Hull and East Riding Prescribing Committee

Guidelines for Treatment of Infections in Primary Care

in Hull and East Riding
This document is based on the Health Protection Agency advice which can be found
at
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/62263
7/Managing_common_infections.pdf (Public Health England Last Update May 2017)

The guidelines have been subject to consultation within primary care, public health
and clinicians within the Acute Trust and have been approved by the Advisory
Committee on Antimicrobial Therapy (ACAT).

Dr Gavin Barlow
Consultant in Infectious Diseases
Hull and East Yorkshire Hospitals NHS Trust

A summary table of main guidance can also be found at

http://www.hey.nhs.uk/herpc/prevention-infection.htm

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 1 of 22
Contents

Section Page

Aims of Guidelines and Principles of Treatment 3

General information on prescribing recommendations 4

Risk factors for Clostridium difficile associated diarrhoea 5

Additional guidance on sampling 6

Upper Respiratory Tract Infections 6

Lower Respiratory Tract Infections 8

Meningitis 9

Urinary Tract Infections 10

Genito-Urinary Tract Infections 13

Gastrointestinal Infections 15

Skin/soft tissue infections 17

Viral Infections 20

Oral infections 21

Miscellaneous 21

References 22

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 2 of 22
 Use TARGET toolkit as a resource to optimise antibiotic prescribing
within primary care settings

Aims of Guidelines
 To provide a simple, evidence based approach to the empirical treatment of common infections
 To promote the safe, effective and economic use of antibiotics
 Minimise the risk of toxicity/ adverse effects e.g. Clostridium difficile associated diarrhoea (CDAD)
 Delay the emergence and reduce the prevalence of bacterial resistance in the community

Principles of Treatment
 This guidance is based on the best available evidence. Professional judgement should be used and
patients should be involved in the decision.
 Prescribe an antibiotic only when there is likely to be a clear clinical benefit (and where benefits
outweigh risks).
 It is important to initiate antibiotics as soon as possible in severe infection
 Have a lower threshold for antibiotics in immunocompromised or those with multiple morbidities;
consider culture and seek advice
 Do not prescribe an antibiotic for viral sore throat, simple coughs and colds.
 Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.
 Limit prescribing over the telephone to exceptional cases.
 Use simple generic antibiotics first whenever possible. Avoid broad spectrum antibiotics (e.g.
quinolones, cephalosporins, clindamycin, co-amoxiclav) when narrow spectrum agents remain
effective, as use of broad spectrum agents increase the risk of Clostridium difficile, MRSA and
resistant UTIs.
 Cephalosporins and quinolones should NOT routinely be used as first line antimicrobials except
where indicated in this guidance.
 Macrolide antibiotics should be only be prescribed in preference to penicillins where the patient is
truly hypersensitive (penicillin allergy is presence of rash or anaphylaxis following treatment with a
penicillin).
 The recommended macrolide for general use is clarithromycin (except in pregnancy and breast
feeding) due to improved tolerability, absorption and compliance compared to erythromycin.
 Avoid widespread use of topical antibiotics (especially those agents also available as systemic
preparations) e.g. fusidic acid (Fucibet®, Fucidin®, - ophthalmic use ok).
 In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose (> 400mg)
metronidazole. Short term use of trimethoprim after the first trimester (unless low folate status or on
other folate antagonists e.g. antiepileptics) is unlikely to cause harm to the foetus.
 In children AVOID tetracyclines and quinolones.
 Give antibiotics for the SHORTEST time possible. In most uncomplicated and non-serious/ non-
severe infections 5 days of treatment or less is usually sufficient.
 When first-line antibiotic sensitivities are provided, further sensitivity results are usually available for
special situations. Consultant medical microbiologists can be contacted for specialist advice by
Registered Medical Practitioners on 01482 674991 during laboratory hours or out of hours (for
urgent advice) via HEY switchboard 01482 875875.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 3 of 22
General information on prescribing recommendations

The information contained within this document is for guidance to assist in the prescribing of anti-
microbials. The doses specified are recommended for use in those with normal pharmacokinetic handling
of the drug. Dose adjustments may be necessary in children or those of advanced age or with co-
morbidities that could affect the pharmacokinetics of the drug (e.g. liver or renal impairment, pregnancy).
Certain drug interactions may also have an impact on anti-microbial drug dosing.

Before prescribing, the information contained within these guidelines should be read in conjunction with the
most recent British National Formulary (www.bnf.org or www.bnfc.org) or the electronic medicines
compendium www.medicines.org.uk for contraindications, cautions, use in pregnancy/ breast feeding and
other disease states (e.g. renal or hepatic impairment) and drug interactions.

Unless otherwise stated the doses are for ADULT patients.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 4 of 22
Main risk factors for Clostridium difficile infection (CDI)

Risk factors for CDI are given below. The more of these risk factors a patient has, the higher the risk is
likely to be.
 Age >65 years (especially >75 years)*
 Previous CDAD*
 Recent exposure to cephalosporins*, quinolones* or clindamycin* or other broad-spectrum
antibiotics such as co-amoxiclav (Augmentin®) – see graph below
 Recent prolonged*/multiple* or IV antibiotic exposure (especially if antibiotics above)
 Nursing/residential home resident
 NG or PEG tube in-situ
 Recent hospital stay
 Extensive co-morbidity
 Gastrointestinal surgery
 Severe underlying/inter-current illness
 Low albumin/poor nutritional status
 H2 antagonist or proton pump inhibitor therapy (Ask, does the patient really need this?
Consider stopping)
 Immunosuppression

These are probably the most important, particularly in combination.

RISK OF COMMUNITY-ASSOCIATED CDI FOR DIFFERENT ANTIBIOTICS

Linear association between a 4-point antibiotic risk index and community-associated CDI
risks.

Brown K A et al. Antimicrob. Agents Chemother.

