 days
evidence that nasal saline or nasal phenoxymethylpenicillin
decongestants help, but people may want to try Penicillin allergy: 200mg on day 1,
them. doxycycline (not in under then 100mg OD
Symptoms for 10 days or less: no antibiotic. 12s) OR
Symptoms with no improvement for more clarithromycin OR 500mg BD 5 days
than 10 days: no antibiotic or back-up antibiotic erythromycin (preferred if 250 to 500mg
Public Health depending on likelihood of bacterial cause. pregnant) QDS or
England Consider high-dose nasal corticosteroid (if over 500 to 1000mg BD
12 years). Second choice or first 500/125mg TDS
Systemically very unwell or high risk of choice if systemically
Last updated:
Oct 2017
complications: immediate antibiotic. very unwell or high risk 5 days
For detailed information click on the visual summary. of complications:
co-amoxiclav
Lower respiratory tract infections
Acute Many exacerbations are not caused by bacterial First choice: 500mg TDS (see
exacerbation infections so will not respond to antibiotics. amoxicillin OR BNF for severe -
of COPD Consider an antibiotic, but only after taking into infection)
account severity of symptoms (particularly doxycycline OR 200mg on day 1,
sputum colour changes and increases in volume 5 days
then 100mg OD
or thickness), need for hospitalisation, previous -
(see BNF for
exacerbations, hospitalisations and risk of severe infection)
complications, previous sputum culture and
clarithromycin 500mg BD -
susceptibility results, and risk of resistance with
repeated courses. Second choice: use alternative first choice
Public Health
England Some people at risk of exacerbations may have Alternative choice (if 500/125mg TDS
antibiotics to keep at home as part of their person at higher risk of
-
exacerbation action plan. treatment failure):
For detailed information click on the visual summary. co-amoxiclav OR
Last updated: See also the NICE guideline on COPD in over 16s.
Dec 2018 co-trimoxazole OR 960mg BD -
levofloxacin (with 500mg OD 5 days
specialist advice if co-
amoxiclav or co-
-
trimoxazole cannot be
used; consider safety
issues)
IV antibiotics (click on visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 3

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute Send a sputum sample for culture and First choice empirical 500mg TDS
exacerbation susceptibility testing. treatment:
of Offer an antibiotic. amoxicillin (preferred if
bronchiectasis pregnant) OR 7 to 14 days
When choosing an antibiotic, take account of
(non-cystic doxycycline (not in under 200mg on day 1,
severity of symptoms and risk of treatment
fibrosis) 12s) OR then 100mg OD
failure. People who may be at higher risk of
treatment failure include people who’ve had clarithromycin 500mg BD
repeated courses of antibiotics, a previous Alternative choice (if 500/125mg TDS
sputum culture with resistant or atypical person at higher risk of
bacteria, or a higher risk of developing treatment failure)
complications. empirical treatment:
Course length is based on severity of co-amoxiclav OR
Public Health broncheictasis, exacerbation history, severity of
England levofloxacin (adults only: 500mg OD or BD
exacerbation symptoms, previous culture and
with specialist advice if
susceptibility results, and response to treatment. co-amoxiclav cannot be 7 to 14 days
Do not routinely offer antibiotic prophylaxis to used; consider safety
Last updated: prevent exacerbations. issues) OR
Dec 2018
Seek specialist advice for preventing ciprofloxacin (children -
exacerbations in people with repeated acute only: with specialist advice
exacerbations. This may include a trial of if co-amoxiclav cannot be
antibiotic prophylaxis after a discussion of the used; consider safety
possible benefits and harms, and the need for issues)
regular review.
IV antibiotics (click on visual summary)
For detailed information click on the visual
When current susceptibility data available: choose antibiotics accordingly
summary.

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 4

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute cough Some people may wish to try honey (in over 1s), Adults first choice: 200mg on day 1,
the herbal medicine pelargonium (in over 12s), doxycycline then 100mg OD -
cough medicines containing the expectorant Adults alternative first 500mg TDS
guaifenesin (in over 12s) or cough medicines choices:
containing cough suppressants, except codeine, amoxicillin (preferred if -
(in over 12s). These self-care treatments have pregnant) OR
Public Health limited evidence for the relief of cough 5 days
symptoms. clarithromycin OR 250mg to 500mg
England -
BD
Acute cough with upper respiratory tract
infection: no antibiotic. erythromycin (preferred if 250mg to 500mg
Last updated: pregnant) QDS or
Acute bronchitis: no routine antibiotic. 500mg to 1000mg -
Feb 2019
Acute cough and higher risk of BD
complications (at face-to-face examination):
Children first choice: -
immediate or back-up antibiotic.
amoxicillin
Acute cough and systemically very unwell (at
Children alternative first -
face to face examination): immediate
choices:
antibiotic.
clarithromycin OR
Higher risk of complications includes people with
erythromycin OR -
pre-existing comorbidity; young children born
prematurely; people over 65 with 2 or more of, doxycycline (not in under -
or over 80 with 1 or more of: hospitalisation in 12s)
previous year, type 1 or 2 diabetes, history of
congestive heart failure, current use of oral
corticosteroids. 5 days
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. See also the NICE guideline on
pneumonia for prescribing antibiotics in adults
with acute bronchitis who have had a C-reactive
protein (CRP) test (CRP<20mg/l: no routine
antibiotic, CRP 20 to 100mg/l: back-up antibiotic,
CRP>100mg/l: immediate antibiotic).

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 5

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Community- Assess severity in adults based on clinical First choice (low severity 500mg TDS
acquired judgement guided by mortality risk score in adults or non-severe (higher doses can
pneumonia (CRB65 or CURB65). See the NICE guideline in children): be used, see BNF)
on pneumonia for full details: amoxicillin
low severity – CRB65 0 or CURB65 0 or 1 Alternative first choice 200mg on day 1,
(low severity in adults or then 100mg OD
moderate severity – CRB65 1 or 2 or CURB65 5 days*
non-severe in children):
2
doxycycline (not in under
high severity – CRB65 3 or 4 or CURB65 3 to 12s) OR
Public Health
5. clarithromycin OR 500mg BD
England
1 point for each parameter: confusion, (urea >7 erythromycin (in 500mg QDS
mmol/l), respiratory rate ≥30/min, low systolic pregnancy)
Last updated: Sept (<90 mm Hg) or diastolic (≤60 mm Hg) blood First choice (moderate 500mg TDS
2019 pressure, age ≥65. severity in adults): (higher doses can
Assess severity in children based on clinical amoxicillin be used, see BNF) -
judgement. AND (if atypical
Offer an antibiotic. Start treatment as soon as pathogens suspected)
possible after diagnosis, within 4 hours (within 1 clarithromycin OR 500mg BD -
hour if sepsis suspected and person meets any erythromycin (in 500mg QDS 5 days*
-
high risk criteria – see the NICE guideline on pregnancy)
sepsis). Alternative first choice 200mg on day 1,
(moderate severity in then 100mg OD
When choosing an antibiotic, take account of -
adults):
severity, risk of complications, local antimicrobial
doxycycline OR
resistance and surveillance data, recent
clarithromycin 500mg BD -
antibiotic use and microbiological results.
First choice (high 500/125mg TDS
* Stop antibiotics after 5 days unless severity in adults or
microbiological results suggest a longer course severe in children):
is needed or the person is not clinically stable. co-amoxiclav
For detailed information click on the visual summary. AND (if atypical
See also the NICE guideline on pneumonia. pathogens suspected)
clarithromycin OR 500mg BD 5 days*
erythromycin (in 500mg QDS
pregnancy)
Alternative first choice 500mg BD
(high severity in adults):
-
levofloxacin (consider
safety issues)
IV antibiotics (click on visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 6