2013;57:2326-2332

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 5 of 22
Additional guidance on sampling

Catheter Urine Specimens

By 14 days post-catheterisation, almost all urine samples from catheterised patients will yield bacterial
growth. There is no evidence that giving antibiotics to asymptomatic catheterised patients will produce any
clinical benefit whilst they are asymptomatic, and antibiotics do not cure catheter blockage, by-passing of
catheters, peri-urethral discharge, and are not an appropriate solution to malodorous urine.

Repetitious use of antibiotics produces selection of highly-resistant strains of bacteria and culminates in
colonisation with yeasts. Subsequent manipulation of the catheter may result in bacteraemia blood
stream infection with these resistant bacteria and fungi. It is therefore inappropriate to test for the current
bacteria present in the urinary system where the patient has no symptoms, except when manipulation of
the urinary tract is planned i.e. a urological procedure. In those cases it is appropriate to send a pre-
procedure sample, allowing sufficient time (72 hours) for the sample to arrive and for sensitivity tests to be
performed.
Routine catheter replacement does not require antibiotic prophylaxis. If a patient is treated for
catheter associated UTI, the catheter must be changed whilst patients is on antibiotics.

Wound Swabs, Ulcers of the Skin, Pressure sores, Surface Abrasions and Drain sites
Breaches in the skin result in fluid exudate in a considerable proportion of wounds. The fluid is highly
nutritious for bacteria and the growth of a number of organisms to a high level is to be expected. Swabs of
such wounds will therefore yield growth. The use of antibiotics in such circumstances will be futile in
improving the patient’s condition where no clinical evidence of infection is present.

Specimens from wound swabs should therefore state that redness, swelling, pain, pus or systemic infection
is evident (CRP is a useful test to demonstrate systemic infection) and should state the intended antibiotics
which should be started after the swab has been obtained. A swab is always a poor substitute for obtaining
pus and if pus is available, this should be placed in a sterile container and sent instead of a swab. The
same considerations apply to ulcers of the skin, pressure sores, surface abrasions and drain sites.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 6 of 22
UPPER RESPIRATORY TRACT INFECTIONS
ILLNESS COMMENTS DRUG DOSE DURATION OF
Tx
Influenza Latest guidance on vaccination and treatment of influenza can be found at PHE website
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/580509/PHE_guida
nce_antivirals_influenza_2016_2017.pdf

Acute sore Avoid antibiotics as 90% First line (where indicated)

B- A-
throat resolve in 7 days without, and Phenoxymethylpenicillin Adult: 500 mg QDS 10 days
A+
pain only reduced by 16 hours .
Use FeverPAIN Score: Fever in Child: see BNF for children
last 24h, Purulence, Attend rapidly Second line / penicillin
under 3d, severely Inflamed allergic (where indicated)
tonsils, No cough or coryza).
A+
Score 0-1: 13-18% streptococci, Clarithromycin Adults: 500mg BD 5 days
use NO antibiotic strategy; 2-3:
34-40% streptococci, use 3 day Child: see BNF for children
back-up antibiotic; 4 or more: 62-
65% streptococci, use immediate
antibiotic if severe, or 48hr short
5A-
back-up prescription.
Acute otitis Optimise analgesiaB- First line (where indicated)
media
Avoid antibiotics as 60% are A+ A+
Amoxicillin Adult: 500mg TDS 5 days
better in 24 hours without: they
only reduce pain at 2 days and do
A+ Child: see BNF for children
not prevent deafness .
Second line/penicillin
Consider 2 or 3-day delayed or allergic (where indicated)
immediate antibiotics if: A+
 < 2yrs with bilateral AOM or CHILD: Clarithromycin See BNF for children 5 days
bulging membrane and 3 or
A+ ADULT & CHILD over 12
more marked symptoms
 all ages with otorrhoea
A years:
A+
Doxycycline 200 mg stat/100 mg OD 5 days
Otitis externa Use analgesia and topical First line (12 years and over)
A +
preparations first line +. Acetic acid 2%. 1 spray TDS 7 days
Consider oral antibiotics if
spreading cellulitis, extending Second line (2 years &over)
outside of ear canal or A+
systemically unwell (see treatment Otomize ear spray OR 7-14 days
guidelines for cellulitis). 1 spray TDS
Second line (any age)
A+
Hydrocortisone 1% + 2-4 drops, 3-4 times daily, 7-14 days
gentamicin 0.3% ear drops and at night
Rhinosinusitis Avoid antibiotics as 80% First line (where indicated)
resolve in 14 days without, and Amoxicillin
A+ Adult: 500mg TDS 7 days
they only offer marginal benefit
,A+
after 7 days Child: see BNF for children
Only use for persistent symptoms Second line/penicllin allergic
and purulent discharge lasting at (where indicated)
least 7 days or if severe CHILD: Clarithromycin See BNF for children 7 days
symptoms, or high risk of serious
complications (e.g. ADULT & CHILD over 12
immunocompromised, cystic years: Doxycycline 200 mg stat/100 mg OD 7 days
A+
fibrosis) .
B
Use adequate analgesia +.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 7 of 22
LOWER RESPIRATORY TRACT INFECTIONS
Note: Low doses of penicillins are more likely to select out resistance. Do NOT use quinolones (ciprofloxacin and
ofloxacin) first line due to poor activity against pneumococci. However, they do have use in PROVEN pseudomonal
infections. Reserve ALL quinolones for proven resistant infections.

ILLNESS COMMENTS DRUG DOSE DURATION

OF Tx
Acute cough, Antibiotic little benefit if no co- First line
Bronchitis morbidity A+ (where indicated)
Patient leaflets can reduce antibiotic Amoxicillin Adult: 500mg TDS 5 days
A-
use.
Child: see BNF for children
Consider immediate antibiotics if > Second line /penicillin Second line /penicillin
80yr and ONE of: hospitalisation in allergic (where indicated) allergic
last year, oral steroids, diabetic, CCF
OR > 65 years with 2 of above CHILD: Clarithromycin See BNF for children 5 days

200mg stat /100mg OD 5 days

ADULT & CHILD over 12
years: Doxycycline

Acute Consider whether antibiotics First line:

exacerbation are needed. 30% is viral, 30-50% is Amoxicillin 500 mg TDS 5 days
of COPD bacterial (rest undetermined). BTS
COPD guidelines – only prescribe if
A+
two out of three are present : Second line/ penicillin
 allergic
Dyspnoea

Doxycycline 200mg stat /100mg OD 5 days
Increased sputum

Purulent sputum
Consider a sputum sample in non-
responders
Community - Manage using clinical First line for CRB65=0:
acquired judgement and CRB-65 score A+
pneumonia - with review: Amoxicillin 500 mg TDS 5 days
treatment in
the Second line or
CRB scoring: each scores 1: CRB65=1or2
community Confusion (AMT<8);Respiratory / allergic to penicillin
rate>30/min;BP systolic<90 or
(simplified diastolic<=60;Age >65 years. Doxycycline 100mg BD 5-7 days
from NICE
guideline) Score 0 suitable for home treatment;
1-2 consider hospital referral and
assessment
3-4 urgent hospital admission.

For guidance for assessment in

children see BTS Guidelines

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 8 of 22
MENINGITIS

https://www.gov.uk/guidance/meningococcal-disease-clinical-and-public-health-management
In children: http://guidance.nice.org.uk/CG102/Guidance
ILLNESS COMMENTS DRUG DOSE DURATION
OF Tx
Suspected Transfer all patients to hospital First line: Adults and children STAT
meningococ immediately. Benzylpenicillin IV or IM 10 years and over:
cal disease 1200 mg
IF time before admission, and Children 1 - 9 year:
non blanching rash, administer 600 mg
benzylpenicillin (or cefotaxime) Children <1 year:
prior to admission, unless
300 mg
hypersensitive i.e. history of
breathing difficulties, collapse, If allergic to penicillin Adult and children STAT
loss of consciousness or urticaria (and available):
12 years and over: 1g
or rash within 1 hour of Cefotaxime IV or IM
Children <12 yrs:
administration of beta lactam 50mg/kg (max 1g)

Ideally IV but IM if a vein cannot

be found.

Prevention Only prescribe following advice from Public Health Doctor

of secondary 9 am – 638636
case of Out of hours: Contact on-call doctor via TENYAS switchboard 01904 666030
meningitis

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 9 of 22
URINARY TRACT INFECTIONS
Note: Amoxicillin resistance is common therefore only use if culture confirms susceptibility.
Do not treat asymptomatic bacteriuria in adults except in pregnancy; it is common (especially in > 65 years) but is
B+
not associated with increased morbidity. In this population urine cultures are useful only to exclude UTI not to make a
diagnosis.
In the presence of a catheter, antibiotics will not eradicate bacteriuria and will select out more resistant organisms
making subsequent treatment more difficult; only treat if systemically unwell or evidence of pyelonephritis. Do not use
3B
prophylactic antibiotics for catheter changes unless history of catheter-change-associated UTI or trauma (NICE & SIGN
guidance).

HPA guidance: https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis

Sexual Health: https://www.bashh.org/guidelines
ILLNESS COMMENTS DRUG DOSE DURATION OF
Tx
Uncomplicated Women: severe or ≥ 3 DO NOT TREAT
1, 2A 3C
UTI symptoms: Treat ASYMPTOMATIC
(no fever or Women: mild or ≤ 2 BACTERURIA OR
flank pain) symptoms: use dipstick and ASYMPTOMATIC
presence of cloudy urine to POSITIVE DIPSTICK
NOT
PREGNANT guide treatment. Nitrite & First line:
B+
blood/ leucocytes has 92% Nitrofurantoin caps
positive predictive value; -ve May be used with caution if
NOTE: Perform
cultures in all
nitrite, leucocytes, and blood eGFR 30–44 ml/minute to 100mg MR BD Women: 3 days
A+
4A- treat uncomplicated lower
treatment has a 76% NPV . Clear urine Or C
UTI caused by suspected or 50mg QDS Men: 7 days
failures OR has 97% NPV for no UTI. proven multidrug resistant
when risk of Dipsticks likely to be less bacteria and only if potential
resistance is useful in older patients in benefit outweighs risk
considered high whom asymptomatic (Otherwise If eGFR <
(e.g. recent bacteruria is common. 2
45ml/min/1.73m use
prior antibiotic trimethoprim as above
therapy, nd
OR one of the 2 line
recurrent UTI, Men: Consider prostatitis &
1,5C options below)
previous send pre-treatment MSU OR
resistant if symptoms mild/non-specific,
organism) use -ve dipstick to exclude UTI. Otherwise
6C
Refer male patients with > 1 UTI If risk of resistance low
NOTE 2: In mild episode to urology or organism known to
be sensitive use:
to moderate, B+ 200 mg BD
uncomplicated Macrocrystalline nitrofurantoin (i.e. Trimethoprim
UTI in non- capsules or m/r capsules) preferred Second line
B-
pregnant due to reduced side effects .) (perform culture in all
females aged treatment failures)
18-65 years, a
recent trial Second line
showed two- (Perform culture in all
thirds of women treatment failures. For
recovered options in resistance, see
without below)
antibiotics
following a 3 Pivmecillinam 400mg stat then 200mg
A+
day course of TDS Women: 3 days
ibuprofen
C
400mg/8hrs – Amoxicillin (Only use if 500mg TDS Men: 7 days
Consider as isolate known to be
sensitive)