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Hospital- If symptoms or signs of pneumonia start within First choice (non-severe 500/125 mg TDS
acquired 48 hours of hospital admission, see community and not higher risk of 5 days then
pneumonia acquired pneumonia. resistance): review
Offer an antibiotic. Start treatment as soon as co-amoxiclav
possible after diagnosis, within 4 hours (within 1 Adults alternative first 200mg on day 1,
hour if sepsis suspected and person meets any choice (non-severe and then 100mg OD
high risk criteria – see the NICE guideline on not higher risk of
sepsis). resistance)
Public Health Choice based on specialist -
When choosing an antibiotic, take account of
England microbiological advice and
severity of symptoms or signs, number of days
in hospital before onset of symptoms, risk of local resistance data
developing complications, local hospital and Options include:
Last updated: Sept ward-based antimicrobial resistance data, recent
2019
doxycycline
antibiotic use and microbiological results, recent 5 days then
cefalexin (caution in 500 mg BD or TDS review
contact with a health or social care setting penicillin allergy) (can increase to 1
before current admission, and risk of adverse -
to 1.5g TDS or
effects with broad spectrum antibiotics. QDS)
No validated severity assessment tools are co-trimoxazole 960mg BD -
available. Assess severity of symptoms or signs
levofloxacin (only if 500mg OD or BD
based on clinical judgement. switching from IV
Higher risk of resistance includes relevant levofloxacin with specialist -
comorbidity (such as severe lung disease or advice; consider safety
immunosuppression), recent use of broad issues)
spectrum antibiotics, colonisation with multi-drug
Children alternative first -
resistant bacteria, and recent contact with health
choice (non-severe and
and social care settings before current
not higher risk of
admission.
resistance):
If symptoms or signs of pneumonia start within clarithromycin
days 3 to 5 of hospital admission in people not Other options may be -
at higher risk of resistance, consider following suitable based on
community acquired pneumonia for choice of specialist microbiological
antibiotic. advice and local
For detailed information click on the visual summary. resistance data
See also the NICE guideline on pneumonia.
For first choice IV antibiotics (severe or higher risk of resistance) and
antibiotics to be added if suspected or confirmed MRSA infection see
visual summary

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 7

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Urinary tract infections
Lower urinary Advise paracetamol or ibuprofen for pain. Non-pregnant women 100mg m/r BD (or
tract infection Non-pregnant women: back up antibiotic (to first choice: if unavailable
-
use if no improvement in 48 hours or symptoms nitrofurantoin (if eGFR 50mg QDS)
≥45 ml/minute) OR 3 days
worsen at any time) or immediate antibiotic.
Pregnant women, men, children or young trimethoprim (if low risk of 200mg BD
-
people: immediate antibiotic. resistance)
When considering antibiotics, take account of Non-pregnant women 100mg m/r BD (or
severity of symptoms, risk of complications, second choice: if unavailable
Public Health - 3 days
previous urine culture and susceptibility results, nitrofurantoin (if eGFR 50mg QDS)
England previous antibiotic use which may have led to ≥45 ml/minute) OR
resistant bacteria and local antimicrobial pivmecillinam (a penicillin) 400mg initial dose,
resistance data. - 3 days
OR then 200mg TDS
Last updated: If people have symptoms of pyelonephritis (such fosfomycin 3g single dose
Oct 2018 as fever) or a complicated UTI, see acute - single dose
sachet
pyelonephritis (upper urinary tract infection) for
Pregnant women first 100mg m/r BD (or
antibiotic choices.
choice: nitrofurantoin if unavailable
For detailed information click on the visual summary. - 7 days
(avoid at term) – if eGFR 50mg QDS)
See also the NICE guideline on urinary tract infection
≥45 ml/minute
in under 16s: diagnosis and management and the
Public Health England urinary tract infection: Pregnant women second 500mg TDS
diagnostic tools for primary care. choice: amoxicillin (only if
-
culture results available 7 days
and susceptible) OR
cefalexin 500mg BD -
Treatment of asymptomatic bacteriuria in pregnant women: choose from
nitrofurantoin (avoid at term), amoxicillin or cefalexin based on recent culture
and susceptibility results
Men first choice: 200mg BD
-
trimethoprim OR
nitrofurantoin (if eGFR 100mg m/r BD (or 7 days
≥45 ml/minute) if unavailable -
50mg QDS)
Men second choice: consider alternative diagnoses basing antibiotic choice
on recent culture and susceptibility results

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 8

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Children and young -
people (3 months and
over) first choice:
trimethoprim (if low risk of
resistance) OR
nitrofurantoin (if eGFR -
≥45 ml/minute)
Children and young -
people (3 months and -
over) second choice:
nitrofurantoin (if eGFR
≥45 ml/minute and not
used as first choice) OR
amoxicillin (only if culture -
results available and
susceptible) OR
cefalexin -
Acute Advise paracetamol (+/- low-dose weak opioid) First choice (guided by 500mg BD
prostatitis for pain, or ibuprofen if preferred and suitable. susceptibilities when
Offer antibiotic. available): -
ciprofloxacin (consider
Review antibiotic treatment after 14 days and
safety issues) OR
either stop antibiotics or continue for a further 14 days then
14 days if needed (based on assessment of ofloxacin (consider safety 200mg BD
- review
history, symptoms, clinical examination, urine issues) OR
and blood tests). trimethoprim (if 200mg BD
Public Health fluoroquinolone not
For detailed information click on the visual -
England appropriate; seek
summary. specialist advice)
Second choice (after 500mg OD
Last updated: discussion with specialist):
- 14 days, then
levofloxacin (consider
Oct 2018 safety issues) OR review
co-trimoxazole 960mg BD -
IV antibiotics (click on visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 9

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute Advise paracetamol (+/- low-dose weak opioid) Non-pregnant women 500mg BD or TDS
pyelonephritis for pain for people over 12. and men first choice: (up to 1g to 1.5g
- 7 to 10 days
(upper urinary Offer an antibiotic. cefalexin OR TDS or QDS for
tract) severe infections)
When prescribing antibiotics, take account of
severity of symptoms, risk of complications, co-amoxiclav (only if 500/125mg TDS
previous urine culture and susceptibility results, culture results available - 7 to 10 days
previous antibiotic use which may have led to and susceptible) OR
resistant bacteria and local antimicrobial trimethoprim (only if 200mg BD
resistance data. culture results available - 14 days
Avoid antibiotics that don’t achieve adequate and susceptible) OR
levels in renal tissue, such as nitrofurantoin. ciprofloxacin (consider 500mg BD
Public Health - 7 days
For detailed information click on the visual summary. safety issues)
England See also the NICE guideline on urinary tract infection Non-pregnant women and men IV antibiotics (click on visual summary)
in under 16s: diagnosis and management and the
Public Health England urinary tract infection: Pregnant women first 500mg BD or TDS
diagnostic tools for primary care. choice: (up to 1g to 1.5g
- 7 to 10 days
Last updated: cefalexin TDS or QDS for
Oct 2018 severe infections)
Pregnant women second choice or IV antibiotics (click on visual summary)
Children and young -
people (3 months and
over) first choice:
cefalexin OR -
co-amoxiclav (only if -
culture results available
and susceptible)
Children and young people (3 months and over) IV antibiotics (click on
visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 10