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 10 of 22
treatment Multiresistant E.coli with Extended Resistance:
strategy in Spectrum Beta-Lactamases Treat depending on
females without (ESBLs) are increasing so perform sensitivity of organism
contraindication A
culture in all treatment failures OR isolated. Options in order
s after when risk of resistance is high. of preference are:
discussion with
A C
patient Nitrofurantoin caps 100mg MR BD Women – 3 days
(See: (avoid if GFR < OR Men – 7 days
2
https://www.ncb 45ml/min/1.73m ) 50mg QDS
i.nlm.nih.gov/p
mc/articles/PM Or
C4688879/)
Pivmecillinam 400mg stat then 200mg Women – 3 days
TDS Men – 7 days
OR
A
Fosfomycin 3g sachet once at night Women – single
nd
(with a 2 dose only in dose of 3g
nd
men on day 3 or 4) Men - 2 3g dose
in men 3 days
later (unlicensed
dose)

UTI and Send MSU for sensitivities and start First Line
st nd
asymptomatic empirical antibiotics
A 1 /2 trimester: 100mg MR BD
C
7 days
C

bacteruria in Nitrofurantoin caps OR

st (avoid if GFR <
pregnancy Avoid trimethoprim in 1 trimester 50mg QDS
45ml/min/1.73m2)
and in those with low folate status or
on folate antagonists.
rd
3 trimester: C
Nitrofurantoin – short term use is 200mg BD 7 days
Trimethoprim
unlikely to cause harm to foetus but
still recommend avoiding at term Second line
(due to foetal haemolysis) Amoxicillin (if sensitive) 500mg TDS 7 days
C

OR
C
Cefalexin 500mg TDS 7 days

Children Child<3month s with suspected UTI: First line

1C
refer urgently for assessment A
Trimethoprim OR A+
See BNF for dosage 3 days
Child≥ 3 months: use positive nitrite Nitrofurantoin
A-
1A+
to start antibiotics
Send pre-treatment MSU for all
Second line
A+
Referral for imaging: only refer if Amoxicillin (if sensitive) See BNF for dosage 3 days
1C
child < 6 months or atypical UTI OR
C
Cefalexin A+
Refer for recurrent UTI – 2 or more See BNF for dosage 3 days
episodes of UTI including one
episode of pyelonephritis OR 3 or Acute pyelonephritis
more episodes of UTI Co-amoxiclav
A

A+
(seek specialist advice if See BNF for dosage 7-10 days
penicillin allergic)
Acute If admission to hospital not needed First line
pyelonephritis in send MSU for culture & sensitivities Co-trimoxazole** 960mg BD 7 days
C
ADULTS and start antibiotics . (STOP If rash)
C
If no response within 48 hours –
Admit to hospital. Allergic to trimethoprim
or sulphonamides:
C
** Co-trimoxazole – reduce dose by Co-amoxiclav 625mg TDS 7 days

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 11 of 22
 50% if GFR 15-30 ml/min/1.73m2 and If co-trimoxazole/co-
avoid if GFR < 15ml/min/1.73m2 amoxiclav both
-do not use in patients prescribed contraindicated
drugs which increase potassium Ciprofloxacin
(e.g. ACE, ARB, potassium sparing 500mg BD 7 days
diuretics)

Recurrent UTI Educate patient on hygiene, First line

in women lifestyle, diet measures likely to Nitrofurantoin caps 100mg ON or 50mg BD 3-6 months then
>= 3 UTIs/year reduce risk of recurrence review recurrence
Cranberry products,
A+, A+
OR Post- [unlicensed dose]
B+ B+ rate and need
coital OR standby antibiotics Second line
may reduce recurrence. Trimethoprim (if recent 200mg ON
Nightly antibiotics: reduces UTIs but culture shows sensitivity) Or stat for post-
A+
[unlicensed dose] coital dose
adverse effects Or
Pivmecillinam 200mg ON [unlicensed
dose)
Consider referral to secondary care. Further notes on prescribing:
Long-term antibiotics are last Prophylaxis choice must be based on previous microbiology.
resort because of risk of resistant
Recommendations above assume normal renal function and folate status
organisms emerging.
(for trimethoprim).
Treatment with cyclical antibiotics
are not recommended.
Alternative regimes are not recommended except on advice of
Microbiology, Infectious Disease or Urology consultant.

Acute prostatitis Refer all suspected cases of First line (if sensitive)
C C
acute prostatitis to secondary Trimethoprim 200mg BD 28 days
care
Second line/ culture
Send MSU for culture and start negative cases
C C C
antibiotics immediately . Ciprofloxacin 500mg BD 28 days

Anti-microbial therapy may need

adjusted according to
microbiology

Epididymo- Refer all suspected cases to Gonococcal:

orchitis Urology or GUM (if STI Ceftriaxone IM 500mg IM STAT
C
suspected) (or Cefixime oral) AND (or 400mg PO) AND
Doxycycline 100mg BD 14 days

Chlamydial:
Doxycycline 100mg BD 14 days

Gram negative:
st
1 line (if sensitive)

Trimethoprim 200mg BD 14 days

(or longer)
nd
2 line / culture negative
As per sensitivities or
if culture negative:

Ciprofloxacin 500mg BD 14 days

(or longer)

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 12 of 22
GENITO- URINARY TRACT INFECTIONS – always check BASHH guidance https://www.bashh.org/guidelines
Note: People with risk factors should be screened for Chlamydia, gonorrhoea, HIV, syphilis. Refer individual and partners
to GUM service. Risk factors: <25y, no condom, recent (<12mth)/frequent change of partner, symptomatic partner, area
of high HIV
Refer patients with STIs, including trichomoniasis, to GUM clinic for contact tracing. If laboratory testing for test of cure
in Chlamydia infection is required then it should be performed at least 3 weeks after the initiation of therapy to avoid false
positive results
ILLNESS COMMENTS DRUG DOSE DURATION OF Tx
Vaginal All topical and oral azoles give 75% First line
A+ A+
candidiasis cure. Clotrimazole pessary 500mg STAT

If extensive, severe or unresponsive Second line

A+
to first line treatment consider oral Fluconazole (oral) 150mg STAT
therapy.
Add clotrimazole 1% or 2% cream, Pregnancy
BD to TDS for symptomatic relief.
(if symptomatic)
A+ C
.B Clotrimazole pessary 100mg ON 6 nights
In pregnancy avoid fluconazole

Or
A+
Miconazole 2% cream 5g Intravaginally BD 7 days

Bacterial Topical treatment gives similar cure First Line

A+ A+
vaginosis rates but is more expensive. Metronidazole 400 mg BD 7 days
A+

Clindamycin may damage latex

condoms and diaphragms. Second Line
Metronidazole vaginal gel is not Metronidazole A+
recommended during menstruation. A+ 5 nights
0.75% vag gel 5 g applicator full ON
OR A+
A+ 7 nights
Clindamycin 2% cream
Uncomplicated Opportunistically screen all aged 15- First line
A+ A+
Chlamydia 25 years. Doxycycline or 100mg BD 7 days
trachomatis in Refer patient to GUM for
men and Second line
partner notification and follow A+ A+
women B Azithromycin 1 g STAT 1 hr before or 2
up +. hrs after food
Pregnancy or
breastfeeding
First line
A+ A+
Azithromycin 1 g STAT 1 hr before or 2
(unlicensed) hrs after food

Second line
A+
Erythromycin 500mg QDS 14 days
A+ A+
Trichomoniasi Refer patients and contacts to Metronidazole 400 mg BD 7 days
B A+
s GUM +. or 2 g in single dose
Treat partners simultaneously B+
Clotrimazole 100 mg pessary ON 6 days
Avoid 2g stat dose of metronidazole
in pregnancy or breast feeding
If oral treatment declined, offer
clotrimazole (unlicensed) for
SYMPTOMATIC relief and treat post-
natally.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 13 of 22
Pelvic Test for Chlamydia & N. gonorrhoea First line
Inflammatory Refer patients and contacts to Ceftriaxone IM AND 500mg IM AND STAT
Disease Metronidazole AND 400 mg BD AND 14 days
GUM clinic B
(PID) Doxycycline 100 mg BD 14 days

These regimens are not for use in

pregnancy. Please discuss these Second line
B+
cases with secondary care. Ofloxacin AND 400mg BD AND 14 days
Metronidazole 400mg BD 14 days
28%of gonorrhoea isolates now
B+
resistant to quinolones so only
use ofloxacin based regimens if
gonococcal PID unlikely.
Genital Refer patients and contacts to First line
herpes GUM clinic Aciclovir 200mg FIVE times daily 5 days
Higher doses may be required in
severe infection or OR
immunocompromised
Aciclovir 400mg TDS 5 days

Longer courses required if new

lesions appear during treatment
period or if healing is incomplete
Genital warts Refer patients and contacts to Treatments include:
GUM clinic
Podophyllotoxin solution BD for three days Repeat weekly
or cream (then 4 day break) until lesions
Treatment depends on site,
resolve.
character and area involved.
(max of 4
weeks)
Cryotherapy is first line treatment for
some cases (e.g. keratinised warts) Imiquimod cream Three times a week, at night Until lesions
resolve
(max 16
Avoid podophyllotoxin in pregnancy / weeks)
breast feeding
Imiquimod may damage latex
condoms and diaphragms.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 14 of 22
GASTRO-INTESTINAL TRACT INFECTIONS

CDI: https://www.gov.uk/government/collections/clostridium-difficile-guidance-data-and-analysis
ILLNESS COMMENTS DRUG DOSE DURATION OF
Tx
Oral Candida Typically presents as white plaques
on mucosal surfaces. They can be Miconazole oral gel 5ml qds (retain gel in mouth Continue for
wiped off to reveal a raw near lesions) 48hrs after
erythematous base that may bleed. Consider change of use lesions have
There are many possible causes of to nystatin if patient Dental prosthesis should be healed.
white lesions. However should be taking a statin or warfarin removed at night and
distinguished from leukoplakia, a brushed with gel. Review with a
pre-malignant condition where that dental
plaque cannot be wiped off. practitioner
It is important to treat any pre-
disposing factors:
 Diabetes mellitus Antifungal agents
 Corticosteroids (inhaled/oral) absorbed from the
 Oral antibiotics should be gastrointestinal tract
reviewed prevent oral candidiasis
 Medication that causes a dry in patients receiving
A+
mouth treatment for cancer.
Denture hygiene should be
optimised
A+
Eradication of Eradication is beneficial in DU, First line
A+ B+
Helicobacter GU and low grade maltoma , but Lansoprazole AND 30 mg BD
C
pylori not in GORD . In Non-Ulcer NNT Amoxicillin AND 1 g BD 7 days
A+
is 14. Clarithromycin OR 500 mg BD OR
Triple treatment attain >85% Metronidazole 400mg BD
A-
eradication. As resistance is
A+
increasing, avoid clarithromycin or Penicillin allergic
A+
metronidazole if used in past year Lansoprazole AND 30 mg BD 7 days
A+
for any infection. Clarithromycin AND 500 mg BD
Metronidazole 400 mg BD
DU / GU: retest for H.pylori if
A-
symptomatic. Treatment failure 14 days
Non ulcerable dyspepsia (NUD): do Lansoprazole plus 30mg BD (for relapse and
C
not retest, treat as functional Bismuth salt (De- 240mg BD MALToma)
dyspepsia. noltab®)
AND two unused
In treatment failure consider antibiotics:
endoscopy for culture & Amoxicillin 1g BD
C
sensitivities. Metronidazole 400mg TDS
Tetracycline 500mg QDS
st nd
Clostridium Stop unnecessary antibiotics and/or 1 / 2 episode of non-
B+
difficile (CDI) PPIs . severe
A- C
70% respond to metronidazole in 5 Metronidazole (oral) 400mg TDS 10-14 days
days, 92% in 14 days.
0 Severe or
Admit if severe: T>38.5 ; WCC>15, rd
3 /subsequent episode
rising creatinine or signs/symptoms Vancomycin 125mg QDS 10-14 days
C
C
of severe colitis
Fidaxomicin is option for
Antimotility agents should NOT recurrent CDI – discuss with http://www.hey.nhs.uk/herp
infection team consultant c/guidelines/led/fidaxomicin
be prescribed in acute episodes before prescribing
.pdf