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Recurrent First advise about behavioural and personal First choice antibiotic 200mg single dose
urinary tract hygiene measures, and self-care (with D- prophylaxis: trimethoprim when exposed to a
-
infection mannose or cranberry products) to reduce the (avoid in pregnancy) OR trigger or
risk of UTI. 100mg at night
For postmenopausal women, if no improvement, nitrofurantoin (avoid at 100mg single dose
consider vaginal oestrogen (review within term) - if eGFR when exposed to a
12 months). ≥45 ml/minute trigger or -
For non-pregnant women, if no improvement, 50 to 100mg at
Public Health consider single-dose antibiotic prophylaxis for night
England exposure to a trigger (review within 6 months). Second choice antibiotic 500mg single dose
For non-pregnant women (if no improvement or prophylaxis: when exposed to a
-
Last updated Oct no identifiable trigger) or with specialist advice amoxicillin OR trigger or
2018 250mg at night
for pregnant women, men, children or young
people, consider a trial of daily antibiotic cefalexin 500mg single dose
prophylaxis (review within 6 months). when exposed to a
For detailed information click on the visual trigger or
summary. See also the NICE guideline on 125mg at night
urinary tract infection in under 16s: diagnosis -
and management and the Public Health England
urinary tract infection: diagnostic tools for
primary care.

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 11

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Catheter- Antibiotic treatment is not routinely needed for Non-pregnant women 100mg m/r BD (or
associated asymptomatic bacteriuria in people with a and men first choice if if unavailable
urinary tract urinary catheter. no upper UTI symptoms: 50mg QDS) -
infection Consider removing or, if not possible, changing nitrofurantoin (if eGFR ≥45
the catheter if it has been in place for more than ml/minute) OR
7 days
7 days. But do not delay antibiotic treatment. trimethoprim (if low risk of 200mg BD
-
Advise paracetamol for pain. resistance) OR
Advise drinking enough fluids to avoid amoxicillin (only if culture 500mg TDS
dehydration. results available and -
susceptible)
Offer an antibiotic for a symptomatic infection.
Public Health When prescribing antibiotics, take account of Non-pregnant women 400mg initial dose,
England severity of symptoms, risk of complications, and men second choice then 200mg TDS
previous urine culture and susceptibility results, if no upper UTI - 7 days
previous antibiotic use which may have led to symptoms:
resistant bacteria and local antimicrobial pivmecillinam (a penicillin)
Last updated:
Nov 2018 resistance data. Non-pregnant women 500mg BD or TDS
Do not routinely offer antibiotic prophylaxis to and men first choice if (up to 1g to 1.5g
-
people with a short-term or long-term catheter. upper UTI symptoms: TDS or QDS for
cefalexin OR severe infections) 7 to 10 days
For detailed information click on the visual summary.
See also the Public Health England urinary tract co-amoxiclav (only if 500/125mg TDS
infection: diagnostic tools for primary care. culture results available -
and susceptible) OR
trimethoprim (only if 200mg BD
culture results available - 14 days
and susceptible) OR
ciprofloxacin (consider 500mg BD
- 7 days
safety issues)
Non-pregnant women and men IV antibiotics (click on visual summary)
Pregnant women first 500mg BD or TDS
choice: (up to 1g to 1.5g
- 7 to 10 days
cefalexin TDS or QDS for
severe infections)
Pregnant women second choice or IV antibiotics (click on visual summary)

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 12

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Children and young -
people (3 months and
over) first choice:
trimethoprim (if low risk of
resistance) OR
amoxicillin (only if culture -
results available and -
susceptible) OR
cefalexin OR -
co-amoxiclav (only if -
culture results available
and susceptible)
Children and young people (3 months and over) IV antibiotics (click on
visual summary)
Meningitis
Suspected Transfer all patients to hospital IV or IM Child <1 year: 300mg5D
meningococcal immediately.1D benzylpenicillin1D,2D Child 1 to 9 years: 600mg5D Not available.
disease If time before hospital admission,2D,3A+ if Adult/child 10+ years: 1.2g5D Stat dose;1D Access the
Public Health suspected meningococcal septicaemia or non- supporting
England give IM, if vein evidence and
blanching rash,2D,4D give IV
cannot be rationales on
benzylpenicillin1D,2D,4D as soon as possible.2D Do
accessed 1D the PHE
Last updated: not give IV antibiotics if there is a definite history
website
Feb 2019 of anaphylaxis;1D rash is not a
contraindication.1D
Prevention of Only prescribe following advice from your local health protection specialist/consultant:  [INSERT PHONE NUMBER]
secondary Out of hours: contact on-call doctor:  [INSERT PHONE NUMBER]
case of
Expert advice is available for managing clusters of meningitis. Please alert the appropriate organisation to any cluster situation.
meningitis
Public Health England, Colindale (tel: 0208 200 4400)
Public Health
England AWARe (all Wales Acute Response team) (tel: 0300 003 0032)
Last updated: Access the supporting evidence and rationales on the PHE website.
July 2019

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 13

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Gastrointestinal tract infections
Oral Topical azoles are more effective than topical Miconazole oral 2.5ml of 24mg/ml
7 days; continue
candidiasis nystatin.1A+ gel1A+,4D,5A- QDS (hold in
for 7 days after
Oral candidiasis is rare in immunocompetent mouth after food) Not available.
4D resolved4D,6D
adults;2D consider undiagnosed risk factors, Access
Public Health supporting
England including HIV.2D If not tolerated: nystatin 1ml;
7 days; continue evidence and
Use 50mg fluconazole if extensive/severe suspension2D,6D,7A- 100,000units/ml rationales on
for 2 days after
candidiasis;3D,4D if HIV or immunocompromised, QDS (half in each the PHE
Last updated: resolved4D
Oct 2018 use 100mg fluconazole.3D,4D side) 2D,4D,7A- website
fluconazole capsules6D,7A- 50mg/100mg 7 to 14 days6D,7A-
OD3D,6D,8A- ,8A-