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 15 of 22
Acute Mild uncomplicated diverticulitis can First line
diverticulitis be managed at home with Co-trimoxazole** AND 960mg BD 7 days
paracetamol (avoid NSAIDS, (STOP if rash)
opioids) and clear fluids.
There is conflicting evidence on Metronidazole 400mg TDS 7 days
benefit of antibiotics but several
guidelines recommend this.
Admit if pain cannot be managed
with paracetamol, hydration cannot Allergic to
be maintained, significant trimethoprim or
conmorbidities likely to complicate sulphonamides
recovery, suspected complications
Co-amoxiclav
D
625mg TDS 7 days
(e.g. rectal bleeding, perforation,
abscess) or if not improving

** Co-trimoxazole – reduce dose by

50% if GFR 15-30 ml/min/1.73m2 and
avoid if GFR < 15ml/min/1.73m2
– do not use in patients prescribed
drugs which increase potassium
(e.g. ACE, ARB, potassium sparing
diuretics)

C
Gastroenteritis Refer previously healthy children with acute painful or bloody diarrhoea to exclude E coli 0157 infection .
C
Antibiotic therapy is not indicated unless systemically unwell
Initiate treatment, on advice of microbiologist, if the patient is systemically unwell (e.g. clarithromycin 500mg BD for
C
5-7 days, if campylobacter suspected and treated early)
Please notify suspected cases of food poisoning to, and seek advice on exclusion of patients, from Public Health
-5pm) Send stool samples in these cases.

Traveller’s Limit prescription of antibacterial to be carried abroad and taken if illness develops. (Ciprofloxacin 500mg twice
C
Diarrhoea daily for 3 days or 500mg stat dose, as a private prescription) Restrict to people travelling to remote areas and for
C
people in whom an episode of infective diarrhoea could be dangerous .
Consider referral of suspected infectious diarrhoea following travel to Department of Infection and Tropical
Medicine, Hull and East Yorkshire Hospitals NHS Trust.
Threadworm Treat all household contacts at the First line (> 6 months)
same time. Advise morning shower / (unlicensed under 2
baths, pants at night and hand years)
Section moved hygiene for 2 weeks.
– previously Mebendazole 100mg
C STAT and
“infestations” PLUS wash sleepwear, bed linen, repeat after 2
C
dust and vacuum on day 1 . weeks
Second line/ infants
First trimester of pregnancy – under 6 months
hygiene only hygiene for 6 weeks
C

Second and third trimester of

pregnancy – use piperazine

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 16 of 22
SKIN / SOFT TISSUE INFECTIONS
Note: Information on the treatment of common skin conditions (including skin infections) is available in ‘A guide to
dermatology’. Available at http://www.hey.nhs.uk/herpc/guidelines/dermatologyAGuideTo.pdf
ILLNESS COMMENTS DRUG DOSE DURATION OF
Tx
Impetigo & As resistance is increasing topical For lesions suitable for
other minor skin antibacterials should be reserved topical use:
B+
infections for very localised skin infections First line Topically TDS 5 days
Hydrogen peroxide cream
®
For extensive, severe or bullous 1% (Crystacide )
C
impetigo, use oral antibiotics .
Second line
If river or sea water exposure, Fusidic acid cream Topically TDS 5 days
discuss with microbiologist.
Systemic treatment
1C
Reserve mupirocin for MRSA First line Adult: 500 mg QDS 7 days
C
Flucloxacillin Child: see BNF for
children
Second line/penicillin
allergic Adult: 500mg BD 7 days
C
Clarithromycin Child: see BNF for
children
Cellulitis If patient afebrile and healthy, other First line
C
than cellulitis, flucloxacillin may be Flucloxacillin 500 mg – 1G QDS 7 days.
C
used as single drug treatment . If slow response a
If febrile and ill, admit for IV further 7 days
C
treatment
C Second line /penicillin may be required
allergic:
If river or sea water exposure Clarithromycin
C
500mg BD 7 days
discuss with infection team. If slow response a
If Facial further 7 days
C
Co-amoxiclav 625mg TDS may be required
Diabetic foot

Urgent referral required Diabetic foot:

Admit if general systemic illness,
spreading cellulitis, critical First line As advised by
C
ischaemia, penetrating foot injury. Flucloxacillin 500 mg – 1G QDS specialist team
Contact consultant / SpR in
Endocrinology via switchboard for
advice.
If admission not required, start Second line /penicillin
antibiotics and refer urgently to allergic: As advised by
diabetic foot service (tel 01482 Doxycycline 100mg BD specialist team
675345 or fax 01482 675370)
http://www.hey.nhs.uk/herpc/guideli
nes/acuteDiabeticFoot.pdf
Infected wound, For severe infections, MRSA First line
including post- skin/soft tissue infections or if Flucloxacillin 500mg – 1G QDS 5 days & review
op wound patients not improving within 48-72
infections hours – refer to specialist team . (+ Metronidazole , if (+ 400mgs TDS)
abdominal / pelvic wound)