Infectious Refer previously healthy children with acute painful or bloody diarrhoea, to exclude E. coli O157 infection.1D
diarrhoea Antibiotic therapy is not usually indicated unless patient is systemically unwell.2D If systemically unwell and campylobacter suspected (such
Public Health as undercooked meat and abdominal pain),3D consider clarithromycin 250mg to 500mg BD for 5 to 7 days, if treated early (within 3 days).3D,4A+
England If giardia is confirmed or suspected – tinidazole 2g single dose is the treatment of choice.5A+
Last updated: Access the supporting evidence and rationales on the PHE website.
Oct 2018
Clostridium Review need for antibiotics,1D,2D PPIs,3B- and First episode: 400mg TDS1D,2D
10 to 14 days1D,4B-
difficile antiperistaltic agents and discontinue use where metronidazole2D,4B-
possible.2D Mild cases (<4 episodes of stool/day) Severe, type 027 or 125mg QDS1D,2D,5A- Not available.
may respond without metronidazole;2D recurrent: 10 to 14 days,1D,2D
Access
70% respond to metronidazole in 5 days; 92% then taper2D supporting
Public Health oral vancomycin1D,2D,5A-
respond to metronidazole in 14 days.4B- evidence and
England Recurrent or second 200mg BD5A- rationales on
If severe (T>38.5, or WCC>15, rising line: the PHE
creatinine, or signs/symptoms of severe fidaxomicin2D,5A- website
Last updated:
colitis):2D treat with oral vancomycin,1D,2D,5A- - 10 days5A-
Oct 2018
review progress closely,1D,2D and consider
hospital referral.2D
Traveller’s Prophylaxis rarely, if ever, indicated.1D Consider Standby: 500mg OD1D,3A+ Not available.
- 1 to 3 days1D,2D,3A+ Access
diarrhoea standby antimicrobial only for patients at high azithromycin
risk of severe illness,2D or visiting high-risk supporting
Public Health Prophylaxis/treatment: 2 tablets QDS1D,2D evidence and
England areas.1D,2D bismuth subsalicylate
- 2 days1D,2D,4A- rationales on
Last updated: the PHE
Oct 2018 website

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 14

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Helicobacter Always test for H.pylori before giving antibiotics. Always use -
pylori Treat all positives, if known DU, GU,1A+ or PPI2D,3D,5A+,12A+
low-grade MALToma.2D,3D NNT in non-ulcer First line and first
dyspepsia: 14.4A+ relapse and no penicillin
Do not offer eradication for GORD.3D allergy
Public Health PPI PLUS 2 antibiotics
England Do not use clarithromycin, metronidazole or
amoxicillin2D,6B+ PLUS 1000mg BD14A+
quinolone if used in the past year for any
infection.5A+,6B+,7A+ clarithromycin2D,6B+ OR 500mg BD8A-
See PHE quick
Penicillin allergy: use PPI PLUS clarithromycin
reference guide
PLUS metronidazole.2D If previous metronidazole2D,6B+ 400mg BD2D
for diagnostic
clarithromycin, use PPI PLUS bismuth salt
advice: PHE Penicillin allergy and -
PLUS metronidazole PLUS tetracycline
H. pylori previous clarithromycin:
hydrochloride.2D,8A-,9D
PPI WITH bismuth 7 days2D
Relapse and no penicillin allergy use PPI
PLUS amoxicillin PLUS clarithromycin or subsalicylate PLUS 2 - MALToma
Last updated: metronidazole (whichever was not used first antibiotics 14 days7A+,16A+
Feb 2019 bismuth subsalicylate13A+ 525mg QDS15D Not available.
line) 2D
PLUS Access
Relapse and previous metronidazole and supporting
metronidazole2D PLUS 400mg BD2D
clarithromycin: use PPI PLUS amoxicillin evidence and
PLUS either tetracycline OR levofloxacin (if rationales on
tetracycline2D 500mg QDS15D
tetracycline not tolerated).2D,7A+ the PHE
Relapse and previous - website
Relapse and penicillin allergy (no exposure metronidazole and
to quinolone): use PPI PLUS metronidazole -
clarithromycin:
PLUS levofloxacin.2D PPI PLUS 2 antibiotics
Relapse and penicillin allergy (with exposure amoxicillin2D,7A+ PLUS 1000mg BD14A+
to quinolone): use PPI PLUS bismuth salt
PLUS metronidazole PLUS tetracycline.2D tetracycline2D,7A+ OR 500mg QDS15D
levofloxacin (if tetracycline 250mg BD7A+
Retest for H. pylori: post DU/GU, or relapse
cannot be used)2D,7A+
after second-line therapy,1A+ using UBT or
Third line on advice: -
SAT,10A+,11A+ consider referral for endoscopy and -
PPI WITH
culture.2D
bismuth subsalicylate 525mg QDS15D
PLUS -
10 days
2 antibiotics as above not -
previously used OR -
rifabutin14A+ OR 150mg BD -
furazolidone17A+ 200mg BD -

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 15

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acute Acute diverticulitis and systemically well: First-choice 500/125mg TDS
diverticulitis Consider no antibiotics, offer simple analgesia (uncomplicated acute
-
(for example paracetamol), advise to re-present diverticulitis):
if symptoms persist or worsen. co-amoxiclav
Acute diverticulitis and systemically unwell, Penicillin allergy or cefalexin: 500mg
immunosuppressed or significant co-amoxiclav unsuitable: BD or TDS (up to
comorbidity: offer an antibiotic. cefalexin (caution in 1g to 1.5g TDS or
Give oral antibiotics if person not referred to penicillin allergy) AND QDS for severe -
Last updated: hospital for suspected complicated acute metronidazole OR infections)
Nov 2019 diverticulitis. metronidazole:
Give IV antibiotics if admitted to hospital with 400mg TDS 5 days*
suspected or confirmed complicated acute trimethoprim AND trimethoprim:
diverticulitis (including diverticular abscess). metronidazole OR 200mg BD
If CT-confirmed uncomplicated acute -
metronidazole:
diverticulitis, review the need for antibiotics. 400mg TDS
* A longer course may be needed based on ciprofloxacin (only if ciprofloxacin:
clinical assessment. switching from IV 500mg BD
ciprofloxacin with metronidazole:
specialist advice; consider 400mg TDS
safety issues) AND
metronidazole
For IV antibiotics in complicated acute diverticulitis (including
diverticular abscess) see visual summary
Threadworm Treat all household contacts at the same Child >6 months: 100mg stat3B- 1 dose;3B- repeat
time.1D mebendazole 1D,3B- in 2 weeks if Not available.
Access
Public Health Advise hygiene measures for 2 weeks1D persistent3B-
supporting
England (hand hygiene;2D pants at night; morning Child <6 months or - evidence and
shower, including perianal area).1D,2D Wash pregnant (at least in first rationales on
Last updated: sleepwear, bed linen, and dust and vacuum. 1D trimester): - - the PHE
Nov 2017
Child <6 months, add perianal wet wiping or only hygiene measure for website
washes 3 hourly.1D 6 weeks1D
Genital tract infections
STI screening People with risk factors should be screened for chlamydia, gonorrhoea, HIV and syphilis. 1D Refer individual and partners to GUM.1D
Public Health Risk factors: <25 years; no condom use; recent/frequent change of partner; symptomatic or infected partner; area of high HIV.2B-
England Access the supporting evidence and rationales on the PHE website.
Last updated:
Nov 2017

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 16

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Chlamydia Opportunistically screen all sexually active First line: 100mg BD4A+,11A- 7 days4A+,11A-,12A+
trachomatis/ patients aged 15 to 24 years for chlamydia doxycycline4A+,11A-,12A+ ,12A+

urethritis annually and on change of sexual partner.1B- Second line/ 1000mg4A+,11A-,12A+ Stat4A+,11A-,12A+
If positive, treat index case, refer to GUM and pregnant/breastfeeding/ then
initiate partner notification, testing and allergy/intolerance:
treatment.2D,3A+ 500mg OD4A+,11A- 2 days4A+,11A-,12A+
azithromycin4A+,11A-,12A+
Public Health ,12A+
(total 3 days)
England As single dose azithromycin has led to
increased resistance in GU infections,
doxycycline should be used first line for
chlamydia and urethritis.4A+
Last updated:
July 2019
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 Not available.
symptoms resolved if urethritis).3A+,4A+ Access
supporting
If chlamydia, test for reinfection at 3 to 6 months - evidence and
following treatment if under 25 years; or rationales on
consider if over 25 years and high risk of the PHE
re-infection.1B-,3B+, 5B- website
Second line, pregnant, breastfeeding,
allergy, or intolerance: azithromycin is most
effective.6A+,7D,8A+,9A+,10D As lower cure rate in
pregnancy, test for cure at least 3 weeks after
end of treatment.3A+
Consider referring all patients with symptomatic
urethritis to GUM as testing should include
Mycoplasma genitalium and Gonorrhoea.11A-
If M.genitalium is proven, use doxycycline
followed by azithromycin using the same dosing
regimen and advise to avoid sex for 14 days
after start of treatment and until symptoms have
resolved.11A-,12A+

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 17

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Epididymitis Usually due to Gram-negative enteric bacteria in Doxycycline1A+,2D OR 100mg BD1A+,2D 10 to 14 days1A+,2D Not available.
men over 35 years with low risk of STI.1A+,2D Access
ofloxacin1A+,2D OR 200mg BD1A+,2D 14 days1A+,2D
supporting
Public Health If under 35 years or STI risk, refer to GUM.1A+,2D ciprofloxacin1A+,2D 500mg BD1A+,2D,3A+ - evidence and
England rationales on
10 days1A+,2D,3A+
Last updated: the PHE
Nov 2017 website
Vaginal All topical and oral azoles give over 80% Clotrimazole1A+,5D OR 500mg pessary1A+ Stat1A+
candidiasis cure.1A+,2A+ fenticonazole1A+ OR 600mg pessary1A+ Stat1A+
Pregnant: avoid oral azoles, the 7 day courses - Not available.
clotrimazole1A+ OR 100mg pessary1A+ 6 nights1A+ Access
Public Health are more effective than shorter ones.1A+,3D,4A+
oral fluconazole1A+,3D 150mg1A+,3D Stat1A+ supporting
England Recurrent (>4 episodes per year):1A+ 150mg evidence and
oral fluconazole every 72 hours for 3 doses If recurrent: 150mg every
rationales on
induction,1A+ followed by 1 dose once a week for fluconazole 72 hours 3 doses the PHE
Last updated: (induction/maintenance)1A+
Oct 2018 6 months maintenance.1A+ THEN - website
150mg once a 6 months1A+
week1A+,3D
Bacterial Oral metronidazole is as effective as topical oral metronidazole1A+,3A+ 400mg BD1A+,3A+ 7 days1A+
vaginosis treatment,1A+ and is cheaper.2D OR OR OR Not available.
7 days results in fewer relapses than 2g stat at Access
2000mg1A+,2D Stat2D supporting
Public Health 4 weeks.1A+,2D
metronidazole 0.75% 5g applicator at - evidence and
England Pregnant/breastfeeding: avoid 2g dose.3A+,4D 5 nights1A+,2D,3A+ rationales on
vaginal gel1A+,2D,3A+ OR night1A+,2D,3A+
Treating partners does not reduce relapse.5A+ the PHE
clindamycin 2% 5g applicator at website
Last updated: cream1A+,2D night1A+,2D 7 nights1A+,2D,3A+
Nov 2017
Genital herpes Advise: saline bathing,1A+ analgesia,1A+ or oral aciclovir1A+,2D,3A+,4A+ 400mg TDS1A+,3A+ 5 days1A+
topical lidocaine for pain,1A+ and discuss OR 800mg TDS (if Not available.
transmission.1A+ 2 days1A+ Access
Public Health recurrent)1A+
supporting
England First episode: treat within 5 days if new lesions valaciclovir1A+,3A+,4A+ OR 500mg BD1A+ 5 days1A+ evidence and
or systemic symptoms,1A+,2D and refer to GUM.2D - rationales on
famciclovir1A+,4A+ 250mg TD1A+ 5 days1A+
Last updated:
Recurrent: self-care if mild,2D or immediate the PHE
short course antiviral treatment,1A+,2D or 1000mg BD (if website
Nov 2017
suppressive therapy if more than 6 episodes per recurrent)1A+ 1 day1A+
year.1A+,2D

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 18

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Gonorrhoea Antibiotic resistance is now very high.1D,2D ceftriaxone2D OR 1000mg IM2D
Stat2D Not available.
Public Health Use IM ceftriaxone if susceptibility not known Access
England prior to treatment2D. supporting
Last updated: Use Ciprofloxacin only If susceptibility is known ciprofloxacin2D 500mg2D - evidence and
Feb 2019 rationales on
prior to treatment and the isolate is sensitive to (only if known to be
Stat2D the PHE
ciprofloxacin at all sites of infection1D,2D sensitive) website
Refer to GUM.3B- Test of cure is essential.2D
Trichomoniasis Oral treatment needed as extravaginal infection metronidazole1A+,2A+,3D,6A+ 400mg BD1A+,6A+ 5 to 7 day1A+
common.1D Not available.
2g (more adverse
Stat1A+,6A+ Access
Treat partners,1D and refer to GUM for other effects)6A+
Public Health supporting
STIs.1D Pregnancy to treat 100mg pessary at evidence and
England -
Pregnant/breastfeeding: avoid 2g single dose symptoms: night5D rationales on
metronidazole;2A+,3D clotrimazole for symptom clotrimazole2A+,4A-,5D 6 nights5D the PHE
Last updated: relief (not cure) if metronidazole declined.2A+,4A- website
Nov 2017 ,5D

Pelvic Refer women and sexual contacts to GUM.1A+ First line therapy: 1000mg IM1A+,3C
Stat1A+,3C
inflammatory Raised CRP supports diagnosis, absent pus ceftriaxone1A+,3C,4C PLUS
disease cells in HVS smear good negative predictive metronidazole1A+,5A+ PLUS 400mg BD1A+ 14 days1A+
value.1A+ doxycycline1A+,5A+ 100mg BD1A+ 14 days1A+ Not available.
Exclude: ectopic pregnancy, appendicitis, Access
Second line therapy: 400mg BD1A+ supporting
Public Health endometriosis, UTI, irritable bowel, complicated 14 days1A+
metronidazole1A+,5A+ PLUS - evidence and
England ovarian cyst, functional pain. rationales on
ofloxacin1A+,2A-,5A+ 400mg BD1A+,2A-
Moxifloxacin has greater activity against likely 14 days1A+ the PHE
pathogens, but always test for gonorrhoea, OR website
chlamydia, and M. genitalium .1A+ moxifloxacin alone1A+ 400mg OD1A+
Last updated:
Feb 2019 If M. genitalium tests positive use (first line for M. genitalium 14 days1A+
moxifloxacin.1A+ associated PID)
Skin and soft tissue infections
Note: Refer to RCGP Skin Infections online training.1D For MRSA, discuss therapy with microbiologist.1D
Cold sores Most resolve after 5 days without treatment.1A-,2A- Topical antivirals applied prodromally can reduce duration by 12 to 18 hours.1A-,2A-,3A-
Public Health If frequent, severe, and predictable triggers: consider oral prophylaxis:4D,5A+ aciclovir 400mg, twice daily, for 5 to 7 days.5A+,6A+
England Access supporting evidence and rationales on the PHE website
Last updated:
Nov 2017