For tetanus prone wound assess Second line /penicillin

and treat/refer for vaccine or allergic:
immunoglobulin. See BNF/Green Doyxcycline 200mg STAT then 7 days & review
book for details..
100mg OD – BD
(+ Metronidazole , if (+ 400mgs TDS)
abdominal / pelvic wound)

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 17 of 22
MRSA / MSSA Give treatment for skin mupirocin 2% nasal Apply to nostrils TDS 5 days
Skin decolonisation when advised by ointment
colonisation specialist team And
Naseptin should be used (for 10 Octenidine (Octenisan Wash DAILY (incl 2 5 days
days) instead of mupirocin nasal body wash) hair washes)
ointment if the isolate is known to
be mupirocin resistant. OR
Naseptin cream Apply to nostrils QDS 10 days
48 hours after course complete And
patient should be re-swabbed. Chlorhexidine 4% Aq Soln Wash DAILY (incl 2 10 days
If patient not decolonised – seek hair washes)
specialist advice
B+
MRSA active MRSA confirmed with lab results doxycycline (>12yrs only) 100mg BD 7 days
infection Seek specialist advice
(Ensure isolate is
doxycycline sensitive)
Other treatment options–
discuss with specialist
PVL producing- Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus. Can rarely cause severe invasive
Staphylococcus infections in healthy people. Send swabs if recurrent boils/ abscesses. Risk factors; Close contact in communities
C
aureus or sport; poor hygiene .
A+
Routine swabs are not recommended. Antibiotics are only indicated if cellulitis is present , and do not improve
Leg ulcers healing. Cultures / swabs are only indicated if diabetic or there is evidence of clinical infection, e.g. inflammation
or redness / cellulitis, increased pain, purulent exudates, rapid deterioration of ulcer or pyrexia. Sampling requires
cleaning then vigorous curettage and aspiration.
C
If active infection, treat as cellulitis (as above). Refer for specialist opinion if severe infection .
Using antibiotics, or adding them to steroids in eczema does not improve healing unless there are visible signs of
Eczema B C
infection . Where treatment indicated treat as per Impetigo .
C
Bites Thorough irrigation is important . First line animal & First line animal & Review at 24 &
Animal bite Assess tetanus and rabies risk .
C human prophylaxis and human prophylaxis and 48hrs
Antibiotic prophylaxis advised for – treatment treatment
C C
puncture wounds, bite involving co-amoxiclav 625mg TDS Treatment -7 days
hand, face, foot,joint, tendon or Child – see BNF for
ligament. It is also recommended Prophylaxis – 5
children days
for at risk patients e.g. diabetic,
asplenic, immunosuppressed, Penicillin allergic in
cirrhotic, prosthetic valve or joint ADULTS:
Antibiotic prophylaxis advised; add metronidazole 400mg TDS Treatment -7 days
Human bite
metronidazole if severe. plus Prophylaxis – 5
C
Assess tetanus, HIV/hepatitis B & C doxycycline 100mg BD days
risk
Penicillin allergic in Treatment -7 days
CHILDREN: Prophylaxis – 5
clindamycin See BNF for children days

A+
Scabies Treat whole body including scalp, permethrin 5% cream 2 applications one week
face, neck, ears, under nails. Treat or apart.
all household and sexual contacts
C
within 24 hours . malathion 0.5% aqueous
C
solution

Conjunctivitis Bacterial, usually unilateral and 1st line 2 hourly for 2 days then
yellow-white mucopurulent chloramphenicol
B+
reduce to QDS All for 48 hours
discharge. Most bacterial infections 0.5% drops plus after resolution
are self limiting, 64% resolve on plus at night
A+
placebo . 1% ointment
nd
2 line
fusidic acid 1% gel BD

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 18 of 22
Fungal infection Take nail clippings: Start therapy A+
of the proximal only if infection is confirmed by terbinafine 250 mg OD Fingers:
laboratory .
C Use with caution in hepatic 6–12 weeks
fingernail or
or renal impairment Toes :
toenail (Adults)
Idiosyncratic liver reactions occur 3 – 6 months
For children rarely with oral antifungals. If
seek advice patient develops signs of liver
dysfunction treatment should be
A+
stopped immediately

A+
Pulsed itraconazole monthly is Itraconazole 200 mg BD Give for 7 days
recommended for infections with repeat every
yeasts and non-dermatophyte month.
C
moulds. Fingers: 2 Cycles
Toes: 3 Cycles
A+
Fungal infection Terbinafine is fungicidal. Topical terbinafine BD 1-2 weeks
of the skin Imidazole is fungistatic.
OR
Treatment times shorter with
terbinafine. Topical Clotrimazole 1% Apply 2-3 times / day 4 – 6 weeks
A+

Or (i.e. 1-2 weeks

C A+
If candida possible, use imidazole . Miconazole 2% cream after healing)
If intractable, use skin scrapings
and if infection confirmed, use oral
B+
therapy (as above) .
With significant
Scalp infections – discuss with inflammation Apply twice daily Max 1 week
specialist. Clotrimazole 1% +
hydrocortisone 1%
Patients should be given advice or Apply twice daily Max 1 week
regarding general hygiene Miconazole 2% +
measures in order to improve hydrocortisone 1%
healing and reduce the risk of
spread of infection to others.