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 19

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
PVL-SA Panton-Valentine leukocidin (PVL) is a toxin produced by 20.8 to 46% of S. aureus from boils/abscesses.1B+,2B+,3B- PVL strains are rare in healthy
Public Health people, but severe.2B+
England Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking. 4D
Risk factors for PVL: recurrent skin infections;2B+ invasive infections;2B+ MSM;3B- if there is more than one case in a home or close community2B+,3B-
Last updated: (school children;3B- military personnel;3B- nursing home residents;3B- household contacts).3B-
Nov 2017
Access the supporting evidence and rationales on the PHE website.
Eczema No visible signs of infection: antibiotic use (alone or with steroids)1A+ encourages resistance and does not improve healing.1A+
Public Health With visible signs of infection: use oral flucloxacillin2D or clarithromycin,2D or topical treatment (as in impetigo).2D
England
Access the supporting evidence and rationales on the PHE website.
Last updated:
Nov 2017
Impetigo Localised non-bullous impetigo: Topical antiseptic:
Hydrogen peroxide 1% cream (other topical hydrogen peroxide 1% BD or TDS 5 days*
antiseptics are available but no evidence for
impetigo). Topical antibiotic:
If hydrogen peroxide unsuitable or ineffective, First choice: TDS
short-course topical antibiotic. fusidic acid 2%
Widespread non-bullous impetigo: Fusidic acid resistance TDS 5 days*
Public Health
Short-course topical or oral antibiotic. suspected or confirmed:
England
Take account of person’s preferences, mupirocin 2%
practicalities of administration, previous use of Oral antibiotic:
topical antibiotics because antimicrobial First choice: 500mg QDS
Last updated: resistance can develop rapidly with extended or
Feb 2020 flucloxacillin
repeated use, and local antimicrobial resistance
data. Penicillin allergy or 250mg BD
flucloxacillin unsuitable: 5 days*
Bullous impetigo, systemically unwell, or clarithromycin OR
high risk of complications:
erythromycin (in 250 to 500mg
Short-course oral antibiotic.
pregnancy) QDS
Do not offer combination treatment with a topical
and oral antibiotic to treat impetigo.
*5 days is appropriate for most, can be
increased to 7 days based on clinical judgement. If MRSA suspected or confirmed – consult local microbiologist
For detailed information click on the visual
summary.

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 20

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Leg ulcer Manage any underlying conditions to promote First-choice:
infection ulcer healing. flucloxacillin 500mg to 1g QDS - 7 days
Only offer an antibiotic when there are Penicillin allergy or if flucloxacillin unsuitable:
symptoms or signs of infection (such as redness doxycycline OR 200mg on day 1,
or swelling spreading beyond the ulcer, localised then 100mg OD
warmth, increased pain or fever). Few leg ulcers (can be increased
are clinically infected but most are colonised by to 200mg daily) - 7 days
Public Health bacteria. clarithromycin OR 500mg BD
England When prescribing antibiotics, take account of erythromycin (in 500mg QDS
severity, risk of complications and previous pregnancy)
antibiotic use. Second choice:
Last updated: For detailed information click on the visual co-amoxiclav OR 500/125mg TDS
Feb 2020 summary. co-trimoxazole (in 960mg BD - 7 days
penicillin allergy)
For antibiotic choices if severely unwell or MRSA suspected or
confirmed, click on the visual summary
Cellulitis and Exclude other causes of skin redness First choice:
erysipelas (inflammatory reactions or non-infectious flucloxacillin 500mg to 1g QDS 5 to 7 days*
causes).
Consider marking extent of infection with a Penicillin allergy or if flucloxacillin unsuitable:
single-use surgical marker pen. clarithromycin OR 500mg BD
erythromycin (in 500mg QDS
Offer an antibiotic. Take account of severity, site
pregnancy) OR
of infection, risk of uncommon pathogens, any
doxycycline (adults only) 200mg on day 1,
microbiological results and MRSA status. - 5 to 7 days*
OR then 100mg OD
Public Health Infection around eyes or nose is more co-amoxiclav (children -
England concerning because of serious intracranial only: not in penicillin
complications. allergy)
*A longer course (up to 14 days in total) may be If infection near eyes or nose:
Last updated: needed but skin takes time to return to normal, co-amoxiclav 500/125mg TDS 7 days*
Sept 2019 and full resolution at 5 to 7 days is not expected.
Do not routinely offer antibiotics to prevent If infection near eyes or nose (penicillin allergy):
recurrent cellulitis or erysipelas. clarithromycin AND 500mg BD
metronidazole (only add in 400mg TDS
For detailed information click on the visual 7 days*
children if anaerobes
summary.
suspected)
For alternative choice antibiotics for severe infection, suspected or
confirmed MRSA infection and IV antibiotics click on the visual summary

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 21

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Diabetic foot In diabetes, all foot wounds are likely to be Mild infection: first choice
infection colonised with bacteria. Diabetic foot infection flucloxacillin 500mg to 1g QDS - 7 days*
has at least 2 of: local swelling or induration;
erythema; local tenderness or pain; local Mild infection (penicillin allergy):
warmth; purulent discharge. clarithromycin OR 500mg BD
Severity is classified as: erythromycin (in 500mg QDS
Mild: local infection with 0.5 to less than 2cm pregnancy) OR
erythema doxycycline 200mg on day 1, - 7 days*
Public Health Moderate: local infection with more than 2cm then 100mg OD
England erythema or involving deeper structures (such (can be increased
as abscess, osteomyelitis, septic arthritis or to 200mg daily)
fasciitis) For antibiotic choices for moderate or severe infection, infections where
Last updated: Severe: local infection with signs of a systemic Pseudomonas aeruginosa or MRSA is suspected or confirmed, and IV
Oct 2019 inflammatory response. antibiotics click on the visual summary
Start antibiotic treatment as soon as possible.
Take samples for microbiological testing before,
or as close as possible to, the start of treatment
When choosing an antibiotic, take account of
severity, risk of complications, previous
microbiological results and antibiotic use, and
patient preference.
*A longer course (up to a further 7 days) may be
needed based on clinical assessment. However,
skin does take time to return to normal, and full
resolution at 7 days is not expected.
Do not offer antibiotics to prevent diabetic foot
infection.
For detailed information click on the visual
summary.
Tick bites Treatment: Treat erythema migrans Treatment: 100mg BD1D Not available.
(Lyme empirically; serology is often negative early in doxycycline1D Access
disease) infection.1D Alternative: 1,000mg TDS1D supporting
Public Health For other suspected Lyme disease such as amoxicillin1D evidence and
England neuroborreliosis (CN palsy, radiculopathy) seek rationales on
the PHE
Last updated: advice.1D
website
Feb 2020