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 19 of 22
VIRAL INFECTIONS
ILLNESS COMMENTS DRUG DOSE DURATION OF
Tx
Herpes If pregnant /immunocompromised / If indicated:
B+
zoster / neonate seek urgent advice from 800 mg five times a day 7 days
B+
virology dept 01482 626762 aciclovir
Chicken pox
& (Out of hours contact on call Child – see BNF
Varicella consultant microbiologist: 01482
zoster/ 875875)
Shingles
Chicken pox: treat ONLY IF > 14
years or severe pain, dense/oral rash,
secondary household case, on
steroids or smoker and IF can start
B+
within 24 hours of rash .
Shingles: treat ONLY IF over 50
A+
years and within 72 hours of rashB+;
B+
or if active ophthalmic or Ramsey
B+ C
Hunt or eczema .
Cold sores Cold sores resolve after 7-10 days without treatment. Topical antivirals (such as aciclovir 5% cream 5 times a day for
5 days) applied prodromally reduce duration by 12-24 hoursB+

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 20 of 22
DENTAL INFECTIONS
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, who should have an answer-phone message with details of how to access treatment out-of-hours, or call NHS 111
ILLNESS COMMENTS DRUG DOSE DURATION OF
Tx
Mucosal  Temporary pain and swelling relief can Simple saline ½ tsp salt dissolved in Always spit out
1C 1C
ulceration and be attained with saline mouthwash mouthwash glass warm water after use.
inflammation  Use antiseptic mouthwash:
(simple If more severe & pain limits oral hygiene Chlorhexidine 0.12- Rinse mouth for 1 Use until lesions
2-6A+
gingivitis) to treat or prevent secondary infection.
2- 0.2% (Do not minute BD with 5 ml resolve or less pain
8C use within diluted with 5-10 ml allows oral hygiene
30 mins of water.
The primary cause for mucosal ulceration
toothpaste)
or inflammation (aphthous ulcers, oral
lichen planus, herpes simplex infection,
Hydrogen peroxide Rinse mouth for 1 min
oral cancer) needs to be evaluated and 6-8A-
1.5% (spit out QDS (after meals &
treated.
after use) bedtime)
1-7 1-7C
Acute Commence metronidazole and refer to Metronidazole 400 mg TDS 3 days
necrotising dentist for scaling and oral hygiene AND
C
ulcerative advice Chlorhexidine or Until oral hygiene
C
gingivitis Use in combination with antiseptic see above dosing in
hydrogen peroxide possible
mouthwash if pain limits oral hygiene mucosal ulceration
Pericoronitis
1B Refer to dentist for irrigation & Amoxicillin 6
500 mg TDS 3 days
1C
debridement. AND
1-7C 400 mg TDS
If persistent swelling or systemic Metronidazole 3 days
1-5A
symptoms use metronidazole. AND
Use antiseptic mouthwash if pain and see above dosing in
Chlorhexidine or mucosal ulceration Until oral hygiene
trismus limit oral hygiene hydrogen peroxide possible
Dental  Regular analgesia should be first option until a dentist can be seen for urgent drainage, as repeated courses of
B 1
abscess antibiotics for abscess are not appropriate; Repeated antibiotics alone, without drainage are ineffective in
preventing spread of infection.
 Antibiotics are recommended if there are signs of severe infection, systemic symptoms or high risk of
2,3
complications.
 Severe odontogenic infections; defined as cellulitis plus signs of sepsis, difficulty in swallowing, impending
airway obstruction, Ludwigs angina. Refer urgently for admission to protect airway, achieve surgical drainage
and IV antibiotics
9
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 no response to first line drugs when referral is the preferred
6,12C
option.
2 2
If pus drain by incision, tooth extraction or Amoxicillin or 500 mg TDS Up to 5 days
4-7B 11
via root canal. Send pus for Phenoxymethylpenic 2
500 mg – 1g QDS review at 3d
2
microbiology. illin
True penicillin allergy: use clarithromycin True penicillin
C
or clindamycin if severe. allergy:
1. If spreading infection (lymph node Clarithromycin
500 mg BD 5 days
involvement, or systemic signs ie fever Severe infection add
8-10C 8-10 400 mg TDS
or malaise) ADD metronidazole Metronidazole or
11
if allergy 5 days
Clindamycin
3,8-11 300mg QDS

MISCELLANEOUS
Prophylaxis of infection in asplenic and hyposplenic patients

Guidance can be found at the following websites

https://www.gov.uk/government/publications/splenectomy-leaflet-and-card

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 21 of 22
References
The primary reference sources for these guidelines were:

Public Health England Management of Infection Guidance for Primary Care for Consultation & Local Adaptation
https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care

Hull and East Yorkshire Hospitals NHS Trust Adult Sepsis Guidelines (Oct 2013).

Clinical Knowledge Summaries for the NHS http://cks.nice.org.uk, www.bnf.org.uk , BNF for Children www.bnfc.org.uk

Further references are listed in main text or can be found in original PHE document, listed above.

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint
Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West
Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-
group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following
comments from Internet users. If you would like to receive a copy of this guidance with the most recent changes
highlighted please email the author [email protected]
The guidance has been updated regularly as significant research papers, systematic reviews and guidance have been
published. Public Health England (previously Health Protection Agency) works closely with the authors of the Clinical
Knowledge Summaries.

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design Recommendation

Grade

Good recent systematic review of studies A+

One or more rigorous studies, not combined A-
One or more prospective studies B+
One or more retrospective studies B-
Formal combination of expert opinion C
Informal opinion, other information D

APPROVAL PROCESS for HERPC GUIDELINE

Written by: Marie Miller, Interface Pharmacist; updated Jane Morgan – Acting Interface
Pharmacist July 17 (UTI section and links only)
In consultation with Dr Gavin Barlow, Consultant in Infectious Disease,
Formulary SubGroup, HUTH Specialist teams – Sexual Health, ENT
Approved by: Joint formulary Committee
Ratified by: HERPC Sept 15 and May 19 (UTI section only)
Review Date: September 20

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
A+ = systematic review, A- = rigorous RCT, B+ = RCT or cohort study, B- = case-control study
C = formal combination of expert opinion.

HERPC Guidelines for the Treatment of Infections in Primary Care. Date Approved: September 2017
Review Date: September 2020 Page 22 of 22