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 22

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Acne Mild (open and closed comedones)1D or Second line: topical Thinly OD3A+
6 to 8 weeks1D
moderate (inflammatory lesions):1D retinoid1D,2D,3A+ OR
First line: self-care1D (wash with mild soap; do benzoyl peroxide1A- 5% cream OD-
6 to 8 weeks1D Not available.
not scrub; avoid make-up).1D ,2D,3A+,4A- BD3A+ Access
Public Health
England Second line: topical retinoid or benzoyl Third-line: topical 1% cream, thinly supporting
peroxide.2D 12 weeks1A-,2D evidence and
clindamycin3A+ BD3A+
rationales on
Last updated:
Third-line: add topical antibiotic,1D,3A+ or If treatment 500mg BD3A+ the PHE
Nov 2017 consider addition of oral antibiotic.1D failure/severe: 6 to 12 weeks3A+ website
Severe (nodules and cysts):1D add oral oral tetracycline1A-,3A+ OR
antibiotic (for 3 months max)1D,3A+ and refer.1D,2D oral doxycycline3A+,4A- 100mg OD3A+ 6 to 12 weeks3A+
Scabies First choice permethrin: Treat whole body permethrin1D,2D,3A+ 5% cream1D,2D
from ear/chin downwards,1D,2D and under Not available.
nails.1D,2D Permethrin allergy: 0.5% aqueous Access
Public Health supporting
England If using permethrin and patient is under malathion1D liquid1D 2 applications,
evidence and
2 years, elderly or immunosuppressed, or if 1 week apart1D rationales on
Last updated:
treating with malathion: also treat face and the PHE
Oct 2018 scalp.1D,2D website
Home/sexual contacts: treat within 24 hours.1D
Bites Human: thorough irrigation is important.1A+,2D Prophylaxis/treatment 375mg to 625mg
7 days3D
Antibiotic prophylaxis is advised.1A+,2D,3D Assess all: co-amoxiclav2D,3D TDS3D
risk of tetanus, rabies,1A+ HIV, and hepatitis B Human + penicillin 400mg TDS2D
and C.3D allergy: Not available.
Public Health Access
Cat: always give prophylaxis.1A+,3D metronidazole3D,4A+ AND 7 days3D
England supporting
Dog: give prophylaxis if: puncture wound;1A+,3D clarithromycin3D,4A+ 250mg to 500mg evidence and
bite to hand, foot, face, joint, tendon, or BD2D rationales on
ligament;1A+ immunocompromised; cirrhotic; Animal + penicillin 400mg TDS2D the PHE
Last updated: asplenic; or presence of prosthetic allergy: website
July 2019 valve/joint.2D,4A+ metronidazole3D,4A+ AND 7 days3D
Penicillin allergy: Review all at 24 and
doxycycline3D 100mg BD2D
48 hours,3D as not all pathogens are covered.2D,3

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 23

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Mastitis S. aureus is the most common infecting flucloxacillin2D 500mg QDS2D
Not available.
pathogen.1D Suspect if woman has: a painful Penicillin allergy: 250mg to 500mg Access
breast;2D fever and/or general malaise;2D a erythromycin2D OR QDS2D supporting
Public Health
tender, red breast.2D - 10 to 14 days2D evidence and
England clarithromycin2D 500mg BD2D
Breastfeeding: oral antibiotics are appropriate, rationales on
where indicated.2D,3A+ Women should continue the PHE
Last updated: website
Nov 2017
feeding,1D,2D including from the affected breast.2D
Dermatophyte Most cases: use terbinafine as fungicidal, topical terbinafine3A+,4D OR 1% OD to BD2A+ 1 to 4 weeks3A+
infection: skin treatment time shorter and more effective than
with fungistatic imidazoles or topical imidazole2A+,3A+ 1% OD to BD2A+ Not available.
undecenoates.1D,2A+,If candida possible, use Access
Public Health supporting
imidazole.4D Alternative in athlete’s OD to BD2A+
England evidence and
If intractable, or scalp: send skin scrapings,1D foot: rationales on
4 to 6 weeks2A+,3A+
and if infection confirmed: use oral topical undecenoates2A+ the PHE
Last updated:
Feb 2019
terbinafine1D,3A+,4D or itraconazole.2A+,3A+,5D (such as Mycota®)2A+ website
Scalp: oral therapy,6D and discuss with
specialist.1D
Dermatophyte Take nail clippings;1D start therapy only if First line: 250mg OD1D,2A+,6D Fingers:
infection: nail infection is confirmed.1D Oral terbinafine is more terbinafine1D,2A+,3A+,4D,6D 6 weeks1D,6D
effective than oral azole.1D,2A+,3A+,4D Liver Toes: Not available.
reactions 0.1 to 1% with oral antifungals.3A+ If 12 weeks1D,6D Access
candida or non-dermatophyte infection is supporting
Public Health Second line: 200mg BD1D,4D 1 week a month1D evidence and
confirmed, use oral itraconazole.1D,3A+,4D Topical
England itraconazole1D,3A+,4D,6D Fingers: rationales on
nail lacquer is not as effective.1D,5A+,6D
2 courses1D the PHE
To prevent recurrence: apply weekly 1% website
Last updated: topical antifungal cream to entire toe area.6D Toes: 3 courses1D
Oct 2018
Children: seek specialist advice.4D Stop treatment when continual, new, healthy, proximal nail growth.6D

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 24

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Varicella Pregnant/immunocompromised/ First line for chicken pox 800mg 5 times
zoster/ neonate: seek urgent specialist advice.1D and shingles: daily16A-
chickenpox Chickenpox: consider aciclovir2A+,3A+,4D if: onset aciclovir3A+,7A+,10A+,13B+,14A-
,15A+
of rash <24 hours,3A+ and 1 of the following:
Herpes zoster/ >14 years of age;4D severe pain;4D dense/oral Second line for shingles 250mg to 500mg
shingles rash;4D,5B+ taking steroids;4D smoker.4D,5B+ if poor compliance: TDS15A+ OR
not for children: -
Give paracetamol for pain relief.6C 750mg BD15A+ Not available.
Shingles: treat if >50 years7A+,8D (PHN rare if famciclovir8D,14A-, 16A- OR Access
<50 years)9B+ and within 72 hours of rash,10A+ or valaciclovir8D,10A+,14A- 1g TDS14A- supporting
Public Health 7 days14A-,16A- evidence and
if 1 of the following: active ophthalmic;11D
England rationales on
Ramsey Hunt;4D eczema;4D non-truncal
the PHE
involvement;8D moderate or severe pain;8D website
moderate or severe rash.5B+,8D
Last updated: Shingles treatment if not within 72 hours:
Oct 2018 consider starting antiviral drug up to 1 week after
rash onset,12B+ if high risk of severe shingles12B+
or continued vesicle formation;4D older
age;7A+,8D,12B+ immunocompromised;4D or severe
pain.7D,11B+
Eye infections
Conjunctivitis First line: bath/clean eyelids with cotton wool Second line: Eye drops:
dipped in sterile saline or boiled (cooled) water, chloramphenicol1D,2A+,4A- 2 hourly for
to remove crusting.1D ,5A+ 2 days,1D,2A+ then
Treat only if severe,2A+ as most cases are 0.5% eye drop1D,2A+ reduce
Public Health frequency1D to 3 to
viral3D or self-limiting.2A+ OR Not available.
England 4 times daily.1D
Bacterial conjunctivitis: usually unilateral and Access
1% ointment1D,5A+ Eye ointment: 3 to supporting
also self-limiting.2A+,3D It is characterised by red 48 hours after
4 times daily or evidence and
eye with mucopurulent, not watery discharge.3D resolution2A+,7D
once daily at night rationales on
Last updated: 65% and 74% resolve on placebo by days 5 and the PHE
July 2019 if using antibiotic
7.4A-,5A+ Third line: fusidic acid as it has less website
eye drops during
Gram-negative activity.6A-,7D
the day.1D
Third line: BD1D,7D
fusidic acid 1%
gel2A+,5A+,6A-

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 25

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Blepharitis First line: lid hygiene1D,2A+ for symptom Second line: 1% ointment
control,1D including: warm compresses;1D,2A+ lid topical BD2A+,3D 6-week trial3D Not available.
massage and scrubs;1D gentle washing;1D chloramphenicol1D,2A+,3A- Access
Public Health
avoiding cosmetics.1D Third line: 500mg BD3D supporting
England 4 weeks (initial)3D evidence and
Second line: topical antibiotics if hygiene oral oxytetracycline1D,3D 250mg BD3D 8 weeks (maint)3D rationales on
measures are ineffective after 2 weeks.1D,3A+ OR
Last updated: the PHE
Nov 2017 Signs of meibomian gland dysfunction,3D or oral doxycycline1D,2A+,3D 100mg OD3D 4 weeks (initial)3D website
acne rosacea:3D consider oral antibiotics.1D 50mg OD3D 8 weeks (maint)3D
Suspected dental infections in primary care (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, 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 provided details of how to access emergency dental care.
Note: Antibiotics do not cure toothache.1D First-line treatment is with paracetamol1D and/or ibuprofen;1D codeine is not effective for toothache.1D
Mucosal Temporary pain and swelling relief can be Chlorhexidine 1 minute BD with
ulceration and attained with saline mouthwash (½ tsp salt in 0.12 to 0.2%1D, 2A-,3A+,4A+ 10 ml1D
inflammation warm water)1D. Use antiseptic mouthwash if (do not use within Always spit out Not available.
(simple more severe,1D and if pain limits oral hygiene to 30 minutes of after use.1D Access
gingivitis) treat or prevent secondary infection.1D,2A- The toothpaste)1D supporting
Use until lesions evidence and
Public Health primary cause for mucosal ulceration or OR resolve1D or
inflammation (aphthous ulcers;1D oral lichen rationales on
England hydrogen peroxide 6%5A- 2 to 3 minutes less pain allows the PHE
planus;1D herpes simplex infection;1D oral for oral hygiene1D
1D BD/TDS with 15ml website
cancer)1D needs to be evaluated and treated.1D
Last updated: in ½ glass warm
Nov 2017 water1D
Acute Refer to dentist for scaling and hygiene chlorhexidine 0.12 to 0.2% 1 minute BD with
necrotising advice.1D,2D (do not use within 30 10ml1D
ulcerative Antiseptic mouthwash if pain limits oral minutes of toothpaste)1D Not available.
gingivitis hygiene.1D OR Until pain allows Access
for oral hygiene6D supporting
Public Health Commence metronidazole if systemic signs and hydrogen peroxide 6%1D 2 to 3 minutes evidence and
England symptoms.1D,2D,3B-,4B+,5A- BD/TDS with 15ml rationales on
in ½ glass warm the PHE
Last updated: water website
Nov 2017
metronidazole1D,3B-,4B+,5A- 400mg TDS1D,2D 3 days1D,2D

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 26

 Doses Visual
Infection Key points Medicine Length
Adult Child summary
Pericoronitis Refer to dentist for irrigation and debridement.1D metronidazole1D,2A+,3B+ OR 400mg TDS1D 3 days1D,2A+
If persistent swelling or systemic symptoms,1D
use metronidazole1D,2A+,3B+ or amoxicillin.1D,3B+ amoxicillin1D,3B+ 500mg TDS1D 3 days1D Not available.
Public Health Use antiseptic mouthwash if pain and trismus Access
limit oral hygiene.1D chlorhexidine 0.2% (do not 1 minute BD with supporting
England
use within 30 minutes of 10ml1D evidence and
toothpaste)1D OR Until less pain rationales on
allows for oral the PHE
hydrogen peroxide 6%1D 2 to 3 minutes website
Last updated: BD/TDS with 15ml hygiene1D
Nov 2017
in ½ glass warm
water1D
Dental Regular analgesia should be the first option until a dentist can be seen for urgent drainage,1A+,2B-,3A+ as repeated courses of antibiotics for
1A+

abscess abscesses are not appropriate.1A+,4A+ Repeated antibiotics alone, without drainage, are ineffective in preventing the spread of infection. 1A+,5C
Antibiotics are only recommended if there are signs of severe infection,3A+ systemic symptoms,1A+,2B-,4A+ or a high risk of complications.1A+ Patients
with severe odontogenic infections (cellulitis,1A+,3A+ plus signs of sepsis;3A+,4A+ difficulty in swallowing;6D impending airway obstruction)6D should be
referred urgently for hospital admission to protect airway,6D for surgical drainage3A+ and for IV antibiotics. 3A+ The empirical use of
Public Health cephalosporins,6D co-amoxiclav,6D clarithromycin,6D and clindamycin6D do not offer any advantage for most dental patients,6D and should only be
England used if there is no response to first-line drugs.6D
If pus is present, refer for drainage,1A+,2B- tooth amoxicillin6D,8B+,9C,10B+ OR 500mg to 1000mg
extraction, or root canal.
2B- 2B- TDS6D
Not available.
Last updated: Send pus for investigation.1A+ phenoxymethylpenicillin11B- 500mg to 1000mg
Oct 2018 Access
If spreading infection1A+ (lymph node QDS6D Up to 5 days; supporting
6D,10B+ review at evidence and
involvement1A+,4A+ or systemic signs,1A+,2B-,4A+ metronidazole6D,8B+,9C 400mg TDS6D
that is, fever1A+ or malaise)4A+ ADD 3 days9C,10B+ rationales on
metronidazole. 6D,7B+ the PHE
Penicillin allergy: 500mg BD6D website
Use clarithromycin in true penicillin allergy6D clarithromycin 6D

and, if severe, refer to hospital.3A+,6D

Abbreviations
BD, twice a day; eGFR, estimated glomerular filtration rate; IM, intramuscular; IV, intravenous; MALToma, mucosa-associated lymphoid tissue lymphoma; m/r,
modified release; MRSA, methicillin-resistant Staphylococcus aureus; MSM, men who have sex with men; stat, given immediately; OD, once daily; TDS, 3 times a
day; QDS, 4 times a day.

Summary of antimicrobial prescribing guidance – managing common infections (March 2020) 27